HospitalInspections.org

Based on observation, record review, and facility staff interview, the facility failed to ensure the building construction Type II (111) was maintained. Failure to maintain the construction type puts the residents at risk in a fire by increasing the flammability of the structural frame of the building from fire. This facility had a census of one.

1. Observations made 6/11/2019 at approximately 12:41 P.M., of the medical gas storage shed, showed a covered six feet by twenty feet enclosure. Observation showed the enclosure had a 2x6 wood frame construction Type V(000), no sprinkler coverage and contained electrical service with light fixtures. Observation showed the entrance enclosure connected to the Type II (111) hospital.

Record review of NFPA 101, Life Safety Code, 2012 edition, showed Type V (000) construction standard required full sprinkler coverage.

During an interview on 6/20/2019 at approximately 10:06 A.M., the Maintenance Director said the med gas enclosure was built prior to his/her employment in 2012.

2. Observations on 6/10-11/2019, during the building tour, showed four corridor double door sets connected to the fire alarm system with magnetic hold open devices. Observation of the walls above the doors showed every wall had one sheet of 3/4 inch thick drywall on each side of the wall. Observation showed the walls above each cross corridor sets contained multiple holes and penetrations.

Observation did not show ratings for the double door sets installed in the corridors.

Observations showed the boxed corridors above the non rated suspended ceiling contained holes and penetrations exposing the steel frame of the building.

Observation above the unrated lay in ceiling on Hall #3 showed sheet metal covering 8 inch by 12 inch holes between 12 of 12 patient rooms and the corridor. Observation showed the sheet metal held on with construction adhesive.

Observation showed a 4 feet by 4 feet opening above the unrated lay in ceiling on Hall #3 exposing the steel frame of the building.

Observation showed a 12 inch by 12 inch opening above the unrated lay in ceiling on Hall #3 exposing the steel frame of the building.

Observation showed a 12 inch by 12 inch opening above the unrated lay in ceiling near the CEO office exposing the steel frame of the building.

Observation showed a 12 inch by 12 inch opening above the unrated lay in ceiling above the double door set entering cardiac rehab exposing the steel frame of the building.

Observation showed the building did not contain a complete sprinkler system.

Record review of the facility supplied plans did not show locations of rated barriers or rated door assemblies. Additionally, record review did not show the square feet size of the hospital.

Record review of NFPA 101, Life Safety Code, 2012 edition, showed Type II (111) construction standard required one hour protection of the building frame in buildings without sprinkler protection.

Based on observation and facility staff interview. the facility failed to maintain three designated exit corridors free of obstructions. Failure to maintain designated exit corridors free of obstructions has the potential to affect all patients, staff and visitors . This deficient practice could prevent prompt evacuation from the facility in an emergency. The facility census was one.


Observation made during the building tour 6/10-11/2019, showed the following blocked exit and corridor:

-vending machine corridor reduced from 8 feet to 3 feet by vending machine and water fountain;

-Emergency Department (ED) exterior exit door latch did not release and the bottom 2 inches of the door rusted preventing the door from being accessible.

During an interview 6/20/2019 at 10:07 A.M., the Maintenance Director said the corridor and ED exit have been the same since he/she started employment in 2012.

NFPA 101, 2012 edition, section 19.2.1 states:
"19.2.1 General. Every aisle, passageway, corridor, exit discharge,
exit location, and access shall be in accordance with Chapter 7,
unless otherwise modified by 19.2.2 through 19.2.11.

NFPA 101, 2012 edition, section 7.1.10.1 states:
7.1.10.1* General. Means of egress shall be continuously
maintained free of all obstructions or impediments to full instant
use in the case of fire or other emergency."

Based on observation and facility staff interview, facility staff failed to ensure locks in a means of egress could be quickly unlocked to allow evacuation of the building in the event of a fire or other emergency. The facility census was one.


Observation on 6/10-11/2019, during the facility tour, showed the following designated exit doors equipped with slide latch locks:

-Exit door from the clinic,
- Hallway #1 exit double door set left leaf


Observation on 6/11/2019, during the facility tour, showed the C-arm room door equipped with a deadbolt requiring keys to unlock each side of the door.


During an interview 6/20/2019 at 10:08 A.M., the Maintenance Director said the locks have been the same since he/she started employment in 2012.

NFPA 101, 2012 edition, Section 19.2.2.2.6 states:

"19.2.2.2.6 Doors that are located in the means of egress and are
permitted to be locked under other provisions of 19.2.2.2.5 shall
comply with all of the following:
(1) Provisions shall be made for the rapid removal of occupants
by means of one of the following:
(a) Remote control of locks
(b) Keying of all locks to keys carried by staff at all times
(c) Other such reliable means available to the staff at all
times
(2) Only one locking device shall be permitted on each door.
(3) More than one lock shall be permitted on each door, subject
to approval of the authority having jurisdiction."

Based on observation and facility staff interview, facility staff failed to ensure corridor doors and doors to hazardous areas equipped with self-closing devices are held open by devices actuated by the fire alarm system. This has the potential to affect all residents, visitors and staff in the event of a fire by not limiting the passage of smoke and fire through the building structure. The census was one.

Observations on 6/10-11/2019, during the facility tour, showed the following corridor doors and a door to a hazardous area equipped with kick down door stops preventing the doors to close in their frames:

- emergency department corridor door,

-Lab corridor door,

-two double door sets in the cardiac rehab corridor.


During an interview 6/20/2019 at 10:09 A.M., the Maintenance Director said he/she did not know the self closing door requirements.


NFPA 101, 2012 edition, section 19.2.2.2.7 states:

"19.2.2.2.7* Any door in an exit passageway, stairway enclosure,
horizontal exit, smoke barrier, or hazardous area enclosure
shall be permitted to be held open only by an automatic release
device that complies with 7.2.1.8.2. The automatic sprinkler
system, if provided, and the fire alarm system, and the
systems required by 7.2.1.8.2, shall be arranged to initiate the
closing action of all such doors throughout the smoke compartment
or throughout the entire facility."

Based on observation, record review and facility staff interview, facility staff failed to provide two exits without passing through an intervening room. The facility census was one.

1. Observation on 6/11/2019, during the facility tour, showed one of two exits on Hall #4 required patients, staff and visitors to pass through an intervening room to exit the building. The facility census was one.

