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Based on document review and interview, the facility failed to maintain an emergency preparedness (EP) training program. This was evidenced by the failure to ensure that all existing staff received EP training at least annually. This could result in a delay to respond promptly and effectively during an emergency or disaster. This affected 2 residents, staff, and visitors.

Findings:

During document review and interview with the Director of Nursing (DON) on 6/18/19 and 6/19/19, the EP was reviewed, and the annual EP training was requested.

On 6/18/19 at 3:12 p.m., the Disaster Manual was provided by the Director of Facilities. At 5:00 p.m., there was no record of the EP annual training in the Disaster Manual. During an interview on 6/19/19 at 1:25 p.m., the DON checked with the Director of Staff Development and confirmed the annual training was not done.

Based on document review and interview, the facility failed to complete the testing requirements for the emergency preparedness plan (EPP). This was evidenced by the failure to provide documentation for a full scale exercise that was community-based. This could result in failure to safely respond to a disaster or emergency. This affected 2 residents, staff, and visitors.

Findings:

During document review and interview with the Director of Nursing (DON) on 6/18/19 and 6/19/19, the EPP was reviewed, and the documentation for the community-based exercise was requested.

On 6/18/19 at 4:40 p.m., there was no written evidence the facility participated in a full scale community-based exercise. At 4:41 p.m., the DON provided a sign in sheet named 2018 Statewide Medical and Health Exercise - Training & Tabletop Exercise and 2018 Mammoth Hospital Summit dated on October 24, 2018. During a concurrent interview, the DON stated they do not have an after action report for the exercise. She said the facility participated in the first part of the exercise by contacting the hospital to confirm bed availability. The DON stated the full scale exercise was schedule to take place in two weeks.

Based on document review, observation, and interview, the facility failed to maintain the kitchen hood as required by the National Fire Protection Association (NFPA) 96 standard. This was evidenced by the failure to provide two of two semiannual kitchen hood inspections, and by heavy dust accumulation on the grease filters. This could result in malfunction of the kitchen suppression system during a grease fire. This affected one of three smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
11.2 Inspection, Testing, and Maintenance of Fire-Extinguishing Systems.
11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person (s) acceptable to the authority having jurisdiction at least every 6 months.
11.2.2 All actuation and control components, including remote manual stations, mechanical or electrical devices, detectors, and actuators, shall be tested for proper operation during the inspection in accordance with the manufacturer's procedures.
11.2.3 The specific inspection and maintenance requirements of the extinguishing system standards as well as the applicable installation and maintenance manuals for the listed system and service bulletins shall be followed.
11.2.4* Fusible links of the metal alloy type and automatic sprinklers of the metal alloy type shall be replaced at least semiannually except as permitted by 11.2.6 and 11.2.7.
11.2.5 The year of manufacture and the date of the installation of the fusible links shall be marked on the system inspection tag.
11.2.5.1 The tag shall be signed or initialed by the installer.
11.2.5.2 The fusible links shall be destroyed when removed.
11.3 Inspection of Fire Dampers.
11.3.1 Actuation components for fire dampers shall be inspected for proper operation in accordance with the manufacturer's listed procedures.
11.3.3* Documentation Tag.
11.3.3.1 The year of the manufacture and the date of installation of the fusible links shall be documented.
11.3.3.2 The tag shall be signed or initialed by the installer.
11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4.
11.5 Inspection, Testing, and Maintenance of Listed Hoods Containing Mechanical, Water Spray, or Ultraviolet Devices. Listed hoods containing mechanical or fire-actuated dampers, internal washing components, or other mechanically operated devices shall be inspected and tested by properly trained, qualified, and certified persons every 6 months or at frequencies recommended by the manufacturer in accordance with their listings.

13.6.2 All filters shall be cleaned or replaced in accordance with the manufacturer's instructions.

Findings:

During document review, a facility tour, and interview with the Director of Facilities (DF) and Dietary Supervisor on 6/18/19 and 6/19/19, the semiannual hood inspections was requested, and the kitchen grease filters were observed.

1. On 6/18/19 at 5:30 p.m., there was no written evidence the facility conducted two of two semiannual inspection of their kitchen hood assembly. The kitchen was observed with six grease filters and exhaust. At 5:31 p.m., the DF stated he will look to see if he has a record.

2. On 6/19/19 at 11:10 a.m., there was heavy dust accumulation on six of six grease filters. During a concurrent interview, the Dietary Supervisor stated the kitchen staff wash the grease filters every quarter in the dish washing sink.

