HospitalInspections.org

Based on observation and facility staff interview, facility staff failed to provide a two-hour fire rating between floors that separate the hospital and the outpatient sleep lab on the lower level. This compromises the fire-resistance rating and would allow the smoke, fumes and products of combustion to the floor above in the event of a fire. This deficient practice as the potential to effect all patients, staff and visitors in the building. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Observation on 11/08/18, at approximately 11:15 A.M., during the facility tour, showed the door and assembly at the bottom of the stairwell between the Hospital General Medical Floor (GMF) and the outpatient sleep lab on the lower level was one hour rated.

Observation of the lower level showed the basement contained medical business offices, kitchen, laundry, maintenance shop, hazardous storage areas and other plant operations areas in addition to the sleep lab.

During an interview on 11/08/2018 at approximately 5:48 P.M., with the interim Life Safety appointee, he/she said he/she did not know the two hour occupancy separation requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.

19.1.3.4 Contiguous Non-Health Care Occupancies.

19.1.3.4.1* Ambulatory care facilities, medical clinics, and
similar facilities that are contiguous to health care occupancies,
but are primarily intended to provide outpatient services,
shall be permitted to be classified as business occupancies or
ambulatory health care facilities, provided that the facilities
are separated from the health care occupancy by not less than
2-hour fire resistance-rated construction, and the facility is
not intended to provide services simultaneously for four or
more inpatients who are litterborne.

19.1.3.5 Where separated occupancies provisions are used in
accordance with either 19.1.3.3 or 19.1.3.4, the most stringent
construction type shall be provided throughout the building,
unless a 2-hour separation is provided in accordance with
8.2.1.3, in which case the construction type shall be determined
as follows:
(1) The construction type and supporting construction of the
health care occupancy shall be based on the story on
which it is located in the building in accordance with the
provisions of 19.1.6 and Table 19.1.6.1.
(2) The construction type of the areas of the building enclosing
the other occupancies shall be based on the applicable
occupancy chapters of this Code.

Based on observation and facility staff interview, the facility staff failed to ensure all designated exit corridors are illuminated with emergency egress lights not controlled by a light switch. Two designated exit corridors contained switches controlling the emergency egress lighting fixtures. Failure to provide emergency egress lighting fixtures not controlled by a light switch has the potential to affect all patients and staff within the corridor. This deficient practice could delay the safe evacuation of patients, staff and visitors in the event of an emergency. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).


1. Observations on 1/07-08/18, during the building tour, showed the operating room designated exit hallway and outpatient corridor contained switches controlling the emergency egress lighting fixtures.

During an interview on 11/08/2018 at approximately 5:49 P.M., with the interim Life Safety appointee, he/she said he/she did not know the exit corridor lighting requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.

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


7.8.1.2 Illumination of means of egress shall be continuous
during the time that the conditions of occupancy require that
the means of egress be available for use, unless otherwise provided
in 7.8.1.2.2.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside one pharmacy. This deficient practice has the potential to affect all patients within the facility served by the pharmacy. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Observations on 11/08/18, during the Life Safety Code (LCS) tour, showed the light fixtures in the pharmacy controlled by a light switch.

During an interview on 11/08/2018 at approximately 5:49 P.M., with the interim Life Safety appointee, he/she said he/she did not know the emergency lighting requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.


NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) 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, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation and facility staff interview, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 70, The National Electric Code and NFPA 72, National Fire Alarm and Signaling Code. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Observations on 11/08/2018, during the facility tour, showed the following areas missing required smoke detector coverage:

- Emergency Department vestibule hallway containing the fire alarm control panel

- General Medical Floor (GMF) corridor contained one smoke detector 55 feet from the rear exit door in the 120 feet long hallway

- Hospital main entrance/exit vestibule

- Freight elevator lower level lobby

- Freight elevator shaft

- Passenger elevator shaft


2. Observations on 11/08/2018, during the facility tour, showed the following :

- Fire alarm pull station by GMF room #26 measured over 70 inches from the floor

- Light switch used as a fire alarm pull station at main floor freight elevator convenience stairwell

During an interview on 11/08/2018 at approximately 5:50 P.M., with the interim Life Safety appointee, he/she said he/she believed the fire alarm system installation company installed the fire alarm system per code requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.

NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, section 17.14.4 states:

17.14.4 The operable part of each manual fire alarm box
shall be not less than 42 in. (1.07 m) and not more than 48 in.
(1.22 m) above floor level.

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

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

NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.14 and 10.3 states:

17.14 Manually Actuated Alarm-Initiating Devices.
17.14.1 Manual fire alarm boxes shall be used only for fire
alarm initiating purposes.

10.3 Equipment.
10.3.1 Equipment constructed and installed in conformity
with this Code shall be listed for the purpose for which it is
used.

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. Failure to inspect and test all devices has the potential to effect all patients, staff and visitors in the event of a fire. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

Record review of the annual fire alarm inspection records dated 6/15/2018 showed the following devices not tested per code requirements:

- smoke detector sensitivity testing for the facility smoke detectors

- semi annual fire alarm system inspections

- powered fire and smoke dampers

- kitchen range hood to FACP connection test

- two sets of double powered doors in the Operating room designated exit corridor

- two sets of double powered doors in the Emergency department designated exit corridor

During an interview on 11/08/2018 at approximately 5:36 P.M., with the interim Life Safety appointee, he/she said he/she believed the fire alarm system inspection company inspected the fire alarm system per code requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.

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

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

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection
per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. This deficient practice has the potential to effect all facility patients, staff and visitors. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

Observations on 11/08/2018, during the facility tour, showed the General Medical Floor (GMF) nurse's station open to the designated exit corridor without smoke detection.

During an interview on 11/08/2018 at approximately 5:50 P.M., with the interim Life Safety appointee, he/she said he/she believed the fire alarm system installation company installed the fire alarm system per code requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.

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

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

Based on observation and facility staff interview, facility staff failed to ensure the building sprinkler system met NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. This deficient practice could delay prompt fire extinguishment and evacuation in the event of a fire. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

Observations on 11/07-08/2018, during the facility tour, did not show a sprinkler installed in two of two elevator pits containing combustible hydraulic fluid.

During an interview on 11/08/2018 at approximately 5:50 P.M., with the interim Life Safety appointee, he/she said he/she believed the sprinkler system installation company installed the sprinkler system per code requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.


NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS, 2010 Edition section 8.15.5 states:


"8.15.5 Elevator Hoistways and Machine Rooms.

8.15.5.1* Sidewall spray sprinklers shall be installed at the bottom
of each elevator hoistway not more than 2 ft (0.61 m)
above the floor of the pit.

8.15.5.2 The sprinkler required at the bottom of the elevator
hoistway by 8.15.5.1 shall not be required for enclosed, noncombustible
elevator shafts that do not contain combustible
hydraulic fluids."

Based on record review and facility staff interview, facility staff failed to inspect the wet sprinkler system per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. Failure to test and maintain the sprinkler system could affect the sprinkler system's performance in the event of a fire. This deficient practice has the potential to affect all patients, staff and visitors. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).


1) Record review on 11/07/2018 did not show the following inspections:

- monthly inspections/testing (Table 13.1.1.2)

- quarterly inspections/testing (Table 13.1.1.2)

-five year check valve interior inspections (Table 13.1.1.2)

During an interview on 11/08/2018 at approximately 5:43 P.M., with the interim Life Safety appointee, he/she said he/she believed the sprinkler system inspection company inspected the sprinkler system per code requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.

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

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

13.3.2 Inspection.
13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance
with applicable NFPAstandards shall be permitted to be
inspected monthly.
13.3.2.1.2 After any alterations or repairs, an inspection shall
be made by the property owner or designated representative
to ensure that the system is in service and all valves are in the
normal position and properly sealed, locked, or electrically
supervised.
13.3.2.2* The valve inspection shall verify that the valves are in
the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification
13.4 System Valves.
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected
as described in 13.4.1.1 and 13.4.1.2.

