HospitalInspections.org

Reference NFPA 101, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.3.6.1 states when pipes, conduits, cables, wires, air ducts and similar building service equipment pass through floors and smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose. Sleeves are shall be solidly set and the space between the item and the sleeve shall be sealed by approved methods.

Section 8.3.5.3 Required smoke dampers in air transfer openings shall close upon the detection of smoke by approved smoke detectors in accordance with NFPA 72, (National Fire Alarm Code).



Based on observation and staff interview, the facility failed to ensure smoke/fire barrier walls were constructed and properly protected from penetrations in accordance with NFPA 101, section 8.3. Incomplete construction, unprotected penetrations, openings and gaps in smoke/fire barrier walls would permit the movement of smoke and/or fire from one compartment to another, which in the event of fire presents a risk of potential harm to all one-hundred seventy (170) patients located in building #1, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:


A. On 11/29/12 at 2:20 pm, during smoke and fire barrier inspections with Facility Services Staff #1 and Facility Services Staff #2, life safety code surveyor #2 observed an 18"X 24" fire shutter installed in the smoke barrier wall located directly above smoke barrier doors #2700N. This fire shutter is operational only by the presence of heat (fusible link) instead of operational by the presence of smoke (smoke detector) as required.

B. On 11/29/12 at 2:25 pm, during interview, Facility Services Staff #1 stated he was unaware the damper was not motorized to close upon the detection of smoke.

C. On 11/29/12 at 2:30 pm, during smoke and fire barrier inspections with Facility Services Staff #1 and Facility Services Staff #2, life safety code surveyor #2 observed a 1' x 12' section of incomplete construction within the smoke barrier wall located at the east wall of the emergency room waiting area.

D. On 11/29/12 at 2:35 pm, during interview, Facility Services Staff #1 stated he was unaware the construction was incomplete.

E. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.




Based on observation and staff interview, the facility failed to ensure that penetrations between floors were properly sealed in accordance with NFPA 101, section 8.3. Incomplete construction, unprotected penetrations, openings and gaps between floors would permit the movement of smoke and/or fire from one floor to another, which presents a risk of potential harm to all patients located in building #23 as identified by the patient Census Report provided by the Administrator on 12/03/12 at 12:00 pm. The findings are:

A. On 12/03/12 at 12:20 pm, during a tour of the facility with Facility Services Staff #1 and Facility Services Staff #2, life safety code surveyor #2 observed a 4" diameter penetration and 3- 1-1/2" diameter penetrations which traveled between the telecommunications room located on the 1st floor and the electrical room located on the 2nd floor.

B. On 12/03/12 at 12:25 pm, during interview, Facility Services Staff #1 stated he was unaware the penetrations were not properly protected.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

NFPA 101, 2000 Edition 4.6.12.3 requires equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

Reference NFPA 101, 2000
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 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.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.


7.9.2 Performance of System.
7.9.2.2*
The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities






Based on observation and staff interview, the facility's practice failed to ensure emergency lighting is operational in the event of an emergency. This deficient practice presents a risk of potential harm by fire or injury to all staff within the pre-registration office and the chilled water mechanical room at building #1. The findings are:


A. On 11/30/12 at 8:25 am, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed the battery operated emergency light fixture located at the pre-registration office across from administration failed to work when tested.

B. On 11/30/12 at 8:30 am, during interview, the Facility Services Staff #2 confirmed the emergency light did not work.

C. On 11/30/12 at 11:30 am, during a tour of building #1 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed three (3) battery operated emergency light fixtures located at the chilled water mechanical room which failed to work when tested.

D. On 11/30/12 at 11:35 am, during interview, the Facility Services Staff #2 stated there may be something else wrong with the electrical wiring.

E. On 12/03/12 at 10:15 am, during a tour of building #20 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed a combination exit sign and emergency light fixture which failed to work when tested.

F. On 12/03/12 at 11:20 am, during a tour of building #2 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed an emergency light fixture located in the handicap restroom which failed to work when tested.

G. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition
7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.




Based on observation and staff interview, the facility's practice failed to ensure all exit signs are suitably illuminated and are readily visible to provide clear direction of travel to the nearest exit during an emergency. This deficient practice presents a risk of potential harm by fire to all one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:

A. On 11/29/12 at 3:10 pm, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed the exit sign leading from the basement mechanical room was not illuminated in the normal mode.

B. On 11/29/12 at 3:12 pm, during interview, the Facility Services Staff #2 stated that the exit sign was not working.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 72:
Section 1-5.2.5.2
Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.


Reference NFPA 72:
Section 7-1.1.1
Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
Section 7-1.1.2
System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.




Based on observation and staff interview, the facility failed to ensure the fire alarm system is maintained and the control panel is operational in accordance with NFPA 72 (National Fire Alarm Code). This failed practice presents a risk that the fire alarm system would not be operational in the event of fire or other emergency and would prevent staff from responding in a timely manner for safe evacuation of patients. This deficient practice presents a risk of potential harm by fire to all patients in building #19. The findings are:

A. On 12/03/12 at 10:30 am, during a tour of building #19 with Facility Services Staff #2 and the Director of Surgical Services, the Life Safety Code Surveyor #1 observed the fire alarm control panel display screen, located at the front entrance, was not working. The display screen would fail to display any type of trouble or alarm signal.

B. On 12/03/12 at 10:30 am, during interview, the Facility Services Staff #2 confirmed the digital display screen for the fire alarm panel was not working.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.





