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Based on observation, and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed wall and ceiling penetrations. This affected two of two smoke compartments, and could result in the passage of smoke to other areas in the event of a fire.

Findings:

During a tour of the facility, and interview with staff on 7/26/16, the walls and ceilings were observed.

1. At 10:42 a.m., the North Wall in the Housekeeping 1 Room had two, approximately one half inch diameter penetrations above the sink.

2. At 11:55 a.m., the Emergency Room ceiling had an approximately two inch diameter penetration due to the shifting and dropping of a sprinkler escutcheon ring. The finding was confirmed in an interview at the time with Staff 2.

Based on observation, and interview, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed and failed to latch. This affected two of two smoke compartments, and could result in the inability to contain smoke and/or fire to a room.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

Findings:

During a tour of the facility, and interview with staff on 7/26/16, the doors were observed.

1. At 10:35 a.m., the corridor door the Utility Room was observed. The door was equipped with a self-closing device. The door was obstructed from fully closing and latching by the door frame. The finding was confirmed in an interview at the time with Staff 2.

2. At 10:40 a.m., the corridor door to Room 4 was observed. The door was equipped with a self-closing device. The door was obstructed from fully closing and latching by the door frame.

3. At 10:50 a.m., the corridor door to Room 8 was observed. The door was obstructed from fully closing and latching by a jacket hanging on the corridor-side door knob. The finding was confirmed in an interview at the time with Staff 1.

Based on observation, and interview, the facility failed to provide automatic closure by the fire alarm system with doors to hazardous areas held in the open position. This was evidenced by one hazardous room door being held open with a device not designed to automatically close upon activation of the fire alarm system. This affected one of two smoke compartments and could potentially result in the spread of smoke and/or fire.

Findings:

During a facility tour, and interview with staff on 7/26/16, doors to hazardous areas were observed.

At 12:05 p.m., the corridor door to the Laboratory was was observed. The door was equipped with self-closing and hold-open devices. The door was observed in the open position. The door was not equipped with a hold-open releasing device arranged to automatically close the door upon activation of the fire alarm system. The finding was confirmed in an interview at the time with Staff 2 and Staff 1.

Based on observation, and interview, the facility failed to maintain the hazardous areas. This was evidenced by a door to one hazardous area not being equipped with a self-closing device. This affected one of two smoke compartments, and could result in a delay in containing smoke and/or fire to a hazardous area.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.1 states that any hazardous areas shall have smoke-resisting doors that are self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During a facility tour, and interview with staff on 7/26/16, the hazardous areas were observed.

At 11:25 a.m., the corridor door to the Soiled Linen Storage/Shower Room 2 was not equipped with a self-closing device. The room contained two 33 gallon soiled linen barrels. The finding was confirmed in an interview at the time with Staff 2 and Staff 1.

Based on observation, interview, and document review, the facility failed to ensure that exits to a public way are readily accessible at all times. This was evidenced by one exit discharge gate having double-action and concealed latching devices. This affected one of two of smoke compartments and could potentially result in a delayed egress in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

During a tour of the facility, record review, and interview with Staff on 7/26/16, exit access, exit, and exit discharge were observed.

At 11:20 a.m., the Activities Room exit access, exit, and exit discharge to the public way were observed. Document review of the facility map at the time indicated the exit was a designated exit. The North Gate in the exit discharge was observed with two separate latches, a lower latch and an upper latch concealed under an iron guard on the outside of the gate-not located on the egress side. Two distinct actions and special knowledge of the upper latch were required to egress. Staff 1 and 2 confirmed the findings in an interview at the time.

Based on observation, document review, and interview, the facility failed to maintain the emergency lighting. This was evidenced by the failure to provide documentation for testing of emergency lighting with battery back-up. This affected two of two smoke compartments, and could result in a delay in evacuation due to limited visibility.

NFPA 101, Life Safety Code, 2000 Edition
19.2.9 Emergency Lighting.
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 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During observation, document review, and interview with staff on 7/26/16, the testing log for the emergency lighting was requested.

At 10:00 a.m., the facility was observed with emergency battery back-up lighting. No documentation was provided for 30 second testing of the units for the month of September 2015. The finding was confirmed in an interview at the time with Staff 2.

