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Based on observation, the facility failed to maintain the building construction, as evidenced by wall penetrations in three areas. This affected 2 of 6 smoke compartments and had the potential to allow the spread of smoke during a fire.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the facility walls and ceilings were observed.

At 1:34 p.m., in the laundry room adjacent to room 19, there was a four inch by four inch penetration in the east wall behind the washing machine. There were two approximately 3/4 inch copper pipes running through the penetration. In the east wall behind the washing machine there was an approximately 1/2 inch penetration around a one inch electrical conduit. Staff 1 confirmed both wall penetrations.

At 2:10 p.m., there was an approximately one inch circular penetration on the west wall adjacent to the corridor door, in the billing office. Staff 1 confirmed the penetration in the wall.

At 2:13 p.m., the cover plate was missing on the cable TV outlet on the north wall of the lobby. Staff 1 confirmed the cover plate was missing.

Based on observation, the facility failed to mark access to exits, as evidenced by exit signs that were not visible when the smoke barrier doors were closed. This affected 5 of 6 smoke compartments and had the potential to delay evacuation in the event of a fire.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the facility exit signs were observed.

At 2:35 p.m., the north east corridor was separated into two smoke compartments. Only one exit sign was visible in each smoke compartment when the smoke barrier doors were closed. Staff 1 confirmed only one exit sign was visible when the smoke barrier doors were closed.

At 2:49 p.m., only one exit sign was visible in the smoke compartment when the smoke barrier doors adjacent to the unit 2 nurse station were closed. One sign was visible in the corridor on the east side of the barrier. Staff 1 confirmed only one exit sign was visible when the smoke barrier doors were closed.

At 3:00 p.m., when the smoke barrier doors were closed in the north west corridor adjacent to room 9, only one exit sign was visible from the corridor on the south side of the smoke barrier. There was no exit sign on the south side of the smoke barrier. Staff 1 confirmed there was no exit sign on the south side of the smoke barrier.

At 3:10 p.m., there was no sign at the north exit from the Group/Activity Corridor. When standing in the corridor, only the south exit was marked. Staff 1 confirmed there was no exit sign on the north exit.

Based on observation, the facility failed to maintain the smoke barrier doors, as evidenced by one smoke barrier door that failed to latch. This affected 2 of 6 smoke compartments and had the potential to allow the spread of smoke during a fire.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the facility smoke barriers were observed.

At 2:55 p.m., the south leaf in the barrier door, adjacent to the unit 2 nurse station, failed to latch when tested. Staff 1 confirmed the door did not latch.

NFPA 101(1999 edition) 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 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.

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.

Based on interview and document review, the facility failed to maintain the emergency lighting and exit signs, as evidenced by the failure to test the emergency lighting and exit signs for 90 minutes annually. This affected 6 of 6 smoke compartments and had the potential for the lighting to fail.

Findings:

During the document review on April 6, 2010, the emergency lighting test records were reviewed.

At 9:25 a.m., the annual test record for the testing of the exit signs and egress lighting with battery back-up, was dated 12-30-09. The record noted the devices were tested for 45 minutes, not the required 90 minutes. Staff 1 stated he only tested for 45 minutes and that the devices were also connected to the emergency generator.

Based on document review, the facility failed to conduct fire drills quarterly on each shift as evidenced by the failure to provide documentation for 1 of 4 quarters for the 2nd (PM/NOC) shift. This affected 6 of 6 smoke compartments and had the potential for staff to be unable to respond to a fire.

Findings:

During the document review on April 6, 2010, the facility fire drill report logs were reviewed.

At 9:42 a.m., the facility failed to provide documentation for the 2nd shift (PM/NOC) fire drill for the 1st quarter of 2010 (January to March). Staff 1 stated there were no other records for review.

NFPA 101 (2000 Edition) 9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

NFPA 72 (1999 Edition) Table 7-3.2 Testing Frequencies, Item 6(d)(1) requires sealed lead acid batteries to be replaced every 4 years.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by batteries past the replacement date. This affected 6 of 6 smoke compartments and had the potential for fire alarm system failure.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the fire alarm panel was observed.

