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At 11:37 a.m., there was an approximately 1 by 1/2 inch penetration in the ceiling of Room 123. The penetration was in the middle area of the ceiling.

At 11:40 a.m., there was an approximately 1 by 1/2 inch penetration in the ceiling of Closet 118. The penetration was on one side of a pipe.





29665


Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected two of two smoke compartments and could result in the spread of smoke and fire.

Findings:

During the facility tour on 1/11/11, the walls and ceilings were observed.

At 11:09 a.m., there was an approximately 1/4 inch penetration around an old cable, in the left wall of the staff lounge.

At 11:44 a.m., there was an approximately 3/4 inch penetration in the ceiling of Room 107.

Based on observation, the facility failed to maintain their doors. This was evidenced by one door that failed to positive latch. This affected one of two smoke compartments, and could cause the spread of smoke and fire in the event of a fire.

Findings:

During the facility tour on 1/11/11, the doors were observed.
At 11:24 a.m., the door to Room 134 failed to positive latch. The door failed to latch in 4 of 4 attempts.

Based on record review and interview, the facility failed to ensure emergency lighting is tested in accordance with NFPA 101. This was evidenced by no records for testing the emergency lights in the exit corridors. This affected three of three lights and could result in a delay in evacuation in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code?.
7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
7.9.3 Periodic Testing of Emergency Lighting Equipment. 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.
Exception: Self-testing/self-diagnostic, battery-operated emergency
lighting equipment that automatically performs a test for not less than
30 seconds and diagnostic routine not less than once every 30 days
and indicates failures by a status indicator shall be exempt from the
30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

Findings:

During the facility tour with facility staff on 1/11/11, three emergency lights were observed in the corridors. All three lights illuminated when tested with the push button.

During an interview on 1/12/11 at 9:50 a.m., Maintenance Staff 1 was asked for records for testing the emergency lights. He reported there were no records for testing the battery power for the lights. He stated the bulbs were replaced when staff reported a failure of the lights. There were no other records for inspection and testing of the lights.

Based on observation, the facility failed to ensure exit signs are maintained with continuous illumination. This was evidenced by one exit sign that was not illuminated. This affected two of two smoke compartments, and could result in delayed egress, in the event of a fire.

Findings:

During the facility tour on 1/11/11, the exit lights were observed.

At 11:20 a.m., the exit sign was not illuminated above the door leading to the patio area.

During an interview with Maintenance Staff 1 at 11:21 a.m., he reported the patio area is used to evacuate residents. He confirmed the exit sign was not illuminated.

Based on observation, interview and record review, the facility failed to ensure maintenance, inspection and testing of the fire alarm system was completed in accordance with NFPA 72. This was evidenced by no current documentation for monthly activation and annual testing and inspection of the fire alarm system, and by a supervisory trouble alarm displayed at the panel. This affected 13 of 13 patients on 1/11/11 and 15 of 15 patients on 1/12/11. This could result in a delay in notification in the event the alarm system failed during a fire.

NFPA 72 National Fire Alarm Code, 1999 edition

Table 7-2.2 Test Methods
16. Supervising Station Fire Alarm Systems - Transmission Equipment
a. All Equipment
Initiating device shall be actuated. Receipt of the correct initiating device signal at the supervising station within 90 seconds shall be verified. Upon completion of the test, the system shall be restored to its functional operating condition.

Table 7-3.2, Testing Frequencies

1. Control Equipment - Building Connected to Supervising Station - Annual

15. Initiating Devices
f. Fire Alarm Boxes - Annually
h. All Smoke Detectors - Functional - Annually

23. Supervising Station Fire Alarm System Receivers - Monthly

NFPA 72, chapter 7 section 7-5.2., Maintenance, Inspection, and Testing Records, provides an example of an inspection and testing form and requires specific information. Section 7-5.2.2 states, A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section _______."
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type, heat detectors
(12) Other tests as required by equipment manufactures
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During record review and interview with staff on 1/11/11, the records for annual inspection and testing of the fire alarm system were reviewed.

At 9:34 a.m., the facility provided an invoice for fire alarm testing completed in 2008. No other record was provided indicating the complete fire alarm system was inspected and tested in 2009 or in 2010.

