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Based on interview and document review, the facility failed to conduct fire drills at least quarterly on each shift, as evidenced by the failure to provide 1 of 12 fire drills for the NOC shift 2nd quarter of 2014. This could lead to staff not understanding the evacuation procedures in the event of an emergency, and affected 4 of 4 smoke compartments.

Findings:

During document review with Facilities Operations Manager on 1/5/15, the fire drill records were reviewed.

At 10:05 a.m., 1 of 4 fire drills was missing for the NOC shift in 2014. A fire drill for the 2nd quarter NOC shift was missing. A NOC shift fire drill was conducted on 7/1/14. When interviewed, the Facilities Operations Manager stated that the Maintenance Supervisor should have conducted the fire drill 4 hours earlier.

Based on document review and interview, the facility failed to maintain their smoke detectors as evidenced by the failure to provide documentation for the smoke detector sensitivity testing. This could result in the increased risk of a smoke detector malfunction, and affected 4 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
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.

NFPA 72, National Fire Alarm Code, 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 be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
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.

Findings:

During document review and interview with the Regional Facilities Operations Manager on 1/5/15, the records for the smoke detector sensitivity testing were requested.

1. On 1/5/15 at 9:12 a.m., the facility failed to provide documentation to show that the smoke detectors were tested for sensitivity. The annual fire alarm system inspection/certification report dated 6/27/14 indicated that the smoke detectors were tested/cleaned, but no sensitivity readings were in the report. When interviewed, the Regional Facilities Operations Manager did not know if the smoke detectors were tested for sensitivity. The Regional Facilities Operations Manager was asked if a printout of the sensitivity readings could be printed from the fire alarm control panel, since it is an addressable smart system. The Regional Facilities Operations Manager did not know and contacted the vendor. The vendor was scheduled for a site visit on 1/6/15.

2. On 1/6/15 at 9:10 a.m., the vendor was onsite and stated that they just clean and test the smoke detectors. In order to perform the smoke detector sensitivity testing and to printout the results, SimplexGrinnell would have to be onsite to assist. The fire alarm control panel is a SimplexGrinnell smart/addressable system. SimplexGrinnell would have to connect a laptop to the fire alarm control panel in order to obtain a printout of the smoke detector sensitivity readings.

Based on record review and interview, the facility failed to maintain the supervised sprinkler shut-off valve. This was evidenced by the facility's post indicator valve that took five full revolutions before activating a trouble alarm at the fire alarm control panel. This affected 4 of 4 smoke compartments and could result in a delayed notification of a suspension in water supply to the automatic fire sprinkler system.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, waterflow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

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.

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

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

Findings:

During record review and interview with the Regional Facilities Operations Manager on 1/5/14, the facility's automatic fire sprinkler system records were reviewed.

At 1:16 p.m., the vendor's quarterly sprinkler testing report dated 11/26/14 stated failed on Control Valves (tamper) "Riser ID 1: Took 5 turns for the Tamper to activate alarm". When interviewed, the Regional Facilities Operations Manager stated he was aware of the problem and that a work order has been created to have the problem corrected.

Based on observation and interview, the facility failed to maintain its sprinklers as evidenced by sprinklers that did not have at least 18 inch clearance between the deflector and the top of the storage. This could result in a sprinkler malfunction in the event of a fire and affected 1 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition
5-5.6* Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1: Where other standards specify greater minimums, they shall be followed.
Exception No. 2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.


Findings:

During a tour of the facility with the Regional Facilities Operations Manager on 1/5/15, the sprinklers in the facility were observed.

At 11:49 a.m., in the Clean Linen Closet between Rooms 115 and 113, a blue sleeping wedge pillow was stored approximately 10 inches of the sprinkler deflector plate. The Regional Facilities Operations Manager had staff remove the wedge pillow.

Based on interview, document review, and observation, the facility failed to maintain their emergency generator as evidenced by no emergency light by the generator area, and by transfer times exceeding the 10 second maximum. This could lead to a malfunction of the generator in an emergency and not having sufficient lighting to work on the generator. This affected 4 of 4 smoke compartments.

NFPA 99, Standard for Health Care Facilities, 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 101, Life Safety Code, 2000 Edition
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.1.2 Where maintenance of illumination depends on changing from one energy source to another, a delay of not more than 10 seconds shall be permitted.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
5-3 Lighting.
5-3.1 The level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
2-2.2 Type. Type defines the maximum time, in seconds, that the EPSS will permit the load terminals of the transfer switch to be without acceptable electrical power. Table 2-2.2 provides the types defined by this standard. Type 10 10 seconds.

