HospitalInspections.org

Based on observations made on June 17, 2013, the facility failed to assure that the fire and smoke resistance rating of wall assemblies in a building of Type II (000) construction was maintained. This deficiency could affect 29 residents, 8 staff, and visitors that would use the TV room on a daily basis.

The findings include:

In accordance with 19.1.6.2, 19.1.6.3 and 19.1.6.4, facilities must maintain wall and ceiling assemblies to resist the passage of smoke/fire in a sprinkled building.

E-wing of the Main Hospital Building was observed at 3:15 p.m. on June 17, 2013. There was a broken ceiling tile which had a piece missing, exposing a hole into the upper interstitial space above the ceiling tile. The missing piece was in the form of a triangle which measured, 6 inches by 8 inches by 12 inches.

Based on observations made on June 17, 2013, the facility failed to provide for hard surface paths from exit discharges to the public way. This deficiency could affect more than a very limited amount of residents, staff, and visitors and two of four smoke compartments.

The findings include:

There shall be provided a hard surface path from the exit discharge to the public way or area of refuge in climates where weather such as snow or ice or heavy rain may hinder evacuation across lawn or soil surfaces per section 7.7.1 of the Life Safety Code and interpretations from the Centers for Medicare and Medicaid Services (CMS).

The west exit door from the dining room of Spratt was observed at 9:30 a.m. on June 17, 2013. The dining room had received a remodel in 2012, with a new exit door being provided for the enlarged dining area. A cement pad was poured just beyond the exit door, but there was no continuous hard path surface to the public way.

Based on observations made on June 17, 2013, the facility failed to document that battery powered emergency lights were tested on a monthly and annual basis. This deficiency could affect a very limited amount of staff.

The findings include:

In accordance with Section 4.6.12.2, existing life safety features obvious to the public, if not required by the Code, shall be either maintained properly or removed.

A functional test shall be conducted on every required emergency battery-powered lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Review of records for the battery powered emergency light fixtures indicated that all battery pack emergency lighting units had been removed from the Spratt building during the remodel in September of 2012. However, observation revealed that one had been installed in the Med Room by a contractor during the remodel of the Spratt Building. There were no weekly or annual test records for the newly installed emergency light fixture in the Med Room after September of 2012.

Based on observations made on June 17, 2013, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 25, 1998 Edition. The deficiency could affect more than a very limited amount of residents, staff, and visitors in one of four smoke compartments.

The findings include:

In accordance with NFPA 13 and Section 3-2.7.2, escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further, the code states in Annex A-3-2.7.2, the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

Room 2 of B-wing was observed at 1:15 p.m. on June 17, 2013. An escutcheon ring was missing on the sprinkler piping in this room.

Based on observations made on May 17, 2013, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 25, 1998 Edition. The deficiencies could affect more than a very limited amount of residents, staff, and visitors in one room of one of four smoke compartments.

The findings include:

In accordance with NFPA 13 and Section 3-2.7.2, escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further, the code states in Annex A-3-2.7.2, the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

1. Room S-4 was observed at 8:15 a.m. on June 17, 2013. An escutcheon ring was down approximately 1/2 inch, exposing a penetration in the ceiling in this room.

Unacceptable obstructions to spray patterns shall be corrected per section 2-2.1.2 of NFPA 25. Obstructions to spray patterns include horizontal obstructions near the ceiling, vertical obstructions, suspended or floor-mounted obstructions, and clearances between sprinklers and storage below.

2. The basement of Spratt was observed at 10:30 a.m. on June 17, 2013. There were four sprinkler heads which were obstructed by a steam pipe which had been installed directly next to the sprinkler heads, blocking the spray pattern for the sprinkler heads.

Based on review of service records received after the survey on June 17, 2013, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semiannual basis. This deficiency could affect one of four smoke compartments in the main hospital building.

The findings include:

Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals, at least semiannually, prior to surfaces becoming heavily contaminated with grease or oily sludge per section 8-3.1 of NFPA 96, 1998 Edition. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction. Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction per section 8-3.1.1 of NFPA 96. When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned per 8-3.1.2 of NFPA 96.

Service record logs were received by e-mail on June 17, 2013. The log indicated that the hood had been professionally cleaned for the first time on November 15, 2012. An email note indicated that the contracted cleaning company was scheduled to perform a cleaning again on July 9, 2013. The professional cleaning was due no later than June 15, 2012 which includes a one month grace period. The facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned every six months.