During an interview at 9:35 a.m., Maintenance Staff 1 reported these were the only records he had for annual fire alarm testing.

At 2:30 p.m., a faxed report from the monitoring company provided a list of activation signals received during the last 12 months. The report "System Event Report," indicated alarms were activated in 5/10, 8/10, 10/10, 11/10, and 12/10. There were no records that indicated an alarm was activated during the other seven months of 2010.

During the facility tour on 1/11/11, at 10:14 a.m., the panel, in the reception area, indicated a Supervisory trouble signal. A note on the panel was dated 1/3/11. The note indicated the alarm has been reported and they were waiting for a part.

During an interview at 10:18 a.m., Maintenance Staff 1 reported the alarm system was working.

At 2:30 p.m., a faxed report from the monitoring company provided a list of signal activation, of the fire alarm system, during the last 12 months. The report "System Event Report," indicated the system had been in Trouble since 12/10/10.

Based on observation and record review, the facility failed to ensure that at least a local alarm will sound when the sprinkler system valves are closed. This was evidenced by no supervised alarm or trouble signal, received at the panel or at the monitoring company, during testing of 1 of 1 tamper alarm. This could result in a delay in extinguishing a fire if the water supply was shut off for the sprinkler system.

Findings:

During the facility tour and alarm testing with facility staff on 1/11/11, the tamper alarm was observed at the riser.
At 1:45 p.m., the control valve on the O S & Y (open stem and yolk), was closed. There was no alarm or supervisory signal received at the panel. The O S & Y valve controls the water flow from the public supply into the facility sprinkler system.

At 1:48 p.m., the O S & Y valve was closed. There was no audible alarm or trouble signal received at the panel after the valve was closed.

During an interview, Maintenance Staff 2 reported the O S & Y valve was not connected to the fire alarm panel.

At 5:08 p.m., a fax was received from the monitoring company confirming the signals received during testing. There was no signal received during the time the O S & Y valve was closed.

During the facility tour on 1/11/11, the sprinklers were observed.

At 11:23 a.m., there was an approximately 1/4 inch gap between the escutcheon ring and the ceiling, in Utility Closet 133.

At 11:30 a.m., the ceiling tile was broken around the sprinkler, in the exit corridor near Room 126. There was an approximately 2 by 3 inch penetration exposed around the sprinkler.





29665


Based on observation, record review, and interview, the facility failed to maintain their sprinkler system. This was evidenced by no documentation for three of four quarterly sprinkler system inspections, and by one escutcheon ring that was not flush to the ceiling. This affected two of two smoke compartments, and could result in a delay in extinguishing a fire.


NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Findings:

During record review on 1/11/11, the documentation for the quarterly inspections of the sprinkler system was requested.

At 9:35 a.m., the record for the annual inspection of the sprinkler system, by an outside vendor, was provided. The report indicated the sprinkler system was inspected on 8/20/10.

During an interview at 9:49 a.m., Maintenance Staff 2 stated that quarterly testing of the sprinkler system was not performed.

Based on observation, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This was evidenced by ten of ten fire extinguishers that had not been checked monthly. This affected two of two smoke compartments, and could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1 Where required by the provisions of another section
of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

Findings:

During a facility tour on 1/11/11, the fire extinguishers were observed. The tags on the extinguishers indicated they were last certified on 3/30/10.

At 11:15 a.m., the fire extinguisher in the nurses' station had not been checked monthly since it was serviced on 3/30/10.

At 11:16 a.m., the fire extinguisher in the hallway, across from Room 134, had not been checked monthly since it was serviced on 3/30/10.

At 11:29 a.m., the fire extinguisher in the hallway, across from the doctor's lounge, had not been checked monthly since it was serviced on 3/30/10.

At 11:35 a.m., the fire extinguisher in Doctor's Office 2 had not been checked monthly since it was serviced on 3/30/10.

At 11:37 a.m., the fire extinguisher in the hallway, across from Room 120, had not been checked monthly since it was serviced on 3/30/10.