Based on observation and staff interview, the facility failed to ensure the location of the electrical breaker or circuit disconnect dedicated to the fire alarm system was displayed at the fire alarm panel and this breaker was mechanically protected, identified with a red marking, and labeled "FIRE ALARM CIRCUIT CONTROL" in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code). This failed practice presents a risk that the fire alarm system would not be operational in the event of fire or other emergency and would prevent staff from responding in a timely manner for safe evacuation of patients. This deficient practice presents a risk of potential harm by fire to all patients in building #19. The findings are:


A. On 12/03/12 at 11:00 am, during a tour of building #19 with Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed fire alarm control unit failed to identify the location of the fire alarm circuit control or breaker.

B. On 12/03/12 at 11:05 am, during interview, Facility Services Staff #1 stated she was unclear which electrical breaker was dedicated to the fire alarm system and where it was located.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 13
Section 1-5.1 Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.

Reference: NFPA 13, Sect. 1-6.1 states that a building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.



Based on observation and staff interview, the facility failed to ensure the automatic fire sprinkler system was installed in all areas of the facility as required by NFPA 13, (Standard for the Installation of Sprinkler Systems), which includes electrical rooms. This failed practice resulted in two (2) electrical rooms located within building #1 that were not being protected from fire by the facility's automatic fire sprinkler system, which presents a risk of potential harm to all one-hundred seventy (170) patients located in building #1, as identified by the patient Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:


A. On 11/30/12 at 10:00 am, during a tour of building #1 with Facility Services Staff #1 and Facility Services Staff #2, life safety code surveyor #2 observed electrical room #1814E located in the kitchen, was not being protected from fire by the facility's automatic fire sprinkler system.

B. On 11/30/12 at 10:30 am, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, life safety code surveyor #2 observed electrical room #1620 located in maintenance corridor, was not being protected from fire by the facility's automatic fire sprinkler system.

C. On 11/30/12 at 10:35 am, during interview, the Facility Service Staff #1 stated at the time the building was built there was an exception allowing the electrical rooms to be unsprinklered. He stated they are aware that is no longer the case and understands the electrical rooms are now required to be sprinklered. When asked if there were other electrical rooms or spaces that were not protected by the sprinkler system he stated, "I don't think so, but if there are we will ensure they are sprinklered too."

D. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.


Reference NFPA 13, 1999 Edition

Section 1-5.1
Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.


Section 5-5.5.2.1
Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.

Section 5-5.5.2.2
Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of Sections 5-6 through 5-11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.

Section 5-5.5.3* Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard.
Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.



Based on observation and staff interview, the facility failed to maintain the proper distance between automatic sprinkler system heads and obstructions as required by with NFPA 13 (Standard for the Installation of Sprinkler Systems). It is essential sprinkler heads are maintained free of obstructions to ensure proper spray patterns, proper sprinkler coverage and overall proper system performance in the event of fire. This failed practice presents a risk of potential harm to all patients located in building #23 as identified by the patient Census Report provided by the Administrator on 12/03/12 at 12:00 pm. The findings are:

A. On 12/03/12 at 12:45 pm, life code surveyor #2 observed large plastic decorative clouds permanently installed to the ceiling and located under or very close to the sprinkler heads located the length of patient corridor #193 located on the 1st floor. The sprinkler spray pattern is completely obstructed the length of this corridor.

B. On 12/03/12 at 12:50 pm, during interview, Facility Services Staff #1 stated no one has mentioned that the decorative clouds were a problem and he stated they were approved by all agencies.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 96
Section 7-1.2
Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.


Based on observation and staff interview, the facility failed to ensure range hood extinguishing nozzles were properly positioned above cooking appliances as required by NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). In the event of fire underneath the range hoods, the extinguishing systems would not be effective in extinguishing fire, which presents a risk of potential harm to all one-hundred seventy (170) patients located in building #1, as identified by the patient Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:


A. Review of the Range Hood Inspection dated 06/07/12 revealed the following comment regarding building #1 main range hood system:
- "Charbroiler needs to be moved over to the right under the nozzles."

B. Review of the Range Hood Inspection dated 11/30/11 revealed the following comment regarding building #1 cafeteria range hood system:
- "Nozzles appear to not be aligned correctly and shall be corrected."

C. On 11/30/12 at 10:00 am, during a tour of the kitchen with Facility Service Staff #1 and Facility Service Staff #2, life safety code surveyor #2 observed all the appliances located underneath the kitchens main range hood were shifted to the left, which resulted in the deep-fryer being unprotected and the charbroiler being only partially protected by the fire extinguishing nozzles.

D. On 11/30/12 at 10:10 am, during a tour of the cafeteria with Facility Service Staff #1 and Facility Service Staff #2, life safety code surveyor #2 observed the deep fryer located in the cafeteria was shifted to the left, which resulted in the deep-fryer being unprotected by the fire extinguishing nozzles.

E. On 11/30/12 at 10:15 am, life safety code surveyor #2 explained to Facility Service Staff #2 the concern regarding the appliances not being properly protected by the fire extinguishing nozzles and the concern that this issue was first brought up in previous range hood inspections. Facility Service Staff #2 stated that kitchen staff move the appliances for cleaning and no one is assuring the appliances are properly positioned underneath the fire extinguishing nozzles after the cleaning.

F. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.













21700

NFPA 101, 2000 Edition
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies. see exception.


Based on observation, the facility's practice failed to ensure portable space heating devices not be used in health care occupancies. This deficient practice presents a risk of potential harm by fire to all patients in building #20. The findings are:


A. On 12/03/12 at 9:45 am, during a tour of building #20 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed a portable space heater located within exam room #121.


B. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the finding at the exit conference.