Observation showed a room containing tread mills, a sink, office furniture, spray hopper, medical gas outlets and vacuum outlets on the wall, that patients, staff and visitors would have to pass through to exit the building.

Observation showed the intervening room required for an exit from the building due to a limitation to 150 feet travel distance within a non sprinklered building.

Record review of the facility layout showed the room labeled "Cardiac Rehab".

Record review did not show a facility evacuation plan.

During an interview 6/20/2019 at 10:10 A.M., the Maintenance Director said he/she did not know the exiting requirements.

National Fire Protection Association 101, 2012 edition, section 19.2.5.4 Intervening Rooms or Spaces states: "Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies."

19.2.6.2.1 The travel distance between any point in a room
and an exit shall not exceed 150 ft (46 m), unless otherwise
permitted by 19.2.6.2.2.

19.2.6.2.2 The maximum travel distance specified in 19.2.6.2.1
shall be permitted to be increased by 50 ft (15 m) in buildings
protected throughout by an approved, supervised automatic
sprinkler system in accordance with 19.3.5.7.

Based on observation and facility staff interview, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice affects one exit discharge area. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. The facility census was one.


1. Observation on 6/11/2019 at 3:30 P.M., of the dining room and physician's clinic exit, showed an exit discharge area led to a grass covered yard that required residents, staff, and visitors to traverse the grass to reach a sidewalk approximately twenty five feet from the cement exit discharge.

During an interview on 6/20/2019 at 10:11 A.M., the Maintenance Director said he/she did not know the exiting hardpath requirements.

The National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 states:

"7.7 Discharge from Exits.

7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwise
provided in 7.7.1.2 through 7.7.1.4."

Based on observation and facility staff interview, the facility staff failed to ensure all designated exit corridors are illuminated with emergency egress lights not controlled by a light switch. Two marked exit corridors contained switches controlling the emergency egress lighting fixtures. Failure to provide emergency egress lighting fixtures not controlled by a light switch has the potential to affect all patients and staff within the corridor. This deficient practice could delay the safe evacuation of patients, staff and visitors in the event of an emergency. The facility census was one.

1. Observation on 6/11/2019, during the building tour, showed the following marked exitways contained switches controlling the emergency egress lighting fixtures:

-Emergency Department hallway;
-IT corridor;
-Kitchen/Laundry hallway.

2. Observation on 6/11/2019, during the building tour, showed the med surge corridor emergency battery exit sign with egress lighting did not function.


During an interview on 6/20/2019 at 10:18 A.M., the Maintenance Director said he/she did not know light switches were not allowed. Additionally, he/she said he/she did not know the battery lights did not work.

NFPA 101, 2012 edition, Section 19.2.8 states:

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


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, unless otherwise provided
in 7.8.1.2.2."

Based on observation and facility staff interview, the facility staff failed to ensure all designated exits were marked by exit signs. The facility census was one.

On 6/11/2019, During the building tour, observation showed the Emergency Department did not have an exit sign.

On 6/11/2019, During the building tour, observation showed the hand stenciled clinic exit sign did not have illumination connected to the emergency power system. Additionally, the hand stenciled exit sign did not meet the exit signage requirements.


During an interview on 6/20/2019 at 10:14 A.M., the Maintenance Director said he/she did not know exit the sign requirements.

NFPA 101, 2012 edition, Section 7.10 states:

"7.10.1.5 Exit Access.
7.10.1.5.1 Access to exits shall be marked by approved,
readily visible signs in all cases where the exit or way to reach
the exit is not readily apparent to the occupants.

7.10.6.1.1 Externally illuminated signs required by 7.10.1
and 7.10.2, other than approved existing signs, unless otherwise
provided in 7.10.6.1.2, shall read EXIT or shall use other
appropriate wording in plainly legible letters sized as follows:
(1) For new signs, the letters shall be not less than 6 in.
(150 mm) high, with the principal strokes of letters not
less than 3.4 in. (19 mm) wide.
(2) For existing signs, the required wording shall be permitted
to be in plainly legible letters not less than 4 in.
(100 mm) high.
(3) The word EXIT shall be in letters of a width not less than
2 in. (51 mm), except the letter I, and the minimum spacing
between letters shall be not less than 3.8 in. (9.5 mm).
(4) Sign legend elements larger than the minimum established
in 7.10.6.1.1(1) through (3) shall use letter widths,
strokes, and spacing in proportion to their height."

Based on observation, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and marked exit corridors in the facility per NFPA (National Fire Protection Association) requirements. Failure to separate the marked exits and provide rated one hour walls and fire rated doors equipped with a self-closing device puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area and eliminating the two required means of egress. The facility census was one.


1. Observation on 6/11/2019, during the facility tour, showed the following hazardous areas not separated from the marked exit corridors:

- Laundry corridor door by environmental services sign did not have a fire resistance rating or positive latching device. The room contained a large amount of combustible storage, gas fired dryers and did not contain sprinkler coverage;

- Laundry corridor double swinging door set did not have a fire resistance rating or positive latching device. The double door set did not have an astragal or frame to stop the door travel into both the corridor and laundry room. The double door set had a kick down door stop on each door. The room contained a large amount of combustible storage, gas fired dryers and did not contain sprinkler coverage;

- Cafeteria/kitchen corridor door contained a transfer grill and did not have a fire resistance rating or positive latching device. The room was not separated from the kitchen containing a gas fired stove and did not contain sprinkler coverage;

-Dietary services corridor door to the kitchen did not close in the door frame. The room was not separated from the kitchen containing a gas fired stove and did not contain sprinkler coverage;

-Soiled Utility room on the med surge corridor did not have a rating;

-Lab corridor Dutch door had a kick down door stop and did not have a rating;

-Basement fire door fusible link was disconnected and the door drug on the floor preventing it from closing. Observation showed the door was held open by a wire connected to a cast iron pipe protruding from the wall adjacent to the fire door;

-Medical records office corridor door did not have a self closing device and did not have a rating. The room contained a large quantity of combustible paper file storage and measured over 100 square feet;

-Emergency department contained 2 shred containers and kick down door stops on the corridor doors. Observation showed each shred container exceeded 32 gallons capacity. The emergency department did not have sprinkler coverage.


During an interview on 6/20/2019 at 10:13 A.M., the Maintenance Director said the doors and building were in the same condition from when he/she started in 2012.

