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Based on observation and interview, the facility failed to maintain their smoke partitions. This was evidenced by the removal of a door without approval from the authority having jurisdiction. This affected one of two smoke compartments and could result in the faster spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

Findings:

During a facility tour with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, the doors were observed.

At 1:26 p.m., the door to the old medication room was removed. The door frame and previous door hardware (hinges) remained.
During an interview at 1:27 p.m., Nursing Staff 1 stated that the medication room was moved to another area and this room was now used to store resident belongings. He stated that the door was removed two months ago.

Based on record review, and interview, the facility failed to maintain their battery-powered emergency lights. This was evidenced by incomplete records of testing the battery-powered emergency lights. This affected one of two smoke compartments and could result in a delay in evacuation due to limited visibility, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During record review with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, maintenance records were requested. The egress corridors in the patient care areas were equipped with battery-powered bullfrog lights.

At 2:41 p.m., the "Emergency Lighting Testing and Inspection Log" was provided. There were no entries for monthly testing the emergency bullfrog lights for the months of January, February, and May 2015. There were no records showing that the annual 90-minute testing was conducted.

At 4:32 p.m., Maintenance Staff 1 provided a Quality Assurance (QA) report that indicated the 90-minute test on the emergency lights was conducted on 1/15/15. The report did not indicate who conducted the testing and there was no corresponding maintenance log to confirm that the 90-minute test occured.

Based on record review and interview, the facility failed to ensure that fire drills were conducted in accordance with NFPA 101. This was evidenced by no records of fire drills conducted quarterly on each shift. This affected 16 of 16 residents and could result in a delay in staff response, in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9 p.m. (2100 hours) and 6 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During record review with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, the fire drill records were reviewed. The facility staff worked two 12-hour shifts (AM: 7 a.m. to 7 p.m. and NOC: 7 p.m. to 7 a.m.)

At 4:35 p.m., there were no records of an AM shift fire drill conducted during the fourth quarter (October to December) of 2014.
There were no records of fire drills conducted during the first quarter (January to March) of 2015. Only earthquake response drills were conducted during the first quarter.
There were no NOC shift fire drill conducted during the third quarter (July to September) of 2015.
During an interview at 4:36 p.m., Nursing Staff 1 and Nursing Staff 2 stated that facility was unfamiliar with the requirement for quarterly fire drills. Nursting Staff 2 stated that the Safety Officer conducted earthquake response drills quarterly.

Based on record review and interview, the facility failed to maintain their fire alarm system. This was evidenced by no records of an annual inspection of the fire alarm system. This affected two of two smoke compartments and could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.7 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 Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies, requires annual testing of:
1. Control Equipment - Building Systems Connected to Supervising Station
a. Functions
b. Fuses
c. Interfaced Equipment
d. Lamps and LEDs
e. Primary (Main) Power Supply
f. Transponders
6. Batteries - Fire Alarm Systems
d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years.)
2. Discharge Test (30 minutes)
9. Control Unit Trouble Signals
14. Remote Annunciators
15. Initiating Devices
19. Alarm Notification Appliances

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During record review with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, documentation of the annual inspection of the fire alarm system was requested.


At 5:30 p.m., there was no written records of the annual inspection of the fire alarm system were provided.
During an interview at 5:31 p.m., Nursing Staff 2 stated that Maintenance Staff 1 would email the document to the surveyor by 4:00 p.m. the following day.
The documentation was not received.

Based on observation, record review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by one smoke detector that was damaged and by no records of smoke detector sensitivity testing. This affected two of two smoke compartments and could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.5.1 Detection systems, where required, shall be in accordance with Section 9.6.

9.6.1.7 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 Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector 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. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector 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/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

Findings:

During a facility tour with Nursing Staff 1 and Maintenance Staff 1 on 11/17/15, the smoke detectors were observed and maintenance records were requested.

1. At 1:31 p.m., the smoke detector in the corridor outside Room 4 was missing its external cover. The internal elements of the smoke detector were exposed.

2. At 5:30 p.m., during the exit conference, no records of smoke detector sensitivity testing were provided.
During an interview at 5:31 p.m., Nursing Staff 2 stated that Maintenance Staff 1 would email the document to the surveyor by 4:00 p.m. the following day.
Records of smoke detector sensitivity testing were not received.