Reference NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.
8. When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
9. Containers shall not be stored in a tightly closed space such as a closet [see 8-2.1.2.3(c)].
10. Location of Supply Systems.
a. Except as permitted by 4-3.1.1.2(a)10c, supply systems for medical gases or mixtures of these gases having total capacities (connected and in storage) not exceeding the quantities specified in 4-3.1.1.2(b)1 and 2 shall be located outdoors in an enclosure used only for this purpose or in a room or enclosure used only for this purpose situated within a building used for other purposes.
b. Storage facilities that are outside, but adjacent to a building wall, shall be in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
c. Locations for supply systems shall not be used for storage purposes other than for containers of nonflammable gases. Storage of full or empty containers shall be permitted. Other nonflammable medical gas supply systems or storage locations shall be permitted to be in the same location with oxygen or nitrous oxide or both. However, care shall be taken to provide adequate ventilation to dissipate such other gases in order to prevent the development of oxygen-deficient atmospheres in the event of functioning of cylinder or manifold pressure-relief devices.
d. Air compressors and vacuum pumps shall be located separately from cylinder patient gas systems or cylinder storage enclosures. Air compressors shall be installed in a designated mechanical equipment area, adequately ventilated and with required services.
11. Construction and Arrangement of Supply System Locations.
a. Walls, floors, ceilings, roofs, doors, interior finish, shelves, racks, and supports of and in the locations cited in 4-3.1.1.2(a)10a shall be constructed of noncombustible or limited-combustible materials.
b. Locations for supply systems for oxygen, nitrous oxide, or mixtures of these gases shall not communicate with anesthetizing locations or storage locations for flammable anesthetizing agents.
c. Enclosures for supply systems shall be provided with doors or gates that can be locked.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
e. Where enclosures (interior or exterior) for supply systems are located near sources of heat, such as furnaces, incinerators, or boiler rooms, they shall be of construction that protects cylinders from reaching temperatures exceeding 130?F (54?C). Open electrical conductors and transformers shall not be located in close proximity to enclosures. Such enclosures shall not be located adjacent to storage tanks for flammable or combustible liquids.
f. Smoking shall be prohibited in supply system enclosures.
g. Heating shall be by steam, hot water, or other indirect means. Cylinder temperatures shall not exceed 130?F (54?C).
(b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3).
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
2. Nitrous oxide supply systems or storage locations having a total capacity of 3200 lb (1452 kg) [28,000 ft3 (793 m3) (NTP)] or more, including unconnected reserves on hand at the site, shall comply with CGA Pamphlet G-8.1, Standard for the Installation of Nitrous Oxide Systems at Consumer Sites.
3. The walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.
4. Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.
(c) Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.

21-1.2.6 CGA Publications.
Pamphlet P-2.7-1994, Guide for the Safe Storage, Handling and Use of Portable Liquid Oxygen Systems in Health Care Facilities.






Based on observation and staff interview, the facility failed to ensure handling and storage of oxygen was in compliance with NFPA 99 (Standard for Healthcare Facilities). Oxygen cylinders are pressurized vessels, mismanagement could result in fire or accidental discharge. This deficient practice presents a risk of potential harm by fire or injury to all staff and one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:

A. On 11/29/12 at 3:05 pm, during a tour of building #1 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed a member of the facility staff dragging two (2) oxygen cylinders along the concrete floor from the gym area.

B. On 11/29/12 at 3:06 pm, during interview, the Facility Services Staff #2 stated staff was handling the oxygen cylinders unsafely.

C. On 11/30/12 at 10:45 am, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed fifty-four (54) size "E" oxygen cylinders being stored in materials management storage room #1802. Two (2) size "E" cylinders were being stored in an unsecured horizontal position laying atop a cart of other portable oxygen cylinders.

D. On 11/30/12 at 10:47 am, during interview, the Facility Services Staff #1 stated this was not the proper way to store portable oxygen cylinders.

E. On 12/03/12 at 11:15 am, during a tour of building #2 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed one (1) size "E" portable oxygen cylinder left free standing within a storage closet.

F. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Actual Standard NFPA 99
Standard for Health Care Facilities
1999 Edition

5-4.1.1*
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

A-5-4.1.1
Advantages claimed for humidity include avoidance of hypothermia in patients, especially during long operative procedures; the fact that floating particulate matter increases in conditions of low relative humidity; and the fact that the incidence of wound infections can be minimized following procedures performed in those operating rooms in which the relative humidity is maintained at the level of 50 to 55 percent.




Based on observation and staff interview, the facility failed to ensure relative humidity is maintained equal to or greater than 35% in areas where anesthesia is administered. This failed practice presents a risk of potential harm by fire or injury to all one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:




A. On 11/28/12 at 6:30 am, during a tour of building #1 operating rooms with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed the following operating rooms had a relative humidity of less than 35%.
1. Operating room #2 had a relative humidity of 7%.
2. Operating room #3 had a relative humidity of 3%.
3. Operating room #4 had a relative humidity of 9%.
4. Operating room #7 had a relative humidity of 5%.
5. Operating room #9 had a relative humidity of 10%.


