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Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect three (3) of four (4) smoke compartments, residents, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The penetrations of pipes and wires through the smoke barriers were not sealed with material rated or equal to the wall.


The findings include:

Observations, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer and the Engineering Manager revealed the smoke barriers, extending above the ceiling had penetrations of pipes and wires. The penetrations were not filled with a material rated equal to the partition and could not resist the passage of smoke. The locations of the penetrations are as follows:

1) An unsealed wire penetrating the smoke barrier located above the cross corridor doors in the 100 Hall.

2) Four (4) pipes and one (1) wire were penetrating the smoke barrier located above the cross corridor doors next to the Business Office.

3) Two penetrations by wires located above the cross corridor doors in the Front Hall.


Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer and the Engineering Manager revealed they were not aware of the penetrations in the smoke barriers.


Reference: NFPA 101 (2000 Edition).

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:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) 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
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty beds (25) beds with a census of one (01) on the day of the survey. The facility failed to ensure doors located in a smoke barrier would close completely and resist the passage of smoke.

The findings include:

Observation, on 04/17/13 between 11:00 AM and 3:00 PM, with the Engineering Manager revealed the cross corridor doors in the smoke barrier located next to the Business Office had a gap too large and would not resist the passage of smoke.

Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Engineering Manager revealed he was not aware the doors had developed a gap that was too large to resist smoke.


Reference: NFPA 101 (2000 edition)

8.3.4.1* Doors in smoke barriers shall close the opening leaving
only the minimum clearance necessary for proper operation
and shall be without undercuts, louvers, or grilles.

Reference: NFPA 80 (1999 Edition)
Standard for Fire Doors 2-3.1.7
The clearance between the edge of the door on the pull side shall be 1/8 in. (+/-) 1/16 in. (3.18 mm (+/-) 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18mm) for wood doors.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect three (3) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide self-closing devices for rated doors protecting hazardous areas.


The findings include:

Observation, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed rooms required being self-closing or containing a hazardous amount of combustibles did not have a self-closing device to keep the door closed. The rooms identified as hazardous and requiring a rated door with a self-closing device were located in the following areas:

1) The storage rooms located next to rooms 115, 112, 102 and the equipment clean-up room next to room 118 did not have a self-closing device. The doors to these rooms opened outward into the egress path and extended off the wall more than 7 inches when fully opened.

2) Clean Linen room next to room 106 did not have a self-closer.

3) The copy room located at the extended nurses' station did not have a self-closing device.

4) Hazardous storage room located in the kitchen did not have a door or a self-closing device.

5) Oxygen storage room located in Respiratory Therapy did not have a self-closing device.


Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed she was not aware the doors to these rooms did not meet the requirements for protection from hazards.


8.4.1.3
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
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 observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide required illumination outside an exit for discharge.

The findings include:

Observation, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer and the Engineering Manager revealed the exits located at the end of the 100 Hall, the Cave City Exit, and the Basement Exit did not have a light installed outside to provide the required illumination for exit discharge. The exits were equipped with a light fixture with only one bulb installed.

Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer and the Engineering Manager revealed they were not aware the exits did not have the required illumination for egress lighting.


Reference: NFPA 101 (2000 Edition)

19.2.8 Illumination of Means of Egress.
Means of egress shall be illuminated in accordance with Section 7.8.

7.8 ILLUMINATION OF MEANS OF EGRESS
7.8.1 General.
7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
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 in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.
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 observation and interview, it was determined the facility failed to ensure exit signs were maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to ensure exits were clearly recognizable with proper exit signage.

The findings include:

Observation, on 04/17/13 at 12:40 PM, with the Engineering Manager revealed the doors in the Kitchen did not have an exit sign making the path of egress clearly recognizable.

Interview, on 04/17/13 at 12:40 PM, with the Engineering Manager revealed he was not aware the egress path through the Kitchen did not have proper signage.

Reference: NFPA 101 (2000 edition)

7.10.1.2* Exits. Exits, other than main exterior exit doors
that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction
of exit access.

Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on interview and fire drill record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to ensure the fire drills were conducted at unexpected times on all shift.

The findings include:

Fire Drill review, on 04/17/13 at 11:12 AM, with the Engineering Manager revealed the facility failed to conduct fire drills at unexpected times on all shifts. The facility conducted fire drills monthly on all shifts; however, the times were within the same hours on all shifts, and the fire drills were mostly conducted within a few days of each other in the middle of the month.


Interview, on 04/17/13 at 11:12 AM, with the Engineering Manager revealed he was not aware the fire drills were not being conducted as required.


Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Reference: NFPA 101 Life Safety Code (2000 Edition).
19.7* OPERATING FEATURES
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1
The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.
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 to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation and interview, it was determined the facility failed to ensure the fire extinguishers were in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide required extinguishers and signage for fire extinguishers.


The findings include:

Observation, on 04/17/13 at 12:39 PM, with the Engineering Manager revealed there was no K Class extinguisher or placard stating that the hood suppression system must be used before the class K fire extinguisher located in the Kitchen. This type of extinguisher is used as a secondary measure to the range hood extinguishing system.

Interview, on 04/17/13 at 12:39 PM, with the Engineering Manager revealed he was not aware of the extinguisher and signage requirement.


Reference: NFPA 10 1998 edition

3-7 Fire Extinguisher Size and Placement for Class K Fires.

3-7.1 Fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats).
3-7.2
Maximum travel distance shall not exceed 30 ft (9.15 m) from the hazard to the extinguishers.


Reference: NFPA 10 1999

4-3.2* Procedures.
Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d)* Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place
4-3.3 Corrective Action.
When an inspection of any fire extinguisher reveals a deficiency in any of the conditions listed in 4-3.2 (a), (b), (h), and (i), immediate corrective action shall be taken.


Reference: NFPA 10 (1998 Edition).
2-3.2.1 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.


Reference NFPA 10 (1998 Edition).
1-6.10 Fire extinguishers having a gross weight
not exceeding 40 lb (18.14 kg) shall be
installed so that the top of the fire
extinguisher is not more than 5 ft (1.53 m)
above the floor. Fire extinguishers having a
gross weight greater than 40 lb (18.14 kg)
(except wheeled types) shall be so installed
that the top of the fire extinguisher is not
more than 3 1/2 ft (1.07 m) above the floor.
In no case shall the clearance between the
bottom of the fire extinguisher and the floor
be less than 4 in. (10.2 cm).

Based on observation and interview, it was determined the facility failed to ensure cooking facilities were protected in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to ensure the manual activation pull for the hood suppression was located in the egress path and readily accessible.

The findings include:

Observation, on 04/17/13 at 12:39 PM, with the Engineering Manager revealed the manual activation pull for the facilities hood suppression system was not readily accessible due to the pull not being located in the path of egress.

Interview, on 04/17/13 at 12:39 PM, with the Engineering Manager revealed he was not aware of the requirements for the hood suppression manual pull station.



Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect three (3) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to ensure portable heaters did not exceed 212 degrees.


The findings include:

Observation, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed a portable space heater located in the Pharmacy, Kitchen Dry Storage, Billing Office, and the Health Information Management Office. .

Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed she was not aware the heaters element could not exceed 212°F in non-sleeping, staff, and employee areas.


Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212°F (100°C).

Based on flame retardant documentation review and interview, it was determined the facility failed to ensure that combustible decorations were used in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide documentation that personal and seasonal decorations had been treated or were flame retardant.

The findings include:

Flame retardant documentation review, on 04/17/13 at 11:36 AM, with the Engineering Manager revealed the facility did not have documentation that newly introduced personal or seasonal decorations for residents or staff had been treated with a flame retardant material.

Interview, on 04/17/13 at 11:36 AM, with the Engineering Manager revealed he was not aware decorations were required to be treated with a fire retardant and documentation was to be kept on the items that had been treated.


Reference: NFPA 101 (2000 Edition)

19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.

Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders were stored in accordance with NFPA standards. This deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. the facility failed to provide proper signage and separation between oxygen tanks.

The findings include:

Observation, on 04/17/13 at 12:52 PM, with the Chief Nursing Officer and the Engineering Manager revealed the tanks were not clearly identified to be full or empty. There were fourteen "E" tanks which was greater than 8.5 m3 (300 ft3) but less than 85 m3 (3000 ft3) located in the oxygen storage room in Respiratory Therapy. This facility is not protected by an automatic sprinkler system. Further observation revealed the door to the Oxygen Storage Room did not latch when tested. Further observation revealed combustible storage within twenty (20) feet of the oxygen tanks.

Interview, on 04/17/13 at 12:52 PM, with the Chief Nursing Officer and the Engineering Manager revealed they were not aware of the requirements for oxygen storage. Further interview revealed they were not aware the door did not latch.


Reference: NFPA 99 (1999 edition)
8-3.1.11.2
Storage for nonflammable gases greater than 8.5 m3 (300 ft3) but less than 85 m3 (3000 ft3)
(A) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(B) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(C) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) A minimum distance of 6.1 m (20 ft)
(2) A minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) An enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.


8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Based on fire damper testing record review, and interview, it was determined the facility failed to ensure fire/smoke dampers were maintained in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, residents, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide documentation that the smoke/fire dampers were tested within the last four (4) years.

The findings include:


Fire damper testing record review, on 04/17/13 at 11:30 AM with the Engineering Manager revealed the facility did not have documentation that fire/smoke dampers had been tested within the last four (4) years.

Interview, on 04/17/13 at 11:30 AM, with the Engineering Manager revealed he was not aware of the requirements for fire/smoke damper testing.


Reference: NFPA 90A (1999 edition)

3-4.7 Maintenance. At least every 4 years, fusible links (where
applicable) shall be removed; all dampers shall be operated to
verify that they fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.


Reference: NFPA 101 (2000 Edition)

8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
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.
8.3.6.2
Openings occurring at points where floors or smoke barriers meet the outside walls, other smoke barriers, or fire barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is designed for the specific purpose.

Based on generator testing record review, observation and interview, it was determined the facility failed to ensure emergency generators were maintained in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, residents, staff, and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide documentation for the generators monthly transfer times. The facility also failed to ensure the generator room was not used for storage, and was equipped with proper emergency lighting.

The findings include:

Observation, on 04/17/13 at 1:14 PM, with the Engineering Manager revealed storage of combustible items such as paint, wood, work benches, and tools were being stored within the generator room. Further observation revealed the generator room was not equipped with an emergency battery light.

Interview, on 04/17/13 at 1:14 PM, with the Engineering Manager revealed he was not aware items could not be stored in the generator room. Further interview revealed the lights in the generator room were connected to the emergency generator; however, he was not aware the room was required to have an emergency battery light installed in the event the generator failed to start.

Generator Testing Record Review, on 04/17/13 at 2:28 PM, with the Engineering Manager revealed the facility did not provide documentation for the monthly transfer times of the generator.

Interview, on 04/17/13 at 2:28 PM, with the Engineering Manager revealed he was not aware the monthly transfer time for the generator was to be documented.


Reference: NFPA 110 (1999 Edition).

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.

Reference: NFPA 99 (1999 Edition)

Actual NFPA Standard: NFPA 99, 3-5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-5.3.1.
(b) Inspection and Testing. Generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b).
Actual Standard: NFPA 110, 6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.
Actual Standard: NFPA 99, 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1. Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.
Actual Standard: NFPA 99, 3- 3-4.4.2. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.


