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Based on record review and interview, the facility failed to develop policies and procedures that support the execution of the emergency plan. This was evidenced by missing information that addresses the resident population. This affected 14 of 14 residents and could result in a delayed response to an emergency situation.

Findings:

During record review and interview with the Director of Nursing on 10/9/23, the emergency preparedness plan was requested and reviewed.

At 4:18 p.m., the emergency preparedness plan failed to information that addresses resident populations. Upon interview, the Director of Nursing stated that the facility does not accept non-ambulatory residents so she did not realize policies were needed.

Based on record review and interview, the facility failed to develop policies and procedures that support the execution of the emergency plan. This was evidenced by the failure of the emergency preparedness plan to provide policies and procedures for sheltering in place. This affected 14 of 14 residents and could result in a delayed response to an emergency situation.

Findings:

During record review and interview with the Director of Nursing on 10/10/23, the emergency preparedness plan was requested, and reviewed.

At 8:51 a.m., policies and procedures for how the facility will provide a means to shelter in place were missing from the emergency preparedness plan. Upon interview, the Director of Nursing stated that she last checked the emergency preparedness plan last year.

Based on record review and interview, the facility failed to develop policies and procedures that support the execution of the emergency plan. This was evidenced by the failure of the emergency preparedness plan to provide policies and procedures for roles under a waiver declared by the secretary. This affected 14 of 14 residents and could result in a delayed response to an emergency situation.

Findings:

During record review and interview with the Director of Nursing on 10/10/23, the emergency preparedness plan was requested, and reviewed.

At 8:47 a.m., the emergency preparedness plan was missing policies and procedures for facilities role under a waiver declared by the secretary. Upon interview, the Director of Nursing stated that she last checked the emergency preparedness plan last year.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the wall and ceiling. This affected 14 of 14 residents and one of one smoke compartment. This could result in the spread of smoke in the event of a fire.

Findings:

During a tour of the facility and interview with the Director of Nursing on 10/9/23, the building construction was observed.

1. At 1:57 p.m., a penetration approximately one inch in diameter was observed in the corridor wall between the Supervisor's Office and the Nursing Station. Upon interview, the Director of Nursing stated that the penetration was likely due to a resident kicking in the wall.

2. At 2:06 p.m., a penetration approximately one half inch by two inches was observed in the ceiling between Resident Room C and the Utility Room. Upon interview, the Director of Nursing stated that she thinks that the penetration was made by a resident.

Based on record review, and interview, the facility failed to maintain the exit signs. The was evidenced by missing testing/inspections of the exit signs. This affected 14 of 14 residents and one of one smoke compartment. This could result in the delay of evacuation in an emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

7.10.9.2 Testing.
Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment.
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 11/ 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.

Findings:

During record review and interview with the Maintenance Director on 10/10/23, records were requested.

1. At 11:01 a.m., the facility failed to provide records for the thirty second monthly and ninety minute annual testing of the battery powered exit signs. Upon interview, the Maintenance Director stated the records were located off site.

2. At 11:02 a.m., the facility failed to provide records for twelve of twelve monthly exit sign visual inspections. Upon interview, the Maintenance Director stated the records were located off site.

Based on record review and interview, the facility failed to maintain the smoke detectors. This was evidenced by the missing smoke detector sensitivity testing. This affected 14 of 14 residents and one of one smoke compartment and could result in a delay of notification in the event of smoke and fire.

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 Fire Detection, Alarm, and Communications Systems.
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.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
10.15* Protection of Fire Alarm System. In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s), notification appliance circuit power extenders, and supervising station transmitting equipment to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.
14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.
14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced.
14.4.5.3.7 The detector or smoke alarm sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector or smoke alarm.

Findings:

During record review and interview with the Maintenance Director on 10/10/23, the smoke detector sensitivity test records were requested.