B. On 11/28/12 at 6:30 am, during interview, Facility Services Staff #1 stated the facility is aware of the ongoing concerns with the humidity levels. It was also stated, the facility has been working on monitoring and controlling the relative humidity levels within all the operating rooms.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 99 Chapter 3-4.2.2.2 Emergency System.
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
+All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress. No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.
(c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.
3-4.2.2.3 Equipment System.
(a) General. The equipment system shall be connected to equipment described in 3-4.2.2.3(c)through (e).
(b) Connection to Alternate Power Source. The equipment system shall be installed and connected to the alternate power source, such that equipment described in 3-4.2.2.3(d) is automatically restored to operation at appropriate time lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 3-4.2.2.3(e) by either delayed-automatic or manual operation.
(c) AC Equipment for Nondelayed Automatic Connection. Generator accessories, including but not limited to, the transfer fuel pump, electrically operated louvers, and other generator accessories essential for generator operation, shall be arranged for automatic connection to the alternate power source.
(d) * Equipment for Delayed-Automatic Connection. The following equipment shall be arranged for delayed-automatic connection to the alternate power source:
1. Central suction systems serving medical and surgical functions, including controls. It shall be permitted to place such suction systems on the critical branch.
2. Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms
3. Compressed air systems serving medical and surgical functions, including controls. It shall be permitted to place such air systems on the critical branch.
4. Smoke control and stair pressurization systems
5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood
(e) Equipment for Delayed-Automatic or Manual Connection. The following equipment shall be arranged for either delayed-automatic or manual connection to the alternate power source [also see A-3-4.2.2.3(d)]:
1. Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms, and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems
Exception:* Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions:
a. The outside design temperature is higher than +20?F (-6.7?C), or
b. The outside design temperature is lower than +20?F (-6.7?C) and a selected room(s) is provided for the needs of all confined patients [then only such room(s) need be heated], or
c. The facility is served by a dual source of normal power as described in 3-3.2.1.1.
2. Elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power [For elevator cab lighting, control, and signal system requirements, see 3-4.2.2.2(b)(6).]
In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who are confined between floors.
3. Supply, return, and exhaust ventilating systems for surgical and obstetrical delivery suites, intensive care, coronary care, nurseries, and emergency treatment spaces.
4. Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch.
5. Hyperbaric facilities
6. Hypobaric facilities
7. Autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
8. Controls for equipment listed in 3-4.2.2.3.
9. * Other selected equipment shall be permitted to be served by the equipment system.






Based on observation, the facility's practice failed to ensure the complete distribution of emergency power is provided within the facility to medication refrigerators and the emergency power supply system is properly identified as per NFPA 99 (Standard for Healthcare Facilities). This failed practice presents a risk of potential harm of injury to all one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:



A. On 11/29/12 at 2:40 pm, during a tour of building #1 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed three (3) medication refrigerators located at inpatient rehab medication room were not plugged into an outlet that indicates its presence on the emergency power circuit. The surveyor observed the emergency power supply system was marked with red outlets. The outlet at the medication room, where the medications were plugged into, was not red or otherwise distinctively colored.

B. On 11/30/12 at 9:50 am, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed three (3) medication refrigerators located at the pharmacy were not plugged into an outlet that indicates its presence on the emergency power circuit. The surveyor observed the emergency power supply system was marked with red outlets. The outlet at the pharmacy, where the medications were plugged into, was not red or otherwise distinctively colored

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference: NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition:
NFPA 110, Chapter 2-2 Classification of Emergency Power Supply Systems (EPSS)
2-3.4 Level.
2-2.3.1 - Level 1 defines the most stringent equipment performance requirements for application where failure of equipment to perform could result in loss of human life or serious injuries. All Level 1 equipment shall be permanently installed.

3-5.5.2
An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.5.3
Engines equipped with a maintaining shutdown device (air shutdown damper) shall have a set of contacts that monitor the position of this device, with local alarm indication and remote annunciation in accordance with Table 3-5.5.2(d).





Based on observation and staff interview, the facility failed to ensure the emergency generator #2 used to protect residents during times of primary power failure, was provided with an operational remote alarm annunciator as required by NFPA 110 (Standard for Emergency and Standby Power Systems). It is essential the remote alarm annunciator is maintained operational in order to alert staff when the generator is running and any type of malfunction that may arise at the generator such as low fuel, low battery and low oil pressure. In the event of a generator malfunction, staff would not have been alerted promptly. This failed practice presents a risk of potential harm or result in loss of human life or serious injury to all one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:


A. On 11/27/12 at 4:45 pm, during a tour of the facility communications room at building #1, the Life Safety Code Surveyor observed the emergency generator remote annunciator panel #2 was non-operational when lamp tested.

B. On 11/27/12 at 4:50 pm, during interview, the Facility Staff #7 acknowledged the annunciator panel was not working. It was stated that facility staff was unaware how long the emergency generator annunciator panel was not working.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure electrical equipment, circuit breakers were identified in accordance with NFPA 70 (National Electrical Code). It is essential all circuit breakers within electrical panels are properly identified as to what they serve so in the event of emergency selected circuits can be turned off. This failed practice could result in the incorrect breakers being turned off in the event of fire or other emergency and presents a risk of potential harm by fire to all one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:



A. On 11/29/12 at 12:10 pm, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor#1 observed the electrical panel labeled "ELLOI-EOI" had a legend which did not accurately identify all circuit breakers. Circuit breakers #6 through #16 were labeled "spare" but were in the "on" position.

B. On 11/29/12 at 12:15 pm, during interview, the Facility Services Staff #1 confirmed the circuit breakers #6 through #16 were in the "on" position.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.3.6.1 states when pipes, conduits, cables, wires, air ducts and similar building service equipment pass through floors and smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose. Sleeves are shall be solidly set and the space between the item and the sleeve shall be sealed by approved methods.

Section 8.3.5.3 Required smoke dampers in air transfer openings shall close upon the detection of smoke by approved smoke detectors in accordance with NFPA 72, (National Fire Alarm Code).



