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Based on observation, the facility failed to maintain the smoke and fire resistance rating for 2-hour rated fire barrier walls in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2¹. This deficiency affected 2 of 9 smoke compartments.

Findings include:

On 12/29/14 at 10:54 a.m., the two hour fire wall in the boiler room was observed to have a conduit with wire running through the wall. The open end of the conduit was not sealed.

¹ NFPA 101, 2000 Edition, Section 8.2.3.2.4.2, Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to ensure that interior finishes in a sprinklered building met at least a Class C flame spread rating as required in NFPA 101, 2000 Edition, Sections 19.3.3.2¹ and 10.2.3.2(c)². The deficiency affects 1 of 9 smoke compartments.

Findings include:

On 12/29/14 at 4:25 p.m., the tub room on the secured unit was observed to have a sheet of plywood covering the exterior window. The plywood had a shiny finish. During an interview, staff member A, maintenance supervisor, stated a fire retardant material had been applied to the plywood. A data sheet for the material applied was not provide.

¹ NFPA 101, 2000 Edition, Section 19.3.3.2 Interior Wall and Ceiling Finish, Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
(2) Newly installed materials Class A
Exception No. 1: Newly installed walls and ceilings shall be permitted to have Class A or Class B interior finish in individual rooms having a capacity not exceeding four persons.
Exception No. 2: Newly installed corridor wall finish not exceeding 4 ft (1.2 m) in height that is restricted to the lower half of the wall shall be permitted to be Class A or Class B.

² NFPA 101, 2000 Edition, Section 10.2.3.2; Products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale.

Based on observations and interviews, the facility failed to ensure that all corridor doors were free from impediments, latched properly, and resisted the passage of smoke per NFPA 101, 2000 Edition, Sections 19.3.6.3.1, 19.3.6.3.2, and 19.3.6.3.3. These deficiencies have the potential to affect patients/residents, staff, and visitors in 3 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 11:25 a.m., the double doors leading from the LTC dining room to the corridor were observed. The doors had a 1/2 inch gap between them at their meeting edges. Staff member A, maintenance supervisor, stated that the door sweep for the south door leading edge had been removed.¹

2. During an observation of the X-ray department on 12/29/14 at 1:03 p.m., the following was observed:
a.) The lead lined corridor door to the X-ray department was sagging and had greater than 1/2 inch gaps at the top of the door near the hinge and at the door bottom on the latching side.¹
b.) The lead lined corridor door to the X-ray department would not close to positive latching.²

3. During an observation on 12/29/14 at 3:07 p.m., the corridor door to room 207 on Centennial West was held open with a container of Sani Wipes and when exercised, would not latch.³

4. During an observation on 12/29/14 at 3:20 p.m., the corridor door to room 201 on Centennial West would not latch, when exercised.²

5. During an observation on 12/29/14 at 3:32 p.m., the corridor door to the nurses report room/break room on Centennial West was held open with a garbage can. Staff member A, maintenance supervisor, stated the Centennial West wing was added after the south hall. The Centennial West wing has a history of uneven floors due to the building settling.³

6. On 12/29/14 at 3:35 p.m., the corridor door to resident room 170 had two penetrations through the door. Staff member A stated the room had been an office with a magnetic lock on the door which had been removed.¹

¹ NFPA 101, 2000 Edition, Section 19.3.6.3.1, Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

² NFPA 101, 2000 Edition, Section 19.3.6.3.2, Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

³ NFPA 101, 2000 Edition, Section 19.3.6.3.3, Hold-open devices that release when the door is pushed or pulled shall be permitted. Annex A.19.3.6.3.3, doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observations and staff interview, the facility failed to maintain the self-closing corridor doors to hazardous areas in accordance with NFPA 101, 2000 Edition, Section 19.3.2.1.¹ These deficiencies affect 2 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 10:42 a.m., the corridor door to the laundry failed to properly close and latch when released from a fully opened position. During and interview, staff member A, maintenance supervisor, stated the self-closing hinges needed to be replaced with a top mounted self-closer.

2. On 12/29/14 at 2:45 p.m., the self closing door to the Biohazard storage room in the Emergency Room would not close and latch when released from a fully opened position.

¹ NFPA 101, 2000 Edition, Section 19.3.2.1 Hazardous Areas, Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observations, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1¹. These deficiencies affect 5 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 2:30 p.m., the Island tub room smoke barrier wall was observed. There was a four inch by four inch section of gypsum board was missing where a flexible wire conduit entered the wall.

2. On 12/30/14 at 10:35 a.m., the smoke barrier above the shower room in the Nursing East hall was observed. There was a one foot by one foot hole in the barrier. During an interview, staff member A, maintenance supervisor, stated the tub room had been remodeled and some of the plumbing had been changed.

3. On 12/30/14 at 10:40 a.m., the smoke barrier above the smoke doors in the Nursing East hall was observed. There was a penetration with a white wire through the barrier.

4. On 12/30/14 at 10:44 a.m., the smoke barrier in the tub room on the Special Care Unit was observed. There were two unsealed penetrations into the smoke barrier:
a.) A gray PVC pipe.
b.) A white wire in a conduit.

5. On 12/30/14 at 10:58 a.m., the smoke barrier wall in the activities department was observed. There were two unsealed penetrations by the angular wall area of the barrier.
a.) A conduit with white wire.
b.) A metal conduit pipe, two blue wires, two gray wires and one white wire.

¹ NFPA 101, 2000 Edition, Section 8.3.6.1, Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to maintain clear pathways to the exit discharge in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1¹ and Centers for Medicare and Medicaid Services (CMS) Policy S&C-05-38². The deficiency affects 4 of 9 exits.

1. On 12/29/14 at 2:27 p.m., the northeast exit path from the CAH was observed to have an accumulation of drifted snow on the sidewalk.

2. On 12/29/14 at 3:19 p.m., the west exit path from Centennial West was observed to have an accumulation of snow on the sidewalk.

3. On 12/29/14 at 3:29 p.m., the north exit path through the courtyard from Centennial West was observed to have an accumulation of snow on the sidewalk.

4. On 12/29/14 at 3:40 p.m., the east exit path from Centennial East was observed to have an accumulation of snow on sidewalk.

5. On 12/29/14 at 4:00 p.m., the southwest exit path from the West Hallway exit door was observed to have an accumulation of snow on the sidewalk.