At 11:03 a.m., the facility failed to provide records that a smoke detector sensitivity test was conducted within the last two years. The most recent smoke detector sensitivity test provided for review was dated for 4/1/17. Upon interview, the Maintenance Director stated that the records were located with the vendor.

Based on record review and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by missing inspection records for the automatic sprinkler system. This affected 14 of 14 residents and one of one smoke compartment. This could cause a malfunction or delay in extinguishing a fire.

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.
9.7.5 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.
4.1.1.2 Inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.
4.3.1 Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

5.1.1.2
Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Gauges (dry, preaction, and deluge systems) - Weekly/monthly 5.2.4.2, 5.2.4.3, 5.2.4.4
Control valves Table 13.1
Waterflow alarm devices - Quarterly 5.2.5
Valve supervisory alarm devices - Quarterly 5.2.5
Supervisory signal devices (except valve supervisory switches) - Quarterly 5.2.5
Gauges (wet pipe systems) - Monthly 5.2.4.1
Hydraulic nameplate - Quarterly 5.2.6
Buildings - Annually (prior to freezing weather) 4.1.1.1
Hanger/seismic bracing - Annually 5.2.3
Pipe and fittings - Annually 5.2.2
Sprinklers - Annually 5.2.1
Spare sprinklers - Annually 5.2.1.4
Information sign - Annually 5.2.6.1
Fire department connections Table 13.1
Valves (all types) Table 13.1

5.2.1 Sprinklers.
5.2.1.1 *
Sprinklers shall be inspected from the floor level annually.
5.2.4 Gauges.
5.2.4.1 * Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
5.2.5 Waterflow Alarm and Supervisory Devices. Waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.
5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

13.1.1.2 Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Table 13.1.1.2 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance
Control Valves
Locked -Monthly
Tamper switches-Monthly
Alarm Valves
Exterior-Monthly
Gauges-Weekly/monthly
Fire Department Connections-Quarterly
Testing
Main Drains-Annually/quarterly
Waterflow Alarms-Quarterly/semiannually
Pressure Reducing and Relief Valves
Testing
13.4 System Valves.
13.4.1 Inspection of Alarm Valves.
Alarm valves shall be inspected as described in 13.4.1.1 and 13.4.1.2.
13.4.1.1 *
Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4)The retarding chamber or alarm drains are not leaking.
13.6 Backflow Prevention Assemblies.
13.6.1.1.1 Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.
13.6.1.2.1 Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.
13.7 Fire Department Connections.
13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place and operating properly.

Findings:

During record review and interview with the Maintenance Director on 10/10/23, records were requested and reviewed.

1 At 11:03 a.m., the facility failed to provide records for twelve of twelve monthly sprinkler visual inspections. Upon interview, the Maintenance Director stated that the records were located off site.

2. At 11:04 a.m., the facility failed to provide records for four of four quarterly sprinkler inspections. There were no previous records provided for review to when the last quarterly sprinkler inspection was conducted. Upon interview, the Maintenance Director stated that the records were located with the vendor.

3. At 11:05 a.m., the facility failed to provide records of the annual sprinkler inspection. There were no previous records provided for review to when the last annual sprinkler inspection was conducted. Upon interview, the Maintenance Director stated that the records were located with the vendor.

Based on observation and interview, the facility failed to maintain the fire extinguishers. This was evidenced by missing monthly inspections. This affected 14 of 14 residents and one of one smoke compartment. This could result in a malfunction of the fire extinguishers.

NFPA 101 Life Safety Code, 2012 Edition
19.3.5.12 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 selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
7.1.2 Personnel.
7.1.2.1 * Persons performing maintenance and recharging of extinguishers shall be certified.
7.2 Inspection.
7.2.1 Frequency.
7.2.1.1 * Fire extinguishers shall be manually inspected when initially placed in service.
7.2.1.2 * Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.
7.2.4.3 Where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded.
7.2.4.4 Where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method.
7.3 * Maintenance.
7.3.1 Frequency.
7.3.1.1 All Fire Extinguishers.
7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.

