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Reference NFPA 101, 2000 Edition

8.2.3.2.3* Opening Protectives.

8.2.3.2.3.1
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 1 1/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42

Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1-hour fire resistance-rated construction, the opening protectives shall be permitted to have not less than a 20-minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test.

Exception No. 2: The requirement of 8.2.3.2.3.1(2) shall not apply where special requirements for doors in 1-hour fire resistance-rated corridor walls and 1-hour fire resistance-rated smoke barriers are specified in Chapters 18 through 21.

Exception No. 3: Existing doors having a 3/4-hour fire protection rating shall be permitted to continue to be used in vertical openings and in exit enclosures in lieu of the 1-hour rating required by 8.2.3.2.3.1(2).

(3) 1/2-hour fire barrier - 20-minute fire protection rating
Exception: Twenty-minute fire protection-rated doors shall be exempt from the hose stream test of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.


Based on observation and staff interview, the facility failed to ensure 1 1/2 hour rated fire door assemblies were provided in 2-hour fire barrier walls as required by NFPA 101 (Life Safety Code). This failed practice could result in fire breaching the 2-hour wall via the door opening and spreading between the existing hospital building and the new hospital addition, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. On 09/11/12 at 4:00 pm, during a tour of the facility with the Environmental Manager, the surveyor observed a set of fire doors provided in the 2-hour wall (near the nursery), which separates the existing hospital from the new hospital addition. One door leaf in the set was properly rated for 1 1/2 hours, the other door leaf was rated for only 1 hour.

B. On 09/11/12 at 4:05 pm, during interview, the Environmental Manager stated he never noticed the differences in the door ratings.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure doors provided in corridor walls were capable of resisting the passage of smoke and there is no impediment to the closing and latching of these doors. It is essential all doors are maintained to be closed promptly (without impediment) in the event of fire. This failed practice could result in the spread of smoke and/or fire to and from other areas of the facility, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. On 09/11/12, between 1:45 pm and 5:00 pm, during a tour of the facility with the Environmental Manager, the surveyor observed corridor doors propped in the open position with unapproved devices (door wedges, door stops, equipment, etc.) The doors observed are as follows:

1. The door leading into the health information system room was propped open with a door wedge.

2. The door leading into the traction room had numerous equipment overflowing into the path of the door swing, which did not allow
this door to close and latch.

3. The door leading into the staff lounge was propped in the open position with a door wedge.

4. Three examination doors located in physical therapy unit were propped in the open position with door stops.


B. On 09/11/12 at 5:10 pm, during interview, the Environmental Manager stated it was a continual problem with staff propping the doors in the open position.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition
Section. 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift.


Based on record review and staff interview, the facility failed to ensure fire drills were conducted at least quarterly on every shift to assure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This failed practice could result in staff not being adequately prepared to exercise their duties in accordance to the facility's Fire Plan in the event of fire, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the fire drill log with the Environmental Manager indicated the facility had two (2) nursing shifts:

First Shift (7:00 am - 7:00 pm)
Second Shift (7:00 pm - 7:00 am)

1. The following fire drills were conducted on the first shift, all of which exceeded the 90-day spacing between drills on this shift:

- 03/23/11 at 3:35 pm
- 07/07/11 at 10:00 am
- 11/16/11 at 2:15 pm
- 03/02/12 at 1:20 pm
- 07/25/12 at 9:30 am


2. The following fire drills were conducted on the second shift, all of which exceeded the 90-day spacing between drills on this shift:

- 03/27/11 at 7:30 pm
- 07/15/11 at 8:30 pm
- 11/22/11 at 8:15 pm
- 03/02/12 at 8:20 pm
- 07/10/12 at 8:30 pm


B. On 09/11/12 at 12:15 pm, during interview, the Environmental Manager stated he was unaware his fire drills exceeded the 90-day spacing between drills on both shifts.


C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 25, 1-4.2
The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

Reference NFPA 25, 1-4.4
The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.


Reference NFPA 25, 1998 Edition
2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

9-2.6* Main Drain Test.
A main drain test shall be conducted quarterly at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.

9-2.7 Waterflow Alarm.
All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.



Based on observation, record review and staff interview, the facility failed to ensure the sprinkler system was being tested at least quarterly (90 days) in accordance with NFPA 25, (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems), which resulted in alarm devices, main drains and valve supervisory switches being tested only annually. This failed practice could delay operation, or otherwise rendering the sprinkler system inoperable or ineffectual in the event of fire which presents the risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. Review of the Wet Fire Sprinkler Report dated 11/30/12 revealed the sprinkler system (2 risers) were inspected/tested annually instead of quarterly. Components such as alarm devices and main drains require quarterly testing.

