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Based on observation, and interview, the facility failed to maintain their self-closing doors. This was evidenced by doors that were impeded from closing. This could allow smoke and fire to travel in the event of a fire. This affected 1 of 3 smoke compartments.

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

Findings:

During a tour of the facility, and interview with the Director of Facilities on 7/24/17, the doors were inspected.

1. At 9:03 a.m., the self-closing door to the Human Resources Office, was impeded from closing with a rubber wedge under the bottom of the door.

2. At 9:09 a.m., the self-closing door to the Social Services Office, was impeded from closing with a rubber wedge under the door.

3. At 9:14 a.m., the self-closing door to the Medical Records Office, was impeded from closing with a cart full of medical records in the door path.

4. At 9:15 a.m., the Director of Facilities said during an interview, that the door wedges were used to just hold the door open. He said that he was not aware that the doors could not be impeded with a wedge.

Based on document review, and interview, the facility failed to maintain their emergency lights. This was evidenced by no documented testing of the emergency lights. This could delay egress in the event of a power failure. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.

Findings:

During document review, and interview with the Director of Facilities on 7/25/17, the emergency light testing documents were requested.

1. At 11:12 a.m., there was no documented evidence of monthly and annual testing of the 13 emergency lights within the facility. No documented evidence was provided.

2. At 11:13 a.m., the Director of Facilities said during an interview, that the facility was not testing the emergency lights within the facility.

Based on observation, document review, and interview, the facility failed to maintain their exit signs. This was evidenced by exit signs that failed to illuminate when tested, and no documented evidence of testing the exit signs for 3 of 7 months. This could delay egress in the event of a power failure. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.
7.10.9.2 Testing. 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.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.

Findings:

During a tour of the facility, and interview with the Director of Facilities on 7/24/17 to 7/25/17, the exits signs were tested, and testing documents were reviewed.

7/24/17
1. At 9:48 a.m., exit sign number 7 near Room 8, was not illuminating when the test button was pressed.

2. At 10:06 a.m., the south exit sign in the Kitchen, was not illuminating when the test button was pressed.

3. At 10:11 a.m., the exit sign near the entrance to the multi-purpose room near the Kitchen entrance, was not illuminating when the test button was pressed.

4. At 1:47 p.m., the west exit sign in the multi-purpose room near the Kitchen, was not illuminating when tested. Maintenance staff opened up the exit sign, and found that the wire to the battery was not connected.

7/25/17
5. At 9:52 a.m., there was no documented evidence of testing the exit signs for the months of: January, February, March, and April of 2017. The exit sign inspection form was blank for the months indicated.

6. At 9:53 a.m., the Director of Facilities said during an interview, that the facility became aware of the requirement to inspect and test the exit signs in May of 2017. That was when the facility started inspecting and testing the exit signs. The Director of Facilities stated, that the exit signs were last tested on 7/5/17 for 90 seconds.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system. This was evidenced by no monthly documented inspections, and semi-annual testing of the fire alarm system batteries, and by an impeded pull station alarm. This could result in fire alarm system failure and delay access to the fire alarm device. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

9.7.7 Documentation. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.2.1.1.2 Inspection, testing, and maintenance program shall verify correct operation of the system.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.

Table 14.3.1 Visual Inspection Frequencies
3. Batteries
(a) Lead-acid X (Initial) X (Monthly)
(b) Nickel-cadmium X (Initial) X (Monthly) X (Semi-Annual)
(c) Primary (dry cell) X (Initial) X (Monthly)
(d) Sealed lead-acid X (Initial) X (Monthly) X (Semi-Annual)