NFPA 101, 2012 edition, Section 19.3.2.1.5 states:

"19.3.2.1.5 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) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(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."

Based on observation and facility staff interview, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The deficient practice has the potential to effect all facility patients, staff and visitors. The deficient practice could delay fire and emergency personnel response in the event of a fire. The census was one.

1. Observation on 6/11/2019, during the facility tour, showed the following areas did not have smoke detector coverage:

-Emergency Department (ED) from Hall #4 corridor access through ED triage area;

-Clinic waiting area open to the corridor Hall #2;

-Hall #4 continuing through to cardiac rehab double doors;

-Front lobby;

-Vending machine corridor;

-Connecting corridor between CEO office and Hall #3;

-IT hallway;

2. Observation of the electrical circuit breaker box on Hall#2 showed the panel door was not locked. Observation showed the circuit breaker box contained the labeled circuit breaker for the fire alarm system.

During an interview on 6/20/2019 at 10:15 A.M., the Director of Facilities Management stated he believed the fire alarm installation/inspection company installed the fire alarm per code requirements.

National Fire Protection Association 101, 2012 edition, section 19.3.4.1 states:

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

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

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, section:

10.5.5.2 Circuit Identification and Accessibility.

10.5.5.2.1 The location of the dedicated branch circuit disconnecting
means shall be permanently identified at the control
unit.

10.5.5.2.2 For fire alarm systems the circuit disconnecting
means shall be identified as "FIRE ALARM CIRCUIT."

10.5.5.2.3 For fire alarm systems the circuit disconnecting
means shall have a red marking.

10.5.5.2.4 The circuit disconnecting means shall be accessible
only to authorized personnel.

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. Failure to inspect and test all devices has the potential to effect all patients, staff and visitors in the event of a fire. The facility census was one.

Record review of the annual fire alarm inspection records dated 9/26/2018 showed the following devices not tested per code requirements:

- smoke detector sensitivity testing for the facility smoke detectors

- powered fire and smoke dampers (two dampers located above double corridor doors on Hall #3)


During an interview on 6/20/2019 at approximately 10:16 A.M., with the Maintenance Director, he/she said he/she believed the fire alarm system inspection company inspected the fire alarm system per code requirements.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Figure 14.6.2.4 for Example of an Inspection and Testing Form.

Based on record review and facility staff interview, the facility staff failed to ensure the sprinkler supervisory alarms met the requirements of NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was one.

1. Observation on 6/11/2019, of the two sprinkler system control valves, showed the connected flow alarms marked with a label stating "Special Application See Bulletin 5401078".

Record review of bulletin 5401078 stated: "

WARNING
As Stipulated By Factory Mutual And Underwriters Laboratories
This unit is not intended or designed for ordinary use. It is a special application device to be used for unusual conditions such as non-rising stem gate valves where no other approved or listed method of protection is available or practical. As this unit does not meet NFPA codes and standards, requiring restoration signal when the valve is positioned to normal, special attention should be given by the responsible parties to assure that the proper operation of this device is maintained. This device should only be restored to normal when the valve is in the normal condition."

During an interview on 6/20/2019 at 10:16 A.M., the Maintenance Director said he/she believed the fire alarm installation company did the installation per code requirements.

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


1) Record review on 6/11/2019 did not show the following inspections:

- monthly system gauge & valve inspections for the one wet sprinkler system

-Quarterly/semi annual inspection & testing for the one wet sprinkler system

-five (5) year internal pipe inspections/testing for the one wet sprinkler system (Chapter 14)

-five year check valve/backflow interior inspections

-five year gauge calibration/replacement

During an interview on 6/20/2019 at 9:55 A.M., the Maintenance Director said he/she believed the sprinkler inspection company inspected the sprinkler system per code requirements.

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

5.2.4 Gauges.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected
monthly to ensure that they are in good condition and
that normal water supply pressure is being maintained.

13.3.2.2* The valve inspection shall verify that the valves are in
the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

13.3.3.5* Supervisory Switches.
13.3.3.5.1 Valve supervisory switches shall be tested semiannually

13.4.2 Check Valves.
13.4.2.1 Inspection. Valves shall be inspected internally every
5 years to verify that all components operate correctly, move
freely, and are in good condition.


13.4 System Valves.
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected
as described in 13.4.1.1 and 13.4.1.2.

13.4.1.1* Alarm valves and system riser check valves shall be
externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being
maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

13.4.1.2* Alarm valves and their associated strainers, filters,
and restriction orifices shall be inspected internally every
5 years unless tests indicate a greater frequency is necessary.

13.7 Fire Department Connections.
13.7.1 Fire department connections shall be inspected quarterly
to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate
smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place
and operating properly.

13.2.6 Alarm Devices.
13.2.6.1 Mechanical waterflow devices, including but not limited
to water motor gongs, shall be tested quarterly.
13.2.6.2 Vane-type and pressure switch-type waterflow devices
shall be tested semiannually.

5.3.2* Gauges.
5.3.2.1 Gauges shall be replaced every 5 years or tested every
5 years by comparison with a calibrated gauge.

Based on observation, record review and facility staff interview, facility staff did not ensure a compatible portable fire extinguisher was available for use with the range hood suppression system. Failure to provide a compatible portable fire extinguisher has the potential to effect all patients, staff and visitors in the event of a fire. The facility census was one.

Observation on 6/11/2019, of the kitchen, did not show a K-type portable fire extinguisher available for use.

Observation on 6/11/2019 of the range hood suppression system showed it was UL 300 compliant.

Record review of the range hood system report dated 3/26/2019 contained a note stating: "No class K FE" (fire extinguisher).

During an interview on 6/20/2019 at 9:56 A.M., the Maintenance Director said the facility has been pricing a K class portable fire extinguisher for the kitchen.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition, section 6.6 states:

"6.6 Installations for Class K Hazards.

6.6.1 Class K fire extinguishers shall be provided for hazards
where there is a potential for fires involving combustible cooking
media (vegetable or animal oils and fats).

6.6.2 Maximum travel distance shall not exceed 30 ft (9.15 m)
from the hazard to the extinguishers."

Based on observation and facility staff interview, facility staff failed to ensure corridor doors resisted the passage of smoke and positively latched when closed. This deficient practice has the potential to affect all patients, staff and visitors. Failure to ensure corridor doors positively latched when closed and resist the passage of smoke has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. The facility census was one.

