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The facility failed to maintain the emergency lighting per code. Findings include:

During the survey, the following are examples of what was observed:
1. The facility failed to verify the outside emergency egress lighting was on the generator.
2. Per documentation and interview the facility failed to document the monthly/annual testing of the outside emergency egress lighting.

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2000 NFPA 101, 7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following: (1) Buildings or structures where required in Chapters 11 through 42 (2) Underground and windowless structures as addressed in Section 11.7 (3) High-rise buildings as required by other sections of this Code (4) Doors equipped with delayed egress locks (5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.
2000 NFPA 101, 7.9.3 A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The facility failed to conduct fire drills per code. Findings include:

During the survey, the following is an example of what was observed:

Per documentation provided by maintenance staff, facility failed to illustrate that all facility personnel are familiar with the signals and emergency action required under varied conditions during fire drills.
Per interview with facility maintenance staff, staff confirmed that documentation provided of fire drill participation did not include names of all staff in the facility at the time of the fire drills.
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2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
2000 NFPA 101, 4.7.2 Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
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The facility failed to maintain the digital alarm communicator transmitter for the fire alarm system per code. Findings include:

During the survey, the following are examples of what what observed:

1. When the Auto Dialer was tested for phone line 1, phone line one trouble was not indicated at the protected premise within the allotted four (4) minute time frame.

2. When the Auto Dialer was tested for phone line 2, phone line two trouble was not indicated at the protected premise within the allotted four (4) minute time frame.

3. When the Auto Dialer was tested for communication failure, communication failure trouble was not indicated at the protected premise within the allotted fifteen (15) minute time frame (5 minimum to 10 maximum attempts for signal transmission).

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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.


1999 NFPA 72, Table 7-2.2 b. Digital Alarm Communicator
Transmitter (DACT)
The primary line from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault. The secondary means of transmission from the DACT shall be disconnected. Indication of the DACT trouble signal at the premises shall be verified as well as transmission to the supervising station within 4 minutes of detection of the fault.