Based on observations made on June 17, 2013, the facility failed to provide documentation that door coverings were either fire resistant or had been treated with a product made for fabrics to render them fire retardant. This deficiency could affect 24 residents, 6 staff and visitors on B-wing.

The findings include:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

The draperies in the B-wing day room were examined at 1:45 p.m. on June 17, 2013. There was no tag attesting that the fabric contained a fire spread rating.

Based on observations made on June 17, 2013, the facility failed to provide documentation that door coverings were either fire resistant or had been treated with a product made for fabrics to render them fire retardant. This deficiency could affect 29 residents, 7 staff and vistiors of this smoke compartment.

The findings include:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

The Moderco folding partition door in the remodeled dining room was observed at 9:30 a.m. on June 17, 2013. The door had a fabric covering which did not have a fire resistant rating. There was no documentation that was available at that time stating that the door was resistant to fire.

Based on observations and record review made on June 17, 2013, the facility failed to provide for a remote annunciator for the emergency generator in the Spratt Building. This deficiency could affect all residents, staff, and visitors.

The findings include:

A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station per section 3-4.1.1.15 of NFPA 99, 1999 Edition.
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

Records for the emergency generators, which are the source of the emergency power supply were examined at 9:00 a.m. on June 17, 2013. It was confirmed during observations in the hospital buildings that there were no remote annunciators to indicate alarm conditions for the emergency power systems.

Based on observations and record review made on June 17, 2013, the facility failed to provide for a remote annunciator for the emergency generator in the Main hospital building. This deficiency could affect all residents, staff and visitors.

The findings include:

A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station per section 3-4.1.1.15 of NFPA 99, 1999 Edition.
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

Records for the emergency generators, which are the source of the emergency power supply were examined at 9:00 a.m. on June 17, 2013. During observations in the main hospital building it was confirmed that there was no remote annunciators to indicate alarm conditions for the emergency power systems.

Based on review of the emergency generator test reports and logs on June 17, 2013, the facility failed to assure that the emergency generators supplying power (life support systems included) met NFPA 110 requirements for an annual load bank testing or equivalency. This deficiency could affect all residents, staff and visitors.

The findings include:

6-4.2 of NFPA 110 (1999 edition) requires that 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 generator nameplate rating or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. In accordance with 6-4.2.2 of NFPA 110 diesel-powered generators that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually (load bank tested) with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of two continuous hours.

There are two diesel powered generators which provide emergency power for the Main Hospital and Spratt buildings. They are both 300 kilowatt (KW) rated generators which can operate simultaneously or independently of each other depending on demand.

The generator test reports and logs were reviewed at the facility on June 17, 2013. The generator monthly load tests were current including the fact that within the last twelve months the generator had been run for two continuous hours with the available EPSS load. There was no indication or specific documentation that all of the conditions for a load bank test per 6-4.2 or 6-4.2.2 of NFPA 110 had been met in 2011, 2012 or thus far in 2013. This can be done by either the load testing being conducted by the facility or by a service contractor. Information needed would include either documenting the amount/percentage of the generator nameplate rating that was being exercised or documenting such items as exhaust temperatures noted.

Based on review of the emergency generator test reports and logs on June 17, 2013, the facility failed to assure that the emergency generators supplying power (life support systems included) met NFPA 110 requirements for an annual load bank testing or equivalency. This deficiency could affect all residents, staff, and visitors.

The findings include:

In accordance with NFPA 99, 1999 Edition and Section 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.

In accordance with Section 6-4.2 of NFPA 110, 1999 edition, 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 generator nameplate rating or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

Further in accordance with 6-4.2.2 of NFPA 110, diesel-powered generators that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually (load bank tested) with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of two continuous hours.

There are two diesel powered generators which provide emergency power for the Main Hospital and Spratt buildings. They are both 300 kilowatt (KW) rated generators which can operate simultaneously or independently of each other depending on demand.

The generator test reports and logs were reviewed at the facility on June 17, 2013. The generator monthly load tests were current including the fact that within the last twelve months the generator had been run for two continuous hours with the available EPSS load. There was no indication or specific documentation that all of the conditions for a load bank test per 6-4.2 or 6-4.2.2 of NFPA 110 had been met in 2011, 2012 or thus far in 2013. This can be done by either the load testing being conducted by the facility or by a service contractor. Information needed would include either documenting the amount/percentage of the generator nameplate rating that was being exercised or documenting such items as exhaust temperatures noted.

