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Based on record review, observation and interview, the facility failed to ensure Alcohol Based Hand Rub Dispensers (ABHR) were maintained in accordance with NFPA 101. Failure to test and document the operation of ABHR dispensers in accordance with the manufacturer's care and use instructions each time a new refill is installed could result in inadvertently spilling flammable liquids, increasing the risk of fires. This deficient practice affected staff and visitors on the date of the survey. The facility is licensed for 10 CAH beds and had a census of 0 on the day of the survey.

Findings include:

During the review of facility inspection records on September 14, 2017 from approximately 10:00 AM to 1:00 PM, no records were available indicating ABHR dispensers were tested in accordance with manufacturer's care and use instructions when a new refill is installed. ABHR dispensers were observed throughout the facility and when asked, the Maintenance Director stated the facility was not aware of the requirement to test ABHR dispensers each time a new refill is installed.

Actual NFPA standard:

NFPA 101

19.3.2.6% Alcohol-Based Hand-Rub Dispensers.
Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met:
(1) Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1830 mm).
(2) The maximum individual dispenser fluid capacity shall be as follows:
(a) 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors
(b) 0.53 gal (2.0 L) for dispensers in suites of rooms
(3) Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz. (0.51 kg) and shall be limited to Level 1 aerosols as defined in NFPA30B, Cod

Based on record review, observation and interview, the facility failed to inspect, test, and maintain the fire suppression system in accordance with NFPA 25. Failure to maintain fire suppression systems could hinder system performance during a fire event. This deficient practice affected staff and visitors on the date of the survey. The facility is licensed for 10 CAH beds and had a census of 0 on the day of the survey.

Findings include:

During the review of facility inspection records conducted on September 14, 2017 from approximately 10:00 AM to 1:00 PM, no documentation could be located for a five (5) year inspection of the sprinkler system to include internal pipes and gauges. Further review revealed the installed anti-freeze solution was propylene glycol, with a concentration of 48.6 percent, which was in excess of the allowable 40 percent. When asked, the Maintenance Director stated the facility was not aware of the five (5) year inspection requirement, but had been made aware of the elevated antifreeze solution during their annual inspection on September 3, 2017.

Actual NFPA standard:

NFPA 101

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

NFPA 25

5.3.4% Antifreeze Systems. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary.
5.3.4.1% Solutions shall be in accordance with Table 5.3.4.1(a) and Table 5.3.4.1(b).
5.3.4.3.2 If the test results indicate an incorrect freeze point at any point in the system, the system

Based on observation and interview, the facility failed to ensure the Essential Electrical System (EES) generator was equipped with a remote manual stop switch. Failure to provide a remote stop switch prohibits the protection from the impact of adverse generator conditions. This deficient practice affected staff and visitors on the date of the survey. The facility is licensed for 10 CAH beds and had a census of 0 on the day of the survey.

Findings include:

During the facility tour conducted on September 14, 2017 from approximately 1:00 PM to 4:30 PM, observation revealed the facility did not provide a remote manual stop switch for the EES generator located outside the facility. When asked, the Maintenance Director stated the facility was not aware they were required to have a remote stop station for the generator.

Actual NFPA standard:

NFPA 110

5.6.5.6% All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is located outside the building.
5.6.5.6.1 The remote manual stop station shall be labeled.

NFPA 99
6.4.1.1.16.2 Safety indications and shutdowns shall be in accordance with Table 6.4.1.1.16.2.
(SEE TABLE)

Based on observation and interview, the facility failed to ensure the EES (Essential Electrical System) was installed in accordance with NFPA 99. Failure to provide an alarm annunciator for the EES could hinder early notification of equipment failures, leaving the facility without emergency power during an outage. This deficient practice affected staff and visitors on the date of the survey. The facility is licensed for 10 CAH beds and had a census of 0 on the date of the survey.

Findings include:

During the facility tour conducted on September 14, 2017, from approximately 1:00 PM to 4:30 PM, observation of the work station in the facility, did not reveal an alarm annunciator for the EES. When asked, the Maintenance Director stated that he was not aware of an alarm panel, or other device which would indicate the facility was under auxiliary power (generator) during a power outage.

Actual NFPA standard:

NFPA 99
Chapter 6 Electrical Systems
6-4 Essential Electrical System Requirements - Type 1.
6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating
personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to warn of an engine generator alarm condition shall indicate the following:
(a) Low lubricating oil pressure