HospitalInspections.org

Based on observation, staff interview, and record review, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. This facility had a capacity of 25. The facility census was 8 with 4 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 10/09/2019, during the facility tour, showed the wellness exit hallway exit discharge landing led to a grass covered yard that required residents, staff, and visitors to traverse approximately 25 yards of grass to reach the city sidewalk.


Record review of the facility layout showed the exit discharge area designated for patient, staff and visitors use.

During an interview on 10/09/2019 at 5:56 P.M., the Environmental Services Director said he/she did not know the regulation requirement.


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


7.7 Discharge from Exits.

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

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside two of two operating rooms and one medication room. This deficient practice has the potential to affect all patients within the facility served by the operating rooms and a medication room. Failure to provide emergency lighting could prevent proper illumination of required areas in the event of power loss. This facility had a capacity of 25. The facility census was 8 with 4 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 10/09/19, during the Life Safety Code (LCS) tour, showed the following light fixtures controlled by a light switch:

-Emergency Department medication alcove;
-2nd floor medication room

During an interview on 10/09/2019 at 5:57 P.M., the Environmental Services Director said he/she did not know the emergency lighting requirements.


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, record review and facility staff interview, facility staff failed to ensure cooking facilities are separated from the corridor. Two of two pass thru windows to the kitchen were open to the corridor. Facility staff failed to ensure the range hood was inspected every six months. Failure to ensure the kitchen was separated from the corridor increases the risk of delaying exiting from the building by not controlling the passage of smoke and products of combustion from the designated exit corridor 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 25. The facility census was 8 with 4 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 10/09/2019, during the facility tour, showed the kitchen not separated from the designated exit corridor. Observation showed the kitchen contained a gas fired stove. Observations showed 2 pass thru openings in the kitchen wall separating the tray line area and the dining room from the kitchen. Additional observations showed the dining room to corridor unrated glass panel doors between the dining room and the designated exit corridor locked in the open position. Observation showed the doors were not connected to hold open devices connected to the fire alarm system and were not connected to self closing devices.

During an interview on 10/09/2019 at 6:02 P.M., the Environmental Services Director said an architect designed the 2012 renovation and the separation is not on the plans reviewed by the state. Additionally, he/she said the renovation was inspected by the state in 2015.

2. Record review of the facility supplied range hood inspection records on 10/08/2019, showed the facility had the range hood inspected 2/05/2018 and 1/09/2019.

During an interview on 10/09/2019 at 6:02 P.M., the Environmental Services Director said he/she did not know the range hood inspection requirements.

NFPA 101, 2012 edition, Section 19.3.2.5.5 states:

"19.3.2.5.3* Within a smoke compartment, where residential
or commercial cooking equipment is used to prepare meals
for 30 or fewer persons, one cooking facility shall be permitted
to be open to the corridor, provided that all of the following
conditions are met:

(1) The portion of the health care facility served by the cooking
facility is limited to 30 beds and is separated from other
portions of the health care facility by a smoke barrier constructed
in accordance with 19.3.7.3, 19.3.7.6, and 19.3.7.8.

(2) The cooktop or range is equipped with a range hood of a
width at least equal to the width of the cooking surface,
with grease baffles or other grease-collecting and cleanout
capability.

(3)*The hood systems have a minimum airflow of 500 cfm
(14,000 L/min).

(4) The hood systems that are not ducted to the exterior additionally
have a charcoal filter to remove smoke and odor.

(5) The cooktop or range complies with all of the following:
(a) The cooktop or range is protected with a fire suppression
system listed in accordance with UL 300,
Standard for Fire Testing of Fire Extinguishing Systems for
Protection of Commercial Cooking Equipment, or is tested
and meets all requirements of UL 300A, Extinguishing
System Units for Residential Range Top Cooking Surfaces,
in accordance with the applicable testing document ' s
scope.
(b) A manual release of the extinguishing system is provided
in accordance with NFPA 96, Standard for Ventilation
Control and Fire Protection of Commercial Cooking
Operations, Section 10.5.
(c) An interlock is provided to turn off all sources of
fuel and electrical power to the cooktop or range
when the suppression system is activated.