Based on observations made on June 17, 2013, the facility failed to assure that the fire and smoke resistance rating of wall assemblies in a building of Type II (000) construction was maintained. This deficiency could affect 29 residents, 8 staff, and visitors that would use the TV room on a daily basis.

The findings include:

In accordance with 19.1.6.2, 19.1.6.3 and 19.1.6.4, facilities must maintain wall and ceiling assemblies to resist the passage of smoke/fire in a sprinkled building.

E-wing of the Main Hospital Building was observed at 3:15 p.m. on June 17, 2013. There was a broken ceiling tile which had a piece missing, exposing a hole into the upper interstitial space above the ceiling tile. The missing piece was in the form of a triangle which measured, 6 inches by 8 inches by 12 inches.

Based on observations made on June 17, 2013, the facility failed to provide for hard surface paths from exit discharges to the public way. This deficiency could affect more than a very limited amount of residents, staff, and visitors and two of four smoke compartments.

The findings include:

There shall be provided a hard surface path from the exit discharge to the public way or area of refuge in climates where weather such as snow or ice or heavy rain may hinder evacuation across lawn or soil surfaces per section 7.7.1 of the Life Safety Code and interpretations from the Centers for Medicare and Medicaid Services (CMS).

The west exit door from the dining room of Spratt was observed at 9:30 a.m. on June 17, 2013. The dining room had received a remodel in 2012, with a new exit door being provided for the enlarged dining area. A cement pad was poured just beyond the exit door, but there was no continuous hard path surface to the public way.

Based on observations made on June 17, 2013, the facility failed to document that battery powered emergency lights were tested on a monthly and annual basis. This deficiency could affect a very limited amount of staff.

The findings include:

In accordance with Section 4.6.12.2, existing life safety features obvious to the public, if not required by the Code, shall be either maintained properly or removed.

A functional test shall be conducted on every required emergency battery-powered lighting system at 30-day intervals for not less than 30 seconds per section 7.9.3 of the Life Safety Code. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Review of records for the battery powered emergency light fixtures indicated that all battery pack emergency lighting units had been removed from the Spratt building during the remodel in September of 2012. However, observation revealed that one had been installed in the Med Room by a contractor during the remodel of the Spratt Building. There were no weekly or annual test records for the newly installed emergency light fixture in the Med Room after September of 2012.

Based on observations made on June 17, 2013, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 25, 1998 Edition. The deficiency could affect more than a very limited amount of residents, staff, and visitors in one of four smoke compartments.

The findings include:

In accordance with NFPA 13 and Section 3-2.7.2, escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further, the code states in Annex A-3-2.7.2, the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

Room 2 of B-wing was observed at 1:15 p.m. on June 17, 2013. An escutcheon ring was missing on the sprinkler piping in this room.

Based on observations made on May 17, 2013, the facility failed to maintain the automatic sprinkler system in accordance with the standards of NFPA 25, 1998 Edition. The deficiencies could affect more than a very limited amount of residents, staff, and visitors in one room of one of four smoke compartments.

The findings include:

In accordance with NFPA 13 and Section 3-2.7.2, escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further, the code states in Annex A-3-2.7.2, the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

1. Room S-4 was observed at 8:15 a.m. on June 17, 2013. An escutcheon ring was down approximately 1/2 inch, exposing a penetration in the ceiling in this room.

Unacceptable obstructions to spray patterns shall be corrected per section 2-2.1.2 of NFPA 25. Obstructions to spray patterns include horizontal obstructions near the ceiling, vertical obstructions, suspended or floor-mounted obstructions, and clearances between sprinklers and storage below.

2. The basement of Spratt was observed at 10:30 a.m. on June 17, 2013. There were four sprinkler heads which were obstructed by a steam pipe which had been installed directly next to the sprinkler heads, blocking the spray pattern for the sprinkler heads.

Based on review of service records received after the survey on June 17, 2013, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semiannual basis. This deficiency could affect one of four smoke compartments in the main hospital building.

The findings include:

Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals, at least semiannually, prior to surfaces becoming heavily contaminated with grease or oily sludge per section 8-3.1 of NFPA 96, 1998 Edition. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction. Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction per section 8-3.1.1 of NFPA 96. When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned per 8-3.1.2 of NFPA 96.

Service record logs were received by e-mail on June 17, 2013. The log indicated that the hood had been professionally cleaned for the first time on November 15, 2012. An email note indicated that the contracted cleaning company was scheduled to perform a cleaning again on July 9, 2013. The professional cleaning was due no later than June 15, 2012 which includes a one month grace period. The facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned every six months.