¹ NFPA 101, 2000 Edition, Section 7.1.10.1, Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Annex A.7.1.10.1, A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

² CMS Survey and Certification Policy S&C-05-38 Clarification of Life Safety Code Survey Issues in Nursing Homes, Issued 7/14/05.

Based on observation, the facility failed to assure that means of egress were illuminated such that, the failure of the fixture did not leave the area in darkness in accordance with NFPA 101, 2000 Edition, Sections 7.8.1.3¹ and 7.8.1.4². This deficiency affects 1 of 9 exits.

Findings include:

On 12/30/14 at 7:05 a.m., the west exit near rooms 109 & 110 of the CAH was observed. The exterior light was not functioning and the walkway was dark.

¹ NFPA 101, 2000 Edition, Section 7.8.1.3, The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.

² NFPA 101, 2000 Edition, Section 7.8.1.4, Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

Based on observations, the facility failed to ensure all battery-powered emergency light fixtures operated per NFPA 101, 2000 Edition, Section 4.6.12.2 and NFPA 110, 1999 Edition, Section 5-3.1. This deficiency could affect 2 of 9 compartments.

Findings include:

1. On 12/29/14 at 11:09 a.m., the generator room was observed. The emergency light on the east wall would not illuminate when tested.¹ ²

2. On 12/29/14 at 1:10 p.m., the office area next to Labor and Delivery was observed. The emergency light on the wall would not illuminate when tested.¹

¹ NFPA 101, 2000 Edition, Section 4.6.12.2, Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

² NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 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.

Based on record review and staff interview, the facility failed to conduct a load voltage test on the fire alarm control panel batteries semiannually as required per NFPA 72, 1999 Edition, Section 7-3.2¹and Table 7-3.2². The deficiency could affect all nine smoke compartments.

Findings include:

On 12/29/14 at 5:00 p.m., the annual fire alarm panel testing records were reviewed. The records reflected that the load voltage test on the sealed lead-acid batteries for the fire alarm control panel was conducted once on 2/25/14. The next semiannual test should have been conducted on or before 9/23/14 (180 days+30 days = 210 days) and was not.¹

During an interview with staff member A, maintenance supervisor, he stated the load voltage tests were conducted annually and not semiannually.

¹ NFPA 72 National Fire Alarm Code,1999 Edition, Section 7-3.2 Testing, Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

² NFPA 72 , 1999 Edition, Table 7.3.2 (6)(d)(1) & (3), requires sealed lead-acid type batteries to be replaced every four years and have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observation, the facility failed to provide a complete sprinkler system free of obstructions for complete sprinkler pattern coverage in accordance with NFPA 13, 1999 Edition, Section 5-6.6. The deficiency could affect 1 of 9 smoke compartments.

Findings include:

On 12/29/14 at 2:17 p.m., the storage area next to room 101 was observed. A sprinkler head was installed above a cabinet with approximately one inch of clearance to the top of the cabinets.

During an interview, staff member A, maintenance supervisor, stated there had been a separation wall that was removed and the cabinets were added to the area. The sprinkler head over the added cabinets was well within the 18 inches of the sprinkler deflector.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, 5-6.6 Clearance to Storage (Standard Pendent and Upright Spray Sprinklers), The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception: Where other standards specify greater minimums, they shall be followed.

Based on observation, the facility failed to ensure the automatic sprinkler system was maintained per NFPA 13, 1999 Edition, Sections 5-1.1¹. These deficiencies affect occupants in 5 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 10:17 a.m., the kitchen was observed to have multiple ceiling tiles with penetrations and plastic sheeting missing or peeling away from the tiles. The areas observed were the dish room, the southeast corner, and the west side of the kitchen.

2. On 12/29/14 at 10:50 a.m., the maintenance office was observed to have two ceiling tiles moved out of the ceiling assembly. This caused a large penetration in the ceiling.

3. On 12/29/14 at 11:16 a.m., the housekeeping closet in the maintenance hallway was observed to have a penetration around the pipe for the roof drain.

4. On 12/29/14 at 11:19 a.m., the break room in the maintenance hallway was observed. There was a penetration in the ceiling and a piece of the T bar that holds the ceiling tiles in place was broken.

5. On 12/29/14 at 12:54 p.m., the construction area for the new labor and delivery room was observed. There were three ceiling tiles missing. There was not active construction nor staff in the area. The ceiling panels must be replaced when construction is not ongoing unless a fire watch is established because the automatic sprinkler system can delay fire extinguishment without ceiling panels in place.

6. On 12/29/14 at 12:55 p.m., the x-ray control room was observed.
a.) The wire chase going through the ceiling tiles had a two inch circular penetration area around it.
b.) There was also a two inch round penetration through a ceiling tile.

7. On 12/29/14 at 1:10 p.m., the bathroom next to the labor and delivery room was observed to have a ceiling tile missing.

8. On 12/29/14 at 2:17 p.m., a sprinkler head was observed in room 101. The escutcheon ring was missing from the sprinkler head allowing a penetration into the ceiling.

9. On 12/29/14 at 2:39 p.m., a sprinkler head was observed in the nursery. The escutcheon ring was missing from the sprinkler head.

10. On 12/29/14 at 2:40 p.m., the medication room in the CAH was observed.
a. There was a two inch penetration in the ceiling assembly.
b. A sprinkler head was observed at the CAH nurses station. The escutcheon ring was missing from the sprinkler head.

11. On 12/29/14 at 3:00 p.m., a sprinkler head was observed in the ladies locker room located in the hallway between LTC and the CAH. The escutcheon ring was missing from the sprinkler head.

12. On 12/29/14 at 3:17 p.m., the return air vent in the ceiling of the tub room on Centennial West was observed to have a one inch gap around it.

13. On 12/29/14 at 3:20 p.m., the hospice room was observed to have a penetration in the corner of a ceiling tile above the sink.

14. On 12/29/14 at 3:33 p.m., the beauty shop was observed to have a ceiling tile that did not fit properly, allowing a penetration in the ceiling assembly.

15. On 12/29/14 at 4:01 p.m., room 193, the sleep study office, was observed to have a ceiling tile missing.

16. On 12/29/14 at 4:05 p.m., the storage room on the Nursing East hall had an exhaust vent that was hanging down from the ceiling allowing a penetration into the ceiling assembly.

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1, The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observations, the facility failed to ensure that portable fire extinguishers were inspected and maintained in accordance with NFPA 10,1998 Edition, Sections 4-3.1¹ and 4-4.1². The deficiency affected one extinguisher in 1 of 9 smoke compartments.