1. Observation on 6/19/2019, during the building tour, showed the following corridor doors equipped with kick down door stops preventing the doors from closing and latching:

-Lab corridor Dutch door;

-IT hall double doors;

-Outpatient cardiac rehab double doors;

-C-arm double corridor doors;

-ED corridor door;

-Radiology corridor door;

-2 of 2 sterilizing corridor doors;

-2 of 2 old chapel corridor doors.



2. Observation on 6/19/2019, during the building tour, showed the following corridor doors did not positively latch when closed:

-Hall #2 dining room corridor door did not contain a positive latching device;

-IT storage room corridor door with transfer grill did not contain a positive latch.

During an interview on 6/20/2019 at approximately 9:57 A.M., with the Maintenance Director, he/she said the doors were in the same condition they were in when he/she started employment at the facility in 2012.

NFPA 101, 2012 edition, Section 19.3.6.3 states:

"19.3.6.3* Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than
required enclosures of vertical openings, exits, or hazardous
areas shall be doors constructed to resist the passage of smoke
and shall be constructed of materials such as the following:
(1) 13.4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

19.3.6.3.2 The requirements of 19.3.6.3.1 shall not apply
where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink
closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required
to comply with 19.3.6.3.1.

(2) In smoke compartments protected throughout by an approved,
supervised automatic sprinkler system in accordance
with 19.3.5.7, the door construction materials requirements
of 19.3.6.3.1 shall not be mandatory, but the doors
shall be constructed to resist the passage of smoke.

19.3.6.3.10* Doors shall not be held open by devices other
than those that release when the door is pushed or pulled.

19.3.6.3.5* Doors shall be provided with a means for keeping
the door closed that is acceptable to the authority having jurisdiction,
and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully
closed if a force of 5 lbf (22 N) is applied at the latch edge
of the door.
(2) Roller latches shall be prohibited on corridor doors in
buildings not fully protected by an approved automatic
sprinkler system in accordance with 19.3.5.7.

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire
Doors and Other Opening Protectives."

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

Observation on 6/10-11/2019, during the building tour, showed the IT storage room corridor door contained a transfer grill.

Observation on 6/10-11/2019, during the building tour, showed the cafeteria corridor door contained a transfer grill.

During an interview on 6/20/2019 at approximately 9:57 A.M., with the Maintenance Director, he/she said the doors were in the same condition they were in when he/she started employment at the facility in 2012.

NFPA 101, 2012 edition, Section 19.3.6.4 states:

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

Based on observation, record review and facility staff interview, facility staff failed to provide a smoke barrier for the building. Failure to provide a smoke barrier in the building has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors and other areas of the building in the event of a fire. The facility census was 1.

Observations on 6/10-11/2019, during the building tour, showed four corridor double door sets connected to the fire alarm system with magnetic hold open devices. Observation of the walls above the doors showed every wall had one sheet of 3/4 inch thick drywall on each side of the wall. Observation showed the walls above each cross corridor sets contained multiple holes and penetrations.

Observations showed the boxed corridors above the non rated suspended ceiling contained holes and penetrations exposing the steel frame of the building.

Record review of the facility supplied plans did not show locations of rated barriers.

During an interview 6/20/2019 at 9:59 A.M., the Maintenance Director said he/she did not have a way of knowing the barrier wall locations without building blue prints.

Based on observation, record review and facility staff interview, facility staff failed to provide smoke barrier doors to form a smoke compartment for the building. Failure to provide smoke barrier doors to form a smoke compartment in the building has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors and other areas of the building in the event of a fire. The facility census was 1.

Observations on 6/10-11/2019, during the building tour, showed four corridor double door sets connected to the fire alarm system with magnetic hold open devices.

Observation did not show ratings for the double door sets installed in the corridors.

Record review of the facility supplied plans did not show locations of rated barriers or rated door assemblies.

During an interview 6/20/2019 at 9:59 A.M., the Maintenance Director said he/she did not have a way of knowing the barrier wall locations without building blue prints.

Based on observation and facility staff interview, the facility staff failed to ensure the building ventilation system was installed according to NFPA 90B, Standard for the Installation of Warm Heating and Air-Conditioning and Ventilating Systems, 2012 edition and NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition. The census was one.

1. Observation on 6/11/2019 at 1:18 P.M., during the building tour, showed two stand-alone room air conditioners in the Information Technology (IT) room. Additional observation showed the warm air exhaust flexible ducts penetrated the suspended ceiling and exhausted the air into the interstitial space between the ceiling and the roof.

2. Observation on 6/11/2019 at approximately 4:42 P.M., of the Hall #3 soiled utility room did not show an exhaust vent.

3. Observation on 6/19/2019 at approximately 2:15 P.M., of the double door set between the medical records office and the conference room, showed a metal duct work penetrating the wall above the doors. Observation showed the air handler connected to the ductwork pulled air from the kitchen/laundry corridor and discharged the air into the medical records office, the conference room and one office located on the opposite side of the wall containing the double door set. Additionally, observation did not show a damper located in the ductwork. Observation showed the ductwork penetrating the wall had an approximately 4 inch gap surrounding the ductwork in the wall. Observation showed the kitchen/laundry corridor was used as a return air plenum.


During an interview on 6/20/19 at 10:02 A.M., the Maintenance Director said he/she did not know about the HVAC problems.

NFPA 101, 2012 edition, Section 19.5.2 states:

"19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply
with the provisions of Section 9.2 and shall be installed in
accordance with the manufacturer ' s specifications, unless otherwise
modified by 19.5.2.2."

9.2 Heating, Ventilating, and Air-Conditioning.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and
Related Equipment. Air-conditioning, heating, ventilating
ductwork, and related equipment shall be in accordance with
NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, or NFPA 90B, Standard for the Installation of
Warm Air Heating and Air-Conditioning Systems, as applicable, unless
such installations are approved existing installations,
which shall be permitted to be continued in service.

Refer to NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, 2012 edition, Section 4.2.4 thru 4.2.4.2 and Section 4.3.3.1 for additional information.

NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, 2012 edition, Section states: "4.3.12.1.3 An air transfer opening(s) shall not be permitted
in walls or in doors separating egress corridors from adjoining
areas."

NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, 2012 edition, Section states: "4.3.12.2 Exits. Exit passageways, stairs, ramps, and other exits
shall not be used as a part of a supply, return, or exhaust air
system serving other areas of the building."

Based on record review and facility staff interview, facility staff failed to provide an evacuation plan for the building. This deficient practice has the potential to affect all residents in the facility. Failure to provide an evacuation plan could delay evacuation out of the building. The resident census was one.

1. Record review on 6/10/2019, of the facility records, did not show an evacuation route plan for the building.

During an interview on 6/20/2019 at 4:05 P.M., the Maintenance Director said he/she did not know the requirements for evacuation plans.

NFPA 101, 2012 edition, section 19.7 states:

"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.

19.7.1.2 All employees shall be periodically instructed and
kept informed with respect to their duties under the plan required
by 19.7.1.1.

19.7.1.3 A copy of the plan required by 19.7.1.1 shall be
readily available at all times in the telephone operator ' s location
or at the security center."

Based on observation and facility staff interview, the facility does not ensure containers in excess of 32 gallons in size are stored in a room protected as a hazardous area. Two shred containers exceeded 32 gallons in size and were stored in a corridor that was not protected as a hazardous area. This deficient practice affects all occupants in the building. The census was one.

1. Observation on 6/11/2019 showed the emergency department eight feet wide corridor contained 2 shred containers. Observation showed each shred container exceeded 32 gallons capacity.

During an interview on 6/20/2019 at 10:05 A.M., the Maintenance Director said he/she did not know the requirements for trash containers.

NFPA 101, 2012 edition, Section 19.7.5.7 states:

"19.7.5.7 Soiled Linen and Trash Receptacles.

19.7.5.7.1 Soiled linen or trash collection receptacles shall
not exceed 32 gal (121 L) in capacity and shall meet all of the
following requirements:
(1) The average density of container capacity in a room or
space shall not exceed 0.5 gal/ft2 (20.4 L/m2).
(2) A capacity of 32 gal (121 L) shall not be exceeded within
any 64 ft2 (6 m2) area.
(3)*Mobile soiled linen or trash collection receptacles with
capacities greater than 32 gal (121 L) shall be located in a
room protected as a hazardous area when not attended.
(4) Container size and density shall not be limited in hazardous
areas.

19.7.5.7.2* Containers used solely for recycling clean waste or
for patient records awaiting destruction shall be permitted to
be excluded from the requirements of 19.7.5.7.1 where all the
following conditions are met:
(1) Each container shall be limited to a maximum capacity of
96 gal (363 L), except as permitted by 19.7.5.7.2(2) or (3).
(2)*Containers with capacities greater than 96 gal (363 L)
shall be located in a room protected as a hazardous area
when not attended.
(3) Container size shall not be limited in hazardous areas.
(4) Containers for combustibles shall be labeled and listed as
meeting the requirements of FMApproval Standard 6921,
Containers for Combustible Waste; however, such testing, listing,
and labeling shall not be limited to FM Approvals.

A.19.7.5.7.2 It is the intent that this provision permits recycling
of bottles, cans, paper, and similar clean items that do
not contain grease, oil, flammable liquids, or significant plastic
materials, using larger containers or several adjacent containers,
and not require locating such containers in a room
protected as a hazardous area. Containers for medical records
awaiting shredding are often larger than 32 gal (121 L). These
containers are not to be included in the calculations and limitations
of 19.7.5.7.1. There is no limit on the number of these
containers, as FM Approval Standard 6921, Containers for Combustible
Waste, ensures that the fire will not spread outside of
the container. FM approval standards are written for use with
FM Approvals. The tests can be conducted by any approved
laboratory. The portions of the standard referring to FM Approvals
are not included in this reference."

Based on facility staff interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the non rated doors in the building. The facility census was 1.

1. Review of the facility's inspection, testing and maintenance records did not show documentation of an annual inspection of the non rated doors in the building.

2. Review of the facility's inspection, testing and maintenance records did not show documentation of an annual inspection of the rated fire doors in the building.

3. Observation during the facility tour 6/10-11/2019 showed the following doors:

A. Laundry corridor door by environmental services sign did not have a fire resistance rating or positive latching device.

B. Laundry corridor double swinging door set did not have a fire resistance rating or positive latching device. The double door set did not have an astragal or frame to stop the door travel into both the corridor and laundry room;

C. Cafeteria/kitchen corridor door contained a transfer grill, door skin was broken and did not have a fire resistance rating or positive latching device;

D. Dietary services corridor door to the kitchen did not close in the door frame;

E. Soiled Utility room on the med surge corridor did not have a rating;

F. Lab corridor Dutch door did not have a rating;

G. Basement fire door fusible link was disconnected and the door drug on the floor preventing it from closing. Observation showed the door was held open by a wire connected to a cast iron pipe protruding from the wall adjacent to the fire door;

H. Medical records office corridor door did not have a self closing device and did not have a rating;

I. IT storage room corridor door contained a transfer grill;

J. Cafeteria corridor door contained a transfer grill;

K. Dining room 1 1/2 hour rated door on hall #2 did not contain a latching device;

L. Patient room #101 door spine missing door skin for approximately 3 feet on hinge side;

M. Patient room #102 door spine missing door skin for approximately 3 feet on hinge side;

N. Patient room #103 door spine missing door skin for approximately 3 feet on hinge side;

O. Patient room #104 door spine missing door skin for approximately 3 feet on latch side;

P. IT exit corridor door was a hollow core door without a rating;

Q. Patient room #105 door spine missing door skin for approximately 3 feet on hinge side;\

R. Emergency Department (ED) exterior exit door latch did not release and the bottom 2 inches of the door rusted preventing the door from being accessible;

S. Clean supply closet corridor door skin is cracked and missing extending approximately 12 inches up from the bottom of the hinge side;

T. Exterior exit access door left leaf on Hall #3 did not contain a push bar to open the door. Observation showed a slide latch at the top of the door preventing it from opening;

U. Radiology x-ray room door had 4 open areas in the door skin exposing the lead shielding and a kick down door stop with screws penetrating the lead shielding.

During an interview on 6/20/2019 at 10:04 A.M., the Maintenance Director said he/she did not know the door inspection requirements.

NFPA 101, 2012 Edition states:

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.15 Inspection of Door Openings.