5. Fire alarm control unit trouble signals X (weekly)

Table 14.4.2.2
6. Battery tests (specific types)
(a) Primary battery load voltage test The maximum load for a No. 6 primary battery shall not be more than 2 amperes per cell. An individual (1.5 volt) cell shall be replaced when a load of 1 ohm reduces the voltage below 1 volt. A 6. volt assembly shall be replaced when a test load of 4 ohms reduces the voltage below 4 volts.
(b) Lead-acid type
(1) Charger test With the batteries fully charged and connected to the charger, the voltage across the batteries shall be measured with a voltmeter. The voltage shall be 2.30 volts per cell }0.02 volts at 77 (2) Load voltage test Under load, the battery shall not fall below 2.05 volts per cell.
(3) Specific gravity The specific gravity of the liquid in the pilot cell or all of the cells shall be measured as required. The specific gravity shall be within the range specified by the manufacturer. Although the specified specific gravity varies from manufacturer to manufacturer, a range of 1.205.1.220 is typical for regular lead-acid batteries, while 1.240.1.260 is typical for high-performance batteries. A hydrometer that shows only a pass or fail condition of the battery and does not indicate the specific gravity shall not be used, because such a reading does not give a true indication of the battery condition.
(c) Nickel-cadmium type
(1) Charger test With the batteries fully charged and connected to the charger, an ampere meter shall be placed in series with the battery under charge. The charging current shall be in accordance with the manufacturer recommendations for the type of battery used. In the absence of specific information, 1.30 to 1/25 of the battery rating shall be used.
(2) Load voltage test Under load, the float voltage for the entire battery shall be 1.42 volts per cell, nominal. If possible, cells shall be measured individually.
(d) Sealed lead-acid type
(1) Charger test With the batteries fully charged and connected to the charger, the voltage across the batteries shall be measured with a voltmeter. The voltage shall be 2.30 volts per cell }0.02 volts at 77 (2) Load voltage test Under load, the battery shall perform in accordance with the battery manufacturer specifications.
14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

5.13.5* Manual fire alarm boxes shall be installed so that they are conspicuous, unobstructed, and accessible.

10.2.2.1* The property or building owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.
10.2.2.2 The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.
10.2.2.3 Inspection, testing, or maintenance shall be permitted to be done by a person or organization other than the owner if conducted under a written contract.
10.2.2.4 Testing and maintenance of central station service systems shall be performed under the contractual arrangements specified in 8.3.3.

10.2.2.5* Service Personnel Qualifications and Experience.
10.2.2.5.1 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems. Qualified personnel shall include, but not be limited to, one or more of the following:
(1)*Personnel who are factory trained and certified for fire alarm system service of the specific type and brand of system
(2)*Personnel who are certified by a nationally recognized fire alarm certification organization acceptable to the authority having jurisdiction
(3)*Personnel who are registered, licensed, or certified by a state or local authority
(4) Personnel who are employed and qualified by an organization listed by a nationally recognized testing laboratory for the servicing of fire alarm systems
10.2.2.5.2 Evidence of qualifications shall be provided to the authority having jurisdiction upon request.

8.3.3 Contract Requirements. The central station service elements shall be provided under contract to a subscriber by one of the following:
(1) A listed central station that provides all of the elements of central station service with its own facilities and personnel.
(2) A listed central station that provides, as a minimum, the signal monitoring, retransmission, and associated record keeping and reporting with its own facilities and personnel and shall be permitted to subcontract all or any part of the installation, testing, and maintenance and runner service.
(3) A listed fire alarm service-local company that provides the installation, testing, and maintenance with its own facilities and personnel and that subcontracts the monitoring, retransmission, and associated record keeping and reporting to a listed central station. The required runner service shall be provided by the listed fire alarm service-local company with its own personnel or the listed central station with its own personnel.
(4) A listed central station that provides the installation, testing, and maintenance with its own facilities and personnel and that subcontracts the monitoring, retransmission, and associated record keeping and reporting to another listed central station. The required runner service shall be provided by either central station.

Findings:

During a tour of the facility, and interview with the Director of Facilities on 7/24/17 to 7/25/17, the fire alarm system components were inspected, inspection and testing records were requested, and certification for the inspector was requested.

7/24/17
1. At 1:56 p.m., the pull station device near the exit toward the laundry, and by the multi-purpose room was impeded from access with an unattended wheelchair and a walker leaning against the device.

7/25/17
2. At 10:11 a.m., there was no documented evidence that the Kitchen roll down door, was inspected and certified on annual basis.

3. At 10:12 a.m., the Director of Facilities said during an interview, that the he conducted the test on the roll down door. He said that he was certified by a nationally recognized fire alarm certification organization, and had not been factory trained to conduct the test.

4. At 10:42 a.m., there was no documented evidence that the fire alarm control panel sealed lead acid batteries (4), were visually inspected monthly and tested semi-annually. No documented evidence was provided during the survey.

5. At 10:44 a.m., the Director of Facilities said during an interview, that he looked at the fire panel every month, but did not document the inspections, and did not conduct a voltage test on the fire alarm batteries.

Based on observation, document review, and interview, the facility failed to maintain their sprinkler system. This was evidenced by no documented monthly visual inspections of the sprinkler components. T he failure to inspect the sprinkler components could result in a malfunction in the event of a fire. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
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.
5.2.4 Gauges.
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.