At 11:27 a.m., the batteries in the fire alarm panel in the electrical room were dated 6-2-05. Written on the batteries was the instruction to replace on 6-2-09. Staff 1 stated the vendor was to have replaced the batteries and that the batteries were past due for replacement.

At 3:08 p.m., access to the manual fire alarm box located in the lobby was obstructed by a potted plant and a bench. To activate the alarm box required reaching over the plant and the bench. Staff 1 stated the bench and been moved and re-positioned the potted plant and bench to provide unobstructed access to the manual fire alarm box.

NFPA 72 (1999 Edition) 7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

NFPA 72 (1999 Edition), 8-3.5 Unless otherwise recommended by the manufacturer, smoke alarms installed in accordance with Chapters 18, 19, or 21 of NFPA 101, Life Safety Code, shall be replaced when they fail to respond to tests conducted in accordance with 8-3.4 but shall not remain in service longer than 10 years from the date of installation.

NFPA 72 (1999 Edition), 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 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.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-3.3 Single station smoke detectors installed in one- and two-family dwelling units shall be inspected, tested, and maintained as specified in Chapter 8. Single station detectors installed on other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7.

NFPA 101 (2000 Edition), 4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

NFPA 101 (2000 Edition) 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Based on document review and interview, the facility failed to maintain the single station battery operated smoke detector in 1 of 6 smoke compartments as evidenced by the failure to provide documentation for the sensitivity testing, battery changes, weekly testing and installation date of the single station detector and a detector that had been taped over. This had the potential for detector failure.

Findings:

During the document review and facility tour with Staff 1 on April 6, 2010, the test record for the fire alarm systems was reviewed.

At 11:55 a.m., the annual test record dated 8-6-09 did not include the testing of the single station, battery operated smoke detector in the Partial Treatment corridor. The facility failed to provide documentation for the weekly testing of the smoke detector. In molded lettering on the detector it stated "Push and Hold to test weekly." The facility failed to provide documentation for the installation date of the smoke detector. Staff 1 stated there were no other records for the sensitivity testing of the detector, that he only tested the detector monthly and that the detectors were installed prior to his employment at the facility several years ago and that he did not know when it was installed.

At 2:35 p.m., the smoke detector on the south side of the smoke barrier in the north east corridor had been taped over. Staff 1 stated the detector had been taped over while painting the area. Staff 1 removed the tape. The detector was tested at 2:42 p.m. and functioned properly.

NFPA 10 (1998 Edition), 4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

NFPA 96 (1998 Edition) 7-2.1.1 A placard identifying the use of the extinguisher as secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

Based on observation, the facility failed to maintain the portable fire extinguishers as evidenced by a missing tamper tag on an extinguisher and the failure to post a warning sign by the two Class ABC extinguishers in the kitchen. This affected 1 of 6 smoke compartments and had the potential for improper use of the fire extinguisher.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the fire extinguishers were observed.

At 1:25 p.m., there was no sign in the kitchen warning staff to activate the fire extinguishing system prior to using the two Class ABC fire extinguishers. Staff 1 confirmed there were no warning signs near each of the ABC extinguishers.

At 2:40 p.m., the tamper tag was missing on the fire extinguisher in the north east corridor adjacent to the nurse station.

NFPA 90A (1999 Edition) 2-3.4.5 Openings in walls or ceilings shall be provided so that service openings in air ducts are accessible for maintenance and inspection needs.

NFPA 90A (1999 Edition), 2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection devices(s) within.

NFPA 90A (1999 Edition) 2-3.5.1 Air ducts shall be located where they are not subject to damage or rupture, or they shall be protected to maintain their integrity.

NFPA 90A (1999 Edition), 3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.