At 11:11 a.m., the DF confirmed the hood inspection records were not located. He stated the previous vendor is no longer in business and he is looking for a new vendor.

Based on document review and interview, the facility failed to maintain the fire alarm system (FAS) in a reliable system operation. This was evidenced by the failure to provide one of two semi annual test of the fire alarm control panel back up batteries. This could result in a delay in notification of fire and smoke in the event of a fire emergency. This affected three of three smoke compartments.

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.
14.3 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

14.4.2* Test Methods.
14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2.
5. Batteries-general tests
Prior to conducting any battery testing, the person conducting the test shall ensure that all system software stored in volatile memory is protected from loss.
(a) Visual inspection
Batteries shall be inspected for corrosion or leakage. Tightness of connections shall be checked and ensured. If necessary, battery terminals or connections shall be cleaned and coated. Electrolyte level in lead-acid batteries shall be visually inspected.
(b) Battery replacement
Batteries shall be replaced in accordance with the recommendations of the alarm equipment manufacturer or when the recharged battery voltage or current falls below the manufacturer's recommendations.
(c) Charger test Operation of battery charger shall be checked in accordance with charger test for the specific type of battery.
(d) Discharge test With the battery charger disconnected, the batteries shall be load tested following the manufacturer's recommendations. The voltage level shall not fall below the levels specified.
Exception: An artificial load equal to the full fire alarm load connected to the battery shall be permitted to be used in conducting this test.
(e) Load voltage test
With the battery charger disconnected, the terminal voltage shall be measured while supplying the maximum load required by its application. The voltage level shall not fall below the levels specified for the specific type of battery. If the voltage falls below the level specified, corrective action shall be taken and the batteries shall be retested.
Exception: An artificial load equal to the full fire alarm load connected to the battery shall be permitted to be used in conducting this test.

6. Battery tests (specific types)
(a) Primary battery load voltage test
The maximum load for a No. 6 primary battery shall not be more than 2 amperes per cell. An individual (1.5 volt) cell shall be replaced when a load of 1 ohm reduces the voltage below 1 volt. A 6-volt assembly shall be replaced when a test load of 4 ohms reduces the voltage below 4 volts.
(d) Sealed lead-acid type
(1) Charger test
With the batteries fully charged and connected to the charger, the voltage across the batteries shall be measured with a voltmeter. The voltage shall be 2.30 volts per cell ±0.02 volts at 77°C (25°C) or as specified by the equipment manufacturer.
(2) Load voltage test
Under load, the battery shall perform in accordance with the battery manufacturer's specifications.

14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
6. Batteries-fire alarm systems
(d) Sealed lead-acid type 6d
(1) Charger test (Replace battery within 5 years after manufacture or more frequently as needed.) - Annually
(2) Discharge test (30 minutes) - Annually
(3) Load voltage test - Semi-annually

Findings:

During document review and interview with the Director of Facilities (DF) on 6/18/19 and 6/19/19, the semiannual testing of the fire alarm back up batteries were requested.

On 6/18/19 at 4:25 p.m., the facility did not test the fire alarm back up batteries every six months, as required. The FAS was tested and inspected on 6/18/19 and the back up batteries in the fire alarm control panel were dated 1/11/18. There was no other written evidence the batteries were tested semiannually. During a concurrent interview, the DF confirmed the finding and stated the fire alarm panels will let him know if the battery voltage was low.

Based on document review and interview, the facility failed to include notification of the authority having jurisdiction in their policy and procedure when their fire alarm system is out of service. There was no information in their fire watch policy to notify the California Department of Public Health (CDPH) when the fire alarm system malfunctions and/or fails. This could result in failure to inform CDPH when there was an unforeseen disablement of the fire alarm system. This affected three of three smoke compartments.

Findings:

During document review and interview with the Director of Facilities (DF) on 6/18/19 and 6/19/19, the fire watch policy was reviewed.

On 6/18/19 at 3:57 p.m., the fire watch policy was provided by the DF. The policy and procedure did not include they would notify CDPH in the event the fire alarm system or life safety equipment did not work for more than four hours. During a concurrent interview, the DF stated he maintains his fire watch logs in a separate folder however he did not know he needed to notify CDPH. The last fire watch was activated in May 2019 because the fire alarm system telephone phone line was down for 30 minutes.