7.2.1.15.1* Where required by Chapters 11 through 43, the
following door assemblies shall be inspected and tested not
less than annually in accordance with 7.2.1.15.2 through
7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit
hardware in accordance with 7.2.1.7
(2) Door assemblies in exit enclosures
(3) Electrically controlled egress doors
(4) Door assemblies with special locking arrangements subject
to 7.2.1.6

7.2.1.15.2 Fire-rated door assemblies shall be inspected and
tested in accordance with NFPA 80, Standard for Fire Doors and
Other Opening Protectives. Smoke door assemblies shall be inspected
and tested in accordance with NFPA 105, Standard for
Smoke Door Assemblies and Other Opening Protectives.

7.2.1.15.3 The inspection and testing interval for fire-rated
and nonrated door assemblies shall be permitted to exceed 12
months under a written performance-based program in accordance
with 5.2.2 of NFPA 80, Standard for Fire Doors and Other
Opening Protectives.

7.2.1.15.4 A written record of the inspections and testing
shall be signed and kept for inspection by the authority having
jurisdiction.

7.2.1.15.5 Functional testing of door assemblies shall be performed
by individuals who can demonstrate knowledge and
understanding of the operating components of the type of
door being subjected to testing.

7.2.1.15.6 Door assemblies shall be visually inspected from
both sides of the opening to assess the overall condition of the
assembly.

7.2.1.15.7 As a minimum, the following items shall be verified:
(1) Floor space on both sides of the openings is clear of obstructions,
and door leaves open fully and close freely.
(2) Forces required to set door leaves in motion and move to
the fully open position do not exceed the requirements
in 7.2.1.4.5.
(3) Latching and locking devices comply with 7.2.1.5.
(4) Releasing hardware devices are installed in accordance
with 7.2.1.5.10.1.
(5) Door leaves of paired openings are installed in accordance
with 7.2.1.5.11.
(6) Door closers are adjusted properly to control the closing
speed of door leaves in accordance with accessibility requirements.
(7) Projection of door leaves into the path of egress does not
exceed the encroachment permitted by 7.2.1.4.3.
(8) Powered door openings operate in accordance with
7.2.1.9.
(9) Signage required by 7.2.1.4.1(3), 7.2.1.5.5, 7.2.1.6, and
7.2.1.9 is intact and legible.
(10) Door openings with special locking arrangements function
in accordance with 7.2.1.6
(11) Security devices that impede egress are not installed on
openings, as required by 7.2.1.5.12.

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire
Doors and Other Opening Protectives.

Based on observation, record review and facility staff interview, Facility staff failed to provide a medical gas warning system in compliance with NFPA 99, 2012 edition. The facility census was one.

1. Record review of the facility Categorical Risk Assessments showed the medical gas system was a category 3 medical gas system.

2. Observations on 6/10-11/2019, during the building tour, showed the medical gas warning system located at the nurse's station had an oxygen manifold warning light.

3. Observation on 6/11/2019, during the building tour, showed the oxygen system gauge at the nurse's station had a handwritten note stating: "If O2 light come on call maintenance to check O2 bottles." Observation showed the note dated 3-14-2008.


During an interview on 6/20/2019 at 10:26 A.M., the Maintenance Director said he/she did not know the medical gas requirements.


NFPA 99, 2012 edition section 5.3.6.22 Category 3 Warning Systems states:

"5.3.6.22.1 Warning systems for medical gas systems (oxygen
and nitrous oxide) in Category 3 facilities shall provide the following
alarms:
(1) Oxygen main line pressure low
(2) Oxygen main line pressure high
(3) Oxygen changeover to secondary bank or about to changeover
(if automatic)
(4) Nitrous oxide main line pressure low
(5) Nitrous oxide main line pressure high
(6) Nitrous oxide changeover to secondary bank or about to
changeover (if automatic)

5.3.6.22.2 Warning systems shall have at least one single alarm
panel in each treatment facility served by the medical gas source
equipment.

5.3.6.22.3 Alarm panels shall be located in an area of continuous
surveillance while the facility is in operation.

5.3.6.22.4 Pressure switches/sensors that monitor main line
pressure shall be mounted at the source equipment with pressure
alarm indicators (lamp or LED) at the alarm panel.

5.3.6.22.5 Audible and noncancelable alarm visual signals
shall indicate if the pressure in the main line increases or decreases
20 percent from the normal operating pressure.

5.3.6.22.6 Visual indications shall remain until the situation
that caused the alarm is resolved.

5.3.6.22.7 Pressure switches/sensors shall be installed downstream
of any emergency shutoff valves and any other shutoff
valves in the system and shall cause an alarm for the medical
gas if the pressure decreases or increases 20 percent from the
normal operating pressure.

5.3.6.22.8 Acancelable audible indication of each alarm condition
that produces a sound at the alarm panel shall reinitiate
the audible signal if another alarm condition occurs while the
audible signal is silenced."

Based on observation, facility staff interview and record review, the facility failed to develop a maintenance program for the medical gas, vacuum, WAGD (Waste Anesthetic Gas Disposal), or support gas system within the facility. The facility census was one.

1. Review of the facility maintenance program documentation did not show the facility had a program in place which includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets, and an inspection and maintenance schedule for this system.

2. Observation on 6/11/2019, during the building tour, showed the oxygen outlet in the emergency department near the back exit door had a handwritten note attached to it. Observation showed the note stated: "Remove coupler when not in use! Wastes O2 due to a leak."

During an interview on 6/20/2019 at 10:26 A.M., the Maintenance Director said he/she did not know the medical gas requirements.

Section 5.1.14.2.2.1 of the National Fire Protection Association (NFPA 99) states: Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

Based on record review and facility staff interview, the facility staff failed to maintain records of inspections and testing of their piped in oxygen systems in accordance with National Fire Protection Association (NFPA) 99, 2012 edition. The facility census was one.

1. Review of the facility's maintenance program documentation did not show inspections or testing of the piped-in oxygen system.

Record review of the facility Categorical Risk Assessments showed the medical gas system was a category 3 medical gas system.

During an interview on 6/20/2019 at 10:26 A.M., the Maintenance Director said he/she did not know the medical gas requirements.

NFPA 99, 2012 edition, Section 5.3.13.4 states:

"5.3.13.4 Category 3 Gas and Vacuum Systems Maintenance
and Record Keeping.