B. On 09/11/12 at 11:10 am, during interview, the Environmental Manager stated he was unaware certain components of the sprinkler system were not being tested within the proper time intervals.


C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.



Reference NFPA 25, 1998 Edition
5-3.3 Annual Tests.
5-3.3.1*
An annual test of each pump assembly shall be conducted under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharged through approved test devices. This test shall be conducted as described in 5-3.3.1(a), (b), or (c).
Exception*: If available suction supplies do not allow flowing of 150 percent of the rated pump capacity, the fire pump shall be operated at maximum allowable discharge. This reduced capacity shall not constitute a noncompliant test.
(a) Use of the pump discharge via the hose streams; pump suction and discharge pressures and the flow measurements of each hose stream shall determine the total pump output. Care shall be taken to prevent water damage by verifying there is adequate drainage for the high-pressure water discharge from hoses.
(b) Use of the pump discharge via the bypass flowmeter to drain or suction the reservoir; pump suction and discharge pressures and the flowmeter measurements shall determine the total pump output.
(c) Use of the pump discharge via the bypass flowmeter to pump suction (closed-loop metering); pump suction and discharge pressures and the flowmeter measurements shall determine the total pump output.
Where the annual test is conducted periodically in accordance with 5-3.3.1(c), a test shall be conducted every 3 years in accordance with 5-3.3.1(a) or (b) in lieu of the method described in 5-3.3.1(c).
Where 5-3.3.1(b) or (c) is used, the flowmeter shall be adjusted immediately prior to conducting the test in accordance with the manufacturer ' s instructions. If the test results are not consistent with the previous annual test, 5-3.3.1(a) shall be used. If testing in accordance with 5-3.3.1(a) is not possible, a flowmeter calibration shall be performed and the test shall be repeated.

5-5 Maintenance.
5-5.1*
A preventive maintenance program shall be established on all components of the pump assembly in accordance with the manufacturer ' s recommendations. Records shall be maintained on all work performed on the pump, driver, controller, and auxiliary equipment.
In the absence of manufacturer ' s recommendations for preventive maintenance, Table 5-5.1 provides alternative requirements.

5-5.2
The preventive maintenance program shall be initiated immediately after the pump assembly has passed acceptance tests.


Based on observation, record review and staff interview, the facility failed to ensure the fire pump assembly, which provides waterflow and pressure for private fire protection systems, was tested at least every twelve (12) months as required by NFPA 25, (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems), and a fire pump preventative maintenance program was established in accordance with the Manufacture's Recommendation or Table 5-5.1 of NFPA 25. Without this routine testing and maintenance of the fire pump, the sprinkler system may not have the required waterflow and pressure necessary for effective sprinkler system performance in the event of fire, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the facility's maintenance records with the Environmental Manager failed to reveal the following:

1. No record indicating the fire pump was being tested professionally at least every twelve (12) months.
2. No record indicating a preventative maintenance program was being followed for the fire pump assembly.

B. On 09/11/12 at 11:50 am, during interview, the Environmental Manager stated he was unsure if the fire pump assembly was being tested as required. He stated the fire pump was not included in his preventative maintenance program. The Environmental Manager stated he had no further records available for review demonstrating the fire pump assembly was being tested as required.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.




Reference NFPA 25, 1998 Edition

9-7 Fire Department Connections.
Section 9-7.1
Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.


Based on observation and staff interview, the facility failed to ensure all Fire Department Connections (FDC) were properly identified with signage as required by NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). Without this signage, this failed practice could result in emergency response personnel connecting supplemental fire fighting equipment (ie: water pump trucks) to incorrect FDCs or other fire fighting components, which results in delayed emergency response and presents a risk of potential harm harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. On 09/11/12 at 2:30 pm, during a tour of the facility with the Environmental Manager, the surveyor observed the FDC was not provided with identification signage.

B. On 09/11/12 at 2:35 pm, the Environmental Manager stated he was unaware the FDC identification sign was not posted.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Based on observation, record review and staff interview, the facility failed to ensure the hospital building and grounds were maintained smoke-free in accordance with their adopted smoking policy and procedure. This failed practice presents a risk of potential harm by fire to all six (6) patients located in the medical surgical unit as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. Review of the facility's Smoking Policy with the Environmental Manager, revealed the hospital building and grounds were smoke free.