5.3.3 Waterflow Alarm Devices.
5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

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

4.1.1.2 Inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

Findings:

During a tour of the facility, and interview with the Director of Facilities on 7/25/17, the sprinkler components were examined, and inspection documents were requested.

1. At 10:19 a.m., there was no documented evidence of monthly visual inspections of the sprinkler gauges and valves as required. No documented evidence was provided for monthly visual inspections.

2. At 10:21 a.m., the Director of Facilities said, that the gauges were inspected quarterly with the sprinkler flow test.

Based on observation, and interview, the facility failed to maintain their fire extinguishers. This was evidenced by a fire extinguisher that was impeded from access. This could delay access to a fire extinguisher. This affected 1 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
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, 2010 Edition
7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self-expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for non-rechargeable extinguishers using push-to-test pressure indicators

Findings:

During a tour of the facility with the Director of Facilities on 7/24/17, the fire extinguishers were observed, and a staff person was interviewed.

1. At 10:01 a.m., the K-class fire extinguisher in the kitchen was impeded from access with an unattended cart full of produce.

2. At 10:03 a.m., the cook said, that the cart was usually in front of the fire extinguisher.

Based on observation, and interview, the facility failed to maintain their doors. This was evidenced by a door that failed to latch. This could allow the spread of smoke and fire in the event of a fire. This affected 1 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protective's, except as otherwise specified in this Code.

NFPA 80, Standard for Fire Doors and Fire Windows, 2010 Edition
4.3.1* Only labeled fire doors shall be used.

5.2.14.1 Self-closing devices shall be kept in working condition at all times.

Findings:

During a tour of the facility, and interview with the Director of Facilities on 7/26/17, the doors in the facility were inspected.

1. At 9:36 a.m., the self-closing corridor door to the Stamp Room near the nursing station, was not latching when tested.

2. At 9:37 a.m., the Director of Facilities said during an interview, that he tested the door last week, and that the door was latching fine.

Based on observation, and interview, the facility failed to maintain their subdivision of building spaces. This was evidenced by unsealed penetrations. This could allow the spread of smoke and fire in the event of a fire. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2 -hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

Finding:

During a tour of the facility, and interview with the Director of Facilities on 7/24/17, the separation walls were observed.

1. At 12:55 p.m., there were three approximately 1 inch round unsealed pipes through the smoke barrier wall near the Dietary Office. The Director of Facilities acknowledged the finding.

2. At 1:01 p.m., there was an approximately 3 inch round unsealed pipe through the smoke barrier wall near the Director of Patient Services Office. There were blue wires going through the pipe.

3. At 1:10 p.m., there was an approximately 2 foot by 1 foot unsealed penetration, and an approximately 2 foot by 2 foot unsealed penetration in the smoke barrier wall near Room 7.

4. At 1:11 p.m., the Director of Facilities said during an interview, that he thought that the wall was not a smoke wall until he saw it on the architect drawing.

Based on observation, and interview, the facility failed to maintain their smoke barrier doors. This was evidenced by a door that was not flush when tested. This could allow smoke and fire to travel in the event of a fire. This affected 2 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.3.7.6 Openings in smoke barriers shall be protected using one of the following methods:
(1) Fire-rated glazing
(2) Wired glass panels in steel frames
(3) Doors, such as 13.4 in. (44 mm) thick, solid-bonded woodcore doors
(4) Construction that resists fire for a minimum of 20 minutes.
19.3.7.6.1* Nonrated factory- or field-applied protective plates, unlimited in height, shall be permitted.
19.3.7.6.2 Doors shall be permitted to have fixed fire window assemblies in accordance with Section 8.5.
19.3.7.8* Doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.

8.5.4.1* Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3.4 in. (19 mm).
8.5.4.2 Where required by Chapters 11 through 43, doors in smoke barriers that are required to be smoke leakage rated shall comply with the requirements of 8.2.2.4.
8.5.4.3 Latching hardware shall be required on doors in smoke barriers, unless specifically exempted by Chapters 11 through 43.
8.5.4.4* Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Findings:

During a tour of the facility, and interview with the Director of Facilities on 7/25/17, the smoke barrier doors were tested..

1. At 9:17 a.m., the west smoke barrier door near the Dietary Office and Room 8 was approximately 2 inches from being flush to the opposite door when tested. Two attempts were made without the door being flush.

2. At 9:18 a.m., the Director of Facilities said during an interview, that the door was tested approximately two weeks ago and that it was latching.