5.3.13.4.1 Permanent records of all tests required by Section
5.3 shall be maintained on-site in the organization ' s files.

5.3.13.4.2 A periodic testing procedure for Category 3 gas
and vacuum systems and related alarm systems shall be implemented.

5.3.13.4.3 Whenever modifications are made that breach the
pipeline, any necessary installer and verification test specified
in 5.3.9 shall be conducted on the downstream portions of the
medical gas piping system.

5.3.13.4.4 A maintenance program shall be established for
the following:
(1) Relief valves in accordance with applicable codes or
manufacturer ' s recommendation
(2) Drive gas supply system in accordance with manufacturer ' s
recommendations
(3) Vacuum source equipment and accessories in accordance
with manufacturer ' s recommendations
(4) Vacuum piping system and the secondary equipment attached
to vacuum station inlets to ensure the continued
good performance of the entire vacuum system
(5) Scavenging systems to ensure performance

5.3.13.4.5 An audible and visual alarm indicator(s) shall
meet the following requirements:
(1) It shall be periodically tested to determine that it is functioning
properly.
(2) The records of the test shall be maintained until the next
test is performed."

Based on observation, record review and facility staff interview, Facility staff failed to provide labeling and identification in compliance with NFPA 99, 2012 edition. The facility census was one.

Record review of the facility Categorical Risk Assessments showed the medical gas system was a category 3 medical gas system.

Observations on 6/10-11/2019, during the building tour showed the following:

-All exposed piping in patient rooms had multiple layers of paint and were not labeled;

Patient rooms #101, #102, #103, #104, #106, #109, #111, and #112 contained a lever valve on the oxygen piping to each patient bed without warning signage;

During an interview on 6/20/2019 at 10:26 A.M., the Maintenance Director said he/she did not know the medical gas requirements.

NFPA 99, 2012 edition, Section 5.3.13.3 states:

"5.3.13.3 Category 3 Gas and Vacuum Systems Identification and
Warning Signs. The labeling and identification of Category 3
gas and vacuum systems shall comply with the requirements of
5.3.11.

5.3.11 Labeling and Identification.

5.3.11.1 Pipe Labeling.

5.3.11.1.1 Piping, both exposed and concealed, shall be labeled
by stenciling or adhesive markers that identify the system.

5.3.11.1.2 Pipe labels shall show the name of the gas/vacuum
system or its chemical symbol.

5.3.11.1.3 Where positive pressure gas piping systems operate
at nonstandard pressures, the pipe labels shall also include the
nonstandard operating pressure in addition to the name or
symbol of the gas.

5.3.11.1.4 Pipe labels shall be located as follows:
(1) At intervals of not more than 6.1 m (20 ft)
(2) At least once in or above every room
(3) On both sides of walls or partitions penetrated by the piping
(4) At least once in every story height on risers

5.3.11.2 Identification of Shutoff Valves. Shutoff valves shall
be identified with the following information:
(1) Name or chemical symbol for the specific system
(2) Name of the room(s) or area(s) served
(3) Caution to not close (or open) the valve except in an
emergency

5.3.11.3 Identification of Outlets and Inlets. Outlets and inlets
shall be identified as to the name or chemical symbol for the
specific gas, vacuum, or scavenging provided."

Based on observation and facility staff interview, facility staff did not ensure receptacles in wet locations were equipped with GFCI protection. Failure to protect electrical service in a wet location puts any person in the area at risk of electrical shock in the event of water coming into contact with energized electrical equipment. The facility census was one.

Observations on 6/10-11/2019, during the facility tour, showed the following rooms did not contain GFCI protected electrical outlets in wet locations:

-Outlets on light fixtures above the sinks in patient rooms #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, and #112.

During an interview on 6/20/2019 at 10:29 A.M., the Maintenance Director said he/she did not know the GFCI electrical requirements. Additionally, he/she said the light fixtures were original to the building construction in 1952.

NFPA 99, 2012 edition, section 6.3.2.2.4.2 states: "6.3.2.2.4.2* Personnel Protection. If used, ground-fault circuit
interrupters (GFCIs) shall be listed."

Based on record review and facility staff interview, facility staff failed to inspect the facility electrical system per NFPA 99, 2012 edition requirements. The facility census was one.

Record review of the facility supplied records did not show the applicable inspections or testing of the electrical system.

During an interview on 6/20/2019 at 10:20 A.M., the Maintenance Director said he/she did not know the electrical inspection requirements.

NFPA 99, 2012 edition, section 6.3.4 Administration of Electrical Systems state:

6.3.4.1 Maintenance and Testing of Electrical System.

6.3.4.1.1 Where hospital-grade receptacles are required at patient
bed locations and in locations where deep sedation or general
anesthesia is administered, testing shall be performed after
initial installation, replacement, or servicing of the device.

6.3.4.1.2 Additional testing of receptacles in patient care
rooms shall be performed at intervals defined by documented
performance data.

6.3.4.1.3 Receptacles not listed as hospital-grade, at patient
bed locations and in locations where deep sedation or general
anesthesia is administered, shall be tested at intervals not exceeding
12 months.

6.3.4.1.4 The LIM circuit shall be tested at intervals of not more
than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6).

For a LIM circuit with automated self-test and self-calibration capabilities,
this test shall be performed at intervals of not more
than 12 months. Actuation of the test switch shall activate both
visual and audible alarm indicators.

6.3.4.1.5 After any repair or renovation to an electrical distribution
system, the LIM circuit shall be tested in accordance
with 6.3.3.3.2.

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

1. Observation on 6/10-11/2019 during the facility tour, did not show a remote annunciator panel for the emergency generator in a constantly attended location. Additionally, observation showed a remote annunciator panel in the maintenance office in the basement. Observation of the nurse's station showed a junction switch box with a on/off toggle switch, an indicator light, and a note taped to the wall stating: "Generator Failure Alarm".


During an interview on 6/20/2019 at 10:21 A.M., the Maintenance Director said he/she did not know the generator annunciator panel requirements.