Findings include:

On 12/29/14 at 2:59 p.m., the portable fire extinguisher in the nursing care storage room was observed.
a.) The fire extinguisher had not been inspected monthly since September of 2013.¹
b.) The fire extinguisher had not had an annually maintenance performed since September of 2013 which should have been done in September of 2014.²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.1 Frequency, Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

² NFPA 10, 1998 Edition, Section 4-4.1 Frequency, Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Based on interview and observations, the facility did not ensure that the requirements of NFPA 90A, 1999 Edition, Section 2-3.10.2¹ relating to air plenums being free of combustible materials was being met. This deficiency affects all nine smoke compartments being used as return air plenums.

Findings include:

The space above the ceiling throughout the facility serves as a return air plenum. At three locations in the nursing home, it was observed that the space above the ceiling contained fiberglass insulation with a paper backing (a combustible material) which was attached to the roof deck throughout.¹ During an interview on 12/30/14 at 8:30 a.m., staff member A, maintenance supervisor, stated no upgrades have been done to the heating, ventilating, and air conditioning system.

¹ NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems
1999 Edition, Section 2-3.10.2 Ceiling Cavity Plenum, The space between the top of the finished ceiling and the underside of the floor or roof above shall be permitted to be used to supply air to the occupied area, or return or exhaust air from or return and exhaust air from the occupied area, provided that the following conditions are met:
(a) All materials exposed to the airflow shall be noncombustible or limited combustible and have a maximum smoke developed index of 50.
Exception No. 1: The following materials shall be permitted in the ceiling cavity plenum where listed as having a maximum peak optical density of 0.5 or less, an average optical density of 0.15 or less, and a maximum flame spread distance of 5 ft (1.5 m) or less when tested in accordance with the specified test method:
(a) Electrical wires and cables and optical fiber cables - NFPA 262, Standard Method of Test for Flame Travel and Smoke of Wires and Cables for Use in Air-Handling Spaces
(b) Pneumatic tubing for control systems - UL 1820, Standard for Safety Fire Test of Pneumatic Tubing for Flame and Smoke Characteristics
(c) Fire sprinkler piping - UL 1887, Standard for Safety Fire Test of Plastic Sprinkler Pipe for Visible Flame and Smoke Characteristics
(d) Optical-fiber and communication raceways - UL 2024, Standard for Safety Optical-Fiber Cable Raceway
Exception No. 2: Smoke detectors.
Exception No. 3: Loudspeakers and recessed lighting fixtures, including their assemblies and accessories, shall be permitted in the ceiling cavity plenum where listed as having a maximum peak optical density of 0.5 or less, an average optical density of 0.15 or less, and a peak heat release rate of 100 kW or less when tested in accordance with UL 2043, Standard for Safety Fire Test for Heat and Visible Smoke Release for Discrete Products and Their Accessories Installed in Air-Handling Spaces.
Exception No. 4: Supplementary materials for air distribution systems in accordance with 2-3.3.
(b) The integrity of the fire stopping for penetrations shall be maintained.
(c) Light diffusers, other than those made of metal or glass, used in air-handling light fixtures shall be listed and marked " Fixture Light Diffusers for Air-Handling Fixtures. "
(d) The temperature of air delivered to these plenums shall not exceed 250°F (121°C).
(e) Materials used in the construction of a ceiling plenum shall be suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the plenum.
(f) Where the plenum is a part of a floor-ceiling or roof-ceiling assembly that has been tested or investigated and assigned a fire resistance rating of 1 hour or more, the assembly shall meet the requirements of 3-3.3.

Based on observations and interview, the facility failed to maintain the exit access free of obstructions or impediments in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1¹ and CMS Survey & Certification Policies S&C-04-41² & S&C-12-21-LSC³. The deficiencies affects 2 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 2:52 p.m., the exit corridor from x-ray into the clinic was observed. This is a corridor with signage indicating it is an exit. A wide wheelchair was parked in the corridor. A wheel chair was observed in the same location again at 8:00 a.m. on 12/30/14.

2. On 12/29/14 at 3:35 p.m., a gurney was observed parked in the Nursing South wing hallway. The hallway measurement of the corridor was 87 inches wide. During an interview, staff member A, maintenance supervisor, stated the gurney is always parked in this area.

3. On 12/29/14 at 3:50 p.m., a patient lift was observed parked in the Nursing West wing hallway by the smoke doors. The lift was still parked in the same spot at 4:25 p.m.

¹ NFPA 101, 2000 Edition, Section 7.1.10, Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

² CMS Survey & Certification Policy S&C-04-41 Corridor Width and Corridor Mounted Computer Touch Screens in Health Care Facilities, Issued 8/12/04.

³ CMS Survey & Certification Policy S&C-12-21-LSC Instructions Concerning Waivers of Specific Requirements of the 2012 Edition of the National Fire Association, Issued 3/9/12.

Based on record review, observation and staff interview, the facility failed to ensure nonflammable gas cylinders were secured in accordance with NFPA 99, 1999 Edition, Section 4-3.5.2.1(b27) and that an annual inspection was not completed in accordance with NFPA 50, 1996 Edition, Sections 1-3 & 4.-2.1 for bulk oxygen systems. These deficiencies could affect 9 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 1:25 p.m., an E size oxygen tank was observed to be leaning against the wall in the front entrance foyer.¹

2. On 12/29/14 at 2:00 p.m., the medical gas manifold/storage room was observed. Six K size medical air tanks were not secured and two K size nitrous oxide tanks were not secured.¹

3. During review of preventive maintenance paperwork on 12/29/14, the facility did not have documentation of an annual inspection for the bulk oxygen system. Staff member A, maintenance supervisor, indicated that the outside liquid oxygen tank held 900 gallons of liquid oxygen (30.4 cubic feet of gaseous oxygen/gallons x 900 gallons = 27,342 cubic feet of gaseous oxygen). Bulk oxygen systems contain equal to or greater than 20,000 cubic feet of oxygen. ² ³

¹ NFPA 99, 1999 Edition, Section 4-3.5.2.1(b27), Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

² NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 1-3 Definitions, Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

³ NFPA 50, 1996 Edition, Section 4-2.1, Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on observations and interview, the medical gas valves were not secured per NFPA 99, 2000 Edition, Section 4-3.1.2.3 and the medical air supply was not maintained with at least an average day supply per NFPA 99, 2000 Edition Section 4-3.1.1.7. These deficiencies could affect 5 of 9 smoke compartments.

