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Reference NFPA 25, 1998 Edition

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


Based on observation and staff interview, the facility failed to ensure all Fire Department Connections (FDC) were properly identified with signage as required by NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). Without this signage, this failed practice could result in emergency response personnel connecting supplemental fire fighting equipment (ie: water pump trucks) to incorrect FDCs or other fire fighting components, which also results in delayed emergency response and presents a risk of potential harm to all nineteen (19) patients as identified by the "Final Census Report" list provided by the Director of Plant Operations on 08/22/12 at 8:30 am, staff and visitors. The findings are:

A. On 08/22/12 at 10:40 am, the surveyor observed the FDC located at the east side of the facility, along the sidewalk, was not provided with identification signage.

B. On 08/22/12 at 10:41 am, the Director of Plant Operations stated he was unaware the FDC identification sign was not posted.

C. On 08/22/12 at 3:55 pm, the Vice President (V.P.) of Compliance/Acting Chief Operating Officer (COO) and the Director of Plant Operations acknowledged the above finding at the exit conference.


Reference NFPA 25,

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

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

NFPA 25, Table 2-1 lists periodic testing and inspections required for automatic sprinkler systems. These include monthly inspection of gauges and valves on wet systems.

NFPA 25, Sect. 1-8 states that records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

NFPA 25, Sect.1-8.1 states that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25, Sect.1-8.2 states that records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.


Based on observation, record review and staff interview, the facility failed to ensure the automatic fire sprinkler system was inspected at least quarterly in accordance with NFPA 25, (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). It is essential the sprinkler system is inspected quarterly to ensure its effectiveness in the event of fire. This failed practice presents a risk of the sprinkler system failure to prevent or stop fires which through fire and smoke inhalation had the potential harm to all nineteen (19) patients as identified by the "Final Census Report" list provided by the Director of Plant Operations on 08/22/12 at 8:30 am, staff and visitors. The findings are:


A. Review of the sprinkler system maintenance log with the Administrator and the Maintenance Director revealed the last sprinkler system report had been inspected on 04/11/2012. This was the last sprinkler inspection available for review for the last four (4) quarters.

B. On 08/01/12 at 9:55 am, during interview, the Director of Plant operations stated he was not sure why the documentation was unavailable or where it was.

C. On 08/22/12 at 3:55 pm, the Vice President (V.P.) of Compliance/Acting Chief Operating Officer (COO) and the Director of Plant Operations acknowledged the above finding at the exit conference.

Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10


Based on observation and staff interview, the facility failed to ensure means of egress corridors were maintained free of obstructions and impediments to full instant use which resulted in equipment left unattended in the surgical suite corridors. This failed practice presents a risk that in the event of an emergency, facility staff may not evacuate the surgical suite safely and without delay. This failed practice had the potential to harm all nineteen (19) patients as identified by the "Final Census Report" list provided by the Director of Plant Operations on 08/22/12 at 8:30 am, staff and visitors. The findings are:


A. On 08/22 /12 at 6:35 am, during a tour of the surgical suite, the Life Safety Code Surveyor observed the corridor from OR #1 surgical suite was being used to store surgery equipment carts, medical supply carts, a rolling clothing rack with lead protective vest and other miscellaneous equipment, which were left unattended and impeding the path of egress. This stored equipment reduced the eight (8) foot wide corridor to three (3) feet wide.

B. On 08/22 /12 at 6:35 am, during a tour of the surgical suite, the Life Safety Code Surveyor observed the corridor from OR #2 surgical suite was being used to store surgery equipment carts, medical supply carts and other miscellaneous equipment, which were left unattended and impeding the path of egress. This stored equipment reduced the eight (8) foot wide corridor to four (4) feet wide.

C. On 08/22/12 at 3:55 pm, the V.P. of Compliance/Acting COO and the Director of Plant Operations acknowledged the above finding at the exit conference.

NFPA 110:
Section 6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.



Based on record review and staff interview, the facility failed to ensure that the specific gravity of the battery cells for the emergency generator used to protect residents during times of primary power failure were being tested monthly as required in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). This deficient practice could result in the batteries' failure to provide power to start the generator in the event of a power failure, which presents a risk of potential harm to all nineteen (19) patients as identified by the "Final Census Report" list provided by the Director of Plant Operations on 08/22/12 at 8:30 am, staff and visitors. The findings are:


A. Review of the monthly documents for the specific gravity testing from 05/2011-05/2012, showed a single number.

1. The facility is equipped with one (1) generator.

2. The facility's generator is equipped with two (2) batteries each with six (6) cells.

3. The monthly documentation showed a single number recorded for the specific gravity of the two (2) generator batteries. Each cell of the batteries is required to be tested and the reading for each cell number recorded every month to verify the reliability of the batteries.

B. On 08/22/12 at 10:08 am, during interview, the Director of Plant Operations stated that he did not know the specific gravity reading for each battery cell was required.

C. On 08/22/12 at 3:55 pm, the V.P. of Compliance/Acting COO and the Director of Plant Operations acknowledged the above finding at the exit conference.

