HospitalInspections.org

Based upon observation and interview on 3/30/11 the facilty failed to ensure the two-hour fire separation door was maintained to be self closing. The propping open of a fire separation door prevents the door from providing the required fire separation, this practice will allow a fire to spread uncontrolled between occupancies. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

During the facility tour on 3/30/11 at approximately 1:35 PM, observation revealed two weighted balls propping open the self closing fire door between the hospital and the physical therapy room. This wall and door creates the occupancy separation between the hospital and the clinic. This observation was made by the surveyor and discussed with the Maintenance Engineer and Physical Therapist.

Actual NFPA Standard:
LSC 2000
19.1.1.4.1 Additions.
Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)
19.1.1.4.2
Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)
19.1.1.4.3
Doors in barriers required by 19.1.1.4.1 shall normally be kept closed.
Exception: Doors shall be permitted to be held open if they meet the requirements of 19.2.2.2.6.

19.2.2.2.6*
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Based upon observation and testing on 3/30/11 the facility failed to ensure that corridor doors closed and latched securely. This deficient practice allows products of combustion to move freely between rooms and the exit access corridor compromising egress. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

During the facility tour on 3/30/11 between 10:15 AM and 1:45 PM corridor doors were tested and the following were observed to not close and latch securely; Room 104 has a roller latch, room 101 is off-set and would not close and latch, the janitor closet would not close and latch, the shower room would not close and latch. In addition when the door to the clean utility was closed the door knob would not release the latch, due to loose hardware. Testing was conducted by the surveyor and witnessed by the Maintenance Engineer.

Actual NFPA standard:
LSC 2000
19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service. Roller latches are prohibited by 42 CFR 482.41

Based upon observation and interview on 3/30/11 the facility failed to ensure that hazardous area doors automatically or self closed. This deficient practice allows products of combustion to move freely between hazardous areas and the exit access corridor compromising egress. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

1) During the facility tour on 3/30/11 between 10:15 AM and 1:45 PM hazardous area doors were observed to have hinged drop-down door props holding open; the Pantry door and the main storage room. In addition several other self closing doors were observed to be held open similarly, defeating the door closures. This was observed by surveyor and acknowledged as a common practice by the Maintenance Engineer.

2) During the facility tour on 3/30/11 between 10:15 AM and 1:45 PM the hazardous area door on the basement storage room was observed to not be equipped with a self closing device. This hazardous area was adjacent to the only means of egress from the basement. This was observed by surveyor and acknowledged by the Maintenance Engineer.

3) During the facility tour on 3/30/11 between 10:15 AM and 1:45 PM the hazardous area door on the laundry room was observed to not self close and latch. This was observed by surveyor and acknowledged by the Maintenance Engineer as needing adjustment.


Actual NFPA standard:
LSC 2000
19.2.2.2.6*
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based upon observation and interview on 3/30/11 the facility failed to ensure exit discharge was unobstructed to a public way. Failure to provide accessible exit discharge prevents egress to a safe area by wheelchairs, beds and mobility impaired persons. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

During the facility tour on 3/30/11 at 11:05 AM observation revealed the hard surfaced exit discharge from the patient wing did not connect to a public way or parking area, there was approximately 20 feet of grassy surface to cross before a hard surface area was available. This was observed by the surveyor and acknowledged as a potential problem during snow and wet weather by the Maintenance Engineer.

Actual NFPA Standard:

19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Based upon record review and interview conducted on 3/30/11 the facility failed to ensure fire drills were conducted at least once per shift per quarter during the last 12 months. Failure to train personnel in emergency procedures could result in panic and confusion in a true emergency. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

During the record review conducted on 3/30/11 between 10:15 AM and 11:00 AM records were not available to demonstrate that drills were conducted at least once per shift, per quarter. Records indicated only two drills had been conducted on 7/09/10 and on 3/30/11. No other drill records could be presented. This deficient practice was acknowledged by the Director of Nursing and the Administrator during the exit conference.

Actual NFPA standard:
LSC 2000

19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based upon record review and interview on 3/30/11 the facility failed to ensure the fire alarm system was maintained in a reliable operating condition. Failure to maintain the fire alarm system could result in an increased time to identify and control a fire. The facility was licensed for 10 with a census of one on the day of the survey.

Findings include:


During the review of facilty records on 3/30/11 at approximately 10:45 AM the facility was unable to produce a record of an annual inspection/testing being conducted within the last 12 months of the fire alarm/detection system. Review of the Sprinkler system inspection report dated 9/23/10, indicated a problem was identified in the tamper switch signal to the fire alarm control panel, and the water flow system restore feature. This is indicative of a communication problem within the fire alarm control panel and initiating devices. There was no record of this problem being corrected.