B. On 09/11/12 at 2:30 pm, the surveyor observed numerous cigarette butts on the ground and inside the trash recepticle at the garden courtyard.

C. On 09/11/12 at 2:35 pm, during interview, the Environmental Manager stated no one should be smoking on the property.

D. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 96, 1998 Edition
Section 8-3.1
Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with NFPA 96, Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule

Type or Volume of Cooking Frequency Frequency

Systems serving solid fuel cooking operations Monthly

Systems serving high-volume cooking operations,
such as 24-hour cooking, charbroiling or wok cooking Quarterly

Systems serving moderate-volume cooking operations Semi- annually

Systems serving low-volume cooking operations,
such as churches, day camps, seasonal businesses,
or senior centers Annually

8-3.1.1
Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

8-3.1.2
When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

8-3.2
Flammable solvents or other flammable cleaning aids shall not be used.

8-3.3
At the start of the cleaning process, electrical switches that could be activated accidentally shall be locked out.

8-3.4
Components of the fire suppression system shall not be rendered inoperable during the cleaning process.
Exception: Servicing by properly trained and qualified persons in accordance with Section 8-2.

8-3.5
Care shall be taken not to apply cleaning chemicals on fusible links or other detection devices of the automatic extinguishing system.

8-3.6
When cleaning procedures are completed, all electrical switches and system components shall be returned to an operable state. All access panels (doors) and cover plates shall be replaced. Dampers and diffusers shall be positioned for proper airflow.


Based on observation and staff interview, the facility failed to ensure the kitchen hood system and its appurtenances [accessories/parts which includes the hood, extinguishing system, duct and grease removal device] were cleaned to bare metal by a professional at least every 6-months in accordance with NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). Not professionally cleaning the range hood system and its appurtenances could result in fire and could result in ineffectual extinguishing system performance in the event of fire, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. On 09/11/12 at 12:05 pm, review of the kitchen hood maintenance records with the Environmental Manager, revealed no evidence the kitchen hood system was cleaned professionally at least every 6-months.

1. On 09/11/12 at 12:10 pm, during interview, the Environmental Manager stated kitchen staff cleans the hood and filters, but the hood was not being cleaned professionally.

2. On 09/11/12 at 1:50 pm, inspection of the hood system revealed no documentation (sticker) indicating the hood was being cleaned professionally. At this time, the Environmental Manager stated he had no further records available for review to demonstrating the range hood was being cleaned professionally.

B. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 99, 1999 Edition

4-3.1.2.10* Installation Requirements.
(a) Equipment and Component Installation.
1. The installation of individual components shall be made in accordance with the instructions of the manufacturer. Such instructions shall include directions and information deemed by the manufacturer to be adequate for attaining proper installation, testing, maintenance, and operation of the medical gas systems. These instructions shall be left with the owner.


Based on record review and staff interview, the facility failed to ensure the hospital's piped in medical gas system was being tested and maintained for proper operation in accordance with the manufactures instruction. Medical gas systems are essential for supplying piped in oxygen, nitrous oxide, carbon dioxide and medical air to various parts of the hospital. Without periodic testing of the medical gas system, this failed practice could result in unreliable system performance, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. Review of the facility's maintenance records with the Environmental Manager revealed no evidence the medical gas system was subject to periodic testing. There was no evidence a manufacturer's instruction manual was available for the medical gas system.

B. On 09/11/12 at 11:55 am, the Environmental Manager stated there is a professional company which services the medical gas system when the system needs repair. He stated he was unaware if the professional company was performing all of the necessary periodic testing in accordance with an instruction manual. The Environmental Manager stated he had no further records available for review demonstrating the medical gas system was being tested as required.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

NFPA 101, 2000 Edition
7.2.1.9* Powered Doors.
7.2.1.9.1* General.
Where means of egress doors are operated by power upon the approach of a person or doors with power-assisted manual operation, the design shall be such that, in the event of power failure, the door opens manually to allow egress travel or closes where necessary to safeguard the means of egress. The forces required to open such doors manually shall not exceed those required in 7.2.1.4.5, except that the force required to set the door in motion shall not exceed 50 lbf (222 N). The door shall be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4). On the egress side of each door, there shall be a readily visible, durable sign that reads as follows: IN EMERGENCY, PUSH TO OPEN
The sign shall be in letters not less than 1 in. (2.5 cm) high on a contrasting background.