Based on observation and interview, the facility failed to maintain the corridor door. This was evidenced by the failure to prohibit the use of devices that impede the door from closing. This could result in the faster spread of smoke and fire in the event of a fire. This affected one of three smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

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.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing,
or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National
Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair

19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled.

Findings:

During a facility tour with the Director of Facilities (DF) on 6/18/19 and 6/19/19, the corridor doors were observed.

On 6/19/19 at 10:22 a.m., the self-closing door to Room 32 was held open with a wooden wedge. During a concurrent interview, the DF confirmed the finding and stated a family member just brought them in today.

Based on observation and interview, the facility failed to maintain the designated smoking area. This was evidenced by the failure to use a non-combustible ashtrays in the smoking designated area and instead, used a metal container with no self closing cover. This could result in the increased risk of fire. This affected one of three smoke compartments.

Finding:

During a facility tour and interview with the Director of Facilities (DF) on 6/18/19 and 6/19/19, the designated smoking area was observed.

On 6/19/19 at 1:41 p.m., the facility did not use a non-combustible ashtray in the smoking designated area. There were cigarette butts and combustible material were mixed together in a metal container that did not have a cover. During a concurrent interview, the DF confirmed the finding and stated he believed they were going to submit a request for new containers. On 6/20/19 at approximately 10:30 a.m., an invoice for three non-combustible ashtray containers was provided by the Environmental Services Supervisor.

Based on document review and interview, the facility failed to maintain the diesel generator in a reliable operating condition. This was evidenced by the failure to conduct a 1 hour and 30 minutes load bank test within 12 months, and by the failure to complete the annual fuel quality test. This could result in failure to supply emergency power to the facility in the event of a normal power loss. This affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition-Chapter 8, Routine Maintenance and Operational Testing.
8.3 Maintenance and Operational Testing.
8.3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
8.3.2 A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.
8.3.4 A permanent record of the EPSS inspections, test, exercising, operation, and repairs shall be maintained and readily available.
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.
8.4.1.1 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.

Findings:

During document review and interview with the Director of Facilities (DF) on 6/18/19 and 6/19/19, the generator inspection and test records were reviewed, and documentation was requested.

1. On 6/18/19 at 5:25 p.m., the facility did not conduct an annual 1 hour and 30 minute load bank test. During a concurrent interview, the DF confirmed the finding. He stated the vendor estimate was sent to Accounts Payable and he will try to schedule the annual load test next week.

2. At 5:36 p.m., the facility did not conduct the annual fuel quality test. During a concurrent interview, the DF stated it was included in the estimate and it will be done during the annual load bank test.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the failure to connect electrical devices directly into electrical outlets and instead, interconnected a power strip to an extension cord. This could result in an electrical fire. This affected one of three smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
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
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(8)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage 400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals.

Findings:

During a facility tour and interview with the Director of Facilities (DF) on 6/18/19 and 6/19/19, the electrical equipment was observed.

On 6/19/19 at 10:40 a.m., there was a power strip plugged directly into a red extension cord in the X-ray office. The extension cord ran through the tile ceiling and into another office. The extension cord was plugged to the wall outlet. During a concurrent interview, the DF confirmed the finding and stated the power strip was used to connect a computer.

Based on observation and interview, the facility failed to maintain the medical gas cylinders. This was evidenced by the failure to protect oxygen cylinders from continuous exposure to heat. This could result in damage to the cylinders. This affected three of three smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.

NFPA 99, Standard for Healthcare Facilities, 2012 Edition
11.6.5.4 Cylinders stored in the open shall be protected as follows:
(1) Against extremes of weather and from the ground beneath to prevent rusting
(2) During winter, against accumulations of ice or snow
(3) During summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail

11.7.3 Container Storage, Use, and Operation.
11.7.3.1 * Containers shall be stored, used, and operated in accordance with the manufacturer ' s instructions and labeling.
11.7.3.2 Containers shall not be placed in the following areas:
(1) Where they can be tipped over by the movement of a door
(2) Where they interfere with foot traffic
(3) Where they are subject to damage from falling objects
(4) Where exposed to open flames and high-temperature devices

Finding:

During a facility tour and interview with the Director of Facilities (DF) on 6/18/19 and 6/19/19, the medical gas storage was observed.

On 6/19/19 at 11:28 a.m., there were 20 full oxygen "E" type cylinders stored outdoors next to the medical gas tank. The cylinders were not protected or screened from the sunlight. During a concurrent interview, the DF confirmed the finding and stated he will add shade to protect the cylinders from the sun and snow.