Based on observation, document review, and interview, the facility failed to maintain the emergency exit signs. This was evidenced by failure to test emergency exit signs with battery back-up. This affected two of two smoke compartments, and could result in a delay in evacuation in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.9.2 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. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During observation, document review, and interview with staff on 7/26/16, the exit signs were observed and documents were requested.

At 10:05 a.m., the facility was observed with battery back-up exit signs equipped with a test button on the side. No documentation was provided for monthly 30 second testing for the month of September 2015. The finding was confirmed in an interview at the time with Staff 2.

Based on document review, and interview, the facility failed to maintain complete fire drills. This was evidenced by the failure to activate and transmit an alarm device for one of twelve fire drills. This affected two of two smoke compartments, and could lead to staff not understanding the fire and evacuation procedures in the event of an emergency, affecting all staff and patients safety.

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 9:00 p.m. (2100 hours) and 6:00 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 the exterior of the building.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During document review, and interview with staff on 7/26/16, the fire drill records were reviewed.

At 10:35 a.m., there was no documentation that indicated an alarm device was activated during the A.M. Shift fire drill conducted on 6/30/16, at 11:00 a.m. The finding was confirmed in an interview at the time with Staff 2 and the alarm-monitoring company.

Based on observation, and interview, the facility failed to maintain the integrity of the automatic fire sprinkler system and components. This was evidenced by a sprinkler that had debris on it, and less than minimum clearance. This affected one of two smoke compartments, and could result in the ineffective operation of the automatic fire sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision 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.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
5-6.5.1 Performance Objective.
5-6.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-6.5.2 and 5-6.5.3, or additional sprinklers shall be provided to ensure adequate coverage of a hazard.
5-6.6 Clearance to Storage (Standard Pendent and Upright Spray Sprinklers). The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception: Where other standards specify greater minimums, they shall be followed.

NFPA 25, 1998
Chapter 2 Sprinkler Systems, 2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determined the minimum required frequencies for inspections, testing, and maintenance. Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.
1-8*. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and pre-action valves.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
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.

Findings:

During a facility tour, and interview with staff on 7/26/16, the automatic fire sprinkler system and components were observed.

At 11:15 a.m., the facility was observed with an automatic fire sprinkler system. The four sprinkler heads and piping under the West Roof Overhang were observed. The sprinkler head and pipe located directly outside the Business office was obstructed with a birds nest stationed on the sprinkler head and pipe, and nesting debris was inside the deflector and struts. Staff 2 and 1 confirmed the findings in an interview at the time.

Based on observation, and interview, the facility failed to maintain the Oxygen Storage. This was evidenced by the failure to segregate full and empty cylinders in the same enclosure, and to secure tanks. This affected one of two smoke compartments, and could result in an increased safety risk with tank damage, and staff being unable to differentiate between empty and full cylinders in the event of a emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 edition.
4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."
4-5.5.2.2 Storage of Cylinders and Containers
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft2 (85 m3)
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or (gates outdoors) that can be secured against unauthorized entry.

Findings:

During a facility tour, and interview with staff on 7/26/16, the Oxygen Storage was observed.

At 12:00 p.m., the Oxygen Storage Room was observed. There were three full cylinders stored together with four empty cylinders on the same rack, and three unsecured tanks free-standing on the floor. The findings were confirmed in an interview at the time with Staff 2 and 1.

Based on observation, document review, and interview, the facility failed to maintain the emergency power system (EPS). This was evidenced by the failure to conduct weekly visual inspections. This affected two of two smoke compartments, and could potentially result in a generator failure during an emergency power outage.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities, Utilities shall comply with the provisions of section 9.1
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 System.
19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision 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.

NFPA 99, Standard for Health Care Facilities, 1999 edition.
3-4.4.1.1(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
3-4.4.2 Recordkeeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
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 nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
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 EPSS 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, document review, and interview with staff on 7/26/16, the emergency generator was observed and test/inspection records were reviewed.

At 9:30 a.m., the facility was observed with a 25 kilowatt propane EPS. Documentation titled, "Emergency Generator log," was missing weekly visual inspections for the following weeks:
1. May 2016, three weekly visual checks not performed.
2. June 2016, three weekly visual checks not performed.
3. July 2016, two weekly visual checks not performed.
The findings were confirmed with Staff 2 and Staff 1 in an interview at the time.