6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction

6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

Reference: NFPA 101 ( 2000 edition)


7.9.1.2 Where maintenance of illumination depends on
changing from one energy source to another, a delay of not
more than 10 seconds shall be permitted.
Reference: NFPA 110 (1999 ed.)
5-7 Heating, Cooling, and Ventilating.
5-7.1* Consideration shall be given to properly sizing the ventilation
or air-conditioning systems to remove all the heat
rejected to the EPS equipment room by the energy converter,
uninsulated or insulated exhaust pipes, and other heat-producing
equipment.
5-7.2 Adequate ventilation shall be provided to prevent temperatures
or temperature rises in the EPS and related accessory
equipment that exceed the recommendations of the
manufacturer.
5-7.3 For the EPS equipment room, the ventilation or cooling
equipment, or both, shall be sized so that the ambient temperature
shall not exceed the EPS equipment manufacturer ' s criteria
or allowable maximum temperatures.


Reference: NFPA 110 (1999 Edition)


5-2.1 The EPS shall be installed in a separate room for Level
1 installations. EPSS equipment shall be permitted to be
installed in this room. The room shall have a minimum 2-hour
fire rating or shall be located in an adequate enclosure located
outside the building capable of resisting the entrance of snow
or rain at a maximum wind velocity required by local building
codes. No other equipment, including architectural appurtenances,
except those that serve this space, shall be permitted
in this room.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to maintain proper use of power strips, and extension cords.

The findings include:

Observations, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed:

1) A medication distribution machine called "Documed" was plugged into a power strip.

2) Storage in front of electrical panels located in the Soiled Utility Room of the 100 Hall.

3) A power strip was plugged into an extension cord than was run through the ceiling to provide power to an office that use to be a closet located in the Chief Nursing Officers Office.

4) A toaster oven and a mixer were plugged into a power strip located in the Kichen.

5) A microwave was plugged into a power strip located in the Health Information Management Office.

Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed she was not aware the power strips and extension cords had been misused. Further interview revealed she was not aware of the storage in front of electrical panels.



Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


110-26. Spaces

About Electrical Equipment. Sufficient access and working space shall be provided and maintained around 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.

Reference: NFPA 70 (1999 edition)


Reference: NFPA 70 (1999 edition)

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 70 400-8
( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Based on observations and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect three (3) of four (4) smoke compartments, residents, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The penetrations of pipes and wires through the smoke barriers were not sealed with material rated or equal to the wall.


The findings include:

Observations, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer and the Engineering Manager revealed the smoke barriers, extending above the ceiling had penetrations of pipes and wires. The penetrations were not filled with a material rated equal to the partition and could not resist the passage of smoke. The locations of the penetrations are as follows:

1) An unsealed wire penetrating the smoke barrier located above the cross corridor doors in the 100 Hall.

2) Four (4) pipes and one (1) wire were penetrating the smoke barrier located above the cross corridor doors next to the Business Office.

3) Two penetrations by wires located above the cross corridor doors in the Front Hall.


Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer and the Engineering Manager revealed they were not aware of the penetrations in the smoke barriers.


Reference: NFPA 101 (2000 Edition).

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:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) 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
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty beds (25) beds with a census of one (01) on the day of the survey. The facility failed to ensure doors located in a smoke barrier would close completely and resist the passage of smoke.

The findings include:

Observation, on 04/17/13 between 11:00 AM and 3:00 PM, with the Engineering Manager revealed the cross corridor doors in the smoke barrier located next to the Business Office had a gap too large and would not resist the passage of smoke.

Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Engineering Manager revealed he was not aware the doors had developed a gap that was too large to resist smoke.


Reference: NFPA 101 (2000 edition)

8.3.4.1* Doors in smoke barriers shall close the opening leaving
only the minimum clearance necessary for proper operation
and shall be without undercuts, louvers, or grilles.

Reference: NFPA 80 (1999 Edition)
Standard for Fire Doors 2-3.1.7
The clearance between the edge of the door on the pull side shall be 1/8 in. (+/-) 1/16 in. (3.18 mm (+/-) 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18mm) for wood doors.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect three (3) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide self-closing devices for rated doors protecting hazardous areas.


The findings include:

Observation, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed rooms required being self-closing or containing a hazardous amount of combustibles did not have a self-closing device to keep the door closed. The rooms identified as hazardous and requiring a rated door with a self-closing device were located in the following areas:

1) The storage rooms located next to rooms 115, 112, 102 and the equipment clean-up room next to room 118 did not have a self-closing device. The doors to these rooms opened outward into the egress path and extended off the wall more than 7 inches when fully opened.