Based on observation, and interview, the facility failed to maintain their utilities. This was evidenced by electrical outlets that were broken, and by an electrical outlet with a broken faceplate. This could result in an electrical fire. This affected 2 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
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
110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. Informational Note: Accepted industry practices are described in ANSI/NECA 1-2006, Standard Practices for Good Workmanship in Electrical Contracting, and other ANSI-approved installation standards.
(A) Unused Openings. Unused openings, other than those intended for the operation of equipment, those intended for mounting purposes, or those permitted as part of the design for listed equipment, shall be closed to afford protection substantially equivalent to the wall of the equipment. Where metallic plugs or plates are used with nonmetallic enclosures, they shall be recessed at least 6 mm (1/4 in.) from the outer surface of the enclosure.
(B) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

314.20 In Wall or Ceiling. In walls or ceilings with a surface of concrete, tile, gypsum, plaster, or other noncombustible material, boxes employing a flush-type cover or faceplate shall be installed so that the front edge of the box, plaster ring, extension ring, or listed extender will not be set back of the finished surface more than 6 mm (1?4 in.). In walls and ceilings constructed of wood or other combustible surface material, boxes, plaster rings, extension rings, or listed extenders shall be flush with the finished surface or project therefrom.

Finding:

During a tour of the facility, and interview with the Director of Facilities on 7/24/17, the electrical system was examined.

1. At 8:58 a.m., there were two broken ground ports on the electrical outlet near the entrance.

2. At 9:23 a.m., there were two broken ports on the electrical outlet near the Medication Room in the Pharmacy.

3. At 9:40 a.m., there were four broken ground ports on the electrical outlets near Bed D in Room 7.

4. At 10:19 a.m., there were two broken ground ports on the electrical outlet below the clock in Room 14.

5. At 10:23 a.m., there was a broken faceplate on the electrical outlet near Bed A in Room 15. Approximately 1/4 of the bottom of the faceplate was missing.

6. At 10:24 a.m., there four broken ground ports on the electrical outlets between Beds A and B in Room 15.

7. At 10:25 a.m., the Director of Facilities said during an interview, that the facility was not looking at the ground ports during the annual inspection of the outlets.

Based on document review, and interview, the facility failed to conduct fire drills at varying times. This was evidenced by 4 of 4 fire drills for the NOC shift, and 3 of 4 fire drills for the P.M. shift, that were conducted around the same time. This could result in Staff failing to respond during other times in the event of an emergency. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.
19.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.
19.7.1.3 A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center.
19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

Finding:

During document review, and interview with the Director of Facilities on 7/25/17, the fire drill records were reviewed.

1. At 1:45 p.m., three of three fire drills for the P.M. shift were conducted at around 3:30 p.m. The fire drills provided the following information: 4/28/17, the fire drill was conducted at 3:35 p.m., 1/27/17, the fire drill was conducted at 3:30 p.m., and 10/28/16, the fire drill was conducted at 3:30 p.m.

2. At 1:47 p.m., four of four fire drills for the NOC shift were conducted at around 6:30 p.m. The fire drills provided the following information: 5/27/17, the fire drill was conducted at 6:20 a.m., 2/28/17, the fire drill was conducted at 6:30 a.m., 11/29/16, the fire drill was conducted at 6:30 a.m., and 8/18/16, the fire drill was conducted at 6:40 a.m.

3. At 1:50 p.m., the Director of Facilities said during an interview, that it was convenient to conduct a fire drill during a shift change, and acknowledged the finding.

Based on observation, and interview, the facility failed to maintain their generator. This was evidenced by no emergency light inside the generator enclosure. This could delay emergency repairs on the generator in the event of a power failure. This affected 3 of 3 smoke compartments.

NFPA 99, Health Facilities Code, 2012 Edition
15.5.1.3 Emergency Generators and Standby Power Systems. Emergency generators and standby power systems, where required for compliance with this code, shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency Standby Power Systems, 2010 Edition
7.3 Lighting.
7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures
that do not include walk-in access.
7.3.2 The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During a tour of the facility, and interview with the Director of Facilities on 7/24/17, the generator enclosure was observed.

1. At 10:38 a.m., there was no emergency light inside of the enclosed generator building located near the laundry. The generator was located inside of a walk-in tin building.

2. At 10:40 a.m., the Director of Facilities said during an interview, that there was never an emergency light inside of the generator building, and acknowledged the finding.