Reference NFPA 25, 1998 Edition

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


Based on observation and staff interview, the facility failed to ensure all Fire Department Connections (FDC) were properly identified with signage as required by NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). Without this signage, this failed practice could result in emergency response personnel connecting supplemental fire fighting equipment (ie: water pump trucks) to incorrect FDCs or other fire fighting components, which also results in delayed emergency response and presents a risk of potential harm to all nineteen (19) patients as identified by the "Final Census Report" list provided by the Director of Plant Operations on 08/22/12 at 8:30 am, staff and visitors. The findings are:

A. On 08/22/12 at 10:40 am, the surveyor observed the FDC located at the east side of the facility, along the sidewalk, was not provided with identification signage.

B. On 08/22/12 at 10:41 am, the Director of Plant Operations stated he was unaware the FDC identification sign was not posted.

C. On 08/22/12 at 3:55 pm, the Vice President (V.P.) of Compliance/Acting Chief Operating Officer (COO) and the Director of Plant Operations acknowledged the above finding at the exit conference.


Reference NFPA 25,

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

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

NFPA 25, Table 2-1 lists periodic testing and inspections required for automatic sprinkler systems. These include monthly inspection of gauges and valves on wet systems.

NFPA 25, Sect. 1-8 states that records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

NFPA 25, Sect.1-8.1 states that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

NFPA 25, Sect.1-8.2 states that records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.


Based on observation, record review and staff interview, the facility failed to ensure the automatic fire sprinkler system was inspected at least quarterly in accordance with NFPA 25, (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). It is essential the sprinkler system is inspected quarterly to ensure its effectiveness in the event of fire. This failed practice presents a risk of the sprinkler system failure to prevent or stop fires which through fire and smoke inhalation had the potential harm to all nineteen (19) patients as identified by the "Final Census Report" list provided by the Director of Plant Operations on 08/22/12 at 8:30 am, staff and visitors. The findings are:


A. Review of the sprinkler system maintenance log with the Administrator and the Maintenance Director revealed the last sprinkler system report had been inspected on 04/11/2012. This was the last sprinkler inspection available for review for the last four (4) quarters.

B. On 08/01/12 at 9:55 am, during interview, the Director of Plant operations stated he was not sure why the documentation was unavailable or where it was.

C. On 08/22/12 at 3:55 pm, the Vice President (V.P.) of Compliance/Acting Chief Operating Officer (COO) and the Director of Plant Operations acknowledged the above finding at the exit conference.

Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10


Based on observation and staff interview, the facility failed to ensure means of egress corridors were maintained free of obstructions and impediments to full instant use which resulted in equipment left unattended in the surgical suite corridors. This failed practice presents a risk that in the event of an emergency, facility staff may not evacuate the surgical suite safely and without delay. This failed practice had the potential to harm all nineteen (19) patients as identified by the "Final Census Report" list provided by the Director of Plant Operations on 08/22/12 at 8:30 am, staff and visitors. The findings are:


A. On 08/22 /12 at 6:35 am, during a tour of the surgical suite, the Life Safety Code Surveyor observed the corridor from OR #1 surgical suite was being used to store surgery equipment carts, medical supply carts, a rolling clothing rack with lead protective vest and other miscellaneous equipment, which were left unattended and impeding the path of egress. This stored equipment reduced the eight (8) foot wide corridor to three (3) feet wide.

B. On 08/22 /12 at 6:35 am, during a tour of the surgical suite, the Life Safety Code Surveyor observed the corridor from OR #2 surgical suite was being used to store surgery equipment carts, medical supply carts and other miscellaneous equipment, which were left unattended and impeding the path of egress. This stored equipment reduced the eight (8) foot wide corridor to four (4) feet wide.

C. On 08/22/12 at 3:55 pm, the V.P. of Compliance/Acting COO and the Director of Plant Operations acknowledged the above finding at the exit conference.

NFPA 110:
Section 6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.



Based on record review and staff interview, the facility failed to ensure that the specific gravity of the battery cells for the emergency generator used to protect residents during times of primary power failure were being tested monthly as required in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). This deficient practice could result in the batteries' failure to provide power to start the generator in the event of a power failure, which presents a risk of potential harm to all nineteen (19) patients as identified by the "Final Census Report" list provided by the Director of Plant Operations on 08/22/12 at 8:30 am, staff and visitors. The findings are:


A. Review of the monthly documents for the specific gravity testing from 05/2011-05/2012, showed a single number.

1. The facility is equipped with one (1) generator.

2. The facility's generator is equipped with two (2) batteries each with six (6) cells.

3. The monthly documentation showed a single number recorded for the specific gravity of the two (2) generator batteries. Each cell of the batteries is required to be tested and the reading for each cell number recorded every month to verify the reliability of the batteries.

B. On 08/22/12 at 10:08 am, during interview, the Director of Plant Operations stated that he did not know the specific gravity reading for each battery cell was required.

C. On 08/22/12 at 3:55 pm, the V.P. of Compliance/Acting COO and the Director of Plant Operations acknowledged the above finding at the exit conference.