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Based on observation and interview, it was determined the facility failed to ensure fire alarm pull stations were maintained in accordance with National Fire Protection Association (NFPA) Standards and manufacturer's recommendations. The deficiency had the potential to affect eleven (11) of eleven (11) smoke compartments, residents, staff and visitors. The facility is certified for eighty (80) beds with a census of twenty-seven (27) on the day of the survey.

The findings include:

Observation on 06/05/19 at 4:28 PM with the Maintenance Director revealed the facility's fire alarm panel showed a trouble signal due to a faulty duct detector in the air handler.

Interview on 03/01/17 at 4:29 PM with the Maintenance Director and the Administrator revealed the facility was aware of the trouble signal on the facility's fire alarm panel due to a faulty duct detector in the air handler. Further interview revealed the Maintenance Director was aware of the requirements to maintain the facility's fire alarm. In addition, the Maintenance Director revealed they had not scheduled the vendor to repair the duct detector in the air handler. The Maintenance Director was unable to provide a reason as to why the duct detector had not been repaired or was not on the schedule to be repaired.

The census of twenty-seven (27) was verified by the Administrator on 06/05/19. The findings were acknowledged by the Administrator and verified by the Maintenance Director at the exit interview on 06/05/19.


Reference: NFPA 72 Fire Alarm and Signaling Code (2010 ed.)

Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at random times, in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect eleven (11) of eleven (11) smoke compartments, all residents, staff and visitors. The facility has the capacity for eighty (80) beds and at the time of the survey, the census was twenty-seven (27).

The findings include:

Review of the facility's Fire Drill documentation on 06/05/19 at 3:00 PM with the Maintenance Director revealed the facility failed to conduct fire drills on each shift at unexpected times. A fire drill was not conducted on third shift for the 3rd and 4th quarter of 2018.

Interview, on 06/05/19 at 3:01 PM with the Maintenance Director revealed he was not aware of the requirements for fire drills to be conducted on each shift at unexpected times.

The census of twenty- seven (27) was verified by the Administrator on 06/05/19. The findings were acknowledged by the Administrator and verified by the Maintenance Director at the exit interview on 06/05/19.


Actual NFPA Reference: NFPA 101 (2012 Edition)

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.

Based on generator testing record review and interview, the facility failed to maintain the generator according to National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect eleven (11) of eleven (11) smoke compartments, all residents, staff and visitors. The facility has the capacity for eighty (80) beds with a census of twenty-seven (27) on the day of the survey.

The findings include:

Generator testing record review on 06/05/19 at 2:24 PM with the Maintenance Director revealed the facility did not exercise the generator under load for at least thirty (30) minutes on a monthly basis.

Interview on 06/05/19 at 2:25 PM with the Maintenance Director revealed he was not aware of the requirements for generator testing. Further interview revealed the facility generator was exercised on a monthly basis.

The census of twenty-seven (27) was verified by the CEO on 06/05/19. The findings were acknowledged by the CEO and verified by the Maintenance Director at the exit interview on 06/05/19.


Actual NFPA Standard:

Reference:
NFPA 99 Health Care Facilities Code (2012 Edition)
Chapter 6 Electrical Systems

6.4.3 Performance Criteria and Testing (Type 1 EES).

6.4.3.1 Source. The life safety and critical branches shall be installed and connected to the alternate power source specified in
6.4.1.1.4 and 6.4.1.1.5 so that all functions specified herein for the life safety and critical branches are automatically restored to
operation within 10 seconds after interruption of the normal
source.


6.5 Essential Electrical System

6.5.4.1.1.1 Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment,
including all appurtenance 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 6.4.1.1.7 and 6.4.3.1.

6.5.4.2 Record Keeping. Awritten record of inspection, performance, exercising period, and repairs shall be regularly maintained
and available for inspection by the authority having jurisdiction