Based on observation, record review, and interview, the facility failed to maintain their sprinkler system. This was evidenced by sprinkler heads with missing or damaged escutcheon fittings, by one corroded sprinkler head, by one fire department connection (FDC) that failed to rotate smoothly, and by no records of maintaining the standpipe hose system. This affected two of two smoke compartments and could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.


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, 1998 Edition.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

3-3.1.1 A flow test shall be conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply still adequately provides the design pressure at the required flow. Where a flow test of the hydraulically most remote outlet(s) is not practical, the authority having jurisdiction shall be consulted for the appropriate location for the test.
A flow test shall be conducted every 5 years.

3-2.1 Components of standpipe and hose systems shall be visually inspected quarterly or as specified in Table 3-1.

9-7 Fire Department Connections.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During a facility tour with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, the sprinkler system was observed. The facility was partially sprinklered with a wet pipe sprinkler system and was equipped with a standpipe hose system.

1. At 1:41 p.m., the sprinkler head in Room 4 was missing its cover.

2. At 2:01 p.m., the sprinkler head in the corridor, outside of Room 8, had an escutcheon ring that was broken. There was an approximately 1 inch piece of the escutcheon ring missing and the penetration around the sprinkler pipe was exposed.

3. At 2:05 p.m., the sprinkler head in Utility Room 2 was completely corroded.

4. At 2:39 p.m., maintenance logs titled "Fire Sprinkler Testing and Inspection Log for Inspector's Test Valve and Tamper Switch" were provided. The log did not include a quarterly inspection of the FDCs or standpipe system.

At 3:45 p.m., one of two FDCs in the front of the building failed to swivel and rotate. Maintenance Staff 2 could not rotate the FDC.
During an interview at 3:46 p.m., Maintenance Staff 2 stated that the FDCs were not inspected quarterly.

5. At 4:10 p.m., on 11/18/15, Maintenance Staff 1 emailed records of the five-year inspection of the wet pipe sprinkler system. The vendor marked the section for hose systems as not applicable and did not indicate that a flow test was conducted.

Based on observation and record review, the facility failed to maintain their fire extinguishers. This was evidenced by fire extinguishers that were missing monthly checks. This affected one of two smoke compartments and could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 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 installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

Findings:

During a facility tour with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, the fire extinguishers were observed.

1. At 1:53 p.m., the tag on the fire extinguisher outside the Recreational Therapy room was missing a monthly check for July.

2. At 2:11 p.m., there were no monthly checks recorded on the tag of the fire extinguisher in Staff Office 3.

At 2:37 p.m., Maintenance Staff 1 provided a "Fire Extinguisher Testing and Inspection Log" for the year 2015. The log did not specifically indicate which extinguishers staff were checked every month. The log did not confirm if the fire extinguisher in Staff Office 3 was checked monthly or if the Recreational Therapy extinguisher was checked in July.

Based on observation and interview, the facility failed to ensure that portable space heaters were not used in patient care areas. The facility also failed to ensure that portable space heaters used in non-sleeping staff areas complied with the requirements of NFPA 101. This was evidenced by the use of space heaters with heating element temperatures exceeding 212°F . This affected two of two smoke compartments and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Findings:

During a facility tour with Nursing Staff 1 and Maintenance Staff 1 on 11/17/15, portable space-heating devices were observed.

1. At 1:00 p.m., there were two portable space heaters in the employee breakroom. The space heaters had coil heating elements and information about the operating temperature of the heating elements were not provided.

2. At 1:25 p.m., there were three portable space heaters at the nurses station. The heaters were plugged in but not activated. The nurses station was in between both patient care corridors.

3. At 1:49 p.m., there was a portable space heater directly under the desk in Staff Office 1, adjacent to the Music Room. A warning label on the heater stated that the heater should be kept 3 feet away from all furnishings.

4. At 2:12 p.m., there was portable space heater approximately 1 foot away from the desk in Staff Ofice 3. A warning label on the heater stated that the heater should be kept 3 feet away from all furnishings.

Based on observation, record review, and interview, the facility failed to maintain their generator. This was evidenced by the failure to conduct one 30-minute monthly load test, the failure to conduct a 2-hour load bank test in accordance with NFPA 110, by no battery-powered emergency lighting provided in the generator room, and by leaks in the generator that had not been repaired. This affected two of two smoke compartments and could result in the increased risk of generator failure, and a delay in repairing the failure, in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

6-1.1 The routine maintenance and operation testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction.