Based on observation, and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed wall and ceiling penetrations. This affected two of two smoke compartments, and could result in the passage of smoke to other areas in the event of a fire.

Findings:

During a tour of the facility, and interview with staff on 7/26/16, the walls and ceilings were observed.

1. At 10:42 a.m., the North Wall in the Housekeeping 1 Room had two, approximately one half inch diameter penetrations above the sink.

2. At 11:55 a.m., the Emergency Room ceiling had an approximately two inch diameter penetration due to the shifting and dropping of a sprinkler escutcheon ring. The finding was confirmed in an interview at the time with Staff 2.

Based on observation, and interview, the facility failed to maintain the corridor doors. This was evidenced by doors that were obstructed and failed to latch. This affected two of two smoke compartments, and could result in the inability to contain smoke and/or fire to a room.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

Findings:

During a tour of the facility, and interview with staff on 7/26/16, the doors were observed.

1. At 10:35 a.m., the corridor door the Utility Room was observed. The door was equipped with a self-closing device. The door was obstructed from fully closing and latching by the door frame. The finding was confirmed in an interview at the time with Staff 2.

2. At 10:40 a.m., the corridor door to Room 4 was observed. The door was equipped with a self-closing device. The door was obstructed from fully closing and latching by the door frame.

3. At 10:50 a.m., the corridor door to Room 8 was observed. The door was obstructed from fully closing and latching by a jacket hanging on the corridor-side door knob. The finding was confirmed in an interview at the time with Staff 1.

Based on observation, and interview, the facility failed to provide automatic closure by the fire alarm system with doors to hazardous areas held in the open position. This was evidenced by one hazardous room door being held open with a device not designed to automatically close upon activation of the fire alarm system. This affected one of two smoke compartments and could potentially result in the spread of smoke and/or fire.

Findings:

During a facility tour, and interview with staff on 7/26/16, doors to hazardous areas were observed.

At 12:05 p.m., the corridor door to the Laboratory was was observed. The door was equipped with self-closing and hold-open devices. The door was observed in the open position. The door was not equipped with a hold-open releasing device arranged to automatically close the door upon activation of the fire alarm system. The finding was confirmed in an interview at the time with Staff 2 and Staff 1.

Based on observation, and interview, the facility failed to maintain the hazardous areas. This was evidenced by a door to one hazardous area not being equipped with a self-closing device. This affected one of two smoke compartments, and could result in a delay in containing smoke and/or fire to a hazardous area.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.1 states that any hazardous areas shall have smoke-resisting doors that are self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During a facility tour, and interview with staff on 7/26/16, the hazardous areas were observed.

At 11:25 a.m., the corridor door to the Soiled Linen Storage/Shower Room 2 was not equipped with a self-closing device. The room contained two 33 gallon soiled linen barrels. The finding was confirmed in an interview at the time with Staff 2 and Staff 1.

Based on observation, interview, and document review, the facility failed to ensure that exits to a public way are readily accessible at all times. This was evidenced by one exit discharge gate having double-action and concealed latching devices. This affected one of two of smoke compartments and could potentially result in a delayed egress in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

During a tour of the facility, record review, and interview with Staff on 7/26/16, exit access, exit, and exit discharge were observed.

At 11:20 a.m., the Activities Room exit access, exit, and exit discharge to the public way were observed. Document review of the facility map at the time indicated the exit was a designated exit. The North Gate in the exit discharge was observed with two separate latches, a lower latch and an upper latch concealed under an iron guard on the outside of the gate-not located on the egress side. Two distinct actions and special knowledge of the upper latch were required to egress. Staff 1 and 2 confirmed the findings in an interview at the time.

Based on observation, document review, and interview, the facility failed to maintain the emergency lighting. This was evidenced by the failure to provide documentation for testing of emergency lighting with battery back-up. This affected two of two smoke compartments, and could result in a delay in evacuation due to limited visibility.

NFPA 101, Life Safety Code, 2000 Edition
19.2.9 Emergency Lighting.
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 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During observation, document review, and interview with staff on 7/26/16, the testing log for the emergency lighting was requested.

At 10:00 a.m., the facility was observed with emergency battery back-up lighting. No documentation was provided for 30 second testing of the units for the month of September 2015. The finding was confirmed in an interview at the time with Staff 2.