At 11:28 a.m., the fire extinguisher in the laundry room had not been checked monthly since it was serviced on 3/30/10.

At 11:45 a.m., the fire extinguisher in hallway, across from Room 107, had not been checked monthly since it was serviced on 3/30/10.

At 11:56 a.m., the fire extinguisher in the lobby had not been checked monthly since it was serviced on 3/30/10.

1/12/11 -

At 9:41 a.m., the fire extinguisher in the recreation therapy room had not been checked monthly since it was serviced on 3/30/10.

At 9:46 a.m., the fire extinguisher in the staff kitchen had not been checked monthly since it was serviced on 3/30/10.

Based on observation and interview, the facility failed to ensure that soiled linen carts, that are greater than 32 gallons, are stored in a location protected as a hazardous area. This was evidenced by two soiled linen carts, greater than 32 gallons, being stored in exit corridors. This affected two of two smoke compartments, and could result in an increased risk of a fire.

Findings:

During a facility tour on 1/11/11, the soiled linen carts were observed.

At 11:30 a.m., 1:38 p.m., and 3:08 p.m., there was an approximately 64 gallon soiled linen cart in the exit corridor near Room 126.

At 11:33 a.m., 2:15 p.m., and 4:00 p.m., there was an approximately 64 gallon soiled linen cart in the corridor, across from Room 126, connecting the North and South corridors.

During an interview at 11:34 a.m., Maintenance Staff 1 stated that the carts are usually in those locations.


During a facility tour on 1/12/11, the soiled linen carts were observed.

At 8:55 a.m., 10:00 p.m., 10:55 a.m., and 11:50 a.m., there was an approximately 64 gallon soiled linen cart in the exit corridor near Room 126.

At 8:55 a.m., 10:00 p.m., 10:55 a.m., and 11:50 a.m., there was an approximately 64 gallon soiled linen cart in the corridor, across from Room 126, connecting the North and South corridors.

Based on observation, record review and interview, the facility failed to ensure the generator is checked weekly and tested monthly under load for 30 minutes per month in accordance with NFPA 99 and NFPA 110. This was evidenced by incomplete documentation for weekly checks and no records for 30 minute testing under load, for 12 of 12 months. The facility failed to activate the transfer switch, as required, during generator testing. This could result in the failure of the generator during a power outage affecting 15 of 15 patients.

NFPA 99 Health Care Facilities 1999 edition.
3-4.1.1.2 Essential electrical systems shall have a minimum of two independent sources of power: a normal source generally supplying the entire electrical system and one or more alternate sources for use when the normal source is interrupted.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and
Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing
1. Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.

NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition.

6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a
total of 2 continuous hours.

6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

Findings:

During record review and interview with staff on 1/11/11, the generator records were reviewed.

At 9:25 a.m., the generator logs documented the generator was tested for 30 minutes every two weeks. There were no records for 30 minute testing in January or November 2010. The logs indicated that in August and September 2010 the generator was run for less than 30 minutes.

There were no records for weekly inspections for 4 of 4 weeks in January and November 2010 and for 2 of 4 weeks for 10 of 12 months in 2010.

During an interview at 10:07 a.m., Maintenance Staff 2 reported the generator is not tested under load. There was no transfer switch in the generator room. Maintenance Staff 2 demonstrated the switch he used to start the generator. No load was transferred to the generator during the run test.

During generator testing on 1/12/11, at 9:05 a.m., maintenance staff tested the transfer switch located in the electrical room. When the switch was activated the generator failed to start. During an interview at 9:06 a.m., Maintenance Staff 3 reported there was a second transfer switch.

At 9:08 a.m., the second transfer switch was activated and the generator was started within 10 seconds.
During an interview at 9:08 a.m., Maintenance Staff 3 explained that the facility is housed in the old county hospital building and staff were unsure which switch was connected to the facility wing.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by a surge protector plugged into a surge protector. This affected one of two smoke compartments, and could result in an increased risk of an electrical fire.

Findings:

During the facility tour on 1/11/11, the electrical wiring was observed.

At 11:15 a.m., there was a surge protector plugged into a surge protector, plugged into the wall, in the nurse's station, under the charting desk.