(6)*The use of solid fuel for cooking is prohibited.

(7)*Deep-fat frying is prohibited.

(8) Portable fire extinguishers in accordance with NFPA 96
are located in all kitchen areas.

(9)*A switch meeting all of the following is provided:
(a) A locked switch, or a switch located in a restricted
location, is provided within the cooking facility that
deactivates the cooktop or range.
(b) The switch is used to deactivate the cooktop or
range whenever the kitchen is not under staff supervision.
(c) The switch is on a timer, not exceeding a 120-minute
capacity, that automatically deactivates the cooktop
or range, independent of staff action.

(10) Procedures for the use, inspection, testing, and maintenance
of the cooking equipment are in accordance with
Chapter 11 of NFPA 96 and the manufacturer ' s instructions
and are followed.

(11)*Not less than two AC-powered photoelectric smoke alarms,
interconnected in accordance with 9.6.2.10.3, equipped
with a silence feature, and in accordance with NFPA 72,
National Fire Alarm and Signaling Code, are located not closer
than 20 ft (6.1 m) from the cooktop or range.

(12) No smoke detector is located less than 20 ft (6.1 m) from
the cooktop or range.

(13) The smoke compartment is protected throughout by an
approved, supervised automatic sprinkler system in accordance
with Section 9.7.

19.3.2.5.4* Within a smoke compartment, residential or commercial
cooking equipment that is used to prepare meals for
30 or fewer persons shall be permitted, provided that the
cooking facility complies with all of the following conditions:
(1) The space containing the cooking equipment is not a
sleeping room.

(2) The space containing the cooking equipment shall be
separated from the corridor by partitions complying with
19.3.6.2 through 19.3.6.5.

(3) The requirements of 19.3.2.5.3(1) through (10) and (13)
are met.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 11.2 states:

"11.2 Inspection, Testing, and Maintenance of Fire-Extinguishing
Systems.

11.2.1* Maintenance of the fire-extinguishing systems and
listed exhaust hoods containing a constant or fire-activated
water system that is listed to extinguish a fire in the grease
removal devices, hood exhaust plenums, and exhaust ducts
shall be made by properly trained, qualified, and certified person(
s) acceptable to the authority having jurisdiction at least
every 6 months.

11.2.2* All actuation and control components, including remote
manual pull stations, mechanical and electrical devices,
detectors, and actuators, shall be tested for proper operation
during the inspection in accordance with the manufacturer ' s
procedures.

11.2.3 The specific inspection and maintenance requirements
of the extinguishing system standards as well as the applicable
installation and maintenance manuals for the listed
system and service bulletins shall be followed.

11.2.4* Fusible links of the metal alloy type and automatic
sprinklers of the metal alloy type shall be replaced at least
semiannually except as permitted by 11.2.6 and 11.2.7.

11.2.5 The year of manufacture and the date of installation of
the fusible links shall be marked on the system inspection tag.

11.2.5.1 The tag shall be signed or initialed by the installer.

11.2.5.2 The fusible links shall be destroyed when removed.

11.2.6* Detection devices that are bulb-type automatic sprinklers
and fusible links other than the metal alloy type shall be
examined and cleaned or replaced annually.

11.2.7 Fixed temperature-sensing elements other than the
fusible metal alloy type shall be permitted to remain continuously
in service, provided they are inspected and cleaned or
replaced if necessary in accordance with the manufacturer ' s
instructions, every 12 months or more frequently to ensure
proper operation of the system.

11.2.8 Where required, certificates of inspection and maintenance
shall be forwarded to the authority having jurisdiction."