NFPA 90A (1999 Edition), 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on observation and document review, the facility failed to maintain the heating, ventilation and air conditioning system as evidenced by open ducts and failure to provide documentation for the testing and maintenance of the fire damper, the failure to provide drawings of the air duct system showing damper locations and the failure to label an access panel. This affected 6 of 6 smoke compartments and had the potential to fail to contain smoke.

Findings:

During the document review and facility tour with Staff 1 on April 6, 2010, the air conditioning ducts and dampers were observed and damper test records were reviewed.


At 10:38 a.m., above the access panel adjacent to the administrator's office in the corridor, the air duct in the attic space was damaged allowing air to flow into the attic.

At 10:48 a.m., the attic access panel at the intersection of the administration corridor and the partial treatment corridor was not labeled indicating the panel provides access to a smoke damper.

At 2:20 p.m., fire dampers with fusible links were observed in 4 of 6 smoke compartments during the facility tour between the hours of 10:30 a.m. and 2:20 p.m.. Dampers were observed in Classroom 5, the tub room in the north west corridor, the medical billing office and in Administration. The dampers were not listed as having been tested and maintained on the test record dated 11-5-08. Staff 1 stated the dampers were not on the test record and stated they had not been identified by the vendor.

NFPA 101 (2000 Edition), 10.3.1 Where required by the applicable provision of this Code, draperies, curtain, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Based on observation, the facility failed to provide flame resistant privacy curtains affecting patient rooms in 5 of 6 smoke compartments as evidenced by curtains with no tags identifying them as being flame resistant and the failure to have documents from the manufacturer identifying them as being flame resistant which had the potential for the spread of fire.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the facility drapes and curtains were observed.

At 1:35 p.m., the privacy curtains in room 19 were not labeled as being flame resistant. Staff 1 stated the facility did not have the documents from the manufacturer attesting to the flame resistance. During the facility tour between the hours of 10:30 a.m. and 2:20 p.m., there were no privacy curtains in patient rooms identified with a label noting the flame resistance of the curtain.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).

5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].

7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Exception: Shipping crates or storage cartons for cylinders.

Based on observation, the facility failed to maintain the oxygen storage area as evidenced by oxygen stored with combustible materials. This affected 1 of 6 smoke compartments and had the potential for a fire.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the oxygen storage area was observed.

At 1:10 p.m., the oxygen storage area was within the Central Supply storage area. 25 e cylinders of oxygen were store within 12 inches of storage racks containing paper forms, diapers and latex gloves.

DOOR RATING LABELS

NFPA 80 (1999 Edition) 1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Based on observation, the facility failed to maintain the smoke barriers affecting 3 of 6 smoke compartments as evidenced by the smoke barrier door rating labels painted over which had the potential to allow the spread of smoke and fire do to improperly rated smoke barrier doors.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the facility smoke barrier was observed.

At 1:00 p.m., the door labels in the smoke barrier adjacent to Human Resources and the smoke barrier adjacent to rooms 7 and 8 were painted over. The door rating could not be identified. Staff 1 confirmed the labels were painted over.

At 1:21 p.m., the door labels in the corridor barrier doors for the cafeteria were painted over. The door rating could not be identified. Staff 1 confirmed the labels were painted over.

DISASTER DRILL IMPLEMENTATION

NFPA 99 (1999 Edition) 11-5.3.9* Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Based on document review, the facility failed to implement the emergency preparedness plan at least semi-annually as evidenced by the failure to provide documentation for 2 of 2 required drills. This affected 6 of 6 smoke compartments and had the potential for staff to be unprepared to function in a disaster.

Findings:

During the document review on April 6, 2010, the facility disaster drills were requested for review.

At 10:09 a.m., Staff 1 stated there were no disaster drills for review as the facility had not implemented the plan at least semi-annually as required.

NFPA 99 (1999 Edition) 3-5.4 Administration (Type 2 EES).

3-5.4.1 Maintenance and Testing of Essential Electrical System.

3-5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.

(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 3-5.3.1.