6-3.1 The emergency power supply system (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 duration specified for the class.

6-4.1 Level 1 and Level 2 EPSSs (emergency power supply systems), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: 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, provided the appropriate data are recorded.

6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS (emergency power supply) nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During a facility tour with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, the generator was observed and maintenance records were reviewed. The facility was equipped with a 115 KW diesel generator.

1. At 3:07 p.m., the "Emergency Generator Test Log" showed that there was no 30-minute load test conducted between 6/19/15 and 8/5/15.
During an interview at 3:38 p.m., Maintenance Staff 2 stated that he was told not to conduct the 30-minute load test in July because the facility had a long lasting power outage in June.

2. At 3:36 p.m., there was no battery-powered emergency light in the generator room.

3. At 3:37 p.m., there were four (1 foot by 1 foot) cotton pads on the floor of the generator room with oil stains. Two directly below the generator and two under the hose connected to the external filtration system. There were grease laden deposits around some of the generator seals.
During an interview at 3:38 p.m., Maintenance Staff 2 confirmed that there were leaks at the seals. He stated that the facility has not fixed the seals because they plan to replace the generator.

4. At 3:39 p.m., there were no records of a load bank test conducted on the generator.
During an interview at 3:40 p.m., Maintenance Staff 2 stated that he is unsure if the generator is running at 30% of the nameplate rating during the monthly load tests. He stated that the percentage load would be whatever the building is pulling in.

Based on observation and interview, the facility failed to maintain their electrical wiring. This was evidenced by the use of power strips in lieu of permanent wiring. This affected one of two smoke compartments and could result in the increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

400-8 Uses Not Permitted
Unless specifically permitted in Section 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: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with Nursing Staff 1 and Maintenance Staff 1 on 11/17/15, the electrical wiring was observed.

At 1:47 p.m., there was a six-plug power strip plugged into a second six-plug power strip, under the desk at the nurses station.

Based on observation and interview, the facility failed to maintain their smoke partitions. This was evidenced by the removal of a door without approval from the authority having jurisdiction. This affected one of two smoke compartments and could result in the faster spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

Findings:

During a facility tour with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, the doors were observed.

At 1:26 p.m., the door to the old medication room was removed. The door frame and previous door hardware (hinges) remained.
During an interview at 1:27 p.m., Nursing Staff 1 stated that the medication room was moved to another area and this room was now used to store resident belongings. He stated that the door was removed two months ago.

Based on record review, and interview, the facility failed to maintain their battery-powered emergency lights. This was evidenced by incomplete records of testing the battery-powered emergency lights. This affected one of two smoke compartments and could result in a delay in evacuation due to limited visibility, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During record review with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, maintenance records were requested. The egress corridors in the patient care areas were equipped with battery-powered bullfrog lights.

At 2:41 p.m., the "Emergency Lighting Testing and Inspection Log" was provided. There were no entries for monthly testing the emergency bullfrog lights for the months of January, February, and May 2015. There were no records showing that the annual 90-minute testing was conducted.

At 4:32 p.m., Maintenance Staff 1 provided a Quality Assurance (QA) report that indicated the 90-minute test on the emergency lights was conducted on 1/15/15. The report did not indicate who conducted the testing and there was no corresponding maintenance log to confirm that the 90-minute test occured.

Based on record review and interview, the facility failed to ensure that fire drills were conducted in accordance with NFPA 101. This was evidenced by no records of fire drills conducted quarterly on each shift. This affected 16 of 16 residents and could result in a delay in staff response, in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9 p.m. (2100 hours) and 6 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During record review with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, the fire drill records were reviewed. The facility staff worked two 12-hour shifts (AM: 7 a.m. to 7 p.m. and NOC: 7 p.m. to 7 a.m.)

At 4:35 p.m., there were no records of an AM shift fire drill conducted during the fourth quarter (October to December) of 2014.
There were no records of fire drills conducted during the first quarter (January to March) of 2015. Only earthquake response drills were conducted during the first quarter.
There were no NOC shift fire drill conducted during the third quarter (July to September) of 2015.
During an interview at 4:36 p.m., Nursing Staff 1 and Nursing Staff 2 stated that facility was unfamiliar with the requirement for quarterly fire drills. Nursting Staff 2 stated that the Safety Officer conducted earthquake response drills quarterly.