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

13.2.6 Alarm Devices.
13.2.6.1 Mechanical waterflow devices, including but not limited
to water motor gongs, shall be tested quarterly.

Based on observation and facility staff interview, facility staff failed to ensure dual leaf corridor doors equipped with flushbolts closed and latched without being blocked. Facility staff failed to ensure corridor doors resisted the passage of smoke and positively latched when closed. These deficient practices have the potential to affect all patients, staff and visitors. Failure to ensure corridor doors positively latched when closed and resist the passage of smoke has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Observation on 11/07-08/2018, during the building tour, showed the following dual leaf corridor doors equipped with manual flushbolts:

-Electrical closet on the Emergency department entrance corridor double doors

-CT room corridor double doors

Additional observation showed the manual flush bolts did not positive latch within the door frame upon closing the leaf.


2. Observation on 11/07-08/2018, during the building tour, showed the following corridor doors did not resist the passage of smoke or positively latch when closed:

- CT room radiology accordion type corridor door

- dispensing and compounding pharmacy corridor dutch door did not have an astragal, rabbet or bevel. The door did not contain a positive latching device on both the top and bottom leaves.



During an interview on 11/08/2018 at approximately 5:53 P.M., with the interim Life Safety appointee, he/she said he/she did not know the exit corridor door requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.

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

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

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

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

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

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

Based on facility staff interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the non rated doors in the building. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

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

During an interview on 11/08/2018 at approximately 5:45 P.M., with the interim Life Safety appointee, he/she said he/she did not know the fire and non rated door inspection requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.

NFPA 101, 2012 Edition states:

19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.15 Inspection of Door Openings.

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

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

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

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

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

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

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

Based on interview and record review the facility failed to develop a maintenance program for the medical gas, vacuum, WAGD (Waste Anesthetic Gas Disposal), or support gas system within the facility. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

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

During an interview on 11/08/2018 at approximately 5:55 P.M., with the interim Life Safety appointee, he/she said he/she did not know about the maintenance program for the medical gas, vacuum, WAGD, or support gas system requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.

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

Based on record review and interviews, the facility failed to assure they maintained records of inspections and testing of their piped in oxygen systems in accordance with National Fire Protection Association (NFPA) 99, 2012 edition. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Review of the facility's Life Safety Code documentation showed no evidence of any inspections or testing of the piped-in oxygen system.

During an interview on 11/08/2018 at approximately 5:55 P.M., with the interim Life Safety appointee, he/she said he/she did not know about the maintenance program for the piped-in oxygen system requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.

Based on observation and facility staff interview, the facility staff failed to provide a remote annunciator panel (a panel providing information on the condition and problems with the emergency generator) for one of one emergency generators at a constantly attended location. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1. Observation on 11/08/18 during the facility tour, did not show a remote annunciator panel for the emergency generator in a constantly attended location. Additionally, observation showed a remote annunciator panel in the maintenance office.


During an interview on 11/08/2018 at approximately 5:47 P.M., with the interim Life Safety appointee, he/she said he/she believed the generator installation company installed the system per code requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.


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

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

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

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

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

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

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


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

Based on record review and facility staff interview, facility staff failed to conduct an annual load bank test, weekly visual inspections, monthly 30 minute run under load, or provide service records of the emergency generator. Facility staff failed to provide an emergency stop switch away from the generator set location. This facility had a capacity of 19. The facility census was eight with four of those in Swing Bed status (Swing Bed, a Medicare program in which a patient can receive acute care then, if needed Skilled Nursing Home care).

1) Observation 11/08/2018, during the facility tour, showed the emergency generator's emergency stop switch located on the exterior generator casing without protection from activation.

2) Record review on 11/08/2018 did not show records of the following:

-annual testing with the available building electrical load at a minimum of 30% of the generator nameplate rating or load bank records,

-weekly visual inspections,

- monthly 30 minute run under load,

-wet service records of oil, coolant and fuel quality tests,

-transfer switch inspections.