(b) Inspection and Testing. Generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b).

3-5.4.1.2 Maintenance and Testing of Circuitry. Circuitry shall be maintained and tested in accordance with 3-4.4.1.2.

3-5.4.1.3 Maintenance of Batteries. Batteries shall be maintained in accordance with 3-4.4.1.3.

3-5.4.2 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 99 (1999 Edition) 3-4.4.1 Maintenance and Testing of Essential Electrical System.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(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.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems,
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.


NFPA 110 (1999 Edition), 6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for 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.

The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA 110 (1999 Edition) 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.

Based on document review and interview, the facility failed to maintain the emergency generator as evidenced by the failure to provide documentation for 5 of 12 monthly load tests, failed to provide documentation for the annual load test and the failure to provide documentation for 26 of 52 weekly inspections. This affected 6 of 6 smoke compartments and had the potential for generator failure.

Findings:

During the document review on April 6, 2010, the generator test reports were reviewed.

At 10:00 a.m., the facility failed to provide documentation for 5 of 12 (June through October 2009) monthly full load tests. Staff 1 stated the AQMD had shut down the generator during those months as the AQMD did not have record of the facility generator. Staff 1 stated the generator was kept in service for emergencies but was not tested during the period of June through October of 2009. The problem was resolved and monthly testing started again in November of 2009.

At 10:00 a.m., the facility failed to provide documentation confirming the generator reached at least 30% of rated capacity or the minimum exhaust temperature as recommended by the manufacturer when tested under load. The last annual load test was dated 10-29-08. Staff 1 stated the load test was required as the generator did not meet the 30% or temperature requirement. Staff 1 stated the vendor had been requested to conduct the load test but that the vendor had stated it was no longer required.

At 10:00 a.m., the facility failed to provide documentation for the weekly inspection of the generator for 26 of 52 weeks. Staff 1 stated he visually inspected weekly but had only documented the inspection when the generator was run every 2 weeks.

Based on observation, the facility failed to maintain the building construction, as evidenced by wall penetrations in three areas. This affected 2 of 6 smoke compartments and had the potential to allow the spread of smoke during a fire.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the facility walls and ceilings were observed.

At 1:34 p.m., in the laundry room adjacent to room 19, there was a four inch by four inch penetration in the east wall behind the washing machine. There were two approximately 3/4 inch copper pipes running through the penetration. In the east wall behind the washing machine there was an approximately 1/2 inch penetration around a one inch electrical conduit. Staff 1 confirmed both wall penetrations.

At 2:10 p.m., there was an approximately one inch circular penetration on the west wall adjacent to the corridor door, in the billing office. Staff 1 confirmed the penetration in the wall.

At 2:13 p.m., the cover plate was missing on the cable TV outlet on the north wall of the lobby. Staff 1 confirmed the cover plate was missing.

Based on observation, the facility failed to mark access to exits, as evidenced by exit signs that were not visible when the smoke barrier doors were closed. This affected 5 of 6 smoke compartments and had the potential to delay evacuation in the event of a fire.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the facility exit signs were observed.

At 2:35 p.m., the north east corridor was separated into two smoke compartments. Only one exit sign was visible in each smoke compartment when the smoke barrier doors were closed. Staff 1 confirmed only one exit sign was visible when the smoke barrier doors were closed.

At 2:49 p.m., only one exit sign was visible in the smoke compartment when the smoke barrier doors adjacent to the unit 2 nurse station were closed. One sign was visible in the corridor on the east side of the barrier. Staff 1 confirmed only one exit sign was visible when the smoke barrier doors were closed.

At 3:00 p.m., when the smoke barrier doors were closed in the north west corridor adjacent to room 9, only one exit sign was visible from the corridor on the south side of the smoke barrier. There was no exit sign on the south side of the smoke barrier. Staff 1 confirmed there was no exit sign on the south side of the smoke barrier.