Findings:

During document review and a tour of the facility with Regional Facilities Operations Manager on 1/5/15, the emergency generator was observed.

1. At 10:05 a.m. during document review, the generator maintenance logs were observed. On various dates ranges from 1/9/14 to 8/8/14, the transfer times for the monthly load tests were over the 10 second minimum. The transfer times during that time period were ranging from 15 seconds to 30 seconds. The transfer times during that period were as follows: 1/9/14: 27 seconds; 1/23/14: 26 seconds; 2/6/14: 20 seconds; 2/20/14: 26 seconds; 3/6/14: 27 seconds; 3/20/14: 22 seconds; 4/3/14: 20 seconds:4/10/14: 27 seconds; 4/16/14: 26 seconds; 5/1/14: 29 seconds; 5/15/14: 28 seconds; 5/29/14: 30 seconds; 6/12/14: 20 seconds; 6/25/14: 30 seconds; 7/10/14: 30 seconds; 7/24/14: 15 seconds; 8/8/14: 30 seconds. When interviewed, the Regional Facilities Operations Manager stated that he did not know why the transfer times were high, possible error in recording the times or problem with the automatic transfer switch. The Regional Facilities Operations Manager stated that he will contact the vendor to check the automatic transfer switch.

2. At 10:30 a.m., the generator area in the back parking lot was observed. No emergency lighting unit was observed in the generator area. When interviewed, the Regional Facilities Operations Manager stated that since the unit was outside, an emergency lighting unit was not needed.

Based on interview and observation, the facility failed to maintain their electrical wiring and equipment, as evidenced by a missing receptacle faceplate in a resident room. This could lead to an increased risk for an electrical fire, and affected 1 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4) Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b) & 305-4 c)

400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

410-56. Rating and Type.
(e) Position of Receptacle Faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with the Regional Facilities Operations Manager on 1/5/15, the electrical wiring in the facility was observed.

At 11:47 a.m., in Room 115, the receptacle cover for a light switch was missing, exposing an approximately 1/2 penetration around the light switch. When interviewed, the Regional Facilities Operations Manager stated that the resident kicked the cover off the wall and the wall was recently patched, awaiting the cover to be installed.

Based on interview and document review, the facility failed to conduct fire drills at least quarterly on each shift, as evidenced by the failure to provide 1 of 12 fire drills for the NOC shift 2nd quarter of 2014. This could lead to staff not understanding the evacuation procedures in the event of an emergency, and affected 4 of 4 smoke compartments.

Findings:

During document review with Facilities Operations Manager on 1/5/15, the fire drill records were reviewed.

At 10:05 a.m., 1 of 4 fire drills was missing for the NOC shift in 2014. A fire drill for the 2nd quarter NOC shift was missing. A NOC shift fire drill was conducted on 7/1/14. When interviewed, the Facilities Operations Manager stated that the Maintenance Supervisor should have conducted the fire drill 4 hours earlier.

Based on document review and interview, the facility failed to maintain their smoke detectors as evidenced by the failure to provide documentation for the smoke detector sensitivity testing. This could result in the increased risk of a smoke detector malfunction, and affected 4 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
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.

NFPA 72, National Fire Alarm Code, 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 be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
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.

Findings:

During document review and interview with the Regional Facilities Operations Manager on 1/5/15, the records for the smoke detector sensitivity testing were requested.

1. On 1/5/15 at 9:12 a.m., the facility failed to provide documentation to show that the smoke detectors were tested for sensitivity. The annual fire alarm system inspection/certification report dated 6/27/14 indicated that the smoke detectors were tested/cleaned, but no sensitivity readings were in the report. When interviewed, the Regional Facilities Operations Manager did not know if the smoke detectors were tested for sensitivity. The Regional Facilities Operations Manager was asked if a printout of the sensitivity readings could be printed from the fire alarm control panel, since it is an addressable smart system. The Regional Facilities Operations Manager did not know and contacted the vendor. The vendor was scheduled for a site visit on 1/6/15.

2. On 1/6/15 at 9:10 a.m., the vendor was onsite and stated that they just clean and test the smoke detectors. In order to perform the smoke detector sensitivity testing and to printout the results, SimplexGrinnell would have to be onsite to assist. The fire alarm control panel is a SimplexGrinnell smart/addressable system. SimplexGrinnell would have to connect a laptop to the fire alarm control panel in order to obtain a printout of the smoke detector sensitivity readings.