Findings include:

1. On 12/29/14 between 10:54 a.m. and 2:43 p.m., multiple medical gas shutoff valve boxes were observed to have protective window covering missing. The areas included: maintenance hallway, nursery, recovery area, CAH rooms 110-121 and an emergency room.¹

2. On 12/29/14 at 1:07 p.m., a monitor for medical air in the CAH across from room 101 was observed to have an alarm light on. Staff member A, maintenance supervisor, stated it was because the medical air had run out and they were getting a delivery.²

3. The medical gas manifolds/storage room was observed on 12/29/14 at 2:00 p.m. Neither the replacement medical air compressed gas cylinders, nor existing medical air compressed gas cylinders were attached as the primary or secondary (emergency) medical air supply at the manifold. Eight replacement medical air compressed gas cylinders were present. The reserve or emergency supply shall not be used until it is depleted and at least a day's supply should be available at all times.² During an interview, staff member A, maintenance supervisor, stated the supplier does not connect the medical air to the manifold.

¹NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access. (Note: This is only a portion of this section.)

²NFPA 99, 1999 Edition, Section 4-3.1.1.7 Bulk Medical Gas Systems, (a) The bulk system shall consist of two sources of supply, one of which shall be a reserve supply for use only in an emergency. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the reserve begins to supply the system. There are two types of bulk supply systems:
1. The alternating type with two or more units alternately supplying the piping system. When the primary supply is unable to supply the bulk system, the secondary supply automatically becomes the primary supply and a new secondary supply, not the reserve supply, is connected when or before this changeover takes place. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover occurs.
2. The continuous type with one or more units continuously supplying the piping system while another unit remains as the reserve supply and operates only in case of an emergency.
(b) The secondary supply and the reserve supply referred to in 4-3.1.1.7(a) shall each contain at least an average day ' s supply and shall consist of the following:
1. Three or more manifolded high-pressure cylinders connected as required under 4-3.1.1.5(a) and 4-3.1.1.8(b), and provided with an actuating switch, which shall operate the master alarm signal when the reserve supply is reduced to one day ' s average supply; or
2. A cryogenic liquid storage unit used as the reserve for a bulk supply system provided with an actuating switch that shall operate the master alarm signal when the contents of the reserve are reduced to one day ' s average supply, and another actuating switch that shall operate the master alarm signal if the gas pressure available in the reserve unit is reduced below the pressure required to function properly. It shall also be designed to prevent the loss of gas produced by the evaporation of the cryogenic liquid in the reserve and so that the gas produced shall pass through a line pressure regulator before entering the piped distribution system.

Based on observations and interview, the facility failed to provide for a functioning Type I Essential Electrical System due to failure of emergency generator to start within 10 seconds and failed to maintain engine water temperatures at 90 degrees Fahrenheit or above according to NFPA 99, 2000 Edition, Sections 3-4.1.1.8 & 3-4.1.1.9 and NFPA 110, 1999 Edition, Sections 3-3.1 & 6-3.1. These deficiencies affect the entire CAH and LTC and all nine smoke compartments.

The findings include:

1. On 12/29/14 at 11:00 a.m., the Kohler 230 kilowatt diesel generator was observed to be leaking antifreeze. The pan under the engine contained absorbent material and staff member A, maintenance supervisor, stated that the fuel pump had been replaced last week. There was also green antifreeze in the pan under the generator and visible leakage from the engine radiator.¹

2. On 12/30/14 at 8:30 a.m., staff member A, maintenance supervisor, was requested to start the generator. The outside ambient temperature was approximately negative 15 degrees Fahrenheit. The generator initially started but was shut down because of an alarm indicating low water temperature.

In an interview with staff member A, he stated other maintenance staff informed him that the generator started and ran its weekly automatic Tuesday morning run, but a relay switch for the block heater failed this morning and the facility was trying to procure a replacement relay switch. The relay plastic casing was visibly melted.²

At 8:50 a.m., staff member A made several unsuccessful attempts to manually start the generator. Staff member A began correcting the cold water temperature and replacing the relay for the block heaters.³ 4
During an interview at 9:02 a.m., staff member B, Chief Nursing Officer/Acting Interim Chief Operating Officer, stated there were no scheduled surgeries today. Staff member B was told that the generator must start before the surveyors could leave the building.

At 10:00 a.m., staff member A stated he had run extension cords to the block heaters to warm the water and at 11:15 a.m., after replacing the relay switch, the generator was able to be manually started without a low water temperature light.

¹ NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-3.1, The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

² NFPA 99 Standard of Health Care Facilities, 1999 Edition, Section 3-4.1.1.8 Load Pickup, The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

³ NFPA 99, 1999 Edition 3-4.1.1.9 Maintenance of Temperature., Provisions shall be made to maintain the generator room at not less than 50°F (10°C) or the engine water-jacket temperature at not less than 90°F (32°C). [110: 3-3.1, 5-7.6]

4 NFPA 110, 1999 Edition, Section 3-3.1, Provision shall be made to maintain the temperature of the energy converter room containing Level 1 rotating equipment as specified in 5-7.6. Where an engine water jacket heater is required, it shall maintain the jacket water temperature at not less than 90°F (32°C). Units housed outdoors shall have an automatically controlled heater to keep the jacket water temperature at not less than 90°F (32°C). Provision shall be made for units housed outdoors to maintain the energy converter enclosure at not less than 32°F (0°C), or battery heaters shall be provided to maintain battery temperature at a minimum of 50°F (10°C) and shall automatically shut off when the battery temperature reaches 90°F (32°C). All prime mover heaters shall be automatically deactivated while the prime mover is running. (For combustion turbines, see 5-7.6.)
Exception: Air-cooled prime movers shall be permitted to employ a heater to maintain lubricating oil temperature as recommended by the prime mover manufacturer.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition, Article 110-26. This deficiency could affect at least 5 of 9 smoke compartments.

Findings include:

On 12/29/14 at 3:10 p.m., the housekeeping closet by the nurses station in LTC was observed. Three housekeeping carts were parked directly in front of the electrical panels preventing access.¹

¹ NFPA 70 National Electric Code, 1999 Edition, Article 110-26 Spaces About Electrical Equipment, Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
Table 110-26(a). Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage
to Ground Condition 1 Condition 2 Condition 3
0-150 3 3 3
151-600 3 3 1/2 4

Notes:
1. For SI units, 1 ft = 0.3048 m.
2. Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.

Based on observation, the facility failed to maintain the smoke and fire resistance rating for 2-hour rated fire barrier walls in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2¹. This deficiency affected 2 of 9 smoke compartments.

Findings include:

On 12/29/14 at 10:54 a.m., the two hour fire wall in the boiler room was observed to have a conduit with wire running through the wall. The open end of the conduit was not sealed.

¹ NFPA 101, 2000 Edition, Section 8.2.3.2.4.2, Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to ensure that interior finishes in a sprinklered building met at least a Class C flame spread rating as required in NFPA 101, 2000 Edition, Sections 19.3.3.2¹ and 10.2.3.2(c)². The deficiency affects 1 of 9 smoke compartments.

Findings include:

On 12/29/14 at 4:25 p.m., the tub room on the secured unit was observed to have a sheet of plywood covering the exterior window. The plywood had a shiny finish. During an interview, staff member A, maintenance supervisor, stated a fire retardant material had been applied to the plywood. A data sheet for the material applied was not provide.

¹ NFPA 101, 2000 Edition, Section 19.3.3.2 Interior Wall and Ceiling Finish, Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
(2) Newly installed materials Class A
Exception No. 1: Newly installed walls and ceilings shall be permitted to have Class A or Class B interior finish in individual rooms having a capacity not exceeding four persons.
Exception No. 2: Newly installed corridor wall finish not exceeding 4 ft (1.2 m) in height that is restricted to the lower half of the wall shall be permitted to be Class A or Class B.

² NFPA 101, 2000 Edition, Section 10.2.3.2; Products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale.

Based on observations and interviews, the facility failed to ensure that all corridor doors were free from impediments, latched properly, and resisted the passage of smoke per NFPA 101, 2000 Edition, Sections 19.3.6.3.1, 19.3.6.3.2, and 19.3.6.3.3. These deficiencies have the potential to affect patients/residents, staff, and visitors in 3 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 11:25 a.m., the double doors leading from the LTC dining room to the corridor were observed. The doors had a 1/2 inch gap between them at their meeting edges. Staff member A, maintenance supervisor, stated that the door sweep for the south door leading edge had been removed.¹

2. During an observation of the X-ray department on 12/29/14 at 1:03 p.m., the following was observed:
a.) The lead lined corridor door to the X-ray department was sagging and had greater than 1/2 inch gaps at the top of the door near the hinge and at the door bottom on the latching side.¹
b.) The lead lined corridor door to the X-ray department would not close to positive latching.²

3. During an observation on 12/29/14 at 3:07 p.m., the corridor door to room 207 on Centennial West was held open with a container of Sani Wipes and when exercised, would not latch.³

4. During an observation on 12/29/14 at 3:20 p.m., the corridor door to room 201 on Centennial West would not latch, when exercised.²

5. During an observation on 12/29/14 at 3:32 p.m., the corridor door to the nurses report room/break room on Centennial West was held open with a garbage can. Staff member A, maintenance supervisor, stated the Centennial West wing was added after the south hall. The Centennial West wing has a history of uneven floors due to the building settling.³

6. On 12/29/14 at 3:35 p.m., the corridor door to resident room 170 had two penetrations through the door. Staff member A stated the room had been an office with a magnetic lock on the door which had been removed.¹

¹ NFPA 101, 2000 Edition, Section 19.3.6.3.1, Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

² NFPA 101, 2000 Edition, Section 19.3.6.3.2, Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

³ NFPA 101, 2000 Edition, Section 19.3.6.3.3, Hold-open devices that release when the door is pushed or pulled shall be permitted. Annex A.19.3.6.3.3, doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observations and staff interview, the facility failed to maintain the self-closing corridor doors to hazardous areas in accordance with NFPA 101, 2000 Edition, Section 19.3.2.1.¹ These deficiencies affect 2 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 10:42 a.m., the corridor door to the laundry failed to properly close and latch when released from a fully opened position. During and interview, staff member A, maintenance supervisor, stated the self-closing hinges needed to be replaced with a top mounted self-closer.

2. On 12/29/14 at 2:45 p.m., the self closing door to the Biohazard storage room in the Emergency Room would not close and latch when released from a fully opened position.

¹ NFPA 101, 2000 Edition, Section 19.3.2.1 Hazardous Areas, Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observations, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1¹. These deficiencies affect 5 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 2:30 p.m., the Island tub room smoke barrier wall was observed. There was a four inch by four inch section of gypsum board was missing where a flexible wire conduit entered the wall.

2. On 12/30/14 at 10:35 a.m., the smoke barrier above the shower room in the Nursing East hall was observed. There was a one foot by one foot hole in the barrier. During an interview, staff member A, maintenance supervisor, stated the tub room had been remodeled and some of the plumbing had been changed.

3. On 12/30/14 at 10:40 a.m., the smoke barrier above the smoke doors in the Nursing East hall was observed. There was a penetration with a white wire through the barrier.

4. On 12/30/14 at 10:44 a.m., the smoke barrier in the tub room on the Special Care Unit was observed. There were two unsealed penetrations into the smoke barrier:
a.) A gray PVC pipe.
b.) A white wire in a conduit.

5. On 12/30/14 at 10:58 a.m., the smoke barrier wall in the activities department was observed. There were two unsealed penetrations by the angular wall area of the barrier.
a.) A conduit with white wire.
b.) A metal conduit pipe, two blue wires, two gray wires and one white wire.

¹ NFPA 101, 2000 Edition, Section 8.3.6.1, Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to maintain clear pathways to the exit discharge in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1¹ and Centers for Medicare and Medicaid Services (CMS) Policy S&C-05-38². The deficiency affects 4 of 9 exits.

1. On 12/29/14 at 2:27 p.m., the northeast exit path from the CAH was observed to have an accumulation of drifted snow on the sidewalk.

2. On 12/29/14 at 3:19 p.m., the west exit path from Centennial West was observed to have an accumulation of snow on the sidewalk.

3. On 12/29/14 at 3:29 p.m., the north exit path through the courtyard from Centennial West was observed to have an accumulation of snow on the sidewalk.

4. On 12/29/14 at 3:40 p.m., the east exit path from Centennial East was observed to have an accumulation of snow on sidewalk.

5. On 12/29/14 at 4:00 p.m., the southwest exit path from the West Hallway exit door was observed to have an accumulation of snow on the sidewalk.

¹ NFPA 101, 2000 Edition, Section 7.1.10.1, Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Annex A.7.1.10.1, A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

² CMS Survey and Certification Policy S&C-05-38 Clarification of Life Safety Code Survey Issues in Nursing Homes, Issued 7/14/05.