At 3:10 p.m., there was no sign at the north exit from the Group/Activity Corridor. When standing in the corridor, only the south exit was marked. Staff 1 confirmed there was no exit sign on the north exit.

Based on observation, the facility failed to maintain the smoke barrier doors, as evidenced by one smoke barrier door that failed to latch. This affected 2 of 6 smoke compartments and had the potential to allow the spread of smoke during a fire.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the facility smoke barriers were observed.

At 2:55 p.m., the south leaf in the barrier door, adjacent to the unit 2 nurse station, failed to latch when tested. Staff 1 confirmed the door did not latch.

NFPA 101(1999 edition) 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 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.

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.

Based on interview and document review, the facility failed to maintain the emergency lighting and exit signs, as evidenced by the failure to test the emergency lighting and exit signs for 90 minutes annually. This affected 6 of 6 smoke compartments and had the potential for the lighting to fail.

Findings:

During the document review on April 6, 2010, the emergency lighting test records were reviewed.

At 9:25 a.m., the annual test record for the testing of the exit signs and egress lighting with battery back-up, was dated 12-30-09. The record noted the devices were tested for 45 minutes, not the required 90 minutes. Staff 1 stated he only tested for 45 minutes and that the devices were also connected to the emergency generator.

Based on document review, the facility failed to conduct fire drills quarterly on each shift as evidenced by the failure to provide documentation for 1 of 4 quarters for the 2nd (PM/NOC) shift. This affected 6 of 6 smoke compartments and had the potential for staff to be unable to respond to a fire.

Findings:

During the document review on April 6, 2010, the facility fire drill report logs were reviewed.

At 9:42 a.m., the facility failed to provide documentation for the 2nd shift (PM/NOC) fire drill for the 1st quarter of 2010 (January to March). Staff 1 stated there were no other records for review.

NFPA 101 (2000 Edition) 9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

NFPA 72 (1999 Edition) Table 7-3.2 Testing Frequencies, Item 6(d)(1) requires sealed lead acid batteries to be replaced every 4 years.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by batteries past the replacement date. This affected 6 of 6 smoke compartments and had the potential for fire alarm system failure.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the fire alarm panel was observed.

At 11:27 a.m., the batteries in the fire alarm panel in the electrical room were dated 6-2-05. Written on the batteries was the instruction to replace on 6-2-09. Staff 1 stated the vendor was to have replaced the batteries and that the batteries were past due for replacement.

At 3:08 p.m., access to the manual fire alarm box located in the lobby was obstructed by a potted plant and a bench. To activate the alarm box required reaching over the plant and the bench. Staff 1 stated the bench and been moved and re-positioned the potted plant and bench to provide unobstructed access to the manual fire alarm box.

NFPA 72 (1999 Edition) 7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

NFPA 72 (1999 Edition), 8-3.5 Unless otherwise recommended by the manufacturer, smoke alarms installed in accordance with Chapters 18, 19, or 21 of NFPA 101, Life Safety Code, shall be replaced when they fail to respond to tests conducted in accordance with 8-3.4 but shall not remain in service longer than 10 years from the date of installation.

NFPA 72 (1999 Edition), 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 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.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-3.3 Single station smoke detectors installed in one- and two-family dwelling units shall be inspected, tested, and maintained as specified in Chapter 8. Single station detectors installed on other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7.

NFPA 101 (2000 Edition), 4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

NFPA 101 (2000 Edition) 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Based on document review and interview, the facility failed to maintain the single station battery operated smoke detector in 1 of 6 smoke compartments as evidenced by the failure to provide documentation for the sensitivity testing, battery changes, weekly testing and installation date of the single station detector and a detector that had been taped over. This had the potential for detector failure.

Findings:

During the document review and facility tour with Staff 1 on April 6, 2010, the test record for the fire alarm systems was reviewed.