Based on observation and staff interview, the facility failed to ensure smoke/fire barrier walls were constructed and properly protected from penetrations in accordance with NFPA 101, section 8.3. Incomplete construction, unprotected penetrations, openings and gaps in smoke/fire barrier walls would permit the movement of smoke and/or fire from one compartment to another, which in the event of fire presents a risk of potential harm to all one-hundred seventy (170) patients located in building #1, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:


A. On 11/29/12 at 2:20 pm, during smoke and fire barrier inspections with Facility Services Staff #1 and Facility Services Staff #2, life safety code surveyor #2 observed an 18"X 24" fire shutter installed in the smoke barrier wall located directly above smoke barrier doors #2700N. This fire shutter is operational only by the presence of heat (fusible link) instead of operational by the presence of smoke (smoke detector) as required.

B. On 11/29/12 at 2:25 pm, during interview, Facility Services Staff #1 stated he was unaware the damper was not motorized to close upon the detection of smoke.

C. On 11/29/12 at 2:30 pm, during smoke and fire barrier inspections with Facility Services Staff #1 and Facility Services Staff #2, life safety code surveyor #2 observed a 1' x 12' section of incomplete construction within the smoke barrier wall located at the east wall of the emergency room waiting area.

D. On 11/29/12 at 2:35 pm, during interview, Facility Services Staff #1 stated he was unaware the construction was incomplete.

E. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.




Based on observation and staff interview, the facility failed to ensure that penetrations between floors were properly sealed in accordance with NFPA 101, section 8.3. Incomplete construction, unprotected penetrations, openings and gaps between floors would permit the movement of smoke and/or fire from one floor to another, which presents a risk of potential harm to all patients located in building #23 as identified by the patient Census Report provided by the Administrator on 12/03/12 at 12:00 pm. The findings are:

A. On 12/03/12 at 12:20 pm, during a tour of the facility with Facility Services Staff #1 and Facility Services Staff #2, life safety code surveyor #2 observed a 4" diameter penetration and 3- 1-1/2" diameter penetrations which traveled between the telecommunications room located on the 1st floor and the electrical room located on the 2nd floor.

B. On 12/03/12 at 12:25 pm, during interview, Facility Services Staff #1 stated he was unaware the penetrations were not properly protected.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

NFPA 101, 2000 Edition 4.6.12.3 requires equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

Reference NFPA 101, 2000
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 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.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.


7.9.2 Performance of System.
7.9.2.2*
The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities






Based on observation and staff interview, the facility's practice failed to ensure emergency lighting is operational in the event of an emergency. This deficient practice presents a risk of potential harm by fire or injury to all staff within the pre-registration office and the chilled water mechanical room at building #1. The findings are:


A. On 11/30/12 at 8:25 am, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed the battery operated emergency light fixture located at the pre-registration office across from administration failed to work when tested.

B. On 11/30/12 at 8:30 am, during interview, the Facility Services Staff #2 confirmed the emergency light did not work.

C. On 11/30/12 at 11:30 am, during a tour of building #1 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed three (3) battery operated emergency light fixtures located at the chilled water mechanical room which failed to work when tested.

D. On 11/30/12 at 11:35 am, during interview, the Facility Services Staff #2 stated there may be something else wrong with the electrical wiring.

E. On 12/03/12 at 10:15 am, during a tour of building #20 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed a combination exit sign and emergency light fixture which failed to work when tested.

F. On 12/03/12 at 11:20 am, during a tour of building #2 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed an emergency light fixture located in the handicap restroom which failed to work when tested.

G. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition
7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.




Based on observation and staff interview, the facility's practice failed to ensure all exit signs are suitably illuminated and are readily visible to provide clear direction of travel to the nearest exit during an emergency. This deficient practice presents a risk of potential harm by fire to all one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:

A. On 11/29/12 at 3:10 pm, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed the exit sign leading from the basement mechanical room was not illuminated in the normal mode.

B. On 11/29/12 at 3:12 pm, during interview, the Facility Services Staff #2 stated that the exit sign was not working.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 72:
Section 1-5.2.5.2
Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.


Reference NFPA 72:
Section 7-1.1.1
Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
Section 7-1.1.2
System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.




Based on observation and staff interview, the facility failed to ensure the fire alarm system is maintained and the control panel is operational in accordance with NFPA 72 (National Fire Alarm Code). This failed practice presents a risk that the fire alarm system would not be operational in the event of fire or other emergency and would prevent staff from responding in a timely manner for safe evacuation of patients. This deficient practice presents a risk of potential harm by fire to all patients in building #19. The findings are:

A. On 12/03/12 at 10:30 am, during a tour of building #19 with Facility Services Staff #2 and the Director of Surgical Services, the Life Safety Code Surveyor #1 observed the fire alarm control panel display screen, located at the front entrance, was not working. The display screen would fail to display any type of trouble or alarm signal.

B. On 12/03/12 at 10:30 am, during interview, the Facility Services Staff #2 confirmed the digital display screen for the fire alarm panel was not working.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.





Based on observation and staff interview, the facility failed to ensure the location of the electrical breaker or circuit disconnect dedicated to the fire alarm system was displayed at the fire alarm panel and this breaker was mechanically protected, identified with a red marking, and labeled "FIRE ALARM CIRCUIT CONTROL" in accordance with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm Code). This failed practice presents a risk that the fire alarm system would not be operational in the event of fire or other emergency and would prevent staff from responding in a timely manner for safe evacuation of patients. This deficient practice presents a risk of potential harm by fire to all patients in building #19. The findings are:


A. On 12/03/12 at 11:00 am, during a tour of building #19 with Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed fire alarm control unit failed to identify the location of the fire alarm circuit control or breaker.

