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Based on observation and facility staff interview, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 70, The National Electric Code and NFPA 72, National Fire Alarm and Signaling Code. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 14.

Observations on 3/02/2017, during the facility tour, showed the following areas missing required smoke detector coverage:

- 66 feet between smoke detectors in the corridor extending from the Emergency Department vestibule door through the corridor to the barrier doors in the corridor near the cafeteria entrance.

- 76 feet between smoke detectors in the corridor extending from the barrier doors in the "Wall of Honor" extending through to patient room #142.

During an interview on 3/03/2017 at 2:30 P.M., the Plant Operations Director said he believed the fire alarm system installation company installed the fire alarm system per code requirements.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on staff interview and record review, facility staff failed to inspect the wet & dry sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 14.

Record review on 03/01/2017 did not show the following inspections:

- three (3) year dry system full trip test for the dry sprinkler system

- weekly, monthly, quarterly, semi annual inspections/testing for the wet and dry sprinkler systems

-five (5) year internal pipe inspections/testing for the wet and dry sprinkler systems

During an interview on 03/03/2017 at 2:37 P.M., the Plant Operations Director said he believed the sprinkler inspection companies conducted the sprinkler inspections per code requirements.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on observation, facility staff failed to ensure transfer grills were not installed in corridors. One of five electrical rooms had transfer grills installed in the corridor doors. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure transfer grills were not installed in corridors has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. The facility census was 14.

Observation on 3/02/2017, during the building tour, showed electrical room #145 had four doors each containing transfer grills measuring approximately 12 inches by 12 inches. Observation showed the room contained one transformer and three panelboards.

NFPA 101, 2012 edition, Section 19.3.6.4 states:

"19.3.6.4 Transfer Grilles.
19.3.6.4.1 Transfer grilles, regardless of whether they are
protected by fusible link-operated dampers, shall not be used
in corridor walls or doors."

Based on observation facility staff failed to ensure all electrical rooms comply with NFPA 70 (National Electrical Code) 2011 edition requirements. Three of five electrical rooms did not have a ceiling separating the electrical rooms from the open space above the corridors and adjacent areas. Failure to ensure all electrical rooms have a ceiling separating the electrical rooms has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire into the open space above the corridors and adjacent areas from in the event of a fire. The facility census was 14.

Observation on 3/02/17, during the facility tour, showed the following electrical rooms did not have ceilings:

-Electrical room #735 by patient room #22 showed the room contained four panelboards and two transformers. Additional observation showed the room did not have a ceiling and shared the airspace above the room.

-Electrical room #618 in the Radiology Department showed the room contained four panelboard. Additional observation showed the room did not have a ceiling and shared the airspace above the room.

-Electrical room #110 Clinic Electrical room by exam room #8 showed the room contained three panelboards, one transformer and one electrical shutoff switch. Additional observation showed the room did not have a ceiling and shared the airspace above the room.


NFPA 101, 2012 edition, Section 19.5.1 states:
"19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1."

NFPA 101, 2012 edition, Section 9.1.2 states:

"9.1.2 Electrical Systems. Electrical wiring and equipment
shall be in accordance with NFPA 70, National Electrical Code,
unless such installations are approved existing installations,
which shall be permitted to be continued in service."

NFPA 70, National Electrical Code, Article 110.26 Requirements for Electrical installations state:

"(1) Indoor. Indoor installations shall comply with
110.26(E)(1)(a) through (E)(1)(d).

(a) Dedicated Electrical Space. The space equal to the
width and depth of the equipment and extending from the
floor to a height of 1.8 m (6 ft) above the equipment or to
the structural ceiling, whichever is lower, shall be dedicated
to the electrical installation. No piping, ducts, leak protection
apparatus, or other equipment foreign to the electrical
installation shall be located in this zone.
Exception: Suspended ceilings with removable panels shall
be permitted within the 1.8-m (6-ft) zone.

(b) Foreign Systems. The area above the dedicated
space required by 110.26(E)(1)(a) shall be permitted to
contain foreign systems, provided protection is installed to
avoid damage to the electrical equipment from condensation,
leaks, or breaks in such foreign systems.

(c) Sprinkler Protection. Sprinkler protection shall be
permitted for the dedicated space where the piping complies
with this section.

(d) Suspended Ceilings. A dropped, suspended, or
similar ceiling that does not add strength to the building
structure shall not be considered a structural ceiling."