Findings:

During a tour of the facility and interview with the Director of Nursing on 10/9/23, the fire extinguishers were observed.

1. At 2:14 p.m., the inspection tag for the fire extinguisher located in the Break Room next to Resident Room 7 did not have an annual inspection that was conducted within the last 12 months. The annual inspection was dated for 6/9/22.

2. At 2:15 p.m., the inspection tag was missing 4 of 12 monthly visual inspections. The months of January, February, March, and June of 2023 were missing. Upon interview, the Director of Nursing stated that she conducts an environmental safety walkthrough twice a year to check the equipment.

Based on observation and interview, the facility failed to maintain the smoke barrier wall. This was evidenced by a penetration in the smoke barrier wall. This affected 14 of 14 residents and one of one smoke compartment. This could result in the spread of smoke in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(ac).
(B) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.
8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.

Findings:

During a tour of the facility and interview with the Maintenance Director on 10/10/23, the smoke barrier wall was observed.

At 9:13 a.m., a penetration approximately two feet by one foot was observed in the smoke barrier wall at the entrance corridor located on the second floor. Upon interview, the Maintenance Director stated that the penetration was due to communication wires were installed.

Based on record review, and interview, the facility failed to maintain the heating, ventilating, and air-conditioning (HVAC) system. This was evidenced by the failure to conduct the four-year fire damper testing and maintenance. This affected 14 of 14 residents and one of one smoke compartment. This could result in the failure of the HVAC system.

NFPA 101, Life Safety Code, Edition 2012
19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications, unless otherwise modified by 19.5.2.2.
9.2 Heating, Ventilating, and Air-Conditioning.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 Edition
5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.

NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives, 2010 Edition
6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.
6.5.10* The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature rating, and load rating.
6.6.3 If the damper is not operable, repairs shall begin as soon as possible.

Findings:

During record review and interview with the Maintenance Director on 10/10/23, the fire damper testing records were requested.

At 10:58 a.m., the facility failed to provide the four-year fire damper testing and maintenance record. There were no previous records provided for review to when the last fire damper test was conducted. Upon interview, the Maintenance Director stated that the records are located with the vendor.

Based on record review and interview, the facility failed to maintain the fire doors. This was evidenced by the failure to provide the annual fire door inspection and test. This affected 14 of 14 residents and one of one smoke compartments. This could result in a delay in notification of a malfunctioning fire door.


Findings:

During record review and interview with the Maintenance Director 10/10/23, he facility's fire door maintenance records were requested.

At 11:08 a.m., the facility failed to provide the record of the annual fire door inspection. Upon interview, the Maintenance Director stated that the record was located off site.

Based on observation, record review, and interview, the facility failed to maintain the essential electrical system. This was evidenced by missing emergency lighting in the generator enclosure, and generator testing. This affected 14 of 14 residents and one of one smoke compartments. This could result in a malfunction to generator in an emergency.

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

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.

NFPA 99, Health Care Facilities Code, 2012 Edition.
6.4 Essential Electrical System Requirements - Type 1.
6.4.4.1.3 Maintenance of Batteries. Batteries for on-site generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition
7.3 Lighting.
7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.

8.1* General.
8.1.1 The routine maintenance and operational testing program shall be based on all of the following:
(1) Manufacturer's recommendations
(2) Instruction manuals
(3) Minimum requirements of this chapter
(4) The authority having jurisdiction
8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
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
(4) Testing of any repair for the time as recommended by the manufacturer
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.
8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.
8.4 Operational Inspection and Testing.
8.4.1 *
EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.
8.4.1.1
If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, providing the same record as required by 8.3.4.
.4.2 *
Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
8.4.2.1
The date and time of day for required testing shall be decided by the owner, based on facility operations.
8.4.2.2
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
8.4.2.3
Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