Based on observation and staff interview, the facility failed to ensure power assist sliding doors installed in the means of egress were labeled with signage that reads: IN EMERGENCY, PUSH TO OPEN. In the event of power failure and without clear instruction of how to open these doors, occupants could mistake the egress door as being locked and would not be able to readily exit to the outside in the event of an emergency, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. On 09/11/12 at 1:30 pm, during a tour of the facility with the Environmental Manager, the surveyor observed the power assist sliding doors located at the main entrance were not labeled with clear instruction of how to open in the event of emergency.

B. On 09/11/12 at 1:35 pm, during interview, the Environmental Manager stated he was unaware the doors were not properly labeled.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 110, Standard for Emergency and Standby Power System

Section 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.

6-4.3
Load tests of generator sets shall include complete cold starts.


Based on record review and staff interview, the facility failed to ensure the emergency generators, used to protect residents during the times of primary power failure, were tested underload at least once a month for a minimum of thirty (30) minutes as required by NFPA 110 (Standard for Emergency and Standby Power System). Not conducting underload testing every month could result in an unreliable emergency power source in the event of primary power failure, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the Emergency Generator Log C-15 with the Environmental Manager, revealed no record emergency generator C-15 was tested underload for the month of July 2012.

B. Review of the Emergency Generator Log M-3306 with the Environmental Manager, revealed no record emergency generator M-3306 was tested underload for the month of August 2012.

C. On 09/11/12 at 12:30 pm, during interview, the Environmental Manager stated he was uncertain why the testing wasn't conducted for those months.

D. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.




NFPA 99:
3-4.4.2 Record keeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Based on observation, record review and staff interview, the facility's practice failed to ensure specific gravity was being tested for all generator starting batteries in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). Specific gravity shall be tested and recorded at least once a month for all generator batteries to determine their serviceability. Without this testing, this failed practice could result in generator batteries not being capable to start the emergency generator in the event of power failure, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the Emergency Generator Log C-15 with the Environmental Manager, revealed no record specific gravity was being tested for emergency generator C-15.

B. Review of the Emergency Generator Log M-3306 with the Environmental Manager, revealed no record specific gravity was being tested for emergency generator M-3306.

C. On 09/11/12 at 12:35 pm, during interview, the Environmental Manager stated the specific gravity was being tested for all generator batteries but the results of the testing were not being documented. No further records were available for review.

D. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.



Reference NFPA 99
5-3 Lighting.
5-3.1
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
5-3.2*
The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft-candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.
Exception: This requirement shall not apply to units housed outdoors.


Based on observation and staff interview, the facility failed to ensure the room which houses the emergency generator, was provided with battery-powered emergency lighting. In the event the emergency generator experiences problems such as not starting, battery-back up illumination is needed to perform servicing. This failed practice presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. On 09/11/12 at 4:30 pm, observation of the room which houses emergency generator M-3306 failed to reveal battery-back up emergency lighting fixtures.

B. On 09/11/12 at 4:35 pm, the Environmental Manager stated he was unaware the room required battery-back up emergency lighting fixtures.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Based on record review and staff interview, the facility failed to provide written policies and procedures in the event the fire sprinkler system was out of service for more than 4 hours within a 24 hour period. Without this policy and procedure in place, this failed practice could result in the facility not detecting and controlling early signs of fire within the building during the time the sprinkler system is down, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the sprinkler system maintenance records with the Environmental Manager revealed no evidence written policies and procedures were in place in the event the sprinkler system was out of service longer than the allotted time.

B. On 09/11/12 at 11:20 am, during interview, the Environmental Manager stated staff knows and understands the procedure but he's never seen anything in writing.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Based on record review and staff interview, the facility failed to provide written policies and procedures in the event the fire alarm system was out of service for more than 4 hours within a 24 hour period. Without this policy and procedure in place, this failed practice could result in the facility not detecting and controlling early signs of fire within the building during the time the system is down, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the fire alarm system maintenance records with the Environmental Manager revealed no evidence written policies and procedures were in place in the event the fire alarm system was out of service longer than the allotted time.

B. On 09/11/12 at 11:30 am, during interview, the Environmental Manager stated staff knows and understands the procedure but he's never seen anything in writing.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition

8.2.3.2.3* Opening Protectives.

8.2.3.2.3.1
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 1 1/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42

Exception No. 1: Where the fire barrier specified in 8.2.3.2.3.1(2) is provided as a result of a requirement that corridor walls or smoke barriers be of 1-hour fire resistance-rated construction, the opening protectives shall be permitted to have not less than a 20-minute fire protection rating when tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test.