B. On 12/03/12 at 11:05 am, during interview, Facility Services Staff #1 stated she was unclear which electrical breaker was dedicated to the fire alarm system and where it was located.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 13
Section 1-5.1 Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.

Reference: NFPA 13, Sect. 1-6.1 states that a building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.



Based on observation and staff interview, the facility failed to ensure the automatic fire sprinkler system was installed in all areas of the facility as required by NFPA 13, (Standard for the Installation of Sprinkler Systems), which includes electrical rooms. This failed practice resulted in two (2) electrical rooms located within building #1 that were not being protected from fire by the facility's automatic fire sprinkler system, which presents a risk of potential harm to all one-hundred seventy (170) patients located in building #1, as identified by the patient Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:


A. On 11/30/12 at 10:00 am, during a tour of building #1 with Facility Services Staff #1 and Facility Services Staff #2, life safety code surveyor #2 observed electrical room #1814E located in the kitchen, was not being protected from fire by the facility's automatic fire sprinkler system.

B. On 11/30/12 at 10:30 am, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, life safety code surveyor #2 observed electrical room #1620 located in maintenance corridor, was not being protected from fire by the facility's automatic fire sprinkler system.

C. On 11/30/12 at 10:35 am, during interview, the Facility Service Staff #1 stated at the time the building was built there was an exception allowing the electrical rooms to be unsprinklered. He stated they are aware that is no longer the case and understands the electrical rooms are now required to be sprinklered. When asked if there were other electrical rooms or spaces that were not protected by the sprinkler system he stated, "I don't think so, but if there are we will ensure they are sprinklered too."

D. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.


Reference NFPA 13, 1999 Edition

Section 1-5.1
Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.


Section 5-5.5.2.1
Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.

Section 5-5.5.2.2
Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of Sections 5-6 through 5-11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.

Section 5-5.5.3* Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard.
Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.



Based on observation and staff interview, the facility failed to maintain the proper distance between automatic sprinkler system heads and obstructions as required by with NFPA 13 (Standard for the Installation of Sprinkler Systems). It is essential sprinkler heads are maintained free of obstructions to ensure proper spray patterns, proper sprinkler coverage and overall proper system performance in the event of fire. This failed practice presents a risk of potential harm to all patients located in building #23 as identified by the patient Census Report provided by the Administrator on 12/03/12 at 12:00 pm. The findings are:

A. On 12/03/12 at 12:45 pm, life code surveyor #2 observed large plastic decorative clouds permanently installed to the ceiling and located under or very close to the sprinkler heads located the length of patient corridor #193 located on the 1st floor. The sprinkler spray pattern is completely obstructed the length of this corridor.

B. On 12/03/12 at 12:50 pm, during interview, Facility Services Staff #1 stated no one has mentioned that the decorative clouds were a problem and he stated they were approved by all agencies.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 96
Section 7-1.2
Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.


Based on observation and staff interview, the facility failed to ensure range hood extinguishing nozzles were properly positioned above cooking appliances as required by NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). In the event of fire underneath the range hoods, the extinguishing systems would not be effective in extinguishing fire, which presents a risk of potential harm to all one-hundred seventy (170) patients located in building #1, as identified by the patient Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:


A. Review of the Range Hood Inspection dated 06/07/12 revealed the following comment regarding building #1 main range hood system:
- "Charbroiler needs to be moved over to the right under the nozzles."

B. Review of the Range Hood Inspection dated 11/30/11 revealed the following comment regarding building #1 cafeteria range hood system:
- "Nozzles appear to not be aligned correctly and shall be corrected."

C. On 11/30/12 at 10:00 am, during a tour of the kitchen with Facility Service Staff #1 and Facility Service Staff #2, life safety code surveyor #2 observed all the appliances located underneath the kitchens main range hood were shifted to the left, which resulted in the deep-fryer being unprotected and the charbroiler being only partially protected by the fire extinguishing nozzles.

D. On 11/30/12 at 10:10 am, during a tour of the cafeteria with Facility Service Staff #1 and Facility Service Staff #2, life safety code surveyor #2 observed the deep fryer located in the cafeteria was shifted to the left, which resulted in the deep-fryer being unprotected by the fire extinguishing nozzles.

E. On 11/30/12 at 10:15 am, life safety code surveyor #2 explained to Facility Service Staff #2 the concern regarding the appliances not being properly protected by the fire extinguishing nozzles and the concern that this issue was first brought up in previous range hood inspections. Facility Service Staff #2 stated that kitchen staff move the appliances for cleaning and no one is assuring the appliances are properly positioned underneath the fire extinguishing nozzles after the cleaning.

F. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.













21700

NFPA 101, 2000 Edition
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies. see exception.


Based on observation, the facility's practice failed to ensure portable space heating devices not be used in health care occupancies. This deficient practice presents a risk of potential harm by fire to all patients in building #20. The findings are:


A. On 12/03/12 at 9:45 am, during a tour of building #20 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed a portable space heater located within exam room #121.


B. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the finding at the exit conference.