8.4.9 * Level 1 EPSS shall be tested at least once within every 36 months.
8.4.9.1 Level 1 EPSS shall be tested continuously for the duration of its assigned class (see Section 4.2).
8.4.9.2 Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours.
8.4.9.3 The test shall be initiated by operating at least one transfer switch test function and then by operating the test function of all remaining ATSs, or initiated by opening all switches or breakers supplying normal power to all ATSs that are part of the EPSS being tested.
8.4.9.5.3 For spark-ignited EPSs, loading shall be the available EPSS load.
8.4.9.6 The test required in 8.4.9 shall be permitted to be combined with one of the monthly tests required by 8.4.2 and one of the annual tests required by 8.4.2.3 as a single test.

Findings:

During a tour of the facility, record review, and interview with the Maintenance Director on 10/10/23, the generator enclosure was observed, and records were requested and reviewed.

1. At 9:02 a.m., the generator enclosure was observed without a battery-operated emergency lighting and included a walk-in access. The generator enclosure was located adjacent to Wood Street outside the facility. Upon interview, the Maintenance Director stated that the generator had been recently enclosed.

2. At 9:08 a.m., the facility failed to provide records that a fuel quality test was conducted on the 220-kilowatt diesel back-up generator within the last year. There were no previous records provided for review to when the last load test was conducted. Upon interview, the Maintenance Director stated that the test had not been conducted before.

3. At 10:51 a.m., the facility failed to provide records that a four-hour load test was conducted on the 220-kilowatt diesel back-up generator within the last three years. Upon interview, the Maintenance Director stated that the generator was replaced around three years ago.

4. At 10:59 a.m., 12 of 12 conductance tests were missing for the sealed acid batteries. Upon interview, the Maintenance Director stated that the facility goes through a vendor for tests.

5. At 11:00 a.m., the facility was unable to provide records that a 90-minute annual load test was conducted on the 220-kilowatt diesel backup generator within the last year. There were no previous records provided for review to when the last load test was conducted. Upon interview, the Maintenance Director stated that he needs to find the records.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the a junction box missing a cover. This affected 14 of 14 residents and one of one smoke compartments. This could result in electrical shock or a fire.

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

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
314.28 Pull and Junction Boxes and Conduit Bodies.
Boxes and conduit bodies used as pull or junction boxes shall comply with 314.28(A) through (E).
Exception: Terminal housings supplied with motors shall comply with the provisions of 430.12.
314.28
(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.
314.70 General.
314.72(E) Suitable Covers.
Boxes shall be closed by suitable covers securely fastened in place. Underground box covers that weigh over 45 kg (100 lb) shall be considered meeting this requirement. Covers for boxes shall be permanently marked "DANGER - HIGH VOLTAGE - KEEP OUT." The marking shall be on the outside of the box cover and shall be readily visible. Letters shall be block type and at least 13 mm (1? 2 in.) in height.

Findings:

During a tour of the facility and interview with the Director of Nursing on 10/9/23, the electrical equipment was observed.

At 2:25 p.m., the junction box in the Assistant Director of Nursing Office next to the Discharge Planner Office had exposed wiring and did not have a cover. Upon interview, the Director of Nursing stated that she had not checked for covers before.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by a suspended power strip, and a power strip that was plugged into a power conditioner. This affected 25 of 92 residents, and one of one smoke compartment. This could result in an electrical fire.

Findings:

During a tour of the facility and interview with the Director of Nursing and the Activities Therapist on 10/9/23, the electrical equipment was observed.

1. At 2:30 p.m., a black power conditioner was daisy chained and plugged into a white power strip in the Discharge Planner Office next to the Assistant Director of Nursing Office. Upon interview, the Activities Therapist stated that it is hard to get behind the desks to use the electrical equipment.

2. At 2:45 p.m., a gray power strip in the Nursing Station near the kitchen was suspended approximately four inches off the floor. The power strip was powering four monitors, a computer, a phone, and a mobile phone charger. Upon interview, the Director of Nursing stated that the power strip fell off the ledge it normally rests on.