Based on record review and interview, the facility failed to maintain their fire alarm system. This was evidenced by no records of an annual inspection of the fire alarm system. This affected two of two smoke compartments and could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.7 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 Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies, requires annual testing of:
1. Control Equipment - Building Systems Connected to Supervising Station
a. Functions
b. Fuses
c. Interfaced Equipment
d. Lamps and LEDs
e. Primary (Main) Power Supply
f. Transponders
6. Batteries - Fire Alarm Systems
d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years.)
2. Discharge Test (30 minutes)
9. Control Unit Trouble Signals
14. Remote Annunciators
15. Initiating Devices
19. Alarm Notification Appliances

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During record review with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, documentation of the annual inspection of the fire alarm system was requested.


At 5:30 p.m., there was no written records of the annual inspection of the fire alarm system were provided.
During an interview at 5:31 p.m., Nursing Staff 2 stated that Maintenance Staff 1 would email the document to the surveyor by 4:00 p.m. the following day.
The documentation was not received.

Based on observation, record review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by one smoke detector that was damaged and by no records of smoke detector sensitivity testing. This affected two of two smoke compartments and could result in a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.5.1 Detection systems, where required, shall be in accordance with Section 9.6.

9.6.1.7 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 Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector 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. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector 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/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

Findings:

During a facility tour with Nursing Staff 1 and Maintenance Staff 1 on 11/17/15, the smoke detectors were observed and maintenance records were requested.

1. At 1:31 p.m., the smoke detector in the corridor outside Room 4 was missing its external cover. The internal elements of the smoke detector were exposed.

2. At 5:30 p.m., during the exit conference, no records of smoke detector sensitivity testing were provided.
During an interview at 5:31 p.m., Nursing Staff 2 stated that Maintenance Staff 1 would email the document to the surveyor by 4:00 p.m. the following day.
Records of smoke detector sensitivity testing were not received.

Based on observation, record review, and interview, the facility failed to maintain their sprinkler system. This was evidenced by sprinkler heads with missing or damaged escutcheon fittings, by one corroded sprinkler head, by one fire department connection (FDC) that failed to rotate smoothly, and by no records of maintaining the standpipe hose system. This affected two of two smoke compartments and could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.


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, 1998 Edition.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

3-3.1.1 A flow test shall be conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply still adequately provides the design pressure at the required flow. Where a flow test of the hydraulically most remote outlet(s) is not practical, the authority having jurisdiction shall be consulted for the appropriate location for the test.
A flow test shall be conducted every 5 years.

3-2.1 Components of standpipe and hose systems shall be visually inspected quarterly or as specified in Table 3-1.

9-7 Fire Department Connections.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During a facility tour with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, the sprinkler system was observed. The facility was partially sprinklered with a wet pipe sprinkler system and was equipped with a standpipe hose system.

1. At 1:41 p.m., the sprinkler head in Room 4 was missing its cover.

2. At 2:01 p.m., the sprinkler head in the corridor, outside of Room 8, had an escutcheon ring that was broken. There was an approximately 1 inch piece of the escutcheon ring missing and the penetration around the sprinkler pipe was exposed.

3. At 2:05 p.m., the sprinkler head in Utility Room 2 was completely corroded.

4. At 2:39 p.m., maintenance logs titled "Fire Sprinkler Testing and Inspection Log for Inspector's Test Valve and Tamper Switch" were provided. The log did not include a quarterly inspection of the FDCs or standpipe system.

At 3:45 p.m., one of two FDCs in the front of the building failed to swivel and rotate. Maintenance Staff 2 could not rotate the FDC.
During an interview at 3:46 p.m., Maintenance Staff 2 stated that the FDCs were not inspected quarterly.

5. At 4:10 p.m., on 11/18/15, Maintenance Staff 1 emailed records of the five-year inspection of the wet pipe sprinkler system. The vendor marked the section for hose systems as not applicable and did not indicate that a flow test was conducted.