Please refer to NFPA 13, 2010 edition, Sections 8.15.10, 8.15.10.1, 8.15.10.2 and 8.15.10.3 for sprinkler requirements in electrical rooms.

Based on observation and facility staff interview the facility failed to provide a remote annunciator panel (a panel providing information on the condition and problems with the emergency generator) for one of one emergency generators at a constantly attended location. The facility census was 14.

1. Observation on 03/02/17 during the facility tour, did not show a remote annunciator panel for the emergency generator in a constantly attended location. Additionally, observation showed a remote annunciator panel in the mechanical room.

During an interview on 03/03/2017 at 2:32 P.M., the Plant Operations Director said the annunciator panel was installed by the generator installation company. Additionally, he said he believed the generator company installed the annunciator panel per code requirements.

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
(b) Low water temperature (below that required in
6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains
less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

6.4.1.1.17.1* A remote, common audible alarm shall be provided
as specified in 6.4.1.1.17.4 that is powered by the storage
battery and located outside of the EPS service room at a work
site observable by personnel. [110:5.6.6]

6.4.1.1.17.2 An alarm-silencing means shall be provided, and
the panel shall include repetitive alarm circuitry so that, after
the audible alarm has been silenced, it reactivates after the
fault condition has been cleared and has to be restored to its
normal position to be silenced again. [110:5.6.6.1]

6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA110, a
manual alarm-silencing means shall be permitted that silences
the audible alarm after the occurrence of the alarm condition,
provided such means do not inhibit any subsequent alarms from
sounding the audible alarm again without further manual action.
[110:5.6.6.2]

6.4.1.1.17.4 Individual alarm indication to annunciate any of
the conditions listed in Table 6.4.1.1.16.2 shall have the following
characteristics:
(1) It shall be battery powered.
(2) It shall be visually indicated.
(3) It shall have additional contacts or circuits for a common
audible alarm that signals locally and remotely when any
of the itemized conditions occurs.
(4) It shall have a lamp test switch(es) to test the operation of
all alarm lamps.

6.4.1.1.17.5 Acentralized computer system (e.g., building automation
system) shall not be permitted to be substituted for
the alarm annunciator in 6.4.1.1.17 but shall be permitted to
be used to supplement the alarm annunciator.

6.4.1.2 Battery. Battery systems shall meet all requirements of
Article 700 of NFPA 70, National Electrical Code.


Table 6.4.1.1.16.2 Safety Indications and Shutdowns
Level 1
Indicator Function (at Battery Voltage) CV S RA
(a) Overcrank X X X
(b) Low water temperature X - X
(c) High engine temperature pre-alarm X - X
(d) High engine temperature X X X
(e) Low lube oil pressure pre-alarm X - X
(f) Low lube oil pressure X X X
(g) Overspeed X X X
(h) Low fuel main tank X - X
(i) Low coolant level X O X
(j) EPS supplying load X - -
(k) Control switch not in automatic
position
X - X
(l) High battery voltage X - -
(m) Low cranking voltage X - X
(n) Low voltage in battery X - -
(o) Battery charger ac failure X - -
(p) Lamp test X - -
(q) Contacts for local and remote
common alarm
X - X
(r) Audible alarm-silencing switch - - X
(s) Low starting air pressure X - -
(t) Low starting hydraulic pressure X - -
(u) Air shutdown damper when used X X X
(v) Remote emergency stop - X -
CV: Control panel-mounted visual. S: Shutdown of EPS indication.
RA: Remote audible. X: Required. O: Optional.
Notes:
(1) Item (p) shall be provided, but a separate remote audible signal shall
not be required when the regular work site in 5.6.6 of NFPA110, Standard
for Emergency and Standby Power Systems, is staffed 24 hours a day.
(2) Item (b) is not required for combustion turbines.
(3) Item (r) or (s) is required only where used as a starting method.
(4) Item (j): EPS ac ammeter shall be permitted for this function.
(5) All required CV functions shall be visually annunciated by a remote,
common visual indicator.
(6) All required functions indicated in the RAcolumn shall be annunciated
by a remote, common audible alarm as required in 5.6.5.2(4) of
NFPA 110.
(7) Item (i) requires a low gas pressure alarm on gaseous systems.
(8) Item (b) must be set at 11°C (20°F) below the regulated temperature
determined by the EPS manufacturer, as required in 5.3.1 of
NFPA 110.