2) Clean Linen room next to room 106 did not have a self-closer.

3) The copy room located at the extended nurses' station did not have a self-closing device.

4) Hazardous storage room located in the kitchen did not have a door or a self-closing device.

5) Oxygen storage room located in Respiratory Therapy did not have a self-closing device.


Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed she was not aware the doors to these rooms did not meet the requirements for protection from hazards.


8.4.1.3
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
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 observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect two (2) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide required illumination outside an exit for discharge.

The findings include:

Observation, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer and the Engineering Manager revealed the exits located at the end of the 100 Hall, the Cave City Exit, and the Basement Exit did not have a light installed outside to provide the required illumination for exit discharge. The exits were equipped with a light fixture with only one bulb installed.

Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer and the Engineering Manager revealed they were not aware the exits did not have the required illumination for egress lighting.


Reference: NFPA 101 (2000 Edition)

19.2.8 Illumination of Means of Egress.
Means of egress shall be illuminated in accordance with Section 7.8.

7.8 ILLUMINATION OF MEANS OF EGRESS
7.8.1 General.
7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
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 in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.
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 observation and interview, it was determined the facility failed to ensure exit signs were maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to ensure exits were clearly recognizable with proper exit signage.

The findings include:

Observation, on 04/17/13 at 12:40 PM, with the Engineering Manager revealed the doors in the Kitchen did not have an exit sign making the path of egress clearly recognizable.

Interview, on 04/17/13 at 12:40 PM, with the Engineering Manager revealed he was not aware the egress path through the Kitchen did not have proper signage.

Reference: NFPA 101 (2000 edition)

7.10.1.2* Exits. Exits, other than main exterior exit doors
that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction
of exit access.

Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on interview and fire drill record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to ensure the fire drills were conducted at unexpected times on all shift.

The findings include:

Fire Drill review, on 04/17/13 at 11:12 AM, with the Engineering Manager revealed the facility failed to conduct fire drills at unexpected times on all shifts. The facility conducted fire drills monthly on all shifts; however, the times were within the same hours on all shifts, and the fire drills were mostly conducted within a few days of each other in the middle of the month.


Interview, on 04/17/13 at 11:12 AM, with the Engineering Manager revealed he was not aware the fire drills were not being conducted as required.


Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Reference: NFPA 101 Life Safety Code (2000 Edition).
19.7* OPERATING FEATURES
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1
The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.
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 to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation and interview, it was determined the facility failed to ensure the fire extinguishers were in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide required extinguishers and signage for fire extinguishers.


The findings include:

Observation, on 04/17/13 at 12:39 PM, with the Engineering Manager revealed there was no K Class extinguisher or placard stating that the hood suppression system must be used before the class K fire extinguisher located in the Kitchen. This type of extinguisher is used as a secondary measure to the range hood extinguishing system.

Interview, on 04/17/13 at 12:39 PM, with the Engineering Manager revealed he was not aware of the extinguisher and signage requirement.


Reference: NFPA 10 1998 edition

3-7 Fire Extinguisher Size and Placement for Class K Fires.

3-7.1 Fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats).
3-7.2
Maximum travel distance shall not exceed 30 ft (9.15 m) from the hazard to the extinguishers.


Reference: NFPA 10 1999

4-3.2* Procedures.
Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d)* Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place
4-3.3 Corrective Action.
When an inspection of any fire extinguisher reveals a deficiency in any of the conditions listed in 4-3.2 (a), (b), (h), and (i), immediate corrective action shall be taken.


Reference: NFPA 10 (1998 Edition).
2-3.2.1 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.


