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Based on observation and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by missing quarterly sprinkler inspection reports. This affected all patients and two of two smoke compartments, and could result in an ineffective sprinkler coverage.

NFPA 101 Life Safety Code, 2012 edition

19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected
throughout by an approved, supervised automatic
sprinkler system in accordance with Section 9.7, unless otherwise
permitted by 19.3.5.5.

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years thereafter 2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10


Findings:

During a tour of the facility and interview with the Maintenance Director on 10/26/23, the automatic sprinkler system was observed.

At 3:05 p.m., the facility failed to provide upon request the 2022 fourth quarter sprinkler inspection. Upon interview, the Maintenance Director stated that the contracted sprinkler vendor did not perform the quarterly sprinkler inspection during the fourth quarter of 2022.

Based on observation and interview, the facility failed to maintain the portable heating devices. This was evidenced by a portable heater located in close proximity to combustible materials. This affected one of two smoke compartments and all patients, and could result in a fire.

Findings:

During a tour of the facility with the Maintenance Director on 10/26/23, the portable heater in the Doctor's Lounge was observed.

At 12:48 p.m., a portable heater was observed approximately two feet from a bed in the Doctor's Lounge. The warning label stated, "CAUTION-HIGH TEMPERATURE, keep electrical cords, drapery and other furniture at least 3 feet(0.9m) from the front of the heater and away from sides and rear." Upon interview, the Maintenance Director stated that she was unaware that there was a portable heater in the Doctor's lounge.

Based on observation and interview, the facility failed to maintain the electrical equipment and wiring. This was evidenced by the non-compliant use of power strips. This affected two of two smoke compartments and all patients, and could result in an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

Chapter 9 Building Service and Fire Protection Equipment
9.1 Utilities.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(7) Where subject to physical damage


Findings:

During a facility tour and interview with the Maintenance Director on 10/26/23, the electrical equipment and wiring were observed.

1. At 12:40 p.m., a relocatable power tap was observed in the Emergency Room office suspended approximately three inches off the ground under a desk. Upon interview, the Maintenance Director stated that a vendor adjusted all power taps at the facility and tied all wires together and caused the relocatable power tap to be suspended.

2. At 12:54 p.m., a relocatable power tap was observed in the X-ray supervisor office suspended approximately two feet under the desk. Upon interview, the Maintenance Director stated that a vendor adjusted all power taps at the facility and tied all wires together and caused the relocatable power tap to be suspended.

3. At 12:56 p.m., a relocatable power tap was observed in the Emergency Room Supervisor Lab Manager office with a microwave connected to it. The microwave's manufacturer label stated, "To provide continued protection against electric shock, connect to properly grounded outlets only." The surge protector was also connected to another surge protector underneath the emergency room supervisor's desk. Upon interview, the Maintenance Director stated that the she was unaware that the microwave was attached to a relocatable power tap.

4. At 12:59 p.m., a relocatable power tap was observed in the Drug Room suspended approximately three inches under the desk. Upon interview, the Maintenance Director stated that a vendor adjusted all power taps at the facility and tied all wires together and caused the relocatable power tap to be suspended.