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Based on observation, and staff interviews, the facility failed to ensuring staff is familiar with the facilities fire and disaster policy and procedures. Staff members did not have instant access (keys)on hand to locked exit doors, fire alarm key stations and fire extinguisher boxes. Staff members interviewed did not know the locations of manual pull stations and/or fire extinguishers. Staff members interviewed did not know R.A.C.E. Failure to ensure staff members carry instant access keys and know the location of manual pull stations, and fire extinguishers could result in potential harm to 5 of 5 residents in the event of a fire and/or disaster.

Findings:

During a tour of the facility, on 7/15/10, at 10:15 a.m., staff member N1, was asked to initiate the manual pull station and explain the facilities fire procedures. Staff N1, did not have keys on hand to activate the manual pull station and/or open the fire extinguisher cabinet. Staff N1 was asked to explain R.A.C.E., staff stated they did not know what R.A.C.E., was.

Based on record review, the facility failed to maintain the sprinkler system in reliable operating condition, as evidence by 2-1, 9-6.2. Failure to conduct an annual sprinkler system certification could result in potential harm and/or death to all residents and staff members in 2 of 2 smoke comparments should a fire and/or disaster occur and the sprinkler system failed to operate correctly.

NFPA 25, 1998 Edition, table 2-1:
Summary of Sprinkler System Inspection, Testing, and Maintenance. Sprinkler system devices are to be tested quarterly to ensure system remains in a reliable operating condition.
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10
Findings:During record review, on 7/16/10, at 2:30 p.m., the facility failed to provide documentation for the annual sprinkler system certification. At 2:35 p.m., an interview was conducted with staff member N16, staff confirmed the facility had not had an annual sprinkler system certification done.

Based on observation, the facility failed to ensure fire extinguishers in fire extinguisher cabinets are provided with identification signs mounted along the emergency exit corridor to identify the location of a fire extinguisher when the extinguisher is not visible, as evidence by 1-6.6 and 1-6.12. Failure to ensure fire extinguisher signage is provided to identify the location of a fire extinguisher could result in potential harm to all residents and staff members in 2 of 2 smoke compartments.

NFPA 10, 1998 Edition
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means all be provided to indicate the location.
1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)

Findings:

During a tour of the facility, on 7/13/10, the following deficiencies were observed at the following times and locations:
a) At 10:05 a.m., the fire extinguisher located in the corridor by room 119 was observed mounted inside a fire extinguisher cabinet, no sign was provided identifying the fire extinguishers location.
b) At 10:07 a.m., the fire extinguisher located in the corridor by room 106 was observed mounted inside a fire extinguisher cabinet, no sign was provided identifying the fire extinguishers location.

Based on observation and staff interview, the facility failed to maintain the emergency generator as evidenced failing to conduct monthly full load generator tests for a full 30 minutes. Failure to conduct weekly inspections, for the diesel generator could result in potential harm to all patients and staff members should the generator malfunction during a disaster and/or loss of power.

NFPA 110, 1999 Edition:
6-4., level 1 and Level 2 EPSSs, including all appurtenant
components, shall be inspected weekly and shall be exercised
under load at least monthly.
6-4.2, generator sets in Level 1 and Level 2 service shall be
exercised at least once monthly, for a minimum of 30 minutes,
using one of the following methods:
(a) Under operating temperature conditions or at not less
than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures
as recommended by the manufacturer
The date and time of day for required testing shall be
decided by the owner, based on facility operations.

Effective 1/1/09, "AB2216 codifies specific JCAHO standards under which a health facility is to test each of its diesel generators. These standards require testing to occur 12 times a year with testing intervals of not less than 20 days and not more than 40 days. The tests shall be conducted for at least 30 continuous minutes pursuant to the following:
a) A dynamic load that is at least 305 of the nameplate rating of the generator.
b) A test conducted at less than 30% of the nameplate rating of the generator, in the health facilities revises its existing documented management plant to conform with the National Fire Protection Association 110: Standard for Emergency and Standby Power Systems, 2005 edition, testing and maintenance activities. These activities shall include inspection procedures for assessing the prime mover's exhaust gas temperature against the minimum temperature recommended by the manufacturer.
If a diesel back up generator cannot be tested pursuant to the requirements of either of the above, then it shall be tested for 30 continuous minutes at intervals
with available Emergency Power Supply Systems load and tested annually with supplemental loads of all of the following in the following order for a total of two continuous hours: (1) Twenty-five percent of nameplate rating for 30 minutes. (2) Fifty percent of nameplate rating for 30 minutes. (3) Seventy-five percent of nameplate rating for 60 minutes.

This bill eliminates the requirement to start the backup generator, with or without a load, when the generator is not tested during the week.


Findings

During record review, on 7/16/10, at 12:15 p.m., documentation for the generator full load testing was reviewed. At 12:30 p.m., an interview was conducted with staff member N17. Staff was asked to explain how the generator is tested and how often. Staff stated the generator is ran twice a month under a full load for 22 minutes with a 8 minute cool down time on the diesel generator for a total of 30 minutes.
The facility failed to conduct a monthly full load test for 30 minutes not including the cool down time for the diesel generator.