Based on observation and facility staff interview, the facility staff 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. The facility failed to provide a fire alarm notification appliance for one of two courtyards enclosed by 4 facility exterior walls. Failure to provide a fire alarm notification appliance has the potential to delay exiting the building in the event of a fire or other disaster. This has the potential to effect all residents and visitors who utilize the courtyards. This facility had a capacity of 25. The facility census was 8 with 4 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 10/09/2019, during the facility tour, showed the following areas missing required smoke detector coverage:

-Cafeteria dining room measuring approximately 46 feet by 28 feet;
-Wellness exit hallway measuring 45 feet long;
-Main entrance area;
-Front entrance vestibule;

NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, section 19.3.4.1 States: "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.

2. Observation on 10/09/2019 at 3:11 P.M., showed the Healing Garden courtyard did not contain a fire alarm signaling device.

NFPA 101, 2012 edition, Section 9.6.3 states:

"9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall be provided to alert occupants
of a fire or other emergency where required by other
sections of this Code.

9.6.3.2 Occupant notification shall be in accordance with
9.6.3.3 through 9.6.3.10.2, unless otherwise provided in
9.6.3.2.1 through 9.6.3.2.4.

9.6.3.6.1 The general evacuation alarm signal shall operate
throughout the entire building."

During an interview on 10/09/2019 at 5:58 P.M., the Environmental Services Director said he/she believed the fire alarm inspection company installed the fire alarm system per code requirements.

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. This facility had a capacity of 25. The facility census was 8 with 4 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 dated 1/09/2019 did not show connection function tests for the following devices:

-ED to Radiology 20 minute powered corridor double door set with functional hold open feature;
-fire and smoke dampers;
-2 fire alarm annunciator panels (front entrance reception area, 2nd floor nurse's station);
-door magnetic hold open devices;
-ED to lobby double door set with access controlled locks;

During an interview on 10/09/2019 at 5:37 P.M., the Environmental Services Director said he/she believed the fire alarm inspection company did the inspections per code requirements.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information. Refer to section 10.12 for trouble signal information.

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 deficient practice could delay fire and emergency personnel response in the event of a fire. This facility had a capacity of 25. The facility census was 8 with 4 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 11/29/2018, during the facility tour, showed the following areas open to the designated exit corridors requiring smoke detectors:

-Business office area;
-Radiology West dressing area.

During an interview on 10/09/2019 at 5:58 P.M., the Environmental Services Director said he/she believed the fire alarm inspection company installed the fire alarm system per code requirements.

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 25. The facility census was 8 with 4 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 10/09/2019 at 4:00 P.M., of the Westinghouse elevator, did not show a sprinkler installed in the elevator pit containing combustible hydraulic fluid.

During an interview on 10/09/2019 at 6:04 P.M., the Environmental Services Director said the elevator was installed in 1985 and never had sprinkler coverage.

2. Observations on 10/09/2019 at 3:54 P.M., of the basement access stairwell, did not show sprinkler coverage.

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 five wet sprinkler systems 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 25. The facility census was 8 with 4 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 10/08/2019 did not show the following inspections:

- quarterly inspections/testing (Table 13.1.1.2)

-five year check valve interior inspections (Table 13.1.1.2)

During an interview on 10/09/2019 at 5:49 P.M., the Environmental Services Director said he/she did not know the sprinkler system inspection requirements.


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

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.

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). This facility had a capacity of 25. The facility census was 8 with 4 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 records did not show fire and smoke door inspections.


During an interview on 10/09/2019 at 5:51 P.M., the Environmental Services Director said he/she was unaware the required door inspections needed to be conducted by qualified outside vendors.


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 record review and facility staff interview, the facility failed to ensure that all building systems had been assigned a risk assessment category and documented. This facility had a capacity of 25. The facility census was 8 with 4 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 documents for fire safety, building system tests, and policies did not show categorical risk assessments for the building systems.

During an interview on 10/09/2019 at 5:53 P.M., the Environmental Services Director said he/she did not know the categorical risk assessments for building systems requirements.

