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National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)* The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on interview and record review, there was no documented evidence the facility conducted monthly and annual functional testing of the emergency lighting system prior to January, 2021.

Findings include:

On 6/22/2021, the Director of Maintenance provided a document titled "Monthly Checklist 2021". The Checklist indicated functional testing of the emergency lighting system had been conducted for January, February, March, April, May, and June in 2021. The Director explained after the Life Safety Code inspection of the Skilled Nursing Facility (SNF) on 3/31/2021, some facility maintenance documents dated prior to January, 2021 were purged. The 3/31/2021, SNF inspection did not identify issues with the emergency lighting system.

Based on observation and interview, the facility failed to ensure a corridor door was capable of resisting the passage of smoke.

Findings include:

During a tour of the facility on 6/22/2021, a one-inch hole through the thickness of the door was noted next to the doorknob on the corridor door leading into the business office. The Maintenance Director explained the doorknob had recently been replaced and the hole was from a second bolt from the previous doorknob. This observation was made in the presence of the Maintenance Director and two Plant Operations Workers.

National Fire Protection Association (NFPA) 70, National Electric Code.


PANELBOARD LABELING

Article 408.4 - Field Identification Required
A) Circuit Director of Circuit Identification. Every circuit and circuit modification shall be legible identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others.

CLEARANCES

(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26 (A)(1) unless the requirements of 110.26 (A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed. (Nominal Voltage to Ground of 0 -150 = 3 feet).


Based on observation, the facility did not ensure the electrical system was maintained in accordance with NFPA 70, National Electrical Code.

Findings include:

During a tour of the facility on 6/22/2021, the panelboard labeled "EP" in the mechanical room was obstructed by a hand cart. For that panelboard, the circuit directory did not define what circuit #7 belonged to. These observations were made in the presence of the Maintenance Director and a Plant Operations Worker.

Based on document review and interview, the facility failed to ensure fire drills were held or documented at least quarterly on each shift.

Findings include:

On 6/22/2021, a review of the facility's fire drill documentation revealed fire drills were not held at least quarterly during the first quarter of 2021 (January, February and March). Documentation indicated no fire drills were conducted on the night shift.

No documentation for the third and fourth quarters of 2020 was available for review. The Maintenance Director explained some maintenance documentation prior to January 2021 was purged in April 2021.

Based on interview and record review, there was no documentation the facility conducted testing of the receptacles not listed as hospital-grade at intervals not exceeding 12 months.

Findings include:

The Director explained after the Life Safety Code inspection of the Skilled Nursing Facility (SNF) on 3/31/2021, some facility maintenance documents dated prior to January, 2021 were purged, so documentation of the receptacle test conducted in 2020 was not available. The 3/31/2021, SNF inspection did not identify issues with the testing of the receptacles not listed as hospital-grade.

Based on interview and record review, there was no documentation the facility conducted weekly and monthly inspections of the generator prior to January, 2021.

Findings include:

On 6/22/2021, the Director of Maintenance provided the documents titled "Weekly Checklist Maintenance Department" and "Monthly Checklist 2021". The Checklists indicated inspections of the generator were conducted weekly and monthly for January, February, March, April, May, and June in 2021. The Director explained after the Life Safety Code inspection of the Skilled Nursing Facility on 3/31/2021, some facility maintenance documents dated prior to January, 2021 were purged.