Reference NFPA 10 (1998 Edition).
1-6.10 Fire extinguishers having a gross weight
not exceeding 40 lb (18.14 kg) shall be
installed so that the top of the fire
extinguisher is not more than 5 ft (1.53 m)
above the floor. Fire extinguishers having a
gross weight greater than 40 lb (18.14 kg)
(except wheeled types) shall be so installed
that the top of the fire extinguisher is not
more than 3 1/2 ft (1.07 m) above the floor.
In no case shall the clearance between the
bottom of the fire extinguisher and the floor
be less than 4 in. (10.2 cm).

Based on observation and interview, it was determined the facility failed to ensure cooking facilities were protected in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to ensure the manual activation pull for the hood suppression was located in the egress path and readily accessible.

The findings include:

Observation, on 04/17/13 at 12:39 PM, with the Engineering Manager revealed the manual activation pull for the facilities hood suppression system was not readily accessible due to the pull not being located in the path of egress.

Interview, on 04/17/13 at 12:39 PM, with the Engineering Manager revealed he was not aware of the requirements for the hood suppression manual pull station.



Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect three (3) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to ensure portable heaters did not exceed 212 degrees.


The findings include:

Observation, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed a portable space heater located in the Pharmacy, Kitchen Dry Storage, Billing Office, and the Health Information Management Office. .

Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed she was not aware the heaters element could not exceed 212°F in non-sleeping, staff, and employee areas.


Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212°F (100°C).

Based on flame retardant documentation review and interview, it was determined the facility failed to ensure that combustible decorations were used in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide documentation that personal and seasonal decorations had been treated or were flame retardant.

The findings include:

Flame retardant documentation review, on 04/17/13 at 11:36 AM, with the Engineering Manager revealed the facility did not have documentation that newly introduced personal or seasonal decorations for residents or staff had been treated with a flame retardant material.

Interview, on 04/17/13 at 11:36 AM, with the Engineering Manager revealed he was not aware decorations were required to be treated with a fire retardant and documentation was to be kept on the items that had been treated.


Reference: NFPA 101 (2000 Edition)

19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.

Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders were stored in accordance with NFPA standards. This deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. the facility failed to provide proper signage and separation between oxygen tanks.

The findings include:

Observation, on 04/17/13 at 12:52 PM, with the Chief Nursing Officer and the Engineering Manager revealed the tanks were not clearly identified to be full or empty. There were fourteen "E" tanks which was greater than 8.5 m3 (300 ft3) but less than 85 m3 (3000 ft3) located in the oxygen storage room in Respiratory Therapy. This facility is not protected by an automatic sprinkler system. Further observation revealed the door to the Oxygen Storage Room did not latch when tested. Further observation revealed combustible storage within twenty (20) feet of the oxygen tanks.

Interview, on 04/17/13 at 12:52 PM, with the Chief Nursing Officer and the Engineering Manager revealed they were not aware of the requirements for oxygen storage. Further interview revealed they were not aware the door did not latch.


Reference: NFPA 99 (1999 edition)
8-3.1.11.2
Storage for nonflammable gases greater than 8.5 m3 (300 ft3) but less than 85 m3 (3000 ft3)
(A) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(B) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(C) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) A minimum distance of 6.1 m (20 ft)
(2) A minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) An enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.


8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Based on fire damper testing record review, and interview, it was determined the facility failed to ensure fire/smoke dampers were maintained in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, residents, staff and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide documentation that the smoke/fire dampers were tested within the last four (4) years.

The findings include:


Fire damper testing record review, on 04/17/13 at 11:30 AM with the Engineering Manager revealed the facility did not have documentation that fire/smoke dampers had been tested within the last four (4) years.

Interview, on 04/17/13 at 11:30 AM, with the Engineering Manager revealed he was not aware of the requirements for fire/smoke damper testing.


Reference: NFPA 90A (1999 edition)

3-4.7 Maintenance. At least every 4 years, fusible links (where
applicable) shall be removed; all dampers shall be operated to
verify that they fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.


Reference: NFPA 101 (2000 Edition)

8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
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.
8.3.6.2
Openings occurring at points where floors or smoke barriers meet the outside walls, other smoke barriers, or fire barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is designed for the specific purpose.