Exception No. 2: The requirement of 8.2.3.2.3.1(2) shall not apply where special requirements for doors in 1-hour fire resistance-rated corridor walls and 1-hour fire resistance-rated smoke barriers are specified in Chapters 18 through 21.

Exception No. 3: Existing doors having a 3/4-hour fire protection rating shall be permitted to continue to be used in vertical openings and in exit enclosures in lieu of the 1-hour rating required by 8.2.3.2.3.1(2).

(3) 1/2-hour fire barrier - 20-minute fire protection rating
Exception: Twenty-minute fire protection-rated doors shall be exempt from the hose stream test of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.


Based on observation and staff interview, the facility failed to ensure 1 1/2 hour rated fire door assemblies were provided in 2-hour fire barrier walls as required by NFPA 101 (Life Safety Code). This failed practice could result in fire breaching the 2-hour wall via the door opening and spreading between the existing hospital building and the new hospital addition, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. On 09/11/12 at 4:00 pm, during a tour of the facility with the Environmental Manager, the surveyor observed a set of fire doors provided in the 2-hour wall (near the nursery), which separates the existing hospital from the new hospital addition. One door leaf in the set was properly rated for 1 1/2 hours, the other door leaf was rated for only 1 hour.

B. On 09/11/12 at 4:05 pm, during interview, the Environmental Manager stated he never noticed the differences in the door ratings.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure doors provided in corridor walls were capable of resisting the passage of smoke and there is no impediment to the closing and latching of these doors. It is essential all doors are maintained to be closed promptly (without impediment) in the event of fire. This failed practice could result in the spread of smoke and/or fire to and from other areas of the facility, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. On 09/11/12, between 1:45 pm and 5:00 pm, during a tour of the facility with the Environmental Manager, the surveyor observed corridor doors propped in the open position with unapproved devices (door wedges, door stops, equipment, etc.) The doors observed are as follows:

1. The door leading into the health information system room was propped open with a door wedge.

2. The door leading into the traction room had numerous equipment overflowing into the path of the door swing, which did not allow
this door to close and latch.

3. The door leading into the staff lounge was propped in the open position with a door wedge.

4. Three examination doors located in physical therapy unit were propped in the open position with door stops.


B. On 09/11/12 at 5:10 pm, during interview, the Environmental Manager stated it was a continual problem with staff propping the doors in the open position.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition
Section. 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift.


Based on record review and staff interview, the facility failed to ensure fire drills were conducted at least quarterly on every shift to assure preparedness for emergency response (Federal regulations require that fire drills shall not exceed 90-day spacing between drills on each shift). This failed practice could result in staff not being adequately prepared to exercise their duties in accordance to the facility's Fire Plan in the event of fire, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the fire drill log with the Environmental Manager indicated the facility had two (2) nursing shifts:

First Shift (7:00 am - 7:00 pm)
Second Shift (7:00 pm - 7:00 am)

1. The following fire drills were conducted on the first shift, all of which exceeded the 90-day spacing between drills on this shift:

- 03/23/11 at 3:35 pm
- 07/07/11 at 10:00 am
- 11/16/11 at 2:15 pm
- 03/02/12 at 1:20 pm
- 07/25/12 at 9:30 am


2. The following fire drills were conducted on the second shift, all of which exceeded the 90-day spacing between drills on this shift:

- 03/27/11 at 7:30 pm
- 07/15/11 at 8:30 pm
- 11/22/11 at 8:15 pm
- 03/02/12 at 8:20 pm
- 07/10/12 at 8:30 pm


B. On 09/11/12 at 12:15 pm, during interview, the Environmental Manager stated he was unaware his fire drills exceeded the 90-day spacing between drills on both shifts.


C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 25, 1-4.2
The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

Reference NFPA 25, 1-4.4
The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.


Reference NFPA 25, 1998 Edition
2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

9-2.6* Main Drain Test.
A main drain test shall be conducted quarterly at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.

9-2.7 Waterflow Alarm.
All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.



Based on observation, record review and staff interview, the facility failed to ensure the sprinkler system was being tested at least quarterly (90 days) in accordance with NFPA 25, (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems), which resulted in alarm devices, main drains and valve supervisory switches being tested only annually. This failed practice could delay operation, or otherwise rendering the sprinkler system inoperable or ineffectual in the event of fire which presents the risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. Review of the Wet Fire Sprinkler Report dated 11/30/12 revealed the sprinkler system (2 risers) were inspected/tested annually instead of quarterly. Components such as alarm devices and main drains require quarterly testing.