Based on observation and record review, the facility failed to maintain their fire extinguishers. This was evidenced by fire extinguishers that were missing monthly checks. This affected one of two smoke compartments and could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 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 installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

Findings:

During a facility tour with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, the fire extinguishers were observed.

1. At 1:53 p.m., the tag on the fire extinguisher outside the Recreational Therapy room was missing a monthly check for July.

2. At 2:11 p.m., there were no monthly checks recorded on the tag of the fire extinguisher in Staff Office 3.

At 2:37 p.m., Maintenance Staff 1 provided a "Fire Extinguisher Testing and Inspection Log" for the year 2015. The log did not specifically indicate which extinguishers staff were checked every month. The log did not confirm if the fire extinguisher in Staff Office 3 was checked monthly or if the Recreational Therapy extinguisher was checked in July.

Based on observation and interview, the facility failed to ensure that portable space heaters were not used in patient care areas. The facility also failed to ensure that portable space heaters used in non-sleeping staff areas complied with the requirements of NFPA 101. This was evidenced by the use of space heaters with heating element temperatures exceeding 212°F . This affected two of two smoke compartments and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Findings:

During a facility tour with Nursing Staff 1 and Maintenance Staff 1 on 11/17/15, portable space-heating devices were observed.

1. At 1:00 p.m., there were two portable space heaters in the employee breakroom. The space heaters had coil heating elements and information about the operating temperature of the heating elements were not provided.

2. At 1:25 p.m., there were three portable space heaters at the nurses station. The heaters were plugged in but not activated. The nurses station was in between both patient care corridors.

3. At 1:49 p.m., there was a portable space heater directly under the desk in Staff Office 1, adjacent to the Music Room. A warning label on the heater stated that the heater should be kept 3 feet away from all furnishings.

4. At 2:12 p.m., there was portable space heater approximately 1 foot away from the desk in Staff Ofice 3. A warning label on the heater stated that the heater should be kept 3 feet away from all furnishings.

Based on observation, record review, and interview, the facility failed to maintain their generator. This was evidenced by the failure to conduct one 30-minute monthly load test, the failure to conduct a 2-hour load bank test in accordance with NFPA 110, by no battery-powered emergency lighting provided in the generator room, and by leaks in the generator that had not been repaired. This affected two of two smoke compartments and could result in the increased risk of generator failure, and a delay in repairing the failure, in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

6-1.1 The routine maintenance and operation testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction.

6-3.1 The emergency power supply system (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 duration specified for the class.

6-4.1 Level 1 and Level 2 EPSSs (emergency power supply systems), including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: 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, provided the appropriate data are recorded.

6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS (emergency power supply) nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During a facility tour with Maintenance Staff 1 and Nursing Staff 1 on 11/17/15, the generator was observed and maintenance records were reviewed. The facility was equipped with a 115 KW diesel generator.

1. At 3:07 p.m., the "Emergency Generator Test Log" showed that there was no 30-minute load test conducted between 6/19/15 and 8/5/15.
During an interview at 3:38 p.m., Maintenance Staff 2 stated that he was told not to conduct the 30-minute load test in July because the facility had a long lasting power outage in June.

2. At 3:36 p.m., there was no battery-powered emergency light in the generator room.

3. At 3:37 p.m., there were four (1 foot by 1 foot) cotton pads on the floor of the generator room with oil stains. Two directly below the generator and two under the hose connected to the external filtration system. There were grease laden deposits around some of the generator seals.
During an interview at 3:38 p.m., Maintenance Staff 2 confirmed that there were leaks at the seals. He stated that the facility has not fixed the seals because they plan to replace the generator.

4. At 3:39 p.m., there were no records of a load bank test conducted on the generator.
During an interview at 3:40 p.m., Maintenance Staff 2 stated that he is unsure if the generator is running at 30% of the nameplate rating during the monthly load tests. He stated that the percentage load would be whatever the building is pulling in.

Based on observation and interview, the facility failed to maintain their electrical wiring. This was evidenced by the use of power strips in lieu of permanent wiring. This affected one of two smoke compartments and could result in the increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

400-8 Uses Not Permitted
Unless specifically permitted in Section 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: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with Nursing Staff 1 and Maintenance Staff 1 on 11/17/15, the electrical wiring was observed.

At 1:47 p.m., there was a six-plug power strip plugged into a second six-plug power strip, under the desk at the nurses station.