Based on observation, the facility failed to assure that means of egress were illuminated such that, the failure of the fixture did not leave the area in darkness in accordance with NFPA 101, 2000 Edition, Sections 7.8.1.3¹ and 7.8.1.4². This deficiency affects 1 of 9 exits.

Findings include:

On 12/30/14 at 7:05 a.m., the west exit near rooms 109 & 110 of the CAH was observed. The exterior light was not functioning and the walkway was dark.

¹ NFPA 101, 2000 Edition, Section 7.8.1.3, The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.

² NFPA 101, 2000 Edition, Section 7.8.1.4, Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

Based on observations, the facility failed to ensure all battery-powered emergency light fixtures operated per NFPA 101, 2000 Edition, Section 4.6.12.2 and NFPA 110, 1999 Edition, Section 5-3.1. This deficiency could affect 2 of 9 compartments.

Findings include:

1. On 12/29/14 at 11:09 a.m., the generator room was observed. The emergency light on the east wall would not illuminate when tested.¹ ²

2. On 12/29/14 at 1:10 p.m., the office area next to Labor and Delivery was observed. The emergency light on the wall would not illuminate when tested.¹

¹ NFPA 101, 2000 Edition, Section 4.6.12.2, Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

² NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 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.

Based on record review and staff interview, the facility failed to conduct a load voltage test on the fire alarm control panel batteries semiannually as required per NFPA 72, 1999 Edition, Section 7-3.2¹and Table 7-3.2². The deficiency could affect all nine smoke compartments.

Findings include:

On 12/29/14 at 5:00 p.m., the annual fire alarm panel testing records were reviewed. The records reflected that the load voltage test on the sealed lead-acid batteries for the fire alarm control panel was conducted once on 2/25/14. The next semiannual test should have been conducted on or before 9/23/14 (180 days+30 days = 210 days) and was not.¹

During an interview with staff member A, maintenance supervisor, he stated the load voltage tests were conducted annually and not semiannually.

¹ NFPA 72 National Fire Alarm Code,1999 Edition, Section 7-3.2 Testing, Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

² NFPA 72 , 1999 Edition, Table 7.3.2 (6)(d)(1) & (3), requires sealed lead-acid type batteries to be replaced every four years and have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observation, the facility failed to provide a complete sprinkler system free of obstructions for complete sprinkler pattern coverage in accordance with NFPA 13, 1999 Edition, Section 5-6.6. The deficiency could affect 1 of 9 smoke compartments.

Findings include:

On 12/29/14 at 2:17 p.m., the storage area next to room 101 was observed. A sprinkler head was installed above a cabinet with approximately one inch of clearance to the top of the cabinets.

During an interview, staff member A, maintenance supervisor, stated there had been a separation wall that was removed and the cabinets were added to the area. The sprinkler head over the added cabinets was well within the 18 inches of the sprinkler deflector.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, 5-6.6 Clearance to Storage (Standard Pendent and Upright Spray Sprinklers), The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception: Where other standards specify greater minimums, they shall be followed.

Based on observation, the facility failed to ensure the automatic sprinkler system was maintained per NFPA 13, 1999 Edition, Sections 5-1.1¹. These deficiencies affect occupants in 5 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 10:17 a.m., the kitchen was observed to have multiple ceiling tiles with penetrations and plastic sheeting missing or peeling away from the tiles. The areas observed were the dish room, the southeast corner, and the west side of the kitchen.

2. On 12/29/14 at 10:50 a.m., the maintenance office was observed to have two ceiling tiles moved out of the ceiling assembly. This caused a large penetration in the ceiling.

3. On 12/29/14 at 11:16 a.m., the housekeeping closet in the maintenance hallway was observed to have a penetration around the pipe for the roof drain.

4. On 12/29/14 at 11:19 a.m., the break room in the maintenance hallway was observed. There was a penetration in the ceiling and a piece of the T bar that holds the ceiling tiles in place was broken.

5. On 12/29/14 at 12:54 p.m., the construction area for the new labor and delivery room was observed. There were three ceiling tiles missing. There was not active construction nor staff in the area. The ceiling panels must be replaced when construction is not ongoing unless a fire watch is established because the automatic sprinkler system can delay fire extinguishment without ceiling panels in place.

6. On 12/29/14 at 12:55 p.m., the x-ray control room was observed.
a.) The wire chase going through the ceiling tiles had a two inch circular penetration area around it.
b.) There was also a two inch round penetration through a ceiling tile.

7. On 12/29/14 at 1:10 p.m., the bathroom next to the labor and delivery room was observed to have a ceiling tile missing.

8. On 12/29/14 at 2:17 p.m., a sprinkler head was observed in room 101. The escutcheon ring was missing from the sprinkler head allowing a penetration into the ceiling.

9. On 12/29/14 at 2:39 p.m., a sprinkler head was observed in the nursery. The escutcheon ring was missing from the sprinkler head.

10. On 12/29/14 at 2:40 p.m., the medication room in the CAH was observed.
a. There was a two inch penetration in the ceiling assembly.
b. A sprinkler head was observed at the CAH nurses station. The escutcheon ring was missing from the sprinkler head.

11. On 12/29/14 at 3:00 p.m., a sprinkler head was observed in the ladies locker room located in the hallway between LTC and the CAH. The escutcheon ring was missing from the sprinkler head.

12. On 12/29/14 at 3:17 p.m., the return air vent in the ceiling of the tub room on Centennial West was observed to have a one inch gap around it.

13. On 12/29/14 at 3:20 p.m., the hospice room was observed to have a penetration in the corner of a ceiling tile above the sink.

14. On 12/29/14 at 3:33 p.m., the beauty shop was observed to have a ceiling tile that did not fit properly, allowing a penetration in the ceiling assembly.

15. On 12/29/14 at 4:01 p.m., room 193, the sleep study office, was observed to have a ceiling tile missing.

16. On 12/29/14 at 4:05 p.m., the storage room on the Nursing East hall had an exhaust vent that was hanging down from the ceiling allowing a penetration into the ceiling assembly.

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1, The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observations, the facility failed to ensure that portable fire extinguishers were inspected and maintained in accordance with NFPA 10,1998 Edition, Sections 4-3.1¹ and 4-4.1². The deficiency affected one extinguisher in 1 of 9 smoke compartments.