Reference NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.
8. When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
9. Containers shall not be stored in a tightly closed space such as a closet [see 8-2.1.2.3(c)].
10. Location of Supply Systems.
a. Except as permitted by 4-3.1.1.2(a)10c, supply systems for medical gases or mixtures of these gases having total capacities (connected and in storage) not exceeding the quantities specified in 4-3.1.1.2(b)1 and 2 shall be located outdoors in an enclosure used only for this purpose or in a room or enclosure used only for this purpose situated within a building used for other purposes.
b. Storage facilities that are outside, but adjacent to a building wall, shall be in accordance with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
c. Locations for supply systems shall not be used for storage purposes other than for containers of nonflammable gases. Storage of full or empty containers shall be permitted. Other nonflammable medical gas supply systems or storage locations shall be permitted to be in the same location with oxygen or nitrous oxide or both. However, care shall be taken to provide adequate ventilation to dissipate such other gases in order to prevent the development of oxygen-deficient atmospheres in the event of functioning of cylinder or manifold pressure-relief devices.
d. Air compressors and vacuum pumps shall be located separately from cylinder patient gas systems or cylinder storage enclosures. Air compressors shall be installed in a designated mechanical equipment area, adequately ventilated and with required services.
11. Construction and Arrangement of Supply System Locations.
a. Walls, floors, ceilings, roofs, doors, interior finish, shelves, racks, and supports of and in the locations cited in 4-3.1.1.2(a)10a shall be constructed of noncombustible or limited-combustible materials.
b. Locations for supply systems for oxygen, nitrous oxide, or mixtures of these gases shall not communicate with anesthetizing locations or storage locations for flammable anesthetizing agents.
c. Enclosures for supply systems shall be provided with doors or gates that can be locked.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
e. Where enclosures (interior or exterior) for supply systems are located near sources of heat, such as furnaces, incinerators, or boiler rooms, they shall be of construction that protects cylinders from reaching temperatures exceeding 130?F (54?C). Open electrical conductors and transformers shall not be located in close proximity to enclosures. Such enclosures shall not be located adjacent to storage tanks for flammable or combustible liquids.
f. Smoking shall be prohibited in supply system enclosures.
g. Heating shall be by steam, hot water, or other indirect means. Cylinder temperatures shall not exceed 130?F (54?C).
(b) Additional Storage Requirements for Nonflammable Gases Greater Than 3000 ft3 (85 m3).
1. Oxygen supply systems or storage locations having a total capacity of more than 20,000 ft3 (566 m3) (NTP), including unconnected reserves on hand at the site, shall comply with NFPA 50, Standard for Bulk Oxygen Systems at Consumer Sites.
2. Nitrous oxide supply systems or storage locations having a total capacity of 3200 lb (1452 kg) [28,000 ft3 (793 m3) (NTP)] or more, including unconnected reserves on hand at the site, shall comply with CGA Pamphlet G-8.1, Standard for the Installation of Nitrous Oxide Systems at Consumer Sites.
3. The walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.
4. Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.
(c) Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.

21-1.2.6 CGA Publications.
Pamphlet P-2.7-1994, Guide for the Safe Storage, Handling and Use of Portable Liquid Oxygen Systems in Health Care Facilities.






Based on observation and staff interview, the facility failed to ensure handling and storage of oxygen was in compliance with NFPA 99 (Standard for Healthcare Facilities). Oxygen cylinders are pressurized vessels, mismanagement could result in fire or accidental discharge. This deficient practice presents a risk of potential harm by fire or injury to all staff and one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:

A. On 11/29/12 at 3:05 pm, during a tour of building #1 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed a member of the facility staff dragging two (2) oxygen cylinders along the concrete floor from the gym area.

B. On 11/29/12 at 3:06 pm, during interview, the Facility Services Staff #2 stated staff was handling the oxygen cylinders unsafely.

C. On 11/30/12 at 10:45 am, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed fifty-four (54) size "E" oxygen cylinders being stored in materials management storage room #1802. Two (2) size "E" cylinders were being stored in an unsecured horizontal position laying atop a cart of other portable oxygen cylinders.

D. On 11/30/12 at 10:47 am, during interview, the Facility Services Staff #1 stated this was not the proper way to store portable oxygen cylinders.

E. On 12/03/12 at 11:15 am, during a tour of building #2 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed one (1) size "E" portable oxygen cylinder left free standing within a storage closet.

F. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Actual Standard NFPA 99
Standard for Health Care Facilities
1999 Edition

5-4.1.1*
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

A-5-4.1.1
Advantages claimed for humidity include avoidance of hypothermia in patients, especially during long operative procedures; the fact that floating particulate matter increases in conditions of low relative humidity; and the fact that the incidence of wound infections can be minimized following procedures performed in those operating rooms in which the relative humidity is maintained at the level of 50 to 55 percent.




Based on observation and staff interview, the facility failed to ensure relative humidity is maintained equal to or greater than 35% in areas where anesthesia is administered. This failed practice presents a risk of potential harm by fire or injury to all one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:




A. On 11/28/12 at 6:30 am, during a tour of building #1 operating rooms with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed the following operating rooms had a relative humidity of less than 35%.
1. Operating room #2 had a relative humidity of 7%.
2. Operating room #3 had a relative humidity of 3%.
3. Operating room #4 had a relative humidity of 9%.
4. Operating room #7 had a relative humidity of 5%.
5. Operating room #9 had a relative humidity of 10%.