The National Fire Protection Association 99 Health Care Facilities Code, 2012 edition, Chapter 4 states:

"Chapter 4 Fundamentals

4.1* Building System Categories. Building systems in health
care facilities shall be designed to meet system Category 1
through Category 4 requirements as detailed in this code.

4.1.1* Category 1. Facility systems in which failure of such equipment
or system is likely to cause major injury or death of patients
or caregivers shall be designed to meet system Category 1 requirements
as defined in this code.

4.1.2* Category 2. Facility systems in which failure of such equipment
is likely to cause minor injury to patients or caregivers shall
be designed to meet system Category 2 requirements as defined
in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment
is not likely to cause injury to patients or caregivers, but can
cause patient discomfort, shall be designed to meet system Category
3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment
would have no impact on patient care shall be designed to
meet system Category 4 requirements as defined in this code.

4.2* Risk Assessment. Categories shall be determined by following
and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall
apply to Chapters 5 through 11."

Based on record review and facility staff interview, facility staff failed to categorize the medical gas, med air, surgical vacuum, WAGD, and supply air systems. This facility had a capacity of 25. The facility census was 8 with 4 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 documents for fire safety, building system tests, and policies did not show categorical risk assessments for the gas, air and vacuum systems.

During an interview on 10/09/2019 at 5:53 P.M., the Environmental Services Director said he/she did not know the categorical risk assessments for building systems requirements.

Based on record review and facility staff interview, facility staff failed to provide an emergency stop switch for two of two emergency generators. Additionally, facility staff failed to provide acceptance testing records for one of two emergency generators. This facility had a capacity of 25. The facility census was 8 with 4 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 10/09/2019, during the facility tour, showed the emergency generators emergency stop switches located within the room housing the generator.

2) Observation on 10/09/2019, during the facility tour, showed a new emergency generator installed in the facility. Record review of the generator records did not show acceptance testing records. Record review showed the generator was installed 2012.

During an interview on 10/09/2019 at 5:53 P.M., the Environmental Services Director said he/she did not know the generator code requirements.


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.


7.13 Installation Acceptance.

7.13.1 Upon completion of the installation of the EPSS, the EPS
shall be tested to ensure conformity to the requirements of the
standard with respect to both power output and function.

7.13.2 An on-site acceptance test shall be conducted as a final
approval test for all EPSSs.

7.13.2.1 For new Level 1 installations, the EPSS shall not be
considered as meeting this standard until the acceptance tests
have been conducted and test requirements met.

7.13.2.2 The test shall be conducted after completion of the
installation with all EPSS accessory and support equipment in
place and operating.

7.13.3 The authority having jurisdiction shall be given advance
notification of the time at which the acceptance test is to
be performed so that the authority can witness the test.
7.13.4 The EPSS shall perform within the limits specified in
this standard.

7.13.4.1 The on-site installation acceptance test shall be conducted
in accordance with 7.13.4.1.1 through 7.13.4.1.3.

7.13.4.1.1* In a new and unoccupied building or facility, with
the prime mover in a cold start condition and the emergency
load at operating level, a normal power failure shall be initiated
by opening all switches or circuit breakers supplying the
normal power to the building or facility.

7.13.4.1.2* In an existing occupied building or facility, with
the prime mover in a cold start condition and the emergency
load at operating level, a normal power failure shall be simulated
by operating at least one transfer switch test function or
initiated by opening all switches or breakers supplying normal
power to all ATSs that are part of the EPSS being commissioned
by this initial acceptance test.