B. On 09/11/12 at 11:10 am, during interview, the Environmental Manager stated he was unaware certain components of the sprinkler system were not being tested within the proper time intervals.


C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.



Reference NFPA 25, 1998 Edition
5-3.3 Annual Tests.
5-3.3.1*
An annual test of each pump assembly shall be conducted under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharged through approved test devices. This test shall be conducted as described in 5-3.3.1(a), (b), or (c).
Exception*: If available suction supplies do not allow flowing of 150 percent of the rated pump capacity, the fire pump shall be operated at maximum allowable discharge. This reduced capacity shall not constitute a noncompliant test.
(a) Use of the pump discharge via the hose streams; pump suction and discharge pressures and the flow measurements of each hose stream shall determine the total pump output. Care shall be taken to prevent water damage by verifying there is adequate drainage for the high-pressure water discharge from hoses.
(b) Use of the pump discharge via the bypass flowmeter to drain or suction the reservoir; pump suction and discharge pressures and the flowmeter measurements shall determine the total pump output.
(c) Use of the pump discharge via the bypass flowmeter to pump suction (closed-loop metering); pump suction and discharge pressures and the flowmeter measurements shall determine the total pump output.
Where the annual test is conducted periodically in accordance with 5-3.3.1(c), a test shall be conducted every 3 years in accordance with 5-3.3.1(a) or (b) in lieu of the method described in 5-3.3.1(c).
Where 5-3.3.1(b) or (c) is used, the flowmeter shall be adjusted immediately prior to conducting the test in accordance with the manufacturer ' s instructions. If the test results are not consistent with the previous annual test, 5-3.3.1(a) shall be used. If testing in accordance with 5-3.3.1(a) is not possible, a flowmeter calibration shall be performed and the test shall be repeated.

5-5 Maintenance.
5-5.1*
A preventive maintenance program shall be established on all components of the pump assembly in accordance with the manufacturer ' s recommendations. Records shall be maintained on all work performed on the pump, driver, controller, and auxiliary equipment.
In the absence of manufacturer ' s recommendations for preventive maintenance, Table 5-5.1 provides alternative requirements.

5-5.2
The preventive maintenance program shall be initiated immediately after the pump assembly has passed acceptance tests.


Based on observation, record review and staff interview, the facility failed to ensure the fire pump assembly, which provides waterflow and pressure for private fire protection systems, was tested at least every twelve (12) months as required by NFPA 25, (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems), and a fire pump preventative maintenance program was established in accordance with the Manufacture's Recommendation or Table 5-5.1 of NFPA 25. Without this routine testing and maintenance of the fire pump, the sprinkler system may not have the required waterflow and pressure necessary for effective sprinkler system performance in the event of fire, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the facility's maintenance records with the Environmental Manager failed to reveal the following:

1. No record indicating the fire pump was being tested professionally at least every twelve (12) months.
2. No record indicating a preventative maintenance program was being followed for the fire pump assembly.

B. On 09/11/12 at 11:50 am, during interview, the Environmental Manager stated he was unsure if the fire pump assembly was being tested as required. He stated the fire pump was not included in his preventative maintenance program. The Environmental Manager stated he had no further records available for review demonstrating the fire pump assembly was being tested as required.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.




Reference NFPA 25, 1998 Edition

9-7 Fire Department Connections.
Section 9-7.1
Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.


Based on observation and staff interview, the facility failed to ensure all Fire Department Connections (FDC) were properly identified with signage as required by NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). Without this signage, this failed practice could result in emergency response personnel connecting supplemental fire fighting equipment (ie: water pump trucks) to incorrect FDCs or other fire fighting components, which results in delayed emergency response and presents a risk of potential harm harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. On 09/11/12 at 2:30 pm, during a tour of the facility with the Environmental Manager, the surveyor observed the FDC was not provided with identification signage.

B. On 09/11/12 at 2:35 pm, the Environmental Manager stated he was unaware the FDC identification sign was not posted.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Based on observation, record review and staff interview, the facility failed to ensure the hospital building and grounds were maintained smoke-free in accordance with their adopted smoking policy and procedure. This failed practice presents a risk of potential harm by fire to all six (6) patients located in the medical surgical unit as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. Review of the facility's Smoking Policy with the Environmental Manager, revealed the hospital building and grounds were smoke free.

B. On 09/11/12 at 2:30 pm, the surveyor observed numerous cigarette butts on the ground and inside the trash recepticle at the garden courtyard.

C. On 09/11/12 at 2:35 pm, during interview, the Environmental Manager stated no one should be smoking on the property.

D. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 96, 1998 Edition
Section 8-3.1
Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with NFPA 96, Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule

Type or Volume of Cooking Frequency Frequency

Systems serving solid fuel cooking operations Monthly

Systems serving high-volume cooking operations,
such as 24-hour cooking, charbroiling or wok cooking Quarterly

Systems serving moderate-volume cooking operations Semi- annually

Systems serving low-volume cooking operations,
such as churches, day camps, seasonal businesses,
or senior centers Annually

8-3.1.1
Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

8-3.1.2
When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

8-3.2
Flammable solvents or other flammable cleaning aids shall not be used.

8-3.3
At the start of the cleaning process, electrical switches that could be activated accidentally shall be locked out.

8-3.4
Components of the fire suppression system shall not be rendered inoperable during the cleaning process.
Exception: Servicing by properly trained and qualified persons in accordance with Section 8-2.

8-3.5
Care shall be taken not to apply cleaning chemicals on fusible links or other detection devices of the automatic extinguishing system.

8-3.6
When cleaning procedures are completed, all electrical switches and system components shall be returned to an operable state. All access panels (doors) and cover plates shall be replaced. Dampers and diffusers shall be positioned for proper airflow.


Based on observation and staff interview, the facility failed to ensure the kitchen hood system and its appurtenances [accessories/parts which includes the hood, extinguishing system, duct and grease removal device] were cleaned to bare metal by a professional at least every 6-months in accordance with NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). Not professionally cleaning the range hood system and its appurtenances could result in fire and could result in ineffectual extinguishing system performance in the event of fire, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. On 09/11/12 at 12:05 pm, review of the kitchen hood maintenance records with the Environmental Manager, revealed no evidence the kitchen hood system was cleaned professionally at least every 6-months.

1. On 09/11/12 at 12:10 pm, during interview, the Environmental Manager stated kitchen staff cleans the hood and filters, but the hood was not being cleaned professionally.

2. On 09/11/12 at 1:50 pm, inspection of the hood system revealed no documentation (sticker) indicating the hood was being cleaned professionally. At this time, the Environmental Manager stated he had no further records available for review to demonstrating the range hood was being cleaned professionally.

B. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 99, 1999 Edition

4-3.1.2.10* Installation Requirements.
(a) Equipment and Component Installation.
1. The installation of individual components shall be made in accordance with the instructions of the manufacturer. Such instructions shall include directions and information deemed by the manufacturer to be adequate for attaining proper installation, testing, maintenance, and operation of the medical gas systems. These instructions shall be left with the owner.


Based on record review and staff interview, the facility failed to ensure the hospital's piped in medical gas system was being tested and maintained for proper operation in accordance with the manufactures instruction. Medical gas systems are essential for supplying piped in oxygen, nitrous oxide, carbon dioxide and medical air to various parts of the hospital. Without periodic testing of the medical gas system, this failed practice could result in unreliable system performance, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. Review of the facility's maintenance records with the Environmental Manager revealed no evidence the medical gas system was subject to periodic testing. There was no evidence a manufacturer's instruction manual was available for the medical gas system.

B. On 09/11/12 at 11:55 am, the Environmental Manager stated there is a professional company which services the medical gas system when the system needs repair. He stated he was unaware if the professional company was performing all of the necessary periodic testing in accordance with an instruction manual. The Environmental Manager stated he had no further records available for review demonstrating the medical gas system was being tested as required.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

NFPA 101, 2000 Edition
7.2.1.9* Powered Doors.
7.2.1.9.1* General.
Where means of egress doors are operated by power upon the approach of a person or doors with power-assisted manual operation, the design shall be such that, in the event of power failure, the door opens manually to allow egress travel or closes where necessary to safeguard the means of egress. The forces required to open such doors manually shall not exceed those required in 7.2.1.4.5, except that the force required to set the door in motion shall not exceed 50 lbf (222 N). The door shall be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4). On the egress side of each door, there shall be a readily visible, durable sign that reads as follows: IN EMERGENCY, PUSH TO OPEN
The sign shall be in letters not less than 1 in. (2.5 cm) high on a contrasting background.