B. On 11/28/12 at 6:30 am, during interview, Facility Services Staff #1 stated the facility is aware of the ongoing concerns with the humidity levels. It was also stated, the facility has been working on monitoring and controlling the relative humidity levels within all the operating rooms.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference NFPA 99 Chapter 3-4.2.2.2 Emergency System.
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
+All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress. No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.
(c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.
3-4.2.2.3 Equipment System.
(a) General. The equipment system shall be connected to equipment described in 3-4.2.2.3(c)through (e).
(b) Connection to Alternate Power Source. The equipment system shall be installed and connected to the alternate power source, such that equipment described in 3-4.2.2.3(d) is automatically restored to operation at appropriate time lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 3-4.2.2.3(e) by either delayed-automatic or manual operation.
(c) AC Equipment for Nondelayed Automatic Connection. Generator accessories, including but not limited to, the transfer fuel pump, electrically operated louvers, and other generator accessories essential for generator operation, shall be arranged for automatic connection to the alternate power source.
(d) * Equipment for Delayed-Automatic Connection. The following equipment shall be arranged for delayed-automatic connection to the alternate power source:
1. Central suction systems serving medical and surgical functions, including controls. It shall be permitted to place such suction systems on the critical branch.
2. Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms
3. Compressed air systems serving medical and surgical functions, including controls. It shall be permitted to place such air systems on the critical branch.
4. Smoke control and stair pressurization systems
5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood
(e) Equipment for Delayed-Automatic or Manual Connection. The following equipment shall be arranged for either delayed-automatic or manual connection to the alternate power source [also see A-3-4.2.2.3(d)]:
1. Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms, and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems
Exception:* Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions:
a. The outside design temperature is higher than +20?F (-6.7?C), or
b. The outside design temperature is lower than +20?F (-6.7?C) and a selected room(s) is provided for the needs of all confined patients [then only such room(s) need be heated], or
c. The facility is served by a dual source of normal power as described in 3-3.2.1.1.
2. Elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power [For elevator cab lighting, control, and signal system requirements, see 3-4.2.2.2(b)(6).]
In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who are confined between floors.
3. Supply, return, and exhaust ventilating systems for surgical and obstetrical delivery suites, intensive care, coronary care, nurseries, and emergency treatment spaces.
4. Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch.
5. Hyperbaric facilities
6. Hypobaric facilities
7. Autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
8. Controls for equipment listed in 3-4.2.2.3.
9. * Other selected equipment shall be permitted to be served by the equipment system.






Based on observation, the facility's practice failed to ensure the complete distribution of emergency power is provided within the facility to medication refrigerators and the emergency power supply system is properly identified as per NFPA 99 (Standard for Healthcare Facilities). This failed practice presents a risk of potential harm of injury to all one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:



A. On 11/29/12 at 2:40 pm, during a tour of building #1 with the Facility Services Staff #2, the Life Safety Code Surveyor #1 observed three (3) medication refrigerators located at inpatient rehab medication room were not plugged into an outlet that indicates its presence on the emergency power circuit. The surveyor observed the emergency power supply system was marked with red outlets. The outlet at the medication room, where the medications were plugged into, was not red or otherwise distinctively colored.

B. On 11/30/12 at 9:50 am, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor #1 observed three (3) medication refrigerators located at the pharmacy were not plugged into an outlet that indicates its presence on the emergency power circuit. The surveyor observed the emergency power supply system was marked with red outlets. The outlet at the pharmacy, where the medications were plugged into, was not red or otherwise distinctively colored

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Reference: NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition:
NFPA 110, Chapter 2-2 Classification of Emergency Power Supply Systems (EPSS)
2-3.4 Level.
2-2.3.1 - Level 1 defines the most stringent equipment performance requirements for application where failure of equipment to perform could result in loss of human life or serious injuries. All Level 1 equipment shall be permanently installed.

3-5.5.2
An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.5.3
Engines equipped with a maintaining shutdown device (air shutdown damper) shall have a set of contacts that monitor the position of this device, with local alarm indication and remote annunciation in accordance with Table 3-5.5.2(d).





Based on observation and staff interview, the facility failed to ensure the emergency generator #2 used to protect residents during times of primary power failure, was provided with an operational remote alarm annunciator as required by NFPA 110 (Standard for Emergency and Standby Power Systems). It is essential the remote alarm annunciator is maintained operational in order to alert staff when the generator is running and any type of malfunction that may arise at the generator such as low fuel, low battery and low oil pressure. In the event of a generator malfunction, staff would not have been alerted promptly. This failed practice presents a risk of potential harm or result in loss of human life or serious injury to all one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:


A. On 11/27/12 at 4:45 pm, during a tour of the facility communications room at building #1, the Life Safety Code Surveyor observed the emergency generator remote annunciator panel #2 was non-operational when lamp tested.

B. On 11/27/12 at 4:50 pm, during interview, the Facility Staff #7 acknowledged the annunciator panel was not working. It was stated that facility staff was unaware how long the emergency generator annunciator panel was not working.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure electrical equipment, circuit breakers were identified in accordance with NFPA 70 (National Electrical Code). It is essential all circuit breakers within electrical panels are properly identified as to what they serve so in the event of emergency selected circuits can be turned off. This failed practice could result in the incorrect breakers being turned off in the event of fire or other emergency and presents a risk of potential harm by fire to all one-hundred seventy (170) patients, as identified by the Census Report provided by Facility Services Staff #1 on 11/27/12 at 3:30 pm. The findings are:



A. On 11/29/12 at 12:10 pm, during a tour of building #1 with the Facility Services Staff #1 and Facility Services Staff #2, the Life Safety Code Surveyor#1 observed the electrical panel labeled "ELLOI-EOI" had a legend which did not accurately identify all circuit breakers. Circuit breakers #6 through #16 were labeled "spare" but were in the "on" position.

B. On 11/29/12 at 12:15 pm, during interview, the Facility Services Staff #1 confirmed the circuit breakers #6 through #16 were in the "on" position.

C. On 12/04/12 at 9:00 am, the Facility Services Staff #1, Facility Services Staff #2, Chief Operations Officer, Chief Nursing Officer, and the Performance Improvement Officer #3 acknowledged the above findings at the exit conference.