Findings include:

On 12/29/14 at 2:59 p.m., the portable fire extinguisher in the nursing care storage room was observed.
a.) The fire extinguisher had not been inspected monthly since September of 2013.¹
b.) The fire extinguisher had not had an annually maintenance performed since September of 2013 which should have been done in September of 2014.²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.1 Frequency, Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

² NFPA 10, 1998 Edition, Section 4-4.1 Frequency, Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Based on interview and observations, the facility did not ensure that the requirements of NFPA 90A, 1999 Edition, Section 2-3.10.2¹ relating to air plenums being free of combustible materials was being met. This deficiency affects all nine smoke compartments being used as return air plenums.

Findings include:

The space above the ceiling throughout the facility serves as a return air plenum. At three locations in the nursing home, it was observed that the space above the ceiling contained fiberglass insulation with a paper backing (a combustible material) which was attached to the roof deck throughout.¹ During an interview on 12/30/14 at 8:30 a.m., staff member A, maintenance supervisor, stated no upgrades have been done to the heating, ventilating, and air conditioning system.

¹ NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems
1999 Edition, Section 2-3.10.2 Ceiling Cavity Plenum, The space between the top of the finished ceiling and the underside of the floor or roof above shall be permitted to be used to supply air to the occupied area, or return or exhaust air from or return and exhaust air from the occupied area, provided that the following conditions are met:
(a) All materials exposed to the airflow shall be noncombustible or limited combustible and have a maximum smoke developed index of 50.
Exception No. 1: The following materials shall be permitted in the ceiling cavity plenum where listed as having a maximum peak optical density of 0.5 or less, an average optical density of 0.15 or less, and a maximum flame spread distance of 5 ft (1.5 m) or less when tested in accordance with the specified test method:
(a) Electrical wires and cables and optical fiber cables - NFPA 262, Standard Method of Test for Flame Travel and Smoke of Wires and Cables for Use in Air-Handling Spaces
(b) Pneumatic tubing for control systems - UL 1820, Standard for Safety Fire Test of Pneumatic Tubing for Flame and Smoke Characteristics
(c) Fire sprinkler piping - UL 1887, Standard for Safety Fire Test of Plastic Sprinkler Pipe for Visible Flame and Smoke Characteristics
(d) Optical-fiber and communication raceways - UL 2024, Standard for Safety Optical-Fiber Cable Raceway
Exception No. 2: Smoke detectors.
Exception No. 3: Loudspeakers and recessed lighting fixtures, including their assemblies and accessories, shall be permitted in the ceiling cavity plenum where listed as having a maximum peak optical density of 0.5 or less, an average optical density of 0.15 or less, and a peak heat release rate of 100 kW or less when tested in accordance with UL 2043, Standard for Safety Fire Test for Heat and Visible Smoke Release for Discrete Products and Their Accessories Installed in Air-Handling Spaces.
Exception No. 4: Supplementary materials for air distribution systems in accordance with 2-3.3.
(b) The integrity of the fire stopping for penetrations shall be maintained.
(c) Light diffusers, other than those made of metal or glass, used in air-handling light fixtures shall be listed and marked " Fixture Light Diffusers for Air-Handling Fixtures. "
(d) The temperature of air delivered to these plenums shall not exceed 250°F (121°C).
(e) Materials used in the construction of a ceiling plenum shall be suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the plenum.
(f) Where the plenum is a part of a floor-ceiling or roof-ceiling assembly that has been tested or investigated and assigned a fire resistance rating of 1 hour or more, the assembly shall meet the requirements of 3-3.3.

Based on observations and interview, the facility failed to maintain the exit access free of obstructions or impediments in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1¹ and CMS Survey & Certification Policies S&C-04-41² & S&C-12-21-LSC³. The deficiencies affects 2 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 2:52 p.m., the exit corridor from x-ray into the clinic was observed. This is a corridor with signage indicating it is an exit. A wide wheelchair was parked in the corridor. A wheel chair was observed in the same location again at 8:00 a.m. on 12/30/14.

2. On 12/29/14 at 3:35 p.m., a gurney was observed parked in the Nursing South wing hallway. The hallway measurement of the corridor was 87 inches wide. During an interview, staff member A, maintenance supervisor, stated the gurney is always parked in this area.

3. On 12/29/14 at 3:50 p.m., a patient lift was observed parked in the Nursing West wing hallway by the smoke doors. The lift was still parked in the same spot at 4:25 p.m.

¹ NFPA 101, 2000 Edition, Section 7.1.10, Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

² CMS Survey & Certification Policy S&C-04-41 Corridor Width and Corridor Mounted Computer Touch Screens in Health Care Facilities, Issued 8/12/04.

³ CMS Survey & Certification Policy S&C-12-21-LSC Instructions Concerning Waivers of Specific Requirements of the 2012 Edition of the National Fire Association, Issued 3/9/12.

Based on record review, observation and staff interview, the facility failed to ensure nonflammable gas cylinders were secured in accordance with NFPA 99, 1999 Edition, Section 4-3.5.2.1(b27) and that an annual inspection was not completed in accordance with NFPA 50, 1996 Edition, Sections 1-3 & 4.-2.1 for bulk oxygen systems. These deficiencies could affect 9 of 9 smoke compartments.

Findings include:

1. On 12/29/14 at 1:25 p.m., an E size oxygen tank was observed to be leaning against the wall in the front entrance foyer.¹

2. On 12/29/14 at 2:00 p.m., the medical gas manifold/storage room was observed. Six K size medical air tanks were not secured and two K size nitrous oxide tanks were not secured.¹

3. During review of preventive maintenance paperwork on 12/29/14, the facility did not have documentation of an annual inspection for the bulk oxygen system. Staff member A, maintenance supervisor, indicated that the outside liquid oxygen tank held 900 gallons of liquid oxygen (30.4 cubic feet of gaseous oxygen/gallons x 900 gallons = 27,342 cubic feet of gaseous oxygen). Bulk oxygen systems contain equal to or greater than 20,000 cubic feet of oxygen. ² ³

¹ NFPA 99, 1999 Edition, Section 4-3.5.2.1(b27), Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

² NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 1-3 Definitions, Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

³ NFPA 50, 1996 Edition, Section 4-2.1, Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on observations and interview, the medical gas valves were not secured per NFPA 99, 2000 Edition, Section 4-3.1.2.3 and the medical air supply was not maintained with at least an average day supply per NFPA 99, 2000 Edition Section 4-3.1.1.7. These deficiencies could affect 5 of 9 smoke compartments.