Based on observation and staff interview, the facility failed to ensure power assist sliding doors installed in the means of egress were labeled with signage that reads: IN EMERGENCY, PUSH TO OPEN. In the event of power failure and without clear instruction of how to open these doors, occupants could mistake the egress door as being locked and would not be able to readily exit to the outside in the event of an emergency, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. On 09/11/12 at 1:30 pm, during a tour of the facility with the Environmental Manager, the surveyor observed the power assist sliding doors located at the main entrance were not labeled with clear instruction of how to open in the event of emergency.

B. On 09/11/12 at 1:35 pm, during interview, the Environmental Manager stated he was unaware the doors were not properly labeled.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Reference NFPA 110, Standard for Emergency and Standby Power System

Section 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.

6-4.3
Load tests of generator sets shall include complete cold starts.


Based on record review and staff interview, the facility failed to ensure the emergency generators, used to protect residents during the times of primary power failure, were tested underload at least once a month for a minimum of thirty (30) minutes as required by NFPA 110 (Standard for Emergency and Standby Power System). Not conducting underload testing every month could result in an unreliable emergency power source in the event of primary power failure, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the Emergency Generator Log C-15 with the Environmental Manager, revealed no record emergency generator C-15 was tested underload for the month of July 2012.

B. Review of the Emergency Generator Log M-3306 with the Environmental Manager, revealed no record emergency generator M-3306 was tested underload for the month of August 2012.

C. On 09/11/12 at 12:30 pm, during interview, the Environmental Manager stated he was uncertain why the testing wasn't conducted for those months.

D. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.




NFPA 99:
3-4.4.2 Record keeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Based on observation, record review and staff interview, the facility's practice failed to ensure specific gravity was being tested for all generator starting batteries in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). Specific gravity shall be tested and recorded at least once a month for all generator batteries to determine their serviceability. Without this testing, this failed practice could result in generator batteries not being capable to start the emergency generator in the event of power failure, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the Emergency Generator Log C-15 with the Environmental Manager, revealed no record specific gravity was being tested for emergency generator C-15.

B. Review of the Emergency Generator Log M-3306 with the Environmental Manager, revealed no record specific gravity was being tested for emergency generator M-3306.

C. On 09/11/12 at 12:35 pm, during interview, the Environmental Manager stated the specific gravity was being tested for all generator batteries but the results of the testing were not being documented. No further records were available for review.

D. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.



Reference NFPA 99
5-3 Lighting.
5-3.1
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
5-3.2*
The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft-candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.
Exception: This requirement shall not apply to units housed outdoors.


Based on observation and staff interview, the facility failed to ensure the room which houses the emergency generator, was provided with battery-powered emergency lighting. In the event the emergency generator experiences problems such as not starting, battery-back up illumination is needed to perform servicing. This failed practice presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:

A. On 09/11/12 at 4:30 pm, observation of the room which houses emergency generator M-3306 failed to reveal battery-back up emergency lighting fixtures.

B. On 09/11/12 at 4:35 pm, the Environmental Manager stated he was unaware the room required battery-back up emergency lighting fixtures.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Based on record review and staff interview, the facility failed to provide written policies and procedures in the event the fire sprinkler system was out of service for more than 4 hours within a 24 hour period. Without this policy and procedure in place, this failed practice could result in the facility not detecting and controlling early signs of fire within the building during the time the sprinkler system is down, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the sprinkler system maintenance records with the Environmental Manager revealed no evidence written policies and procedures were in place in the event the sprinkler system was out of service longer than the allotted time.

B. On 09/11/12 at 11:20 am, during interview, the Environmental Manager stated staff knows and understands the procedure but he's never seen anything in writing.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.

Based on record review and staff interview, the facility failed to provide written policies and procedures in the event the fire alarm system was out of service for more than 4 hours within a 24 hour period. Without this policy and procedure in place, this failed practice could result in the facility not detecting and controlling early signs of fire within the building during the time the system is down, which presents a risk of potential harm to all six (6) patients as identified by the Nurses Night Report provided by the Director of Nursing on 09/11/12 at 11:00 am. The findings are:


A. Review of the fire alarm system maintenance records with the Environmental Manager revealed no evidence written policies and procedures were in place in the event the fire alarm system was out of service longer than the allotted time.

B. On 09/11/12 at 11:30 am, during interview, the Environmental Manager stated staff knows and understands the procedure but he's never seen anything in writing.

C. On 09/11/12 at 5:30 pm, the Chief Executive Officer and the Environmental Manager acknowledged the above findings at the exit conference.