At 11:37 a.m., there was an approximately 1 by 1/2 inch penetration in the ceiling of Room 123. The penetration was in the middle area of the ceiling.

At 11:40 a.m., there was an approximately 1 by 1/2 inch penetration in the ceiling of Closet 118. The penetration was on one side of a pipe.





29665


Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected two of two smoke compartments and could result in the spread of smoke and fire.

Findings:

During the facility tour on 1/11/11, the walls and ceilings were observed.

At 11:09 a.m., there was an approximately 1/4 inch penetration around an old cable, in the left wall of the staff lounge.

At 11:44 a.m., there was an approximately 3/4 inch penetration in the ceiling of Room 107.

Based on observation, the facility failed to maintain their doors. This was evidenced by one door that failed to positive latch. This affected one of two smoke compartments, and could cause the spread of smoke and fire in the event of a fire.

Findings:

During the facility tour on 1/11/11, the doors were observed.
At 11:24 a.m., the door to Room 134 failed to positive latch. The door failed to latch in 4 of 4 attempts.

Based on record review and interview, the facility failed to ensure emergency lighting is tested in accordance with NFPA 101. This was evidenced by no records for testing the emergency lights in the exit corridors. This affected three of three lights and could result in a delay in evacuation in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition.
Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code?.
7.9.2.5 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.
7.9.3 Periodic Testing of Emergency Lighting Equipment. 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.
Exception: Self-testing/self-diagnostic, battery-operated emergency
lighting equipment that automatically performs a test for not less than
30 seconds and diagnostic routine not less than once every 30 days
and indicates failures by a status indicator shall be exempt from the
30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

Findings:

During the facility tour with facility staff on 1/11/11, three emergency lights were observed in the corridors. All three lights illuminated when tested with the push button.

During an interview on 1/12/11 at 9:50 a.m., Maintenance Staff 1 was asked for records for testing the emergency lights. He reported there were no records for testing the battery power for the lights. He stated the bulbs were replaced when staff reported a failure of the lights. There were no other records for inspection and testing of the lights.

Based on observation, the facility failed to ensure exit signs are maintained with continuous illumination. This was evidenced by one exit sign that was not illuminated. This affected two of two smoke compartments, and could result in delayed egress, in the event of a fire.

Findings:

During the facility tour on 1/11/11, the exit lights were observed.

At 11:20 a.m., the exit sign was not illuminated above the door leading to the patio area.

During an interview with Maintenance Staff 1 at 11:21 a.m., he reported the patio area is used to evacuate residents. He confirmed the exit sign was not illuminated.

Based on observation, interview and record review, the facility failed to ensure maintenance, inspection and testing of the fire alarm system was completed in accordance with NFPA 72. This was evidenced by no current documentation for monthly activation and annual testing and inspection of the fire alarm system, and by a supervisory trouble alarm displayed at the panel. This affected 13 of 13 patients on 1/11/11 and 15 of 15 patients on 1/12/11. This could result in a delay in notification in the event the alarm system failed during a fire.

NFPA 72 National Fire Alarm Code, 1999 edition

Table 7-2.2 Test Methods
16. Supervising Station Fire Alarm Systems - Transmission Equipment
a. All Equipment
Initiating device shall be actuated. Receipt of the correct initiating device signal at the supervising station within 90 seconds shall be verified. Upon completion of the test, the system shall be restored to its functional operating condition.

Table 7-3.2, Testing Frequencies

1. Control Equipment - Building Connected to Supervising Station - Annual

15. Initiating Devices
f. Fire Alarm Boxes - Annually
h. All Smoke Detectors - Functional - Annually

23. Supervising Station Fire Alarm System Receivers - Monthly

NFPA 72, chapter 7 section 7-5.2., Maintenance, Inspection, and Testing Records, provides an example of an inspection and testing form and requires specific information. Section 7-5.2.2 states, A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section _______."
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type, heat detectors
(12) Other tests as required by equipment manufactures
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During record review and interview with staff on 1/11/11, the records for annual inspection and testing of the fire alarm system were reviewed.