Based on observation, document review, and interview, the facility failed to maintain the emergency exit signs. This was evidenced by failure to test emergency exit signs with battery back-up. This affected two of two smoke compartments, and could result in a delay in evacuation in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.9.2 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. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During observation, document review, and interview with staff on 7/26/16, the exit signs were observed and documents were requested.

At 10:05 a.m., the facility was observed with battery back-up exit signs equipped with a test button on the side. No documentation was provided for monthly 30 second testing for the month of September 2015. The finding was confirmed in an interview at the time with Staff 2.

Based on document review, and interview, the facility failed to maintain complete fire drills. This was evidenced by the failure to activate and transmit an alarm device for one of twelve fire drills. This affected two of two smoke compartments, and could lead to staff not understanding the fire and evacuation procedures in the event of an emergency, affecting all staff and patients safety.

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 9:00 p.m. (2100 hours) and 6:00 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 the exterior of the building.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During document review, and interview with staff on 7/26/16, the fire drill records were reviewed.

At 10:35 a.m., there was no documentation that indicated an alarm device was activated during the A.M. Shift fire drill conducted on 6/30/16, at 11:00 a.m. The finding was confirmed in an interview at the time with Staff 2 and the alarm-monitoring company.

Based on observation, and interview, the facility failed to maintain the integrity of the automatic fire sprinkler system and components. This was evidenced by a sprinkler that had debris on it, and less than minimum clearance. This affected one of two smoke compartments, and could result in the ineffective operation of the automatic fire sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision 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.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
5-6.5.1 Performance Objective.
5-6.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-6.5.2 and 5-6.5.3, or additional sprinklers shall be provided to ensure adequate coverage of a hazard.
5-6.6 Clearance to Storage (Standard Pendent and Upright Spray Sprinklers). The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception: Where other standards specify greater minimums, they shall be followed.

NFPA 25, 1998
Chapter 2 Sprinkler Systems, 2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determined the minimum required frequencies for inspections, testing, and maintenance. Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.
1-8*. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and pre-action valves.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
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.

Findings:

During a facility tour, and interview with staff on 7/26/16, the automatic fire sprinkler system and components were observed.

At 11:15 a.m., the facility was observed with an automatic fire sprinkler system. The four sprinkler heads and piping under the West Roof Overhang were observed. The sprinkler head and pipe located directly outside the Business office was obstructed with a birds nest stationed on the sprinkler head and pipe, and nesting debris was inside the deflector and struts. Staff 2 and 1 confirmed the findings in an interview at the time.

Based on observation, and interview, the facility failed to maintain the Oxygen Storage. This was evidenced by the failure to segregate full and empty cylinders in the same enclosure, and to secure tanks. This affected one of two smoke compartments, and could result in an increased safety risk with tank damage, and staff being unable to differentiate between empty and full cylinders in the event of a emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 edition.
4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."
4-5.5.2.2 Storage of Cylinders and Containers
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft2 (85 m3)
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors or (gates outdoors) that can be secured against unauthorized entry.

Findings:

During a facility tour, and interview with staff on 7/26/16, the Oxygen Storage was observed.

At 12:00 p.m., the Oxygen Storage Room was observed. There were three full cylinders stored together with four empty cylinders on the same rack, and three unsecured tanks free-standing on the floor. The findings were confirmed in an interview at the time with Staff 2 and 1.

Based on observation, document review, and interview, the facility failed to maintain the emergency power system (EPS). This was evidenced by the failure to conduct weekly visual inspections. This affected two of two smoke compartments, and could potentially result in a generator failure during an emergency power outage.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities, Utilities shall comply with the provisions of section 9.1
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 System.
19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision 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.

NFPA 99, Standard for Health Care Facilities, 1999 edition.
3-4.4.1.1(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
3-4.4.2 Recordkeeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
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 nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
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 EPSS 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, document review, and interview with staff on 7/26/16, the emergency generator was observed and test/inspection records were reviewed.

At 9:30 a.m., the facility was observed with a 25 kilowatt propane EPS. Documentation titled, "Emergency Generator log," was missing weekly visual inspections for the following weeks:
1. May 2016, three weekly visual checks not performed.
2. June 2016, three weekly visual checks not performed.
3. July 2016, two weekly visual checks not performed.
The findings were confirmed with Staff 2 and Staff 1 in an interview at the time.