At 11:55 a.m., the annual test record dated 8-6-09 did not include the testing of the single station, battery operated smoke detector in the Partial Treatment corridor. The facility failed to provide documentation for the weekly testing of the smoke detector. In molded lettering on the detector it stated "Push and Hold to test weekly." The facility failed to provide documentation for the installation date of the smoke detector. Staff 1 stated there were no other records for the sensitivity testing of the detector, that he only tested the detector monthly and that the detectors were installed prior to his employment at the facility several years ago and that he did not know when it was installed.

At 2:35 p.m., the smoke detector on the south side of the smoke barrier in the north east corridor had been taped over. Staff 1 stated the detector had been taped over while painting the area. Staff 1 removed the tape. The detector was tested at 2:42 p.m. and functioned properly.

NFPA 10 (1998 Edition), 4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

NFPA 96 (1998 Edition) 7-2.1.1 A placard identifying the use of the extinguisher as secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

Based on observation, the facility failed to maintain the portable fire extinguishers as evidenced by a missing tamper tag on an extinguisher and the failure to post a warning sign by the two Class ABC extinguishers in the kitchen. This affected 1 of 6 smoke compartments and had the potential for improper use of the fire extinguisher.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the fire extinguishers were observed.

At 1:25 p.m., there was no sign in the kitchen warning staff to activate the fire extinguishing system prior to using the two Class ABC fire extinguishers. Staff 1 confirmed there were no warning signs near each of the ABC extinguishers.

At 2:40 p.m., the tamper tag was missing on the fire extinguisher in the north east corridor adjacent to the nurse station.

NFPA 90A (1999 Edition) 2-3.4.5 Openings in walls or ceilings shall be provided so that service openings in air ducts are accessible for maintenance and inspection needs.

NFPA 90A (1999 Edition), 2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection devices(s) within.

NFPA 90A (1999 Edition) 2-3.5.1 Air ducts shall be located where they are not subject to damage or rupture, or they shall be protected to maintain their integrity.

NFPA 90A (1999 Edition), 3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.

NFPA 90A (1999 Edition), 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on observation and document review, the facility failed to maintain the heating, ventilation and air conditioning system as evidenced by open ducts and failure to provide documentation for the testing and maintenance of the fire damper, the failure to provide drawings of the air duct system showing damper locations and the failure to label an access panel. This affected 6 of 6 smoke compartments and had the potential to fail to contain smoke.

Findings:

During the document review and facility tour with Staff 1 on April 6, 2010, the air conditioning ducts and dampers were observed and damper test records were reviewed.


At 10:38 a.m., above the access panel adjacent to the administrator's office in the corridor, the air duct in the attic space was damaged allowing air to flow into the attic.

At 10:48 a.m., the attic access panel at the intersection of the administration corridor and the partial treatment corridor was not labeled indicating the panel provides access to a smoke damper.

At 2:20 p.m., fire dampers with fusible links were observed in 4 of 6 smoke compartments during the facility tour between the hours of 10:30 a.m. and 2:20 p.m.. Dampers were observed in Classroom 5, the tub room in the north west corridor, the medical billing office and in Administration. The dampers were not listed as having been tested and maintained on the test record dated 11-5-08. Staff 1 stated the dampers were not on the test record and stated they had not been identified by the vendor.

NFPA 101 (2000 Edition), 10.3.1 Where required by the applicable provision of this Code, draperies, curtain, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Based on observation, the facility failed to provide flame resistant privacy curtains affecting patient rooms in 5 of 6 smoke compartments as evidenced by curtains with no tags identifying them as being flame resistant and the failure to have documents from the manufacturer identifying them as being flame resistant which had the potential for the spread of fire.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the facility drapes and curtains were observed.

At 1:35 p.m., the privacy curtains in room 19 were not labeled as being flame resistant. Staff 1 stated the facility did not have the documents from the manufacturer attesting to the flame resistance. During the facility tour between the hours of 10:30 a.m. and 2:20 p.m., there were no privacy curtains in patient rooms identified with a label noting the flame resistance of the curtain.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).

5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].

7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Exception: Shipping crates or storage cartons for cylinders.