7.13.4.1.3 The tests conducted in accordance with
7.13.4.1.1 and 7.13.4.1.2 shall be performed in accordance
with (1) through (12).
(1) When the EPSS consists of paralleled EPSs, the quantity
of EPSs intended to be operated simultaneously
shall be tested simultaneously with building load for
the test period identified in 7.13.4.1.3(10).
Subsection 7.13.4.1.3(1) was revised by a tentative interim
amendment (TIA). See page 1.
(2) The test load shall be all loads that are served by the
EPSS. There is no minimum loading requirement for
this portion of the test.
(3) The time delay on start shall be observed and recorded.
(4) The cranking time until the prime mover starts and runs
shall be observed and recorded.
(5) The time taken to reach operating speed shall be observed
and recorded.
(6)*The engine start function shall be confirmed by verifying
operation of the initiating circuit of all transfer switches
supplying EPSS loads.
(7) The time taken to achieve a steady-state condition with all
switches transferred to the emergency position shall be observed
and recorded.
(8) The voltage, frequency, and amperes shall be recorded.
(9) Where applicable, the prime mover oil pressure and water
temperature shall be recorded.
(10) The load test with building load, or other loads that simulate
the intended load as specified in Section 5.4, shall be
continued for not less than 1.5 hours, and the run time
shall be recorded.
(11) When normal power is restored to the building or facility,
the time delay on retransfer to normal power for
each switch with a minimum setting of 5 minutes shall
be recorded.
(12) The time delay on the prime mover cooldown period
and shutdown shall be recorded.

7.13.4.2 After completion of the test performed in 7.13.4.1, the
prime mover shall be allowed to cool for not less than 5 minutes.

7.13.4.3* A load shall be applied for a 2-hour, full-load test. The
building load shall be permitted to serve as part or all of the load,
supplemented by a load bank of sufficient size to provide a load
equal to 100 percent of the nameplate kW rating of the EPS, less
applicable derating factors for site conditions.

7.13.4.3.1 This full-load test shall be initiated after the test specified
in 7.13.4.1.3 by any method that starts the prime mover and,
upon reaching rated rpm, picks up not less than 30 percent of
the nameplate kW rating for the first 30 minutes, not less than
50 percent of the nameplate kW rating for the next 30 minutes,
and 100 percent of the nameplate kWrating for the next 60 minutes,
less applicable derating factors for site conditions.

7.13.4.3.2 A unity power factor shall be permitted for on-site
testing, provided that rated load tests at the rated power factor
have been performed by the manufacturer of the EPS prior to
shipment.

7.13.4.3.3 Where the EPS is a paralleled multi-unit EPS, each
unit shall be permitted to be tested individually at its rating.
7.13.4.3.4 The data specified in 7.13.4.1.3(4), (5), (7), (8), and
(9) shall be recorded at first load acceptance and every 15 minutes
thereafter until the completion of the test period identified
in 7.13.4.1.3(10).
Subsection 7.13.4.3.4 was revised by a tentative interim
amendment (TIA). See page 1.

7.13.4.4 Any method recommended by the manufacturer for
the cycle crank test shall be utilized to prevent the prime
mover from running.

7.13.4.4.1 The control switch shall be set at "run" to cause the
prime mover to crank.

7.13.4.4.2 The complete crank/rest cycle specified in 5.6.4.2
and Table 5.6.4.2 shall be observed.

7.13.4.4.3 The battery charge rate shall be recorded at 5-minute
intervals for the first 15 minutes or until charge rate stabilization.

7.13.4.5 All safeties specified in 5.6.5 and 5.6.6 shall be tested
on site as recommended by the manufacturer.

Exception: It shall be permitted for the manufacturer to test and document
overcrank, high engine temperature, low lube oil pressure and
overspeed safeties prior to shipment.

7.13.4.6 Items (1) through (4) shall be made available to the
authority having jurisdiction at the time of the acceptance test:
(1) Evidence of the prototype test as specified in 5.2.1.2 (for
Level 1 systems)
(2) A certified analysis as specified in 5.6.10.2
(3) A letter of compliance as specified in 5.6.10.5
(4) A manufacturer ' s certification of a rated load test at rated
power factor with the ambient temperature, altitude, and
fuel grade recorded