Based on record review and interview, the facility failed to maintain the supervised sprinkler shut-off valve. This was evidenced by the facility's post indicator valve that took five full revolutions before activating a trouble alarm at the fire alarm control panel. This affected 4 of 4 smoke compartments and could result in a delayed notification of a suspension in water supply to the automatic fire sprinkler system.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, waterflow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

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.

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

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

Findings:

During record review and interview with the Regional Facilities Operations Manager on 1/5/14, the facility's automatic fire sprinkler system records were reviewed.

At 1:16 p.m., the vendor's quarterly sprinkler testing report dated 11/26/14 stated failed on Control Valves (tamper) "Riser ID 1: Took 5 turns for the Tamper to activate alarm". When interviewed, the Regional Facilities Operations Manager stated he was aware of the problem and that a work order has been created to have the problem corrected.

Based on observation and interview, the facility failed to maintain its sprinklers as evidenced by sprinklers that did not have at least 18 inch clearance between the deflector and the top of the storage. This could result in a sprinkler malfunction in the event of a fire and affected 1 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition
5-5.6* Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1: Where other standards specify greater minimums, they shall be followed.
Exception No. 2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.


Findings:

During a tour of the facility with the Regional Facilities Operations Manager on 1/5/15, the sprinklers in the facility were observed.

At 11:49 a.m., in the Clean Linen Closet between Rooms 115 and 113, a blue sleeping wedge pillow was stored approximately 10 inches of the sprinkler deflector plate. The Regional Facilities Operations Manager had staff remove the wedge pillow.

Based on interview, document review, and observation, the facility failed to maintain their emergency generator as evidenced by no emergency light by the generator area, and by transfer times exceeding the 10 second maximum. This could lead to a malfunction of the generator in an emergency and not having sufficient lighting to work on the generator. This affected 4 of 4 smoke compartments.

NFPA 99, Standard for Health Care Facilities, 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 101, Life Safety Code, 2000 Edition
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.1.2 Where maintenance of illumination depends on changing from one energy source to another, a delay of not more than 10 seconds shall be permitted.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
5-3 Lighting.
5-3.1 The level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
2-2.2 Type. Type defines the maximum time, in seconds, that the EPSS will permit the load terminals of the transfer switch to be without acceptable electrical power. Table 2-2.2 provides the types defined by this standard. Type 10 10 seconds.

Findings:

During document review and a tour of the facility with Regional Facilities Operations Manager on 1/5/15, the emergency generator was observed.

1. At 10:05 a.m. during document review, the generator maintenance logs were observed. On various dates ranges from 1/9/14 to 8/8/14, the transfer times for the monthly load tests were over the 10 second minimum. The transfer times during that time period were ranging from 15 seconds to 30 seconds. The transfer times during that period were as follows: 1/9/14: 27 seconds; 1/23/14: 26 seconds; 2/6/14: 20 seconds; 2/20/14: 26 seconds; 3/6/14: 27 seconds; 3/20/14: 22 seconds; 4/3/14: 20 seconds:4/10/14: 27 seconds; 4/16/14: 26 seconds; 5/1/14: 29 seconds; 5/15/14: 28 seconds; 5/29/14: 30 seconds; 6/12/14: 20 seconds; 6/25/14: 30 seconds; 7/10/14: 30 seconds; 7/24/14: 15 seconds; 8/8/14: 30 seconds. When interviewed, the Regional Facilities Operations Manager stated that he did not know why the transfer times were high, possible error in recording the times or problem with the automatic transfer switch. The Regional Facilities Operations Manager stated that he will contact the vendor to check the automatic transfer switch.

2. At 10:30 a.m., the generator area in the back parking lot was observed. No emergency lighting unit was observed in the generator area. When interviewed, the Regional Facilities Operations Manager stated that since the unit was outside, an emergency lighting unit was not needed.

Based on interview and observation, the facility failed to maintain their electrical wiring and equipment, as evidenced by a missing receptacle faceplate in a resident room. This could lead to an increased risk for an electrical fire, and affected 1 of 4 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4) Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b) & 305-4 c)

400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

410-56. Rating and Type.
(e) Position of Receptacle Faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with the Regional Facilities Operations Manager on 1/5/15, the electrical wiring in the facility was observed.

At 11:47 a.m., in Room 115, the receptacle cover for a light switch was missing, exposing an approximately 1/2 penetration around the light switch. When interviewed, the Regional Facilities Operations Manager stated that the resident kicked the cover off the wall and the wall was recently patched, awaiting the cover to be installed.