Based on observation, the facility failed to maintain the oxygen storage area as evidenced by oxygen stored with combustible materials. This affected 1 of 6 smoke compartments and had the potential for a fire.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the oxygen storage area was observed.

At 1:10 p.m., the oxygen storage area was within the Central Supply storage area. 25 e cylinders of oxygen were store within 12 inches of storage racks containing paper forms, diapers and latex gloves.

DOOR RATING LABELS

NFPA 80 (1999 Edition) 1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Based on observation, the facility failed to maintain the smoke barriers affecting 3 of 6 smoke compartments as evidenced by the smoke barrier door rating labels painted over which had the potential to allow the spread of smoke and fire do to improperly rated smoke barrier doors.

Findings:

During the facility tour with Staff 1 on April 6, 2010, the facility smoke barrier was observed.

At 1:00 p.m., the door labels in the smoke barrier adjacent to Human Resources and the smoke barrier adjacent to rooms 7 and 8 were painted over. The door rating could not be identified. Staff 1 confirmed the labels were painted over.

At 1:21 p.m., the door labels in the corridor barrier doors for the cafeteria were painted over. The door rating could not be identified. Staff 1 confirmed the labels were painted over.

DISASTER DRILL IMPLEMENTATION

NFPA 99 (1999 Edition) 11-5.3.9* Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Based on document review, the facility failed to implement the emergency preparedness plan at least semi-annually as evidenced by the failure to provide documentation for 2 of 2 required drills. This affected 6 of 6 smoke compartments and had the potential for staff to be unprepared to function in a disaster.

Findings:

During the document review on April 6, 2010, the facility disaster drills were requested for review.

At 10:09 a.m., Staff 1 stated there were no disaster drills for review as the facility had not implemented the plan at least semi-annually as required.

NFPA 99 (1999 Edition) 3-5.4 Administration (Type 2 EES).

3-5.4.1 Maintenance and Testing of Essential Electrical System.

3-5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.

(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 3-5.3.1.

(b) Inspection and Testing. Generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b).

3-5.4.1.2 Maintenance and Testing of Circuitry. Circuitry shall be maintained and tested in accordance with 3-4.4.1.2.

3-5.4.1.3 Maintenance of Batteries. Batteries shall be maintained in accordance with 3-4.4.1.3.

3-5.4.2 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 99 (1999 Edition) 3-4.4.1 Maintenance and Testing of Essential Electrical System.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(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.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems,
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.


NFPA 110 (1999 Edition), 6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for 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.

The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA 110 (1999 Edition) 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.

Based on document review and interview, the facility failed to maintain the emergency generator as evidenced by the failure to provide documentation for 5 of 12 monthly load tests, failed to provide documentation for the annual load test and the failure to provide documentation for 26 of 52 weekly inspections. This affected 6 of 6 smoke compartments and had the potential for generator failure.

Findings:

During the document review on April 6, 2010, the generator test reports were reviewed.

At 10:00 a.m., the facility failed to provide documentation for 5 of 12 (June through October 2009) monthly full load tests. Staff 1 stated the AQMD had shut down the generator during those months as the AQMD did not have record of the facility generator. Staff 1 stated the generator was kept in service for emergencies but was not tested during the period of June through October of 2009. The problem was resolved and monthly testing started again in November of 2009.

At 10:00 a.m., the facility failed to provide documentation confirming the generator reached at least 30% of rated capacity or the minimum exhaust temperature as recommended by the manufacturer when tested under load. The last annual load test was dated 10-29-08. Staff 1 stated the load test was required as the generator did not meet the 30% or temperature requirement. Staff 1 stated the vendor had been requested to conduct the load test but that the vendor had stated it was no longer required.

At 10:00 a.m., the facility failed to provide documentation for the weekly inspection of the generator for 26 of 52 weeks. Staff 1 stated he visually inspected weekly but had only documented the inspection when the generator was run every 2 weeks.