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Based on observation and interview, the facility failed to maintain self-closing doors. This was evidenced by two doors equipped with self-closing devices in Unit W-1 that failed to close completely. This could result in the spread of smoke affecting one of two floors.

NFPA 101, Life Safety Code, 2012 Edition
7.2.1.8 Self-Closing Devices.
7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.

Findings:

During the facility tour with Staff 2 and 3 on 11/28/18, the self-closing doors were observed.

Unit W-1 First Level

1. At 3:25 p.m., the self closing corridor door to room 1152, failed to close the last 1 1/2 inches.

2. At 3:27 p.m., the self closing corridor door to room 1173A failed to close the last 1 1/2 inches.

In an interview at 3:28 p.m., Staff 2 confirmed that both doors failed to close completely.

Based on observation, interview, and record review, the facility failed to maintain their fire alarm system. This was evidenced by a key switch fire alarm station that failed to activate when tested. This affected one of two floors and could result in the spread of smoke and a delay in notification or evacuation during a fire emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.2.1.1.2 Inspection, testing, and maintenance program shall verify correct operation of the system.
14.2.1.2.2 System defects and malfunctions shall be corrected.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
Table 14.3.1 Visual Inspection Frequencies
3. Batteries
-(d) Sealed lead-acid - Semiannually
5. Fire alarm control unit trouble signals - Semiannually
8. Remote annunciators - Semiannually
9. Initiating devices
-(b) Duct detectors - Semiannually
-(e) Manual fire alarm boxes - Semiannually
-(f) Heat detectors - Semiannually
-(h) Smoke detectors - Semiannually
-(i) Supervisory signal devices - Semiannually
-(j) Waterflow devices - Semiannually
12. Interface equipment - Semiannually
13. Alarm notification appliances - Semiannually
15. Supervising station alarm systems - transmitters - Semiannually

Findings:

During the facility tour and interview with Staff 2 and 3 on 11/28/18, the fire alarm system was observed.

1. At 3:20 p.m., the key switch fire alarm station at the west end of W-1 failed to activate when tested three times.
At 4:10 p.m., Staff 2 explained that maintenance staff found the internal contacts on the key switch bent and that they were in the process of repairing the switch.

Based on document review and interview, the facility failed to provide documentation of fire drills simulating emergency conditions at least every three-month period for each shift. This was evidenced by no record for one night shift fire drill in the fourth quarter of 2017 and no night shift fire drill during the current fourth quarter of 2018. This could result in a delay in evacuation if staff were not familiar with their duties and responsibilities during a fire emergency. This affected the staff practiced response on one of three shifts.

NFPA 101 Life Safety Code, 2012 edition
19.1.1.3.2 Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention procedures and planning, training, and drilling programs for the isolation of fire, transfer of occupants

19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.
19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
19.7.1.6 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.
19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
19.7.2.1* Protection of Patients.
19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.
19.7.1.6 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.

Findings:

During document review and interview with Staff 2 on 11/28/18, the fire evacuation drill records were requested.

1. At 2:22 p.m., there was no record of a night shift fire drill available for the fourth quarter of 2017 and no night shift fire drill during the current fourth quarter of 2018. Staff 2 explained that he would research the missing fire drill.

In an email received on 11/29/18 at 12:14 p.m., Staff 1 explained that there was no fire drill conducted during the fourth quarter of 2017 and that there was a zero census for that month. There was no explanation of why no night fire drill was conducted during October or December of 2017.

Based on interview and record review, the facility failed to maintain their emergency generator. This was evidenced by incomplete monthly battery electrolyte testing for the first seven months of the previous year. There was a potential for delay in providing emergency power during a public utility power outage.

NFPA 101 Life Safety Code, 2012 edition
9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

NFPA 110 Standard for Emergency and Standby Power Systems, 2010 edition.
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

Findings:

During document review interview with Staff 1 on 11/28/18, the emergency generator maintenance records were requested.

1. At 1:15 p.m., there were incomplete records available for monthly specific gravity testing of the battery for the emergency generator. Staff 1 explained that they started testing the batteries when they became aware of the requirement five months earlier.