NFPA 99, 2012 edition, section 6.4.1.1.17 states:

"6.4.1.1.17 Alarm Annunciator. A remote annunciator that is
storage battery powered shall be provided to operate outside of
the generating room in a location readily observed by operating
personnel at a regular work station (see 700.12 of NFPA 70, National
Electrical Code). The annunciator shall be hard-wired to indicate
alarm conditions of the emergency or auxiliary power
source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating
to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to
warn of an engine-generator alarm condition shall indicate
the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in
6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains
less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

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

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

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

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

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

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


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

Based on observation and facility staff interview, facility staff failed to provide electrical receptacle cover plates marking electrical outlets supplied by the life safety and critical branch of the emergency electrical system. Failure to mark emergency powered outlets has the potential to delay connection of essential patient care equipment to a power source in the event the regular electrical service failure. The facility census was one.

Observation on 6/10-11/2019, during the build tour, showed two outlet covers in cardiac rehab were red colored. Observation did not show any other color or marked outlets in the building.

During an interview on 6/20/2019 at 10:21 A.M., the Maintenance Director said he/she did not know the outlet marking requirements.

NFPA 99, 2012 edition, section 6.4.2.2.6 Wiring Requirements states:

"6.4.2.2.6.1* Separation from Other Circuits. The life safety
branch and critical branch shall be kept independent of all other
wiring and equipment.

6.4.2.2.6.2 Receptacles. The requirements for receptacles shall
comply with 6.4.2.2.6.2(A), 6.4.2.2.6.2(B), and 6.4.2.2.6.2(C).
(A) The number of receptacles on a single branch circuit for
areas described in 6.4.2.2.3.3(8) shall be minimized to limit
the effects of a branch-circuit outage.

(B) Branch-circuit overcurrent devices shall be readily accessible
to authorized personnel.

(C)* The electrical receptacles or the cover plates for the electrical
receptacles supplied from the life safety and critical
branches shall have a distinctive color or marking so as to be
readily identifiable."

Based on observation and facility staff interview, facility staff failed to ensure cord and electrical assemblies are listed for the purpose. The facility census was one.

Observation on 6/10-11/2019 showed a junction box with a duplex outlet and cord connected to a duplex outlet in the nurse's station on the crash cart. Observation showed the defibrillator on the crash cart connected to the junction box. Observation showed the junction box with duplex outlets and wiring were made by facility staff. The Maintenance Director confirmed the observation.

Observation of the powered bed in patient room #105 showed an orange colored power cord connected to the bed. Observation showed the replacement power cord were made by facility staff. The Maintenance Director confirmed the observation.

During an interview on 6/20/2019 at 10:22 A.M., the Maintenance Director said he/she did not know the electrical equipment requirements.

10.2.4 Adapters and Extension Cords.
10.2.4.1 Three-prong to two-prong adapters shall not be permitted.
10.2.4.2 Adapters and extension cords meeting the requirements
of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted.
10.2.4.2.1 All adapters shall be listed for the purpose.
10.2.4.2.2 Attachment plugs and fittings shall be listed for
the purpose.
10.2.4.2.3 The cabling shall comply with 10.2.3.

Based on observation, facility staff interview and record review, facility staff failed to provide continuing education regarding the safety guidelines and usage requirements for medical gases and their cylinders to staff involved with the application, handling and maintenance of medical gases and their cylinders. Failure to provide education has the potential for improper handling of medical gases and cylinders which poses an increased risk of fire and injury to patients and staff. This failure has the potential to affect all facility occupants. The facility census one.

1. Observation on 6/10-11/2019, during the build tour, showed all the patient rooms equipped with a piped vacuum/oxygen system.

Review of the facility's personnel continuing education records did not contain documentation of education provided to the facility staff involved with the application, handling and maintenance of medical gases regarding the safety guidelines and usage requirements for medical gases or their cylinders.

During an interview on 6/20/2019 at 10:23 A.M., the Maintenance Director said he/she has not received medical gas training.

NFPA 99, 2012 Edition, Section 11.5.2.1 (Qualifications and Training of Personnel), states:

"11.5.2 Gases in Cylinders and Liquefied Gases in Containers.

11.5.2.1 Qualification and Training of Personnel.

11.5.2.1.1* Personnel concerned with the application and
maintenance of medical gases and others who handle medical
gases and the cylinders that contain the medical gases shall be
trained on the risks associated with their handling and use.

11.5.2.1.2 Health care facilities shall provide programs of continuing
education for their personnel.

11.5.2.1.3 Continuing education programs shall include periodic
review of safety guidelines and usage requirements for
medical gases and their cylinders.

11.5.2.1.4 Equipment shall be serviced only by personnel
trained in the maintenance and operation of the equipment.

11.5.2.1.5 If a bulk cryogenic system is present, the supplier
shall provide annual training on its operation."

Based on observation and facility staff interview, facility staff failed to insure liquid oxygen base tanks were secured to prevent the tanks from falling, tipping or accidentally knocked over. The census was one.

Observation on 6/10-11/2019, during the building tour, showed the medical gas storage shed outside the cardiac rehab exterior door. Observation showed the shed contained the following:

-Eight unrestrained 240 liter base tanks of liquid oxygen;
-Ten unsupported full oxygen gas cylinders stored on their sides in a cart.

During an interview on 6/20/2019 at 10:30 A.M., the Maintenance Director said he/she did not know the storage requirements.

NFPA 99, 2012 Edition, Section 11.2.6.3. states:

"11.6.2.3 Cylinders shall be protected from damage by means
of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical
shock, which is liable to damage the cylinder,
valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or
gangways or in locations where heavy moving objects will
strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized
individuals.
(4) Cylinders or cylinder valves shall not be repaired,
painted, or altered.
(5) Safety relief devices in valves or cylinders shall not be
tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm
- not boiling - water.
(7) A torch flame shall not be permitted, under any circumstances,
to come in contact with a cylinder, cylinder
valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall
not be used as rollers, supports, or for any purpose other
than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger
than 45 kg (100 lb) weight shall be transported on a
proper hand truck or cart complying with 11.4.3.1.
(11) Freestanding cylinders shall be properly chained or supported
in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam
pipes, or heat ducts."


NFPA 99, 2012 Edition, Section 11.7.3.3. states:

11.7.3.3* Liquid oxygen base reservoir containers shall be secured
by one of the following methods while in storage or use
to prevent tipping over caused by contact, vibration, or seismic
activity:
(1) Securing to a fixed object with one or more restraints
(2) Securing within a framework, stand, or assembly designed
to resist container movement
(3) Restraining by placing the container against two points of
contact