Based on generator testing record review, observation and interview, it was determined the facility failed to ensure emergency generators were maintained in accordance with NFPA standards. The deficiency had the potential to affect four (4) of four (4) smoke compartments, residents, staff, and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to provide documentation for the generators monthly transfer times. The facility also failed to ensure the generator room was not used for storage, and was equipped with proper emergency lighting.

The findings include:

Observation, on 04/17/13 at 1:14 PM, with the Engineering Manager revealed storage of combustible items such as paint, wood, work benches, and tools were being stored within the generator room. Further observation revealed the generator room was not equipped with an emergency battery light.

Interview, on 04/17/13 at 1:14 PM, with the Engineering Manager revealed he was not aware items could not be stored in the generator room. Further interview revealed the lights in the generator room were connected to the emergency generator; however, he was not aware the room was required to have an emergency battery light installed in the event the generator failed to start.

Generator Testing Record Review, on 04/17/13 at 2:28 PM, with the Engineering Manager revealed the facility did not provide documentation for the monthly transfer times of the generator.

Interview, on 04/17/13 at 2:28 PM, with the Engineering Manager revealed he was not aware the monthly transfer time for the generator was to be documented.


Reference: NFPA 110 (1999 Edition).

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.

Reference: NFPA 99 (1999 Edition)

Actual NFPA Standard: NFPA 99, 3-5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-5.3.1.
(b) Inspection and Testing. Generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b).
Actual Standard: NFPA 110, 6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.
Actual Standard: NFPA 99, 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1. Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.
Actual Standard: NFPA 99, 3- 3-4.4.2. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.


6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction

6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

Reference: NFPA 101 ( 2000 edition)


7.9.1.2 Where maintenance of illumination depends on
changing from one energy source to another, a delay of not
more than 10 seconds shall be permitted.
Reference: NFPA 110 (1999 ed.)
5-7 Heating, Cooling, and Ventilating.
5-7.1* Consideration shall be given to properly sizing the ventilation
or air-conditioning systems to remove all the heat
rejected to the EPS equipment room by the energy converter,
uninsulated or insulated exhaust pipes, and other heat-producing
equipment.
5-7.2 Adequate ventilation shall be provided to prevent temperatures
or temperature rises in the EPS and related accessory
equipment that exceed the recommendations of the
manufacturer.
5-7.3 For the EPS equipment room, the ventilation or cooling
equipment, or both, shall be sized so that the ambient temperature
shall not exceed the EPS equipment manufacturer ' s criteria
or allowable maximum temperatures.


Reference: NFPA 110 (1999 Edition)


5-2.1 The EPS shall be installed in a separate room for Level
1 installations. EPSS equipment shall be permitted to be
installed in this room. The room shall have a minimum 2-hour
fire rating or shall be located in an adequate enclosure located
outside the building capable of resisting the entrance of snow
or rain at a maximum wind velocity required by local building
codes. No other equipment, including architectural appurtenances,
except those that serve this space, shall be permitted
in this room.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of four (4) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of one (01) on the day of the survey. The facility failed to maintain proper use of power strips, and extension cords.

The findings include:

Observations, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed:

1) A medication distribution machine called "Documed" was plugged into a power strip.

2) Storage in front of electrical panels located in the Soiled Utility Room of the 100 Hall.

3) A power strip was plugged into an extension cord than was run through the ceiling to provide power to an office that use to be a closet located in the Chief Nursing Officers Office.

4) A toaster oven and a mixer were plugged into a power strip located in the Kichen.

5) A microwave was plugged into a power strip located in the Health Information Management Office.

Interview, on 04/17/13 between 11:00 AM and 3:00 PM, with the Chief Nursing Officer revealed she was not aware the power strips and extension cords had been misused. Further interview revealed she was not aware of the storage in front of electrical panels.



Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.


110-26. Spaces

About Electrical Equipment. Sufficient access and working space shall be provided and maintained around 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.

Reference: NFPA 70 (1999 edition)


Reference: NFPA 70 (1999 edition)

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 70 400-8
( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces