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Based on observation and interview, the facility failed to maintain the building's construction. This was evidenced by penetrations through the ceiling. This affected two of two smoke compartments and the Fire Alarm Equipment Room and could result in the passage of smoke and fire in the event of a fire.

Findings:

During a tour of the facility and interview with staff on 7/15/19, the integrity of the building's construction was observed.

1. At 11:37 a.m., the Clean Linen Room was observed with an approximately one and a half inch penetration through the ceiling. Upon interview, Staff 2 confirmed the finding.

2. At 11:50 a.m., the Fire Alarm Equipment Room located next to the Elevator was observed with an approximately one inch penetration through the ceiling. Upon interview, Staff 1 confirmed the finding.

3. At 12:19 p.m., the Nursing Supervisor Room was observed with an approximately one inch by three inch penetration through the ceiling. Upon interview, Staff 3 confirmed the finding.

Based on record review and interview, the facility failed to maintain the fire alarm system. This was evidenced by missing a semi-annual fire alarm system inspection and incomplete testing of the fire alarm control panel batteries. This affected two of two smoke compartments and could result in a malfunctioning fire alarm system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6

9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Table 14.3.1 Visual Inspection Frequencies-semiannually
3. Batteries
5. Fire alarm control unit trouble signals
7. In- building fire emergency voice/alarm communications equipment
8. Remote annunciators
9. Initiating devices
11. Combination systems (a) Fire extinguisher electronic monitoring device/systems
(b) Carbon monoxide detectors/systems
12. Interface equipment
13. Alarm notification appliances
14. Exit marking audible notification appliances

14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

Table 14.4.5 Testing Frequencies
6. Batteries-fire alarm systems
(d) Sealed lead-acid type:
(1) Charger test (Replace battery within 5 years after manufacture or more frequently as needed)-annually
(2) Discharge test (30 minutes)-annually
(3) Load voltage test-semi-annually

Findings:

During record review and interview with staff on 7/15/19, the fire alarm system testing and inspection records were reviewed.

1. At 4:00 p.m., the facility failed to provide documentation indicating that a semi-annual fire alarm system inspection was completed. The facility provided a document titled, "System Record of Inspection and Testing" that indicated the fire alarm system was tested and inspected on 12/13/18. The facility was unable to provide an additional inspection completed within the last 12 months. Upon interview, Staff 2 stated that the fire alarm system was only tested and inspected on an annual basis.

2. At 4:00 p.m., the facility failed to provide documentation indicating that one of two semi-annual load voltage tests were completed on the two sealed lead acid fire alarm control panel batteries. Upon interview, Staff 2 stated that the batteries did not receive a semi-annual load voltage test because the batteries were only tested during the annual test and inspection.

Based on record review and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by the failure to complete 12 of 12 monthly automatic fire sprinkler gauge inspections, and the failure to complete five of 12 monthly automatic fire sprinkler valve inspections. This affected two of two smoke compartments, and could result in a delayed notification of a malfunctioning automatic fire sprinkler system component.

NFPA 101 Life Safety Code, 2012 Edition
19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
4.3.1 Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

13.1.1.2 Table 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Table 13.1.1.2 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance
Inspection
Control Valves
Locked: Monthly 13.3.2.1.1
Tamper switches: Monthly 13.3.2.1.1

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

Findings:

During record review and interview with staff on 7/16/19, the automatic fire sprinkler system inspection records were reviewed.

1. At 9:50 a.m., the facility failed to provide documentation indicating that 12 of 12 monthly visual inspections of the automatic fire sprinkler system gauges were completed. The facility provided a document titled, "Fire Sprinkler System Testing Inspection Log for Inspector's Valve Tamper Switch" that indicated the valves were tested monthly between November 2018 and April 2019, but the documentation did not indicate that the gauges were inspected. Upon interview, Staff 2 stated that inspections of the gauges were completed monthly, but it was not documented on the forms provided.

2. At 9:58 a.m., the facility failed to provide documentation indicating that five of 12 monthly visual inspections of the automatic fire sprinkler system valves were completed. The facility provided a document titled, "Fire Sprinkler System Testing Inspection Log for Inspector's Valve Tamper Switch" that indicated the facility tested the inspectors test valve monthly. The facility was unable to provide documentation for visual inspections of the valves during the months of July, September and October of 2018 and May and June of 2019. Upon interview, Staff 2 confirmed the finding and stated that the valves were inspected during the monthly testing and was not sure why the department responsible for the testing did not complete visual inspections every month.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by one fire extinguisher that was mounted more than five feet above the floor. This affected one of two smoke compartments and could result in a delay in accessing a fire extinguisher during a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3 Protection
19.3.5.12 Portable Fire Extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4.1 Where required by the provisions of another section of this code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2012 Edition
6.1.3.8 Installation Height
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

Findings:

During a tour of the facility and interview with staff on 7/15/19, the facility's fire extinguishers were observed.

1. At 11:20 a.m., the ABC fire extinguisher in the Therapy Room was observed. The top of the fire extinguisher measured approximately sixty six inches above the ground. Upon interview, Staff 3 stated that he was not aware that the fire extinguishers needed to be mounted at or below five feet.

Based on observation and interview, the facility failed to maintain the building services. This was evidenced by two electrical panels that were obstructed. This affected one of two smoke compartments and could result in a delay in accessing the circuit breakers during an electrical fire.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70 National Electrical Code, 2011 edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all
electrical equipment to permit ready and safe operation and maintenance of such equipment.
(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width
of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree
opening of equipment doors or hinged panels.

Findings:

During a tour of the facility and interview with staff on 7/15/19, the facility's electrical panels were observed.

1. At 11:25 a.m., the electrical panels located inside of the Nurses Station Room were observed. Two electrical panels were observed with carts parked directly in front of the panels. Upon interview, Staff 2 confirmed the finding.

Based on record review and interview, the facility failed to conduct the required number of fire drills. This was evidenced by the absence of fire drill records. This affected two of two smoke compartments and could result in a delayed staff response in the event of a fire.

Findings:

During record review and interview with staff on 7/15/19, the fire drill records were requested and reviewed.

1. At 3:15 p.m., the facility failed to provide documentation indicating that the facility conducted fire drills on all shifts during the first quarter of 2019 (January, February, March). Upon interview, Staff 1 stated that they did not conduct fire drills during the first quarter because they conducted earthquake disaster drills instead.

Based on observation, record review, and interview, the facility failed to maintain the emergency generator. This was evidenced by no records of monthly conductance tests of the generator battery. This affected two of two smoke compartments and could result in the increased risk of generator start failure.

NFPA 99, Health Care Facilities Code, 2012 Edition.
6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.

6.4.4.2 Record Keeping. 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, 2010 Edition.
1.1.2 This standard covers installation, maintenance, operation, and testing requirements as they pertain to the performance of the emergency power supply system (EPSS).

8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

Findings:

During a tour of the facility, record review, and interview with staff on 7/15/19, the emergency generator was observed and maintenance records were reviewed.

1. At 3:40 p.m., the facility failed to provide documentation indicating that 12 of 12 monthly conductance tests were completed on the generator battery. The 125 kilowatt diesel generator was observed with one sealed lead acid battery. Upon interview, Staff 2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by the use of a non-compliant power strip within the patient care vicinity. This affected one of two smoke compartments and could result in the increased risk of an electrical fire.

Findings:

During a tour of the facility and interview with staff on 7/15/19, the facility's electrical equipment was observed.

1. At 11:42 a.m., the electrical equipment in the Exam Room was observed. An UL listed power strip was observed supplying power to a patient's exam table. The power strip was used within the patient care vicinity and was not listed as UL 1363A or 60601-1. Upon interview, Staff 2 confirmed the finding.