At 9:34 a.m., the facility provided an invoice for fire alarm testing completed in 2008. No other record was provided indicating the complete fire alarm system was inspected and tested in 2009 or in 2010.

During an interview at 9:35 a.m., Maintenance Staff 1 reported these were the only records he had for annual fire alarm testing.

At 2:30 p.m., a faxed report from the monitoring company provided a list of activation signals received during the last 12 months. The report "System Event Report," indicated alarms were activated in 5/10, 8/10, 10/10, 11/10, and 12/10. There were no records that indicated an alarm was activated during the other seven months of 2010.

During the facility tour on 1/11/11, at 10:14 a.m., the panel, in the reception area, indicated a Supervisory trouble signal. A note on the panel was dated 1/3/11. The note indicated the alarm has been reported and they were waiting for a part.

During an interview at 10:18 a.m., Maintenance Staff 1 reported the alarm system was working.

At 2:30 p.m., a faxed report from the monitoring company provided a list of signal activation, of the fire alarm system, during the last 12 months. The report "System Event Report," indicated the system had been in Trouble since 12/10/10.

Based on observation and record review, the facility failed to ensure that at least a local alarm will sound when the sprinkler system valves are closed. This was evidenced by no supervised alarm or trouble signal, received at the panel or at the monitoring company, during testing of 1 of 1 tamper alarm. This could result in a delay in extinguishing a fire if the water supply was shut off for the sprinkler system.

Findings:

During the facility tour and alarm testing with facility staff on 1/11/11, the tamper alarm was observed at the riser.
At 1:45 p.m., the control valve on the O S & Y (open stem and yolk), was closed. There was no alarm or supervisory signal received at the panel. The O S & Y valve controls the water flow from the public supply into the facility sprinkler system.

At 1:48 p.m., the O S & Y valve was closed. There was no audible alarm or trouble signal received at the panel after the valve was closed.

During an interview, Maintenance Staff 2 reported the O S & Y valve was not connected to the fire alarm panel.

At 5:08 p.m., a fax was received from the monitoring company confirming the signals received during testing. There was no signal received during the time the O S & Y valve was closed.

During the facility tour on 1/11/11, the sprinklers were observed.

At 11:23 a.m., there was an approximately 1/4 inch gap between the escutcheon ring and the ceiling, in Utility Closet 133.

At 11:30 a.m., the ceiling tile was broken around the sprinkler, in the exit corridor near Room 126. There was an approximately 2 by 3 inch penetration exposed around the sprinkler.





29665


Based on observation, record review, and interview, the facility failed to maintain their sprinkler system. This was evidenced by no documentation for three of four quarterly sprinkler system inspections, and by one escutcheon ring that was not flush to the ceiling. This affected two of two smoke compartments, and could result in a delay in extinguishing a fire.


NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Findings:

During record review on 1/11/11, the documentation for the quarterly inspections of the sprinkler system was requested.

At 9:35 a.m., the record for the annual inspection of the sprinkler system, by an outside vendor, was provided. The report indicated the sprinkler system was inspected on 8/20/10.

During an interview at 9:49 a.m., Maintenance Staff 2 stated that quarterly testing of the sprinkler system was not performed.

Based on observation, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This was evidenced by ten of ten fire extinguishers that had not been checked monthly. This affected two of two smoke compartments, and could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1 Where required by the provisions of another section
of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

Findings:

During a facility tour on 1/11/11, the fire extinguishers were observed. The tags on the extinguishers indicated they were last certified on 3/30/10.

At 11:15 a.m., the fire extinguisher in the nurses' station had not been checked monthly since it was serviced on 3/30/10.

At 11:16 a.m., the fire extinguisher in the hallway, across from Room 134, had not been checked monthly since it was serviced on 3/30/10.

At 11:29 a.m., the fire extinguisher in the hallway, across from the doctor's lounge, had not been checked monthly since it was serviced on 3/30/10.

At 11:35 a.m., the fire extinguisher in Doctor's Office 2 had not been checked monthly since it was serviced on 3/30/10.

At 11:37 a.m., the fire extinguisher in the hallway, across from Room 120, had not been checked monthly since it was serviced on 3/30/10.