Based on observations made on June 17, 2013, the facility failed to provide documentation that door coverings were either fire resistant or had been treated with a product made for fabrics to render them fire retardant. This deficiency could affect 24 residents, 6 staff and visitors on B-wing.

The findings include:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

The draperies in the B-wing day room were examined at 1:45 p.m. on June 17, 2013. There was no tag attesting that the fabric contained a fire spread rating.

Based on observations made on June 17, 2013, the facility failed to provide documentation that door coverings were either fire resistant or had been treated with a product made for fabrics to render them fire retardant. This deficiency could affect 29 residents, 7 staff and vistiors of this smoke compartment.

The findings include:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

The Moderco folding partition door in the remodeled dining room was observed at 9:30 a.m. on June 17, 2013. The door had a fabric covering which did not have a fire resistant rating. There was no documentation that was available at that time stating that the door was resistant to fire.

Based on observations and record review made on June 17, 2013, the facility failed to provide for a remote annunciator for the emergency generator in the Spratt Building. This deficiency could affect all residents, staff, and visitors.

The findings include:

A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station per section 3-4.1.1.15 of NFPA 99, 1999 Edition.
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

Records for the emergency generators, which are the source of the emergency power supply were examined at 9:00 a.m. on June 17, 2013. It was confirmed during observations in the hospital buildings that there were no remote annunciators to indicate alarm conditions for the emergency power systems.

Based on observations and record review made on June 17, 2013, the facility failed to provide for a remote annunciator for the emergency generator in the Main hospital building. This deficiency could affect all residents, staff and visitors.

The findings include:

A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station per section 3-4.1.1.15 of NFPA 99, 1999 Edition.
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

Records for the emergency generators, which are the source of the emergency power supply were examined at 9:00 a.m. on June 17, 2013. During observations in the main hospital building it was confirmed that there was no remote annunciators to indicate alarm conditions for the emergency power systems.

Based on review of the emergency generator test reports and logs on June 17, 2013, the facility failed to assure that the emergency generators supplying power (life support systems included) met NFPA 110 requirements for an annual load bank testing or equivalency. This deficiency could affect all residents, staff and visitors.

The findings include:

6-4.2 of NFPA 110 (1999 edition) requires that 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 generator nameplate rating or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. In accordance with 6-4.2.2 of NFPA 110 diesel-powered generators that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually (load bank tested) with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of two continuous hours.

There are two diesel powered generators which provide emergency power for the Main Hospital and Spratt buildings. They are both 300 kilowatt (KW) rated generators which can operate simultaneously or independently of each other depending on demand.

The generator test reports and logs were reviewed at the facility on June 17, 2013. The generator monthly load tests were current including the fact that within the last twelve months the generator had been run for two continuous hours with the available EPSS load. There was no indication or specific documentation that all of the conditions for a load bank test per 6-4.2 or 6-4.2.2 of NFPA 110 had been met in 2011, 2012 or thus far in 2013. This can be done by either the load testing being conducted by the facility or by a service contractor. Information needed would include either documenting the amount/percentage of the generator nameplate rating that was being exercised or documenting such items as exhaust temperatures noted.

Based on review of the emergency generator test reports and logs on June 17, 2013, the facility failed to assure that the emergency generators supplying power (life support systems included) met NFPA 110 requirements for an annual load bank testing or equivalency. This deficiency could affect all residents, staff, and visitors.

The findings include:

In accordance with NFPA 99, 1999 Edition and Section 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.

In accordance with Section 6-4.2 of NFPA 110, 1999 edition, 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 generator nameplate rating or (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

Further in accordance with 6-4.2.2 of NFPA 110, diesel-powered generators that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually (load bank tested) with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of two continuous hours.

There are two diesel powered generators which provide emergency power for the Main Hospital and Spratt buildings. They are both 300 kilowatt (KW) rated generators which can operate simultaneously or independently of each other depending on demand.

The generator test reports and logs were reviewed at the facility on June 17, 2013. The generator monthly load tests were current including the fact that within the last twelve months the generator had been run for two continuous hours with the available EPSS load. There was no indication or specific documentation that all of the conditions for a load bank test per 6-4.2 or 6-4.2.2 of NFPA 110 had been met in 2011, 2012 or thus far in 2013. This can be done by either the load testing being conducted by the facility or by a service contractor. Information needed would include either documenting the amount/percentage of the generator nameplate rating that was being exercised or documenting such items as exhaust temperatures noted.