Findings include:

1. On 12/29/14 between 10:54 a.m. and 2:43 p.m., multiple medical gas shutoff valve boxes were observed to have protective window covering missing. The areas included: maintenance hallway, nursery, recovery area, CAH rooms 110-121 and an emergency room.¹

2. On 12/29/14 at 1:07 p.m., a monitor for medical air in the CAH across from room 101 was observed to have an alarm light on. Staff member A, maintenance supervisor, stated it was because the medical air had run out and they were getting a delivery.²

3. The medical gas manifolds/storage room was observed on 12/29/14 at 2:00 p.m. Neither the replacement medical air compressed gas cylinders, nor existing medical air compressed gas cylinders were attached as the primary or secondary (emergency) medical air supply at the manifold. Eight replacement medical air compressed gas cylinders were present. The reserve or emergency supply shall not be used until it is depleted and at least a day's supply should be available at all times.² During an interview, staff member A, maintenance supervisor, stated the supplier does not connect the medical air to the manifold.

¹NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access. (Note: This is only a portion of this section.)

²NFPA 99, 1999 Edition, Section 4-3.1.1.7 Bulk Medical Gas Systems, (a) The bulk system shall consist of two sources of supply, one of which shall be a reserve supply for use only in an emergency. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the reserve begins to supply the system. There are two types of bulk supply systems:
1. The alternating type with two or more units alternately supplying the piping system. When the primary supply is unable to supply the bulk system, the secondary supply automatically becomes the primary supply and a new secondary supply, not the reserve supply, is connected when or before this changeover takes place. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover occurs.
2. The continuous type with one or more units continuously supplying the piping system while another unit remains as the reserve supply and operates only in case of an emergency.
(b) The secondary supply and the reserve supply referred to in 4-3.1.1.7(a) shall each contain at least an average day ' s supply and shall consist of the following:
1. Three or more manifolded high-pressure cylinders connected as required under 4-3.1.1.5(a) and 4-3.1.1.8(b), and provided with an actuating switch, which shall operate the master alarm signal when the reserve supply is reduced to one day ' s average supply; or
2. A cryogenic liquid storage unit used as the reserve for a bulk supply system provided with an actuating switch that shall operate the master alarm signal when the contents of the reserve are reduced to one day ' s average supply, and another actuating switch that shall operate the master alarm signal if the gas pressure available in the reserve unit is reduced below the pressure required to function properly. It shall also be designed to prevent the loss of gas produced by the evaporation of the cryogenic liquid in the reserve and so that the gas produced shall pass through a line pressure regulator before entering the piped distribution system.

Based on observations and interview, the facility failed to provide for a functioning Type I Essential Electrical System due to failure of emergency generator to start within 10 seconds and failed to maintain engine water temperatures at 90 degrees Fahrenheit or above according to NFPA 99, 2000 Edition, Sections 3-4.1.1.8 & 3-4.1.1.9 and NFPA 110, 1999 Edition, Sections 3-3.1 & 6-3.1. These deficiencies affect the entire CAH and LTC and all nine smoke compartments.

The findings include:

1. On 12/29/14 at 11:00 a.m., the Kohler 230 kilowatt diesel generator was observed to be leaking antifreeze. The pan under the engine contained absorbent material and staff member A, maintenance supervisor, stated that the fuel pump had been replaced last week. There was also green antifreeze in the pan under the generator and visible leakage from the engine radiator.¹

2. On 12/30/14 at 8:30 a.m., staff member A, maintenance supervisor, was requested to start the generator. The outside ambient temperature was approximately negative 15 degrees Fahrenheit. The generator initially started but was shut down because of an alarm indicating low water temperature.

In an interview with staff member A, he stated other maintenance staff informed him that the generator started and ran its weekly automatic Tuesday morning run, but a relay switch for the block heater failed this morning and the facility was trying to procure a replacement relay switch. The relay plastic casing was visibly melted.²

At 8:50 a.m., staff member A made several unsuccessful attempts to manually start the generator. Staff member A began correcting the cold water temperature and replacing the relay for the block heaters.³ 4
During an interview at 9:02 a.m., staff member B, Chief Nursing Officer/Acting Interim Chief Operating Officer, stated there were no scheduled surgeries today. Staff member B was told that the generator must start before the surveyors could leave the building.

At 10:00 a.m., staff member A stated he had run extension cords to the block heaters to warm the water and at 11:15 a.m., after replacing the relay switch, the generator was able to be manually started without a low water temperature light.

¹ NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-3.1, The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

² NFPA 99 Standard of Health Care Facilities, 1999 Edition, Section 3-4.1.1.8 Load Pickup, The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

³ NFPA 99, 1999 Edition 3-4.1.1.9 Maintenance of Temperature., Provisions shall be made to maintain the generator room at not less than 50°F (10°C) or the engine water-jacket temperature at not less than 90°F (32°C). [110: 3-3.1, 5-7.6]

4 NFPA 110, 1999 Edition, Section 3-3.1, Provision shall be made to maintain the temperature of the energy converter room containing Level 1 rotating equipment as specified in 5-7.6. Where an engine water jacket heater is required, it shall maintain the jacket water temperature at not less than 90°F (32°C). Units housed outdoors shall have an automatically controlled heater to keep the jacket water temperature at not less than 90°F (32°C). Provision shall be made for units housed outdoors to maintain the energy converter enclosure at not less than 32°F (0°C), or battery heaters shall be provided to maintain battery temperature at a minimum of 50°F (10°C) and shall automatically shut off when the battery temperature reaches 90°F (32°C). All prime mover heaters shall be automatically deactivated while the prime mover is running. (For combustion turbines, see 5-7.6.)
Exception: Air-cooled prime movers shall be permitted to employ a heater to maintain lubricating oil temperature as recommended by the prime mover manufacturer.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition, Article 110-26. This deficiency could affect at least 5 of 9 smoke compartments.

Findings include:

On 12/29/14 at 3:10 p.m., the housekeeping closet by the nurses station in LTC was observed. Three housekeeping carts were parked directly in front of the electrical panels preventing access.¹

¹ NFPA 70 National Electric Code, 1999 Edition, Article 110-26 Spaces About Electrical Equipment, Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
Table 110-26(a). Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage
to Ground Condition 1 Condition 2 Condition 3
0-150 3 3 3
151-600 3 3 1/2 4

Notes:
1. For SI units, 1 ft = 0.3048 m.
2. Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.