At 11:28 a.m., the fire extinguisher in the laundry room had not been checked monthly since it was serviced on 3/30/10.

At 11:45 a.m., the fire extinguisher in hallway, across from Room 107, had not been checked monthly since it was serviced on 3/30/10.

At 11:56 a.m., the fire extinguisher in the lobby had not been checked monthly since it was serviced on 3/30/10.

1/12/11 -

At 9:41 a.m., the fire extinguisher in the recreation therapy room had not been checked monthly since it was serviced on 3/30/10.

At 9:46 a.m., the fire extinguisher in the staff kitchen had not been checked monthly since it was serviced on 3/30/10.

Based on observation and interview, the facility failed to ensure that soiled linen carts, that are greater than 32 gallons, are stored in a location protected as a hazardous area. This was evidenced by two soiled linen carts, greater than 32 gallons, being stored in exit corridors. This affected two of two smoke compartments, and could result in an increased risk of a fire.

Findings:

During a facility tour on 1/11/11, the soiled linen carts were observed.

At 11:30 a.m., 1:38 p.m., and 3:08 p.m., there was an approximately 64 gallon soiled linen cart in the exit corridor near Room 126.

At 11:33 a.m., 2:15 p.m., and 4:00 p.m., there was an approximately 64 gallon soiled linen cart in the corridor, across from Room 126, connecting the North and South corridors.

During an interview at 11:34 a.m., Maintenance Staff 1 stated that the carts are usually in those locations.


During a facility tour on 1/12/11, the soiled linen carts were observed.

At 8:55 a.m., 10:00 p.m., 10:55 a.m., and 11:50 a.m., there was an approximately 64 gallon soiled linen cart in the exit corridor near Room 126.

At 8:55 a.m., 10:00 p.m., 10:55 a.m., and 11:50 a.m., there was an approximately 64 gallon soiled linen cart in the corridor, across from Room 126, connecting the North and South corridors.

Based on observation, record review and interview, the facility failed to ensure the generator is checked weekly and tested monthly under load for 30 minutes per month in accordance with NFPA 99 and NFPA 110. This was evidenced by incomplete documentation for weekly checks and no records for 30 minute testing under load, for 12 of 12 months. The facility failed to activate the transfer switch, as required, during generator testing. This could result in the failure of the generator during a power outage affecting 15 of 15 patients.

NFPA 99 Health Care Facilities 1999 edition.
3-4.1.1.2 Essential electrical systems shall have a minimum of two independent sources of power: a normal source generally supplying the entire electrical system and one or more alternate sources for use when the normal source is interrupted.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and
Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing
1. Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.

NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition.

6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a
total of 2 continuous hours.

6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

Findings:

During record review and interview with staff on 1/11/11, the generator records were reviewed.

At 9:25 a.m., the generator logs documented the generator was tested for 30 minutes every two weeks. There were no records for 30 minute testing in January or November 2010. The logs indicated that in August and September 2010 the generator was run for less than 30 minutes.

There were no records for weekly inspections for 4 of 4 weeks in January and November 2010 and for 2 of 4 weeks for 10 of 12 months in 2010.

During an interview at 10:07 a.m., Maintenance Staff 2 reported the generator is not tested under load. There was no transfer switch in the generator room. Maintenance Staff 2 demonstrated the switch he used to start the generator. No load was transferred to the generator during the run test.

During generator testing on 1/12/11, at 9:05 a.m., maintenance staff tested the transfer switch located in the electrical room. When the switch was activated the generator failed to start. During an interview at 9:06 a.m., Maintenance Staff 3 reported there was a second transfer switch.

At 9:08 a.m., the second transfer switch was activated and the generator was started within 10 seconds.
During an interview at 9:08 a.m., Maintenance Staff 3 explained that the facility is housed in the old county hospital building and staff were unsure which switch was connected to the facility wing.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by a surge protector plugged into a surge protector. This affected one of two smoke compartments, and could result in an increased risk of an electrical fire.

Findings:

During the facility tour on 1/11/11, the electrical wiring was observed.

At 11:15 a.m., there was a surge protector plugged into a surge protector, plugged into the wall, in the nurse's station, under the charting desk.