During an interview on 11/08/2018 at approximately 5:47 P.M., with the interim Life Safety appointee, he/she said he/she did not know the generator maintenance requirements. Additionally, he/she said he/she became the interim Life Safety appointee on 11/07/2018 and had no prior knowledge of building operations.


NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition states:

5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

8.4.2* Diesel generator sets in service shall be exercised at
least once monthly, for a minimum of 30 minutes, using one
of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures
as recommended by the manufacturer
(2) Under operating temperature conditions and at not less
than 30 percent of the EPS nameplate kW rating

8.4.2.1 The date and time of day for required testing shall be
decided by the owner, based on facility operations.

8.4.2.2 Equivalent loads used for testing shall be automatically
replaced with the emergency loads in case of failure of
the primary source.

8.4.2.3 Diesel-powered EPS installations that do not meet the
requirements of 8.4.2 shall be exercised monthly with the available
EPSS load and shall be exercised annually with supplemental
loads at not less than 50 percent of the EPS nameplate kW
rating for 30 continuous minutes and at not less than 75 percent
of the EPS nameplate kWrating for 1 continuous hour for a total
test duration of not less than 1.5 continuous hours.

8.3 Maintenance and Operational Testing.

8.3.1* The EPSS shall be maintained to ensure to a reasonable
degree that the system is capable of supplying service within the
time specified for the type and for the time duration specified for
the class.

8.3.2 A routine maintenance and operational testing program
shall be initiated immediately after the EPSS has passed
acceptance tests or after completion of repairs that impact the
operational reliability of the system.

8.3.2.1 The operational test shall be initiated at an ATS and
shall include testing of each EPSS component on which maintenance
or repair has been performed, including the transfer of
each automatic and manual transfer switch to the alternate
power source, for a period of not less than 30 minutes under
operating temperature.

8.3.3 A written schedule for routine maintenance and operational
testing of the EPSS shall be established.

8.3.4 A permanent record of the EPSS inspections, tests, exercising,
operation, and repairs shall be maintained and readily
available.

8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective
action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the
manufacturer

8.3.5* Transfer switches shall be subjected to a maintenance and
testing program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.6 Paralleling gear shall be subject to an inspection, testing,
and maintenance program that includes all of the following
operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.7* Storage batteries, including electrolyte levels or battery
voltage, used in connection with systems shall be inspected
weekly and maintained in full compliance with manufacturer ' s
specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the
monthly testing and recording of electrolyte specific gravity. Battery
conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.

8.3.7.2 Defective batteries shall be replaced immediately
upon discovery of defects.

8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

8.4 Operational Inspection and Testing.

8.4.1* EPSSs, including all appurtenant components, shall be
inspected weekly and exercised under load at least monthly.

8.4.6 Transfer switches shall be operated monthly.

8.4.6.1 The monthly test of a transfer switch shall consist of
electrically operating the transfer switch from the standard position
to the alternate position and then a return to the standard
position.

7.2.4* Minimizing the possibility of damage resulting from interruptions
of the emergency source shall be a design consideration
for EPSS equipment.

A.7.2.4 When installing the EPSS equipment and related
auxiliaries, environmental considerations should be given,
particularly with regard to the installation of the fuel tanks
and exhaust lines, or the EPS building, or both.
To protect against disruption of power in the facility, it is recommended
that the transfer switch be located as close to the load
as possible. The following are examples of external influences:
(1) Natural conditions
(a) Storms
(b) Floods
(c) Earthquakes
(d) Tornadoes
(e) Hurricanes
(f) Lightning
(g) Ice storms
(h) Wind
(i) Fire
(2) Human-caused conditions
(a) Vandalism
(b) Sabotage
(c) Other similar occurrences
(3) Material and equipment failures
For natural conditions, EPSS design should consider the
"100-year storm" flooding level or the flooding level predicted
by the Sea, Lake, and Overland Surges from Hurricanes
(SLOSH) models for a Class 4 hurricane.