Actual NFPA standard:

9.6.1.4
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.5
All systems and components shall be approved for the purpose for which they are installed.
9.6.1.6
Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.
9.6.1.7*
To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

Based upon observation, record review and interview the facility failed to test and maintain the automatic sprinkler system in a reliable operating condition in accordance with NFPA 25. This deficient practice could result in the system not being fully functional during an emergency, this practice affected all residents, patients and staff present on the day of the survey. The hospital is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

1) Interview with the Maintenance Engineer on 3/30/11 revealed no system was in place to conduct quarterly inspections and flow alarm testing of the sprinkler system. No records were not available to document quarterly inspection and testing.

2) During record review on 3/30/11 of sprinkler testing documentation, no records were available to document five year testing of gauges.

3) During record review on 3/30/11 of sprinkler testing documentation, no records were available to document analysis of potential obstructions nor an obstruction investigation.

4) During the facility tour on 3/30/11 observation revealed two sprinkler heads in the basement stairwell with evidence of paint on the fusible links.

These observations were acknowledged by the Maintenance Engineer who stated he was unaware of the specific regulations in regards to sprinkler systems.

Actual NFPA Standard:

NFPA 25, 1999 Edition
2-1 General.
This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.
2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7* Hydraulic Nameplate.
The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

10-2.1*
To ensure that piping remains clear of all obstructive foreign matter, an obstruction investigation shall be conducted for system or yard main piping wherever any of the following conditions exist:
(a) Defective intake for fire pumps taking suction from open bodies of water
(b) The discharge of obstructive material during routine water tests
(c) Foreign materials in fire pumps, in dry pipe valves, or in check valves
(d) Foreign material in water during drain tests or plugging of inspector ' s test connection(s)
(e) Plugged sprinklers
(f) Plugged piping in sprinkler systems dismantled during building alterations
(g) Failure to flush yard piping or surrounding public mains following new installations or repairs
(h) A record of broken public mains in the vicinity
(i) Abnormally frequent false tripping of a dry pipe valve(s)
(j) A system that is returned to service after an extended shutdown (greater than 1 year)
(k) There is reason to believe that the sprinkler system contains sodium silicate or highly corrosive fluxes in copper systems
(l) A system has been supplied with raw water via the fire department connection.

10-2.2* Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

A-10-2 (informational only)
For effective control and extinguishment of fire, automatic sprinklers should receive an unobstructed flow of water. Although the overall performance record of automatic sprinklers has been very satisfactory, there have been numerous instances of impaired efficiency because sprinkler piping or sprinklers were plugged with pipe scale, mud, stones, or other foreign material. If the first sprinklers to open in a fire are plugged, the fire in that area cannot be extinguished or controlled by prewetting of adjacent combustibles. In such a situation, the fire can grow to an uncontrollable size, resulting in greater fire damage and excessive sprinkler operation and even threatening the structural integrity of the building, depending on the number of plugged sprinklers and fire severity.
Keeping the inside of sprinkler system piping free of scale, silt, or other obstructing material is an integral part of an effective loss prevention program.

2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Based upon observation and interview on 3/30/11 the facility failed to ensure portable fire extinguishers were inspected and maintained in accordance with NFPA 10. Failure to maintain operable extinguishers could allow incipient fires to spread. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

1) During the facility tour on 3/30/11 between 10:45 AM and 1:45 PM observation revealed that fire extinguishers located in the Laboratory, X-Ray, and Basement storage room, had no record of annual service and testing. This was observed by the surveyor and acknowledged by the Maintenance Engineer who indicated they were missed because they were behind locked doors.

2) During the facility tour on 3/30/11 between 10:45 AM and 1:45 PM observation revealed that fire extinguishers located throughout the building were not being checked monthly and annotated on the affixed tag in accordance with NFPA 10. When asked, the Maintenance Engineer was not aware of this requirement.

Actual NFPA standard:
LSC 101 - 2000
19.3.5.6
Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1*
Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition
4-1.2
The procedure for inspection and maintenance of fire extinguishers varies considerably. Minimal knowledge is necessary to perform a monthly " quick check " or inspection in order to follow the inspection procedure as outlined in Section 4-3. A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer ' s service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.
4-2.1 Inspection.
A " quick check " that a fire extinguisher is available and will operate. It is intended to give reasonable assurance that the fire extinguisher is fully charged and operable. This is done by verifying that it is in its designated place, that it has not been actuated or tampered with, and that there is no obvious or physical damage or condition to prevent its operation.
4-2.2 Maintenance.
A thorough examination of the fire extinguisher. It is intended to give maximum assurance that a fire extinguisher will operate effectively and safely. It includes a thorough examination and any necessary repair or replacement. It will normally reveal if hydrostatic testing or internal maintenance is required.
4-3.1* Frequency.
Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.2* Procedures.
Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Based upon observation and interview conducted on 3/30/11, the facility failed to ensure portable space heating device elements did not exceed 212 degrees Fahrenheit. This deficient practice is considered a significant risk due to the history of fires caused by space heaters. The hospital is licensed for 10 beds with a census of one on the day of the survey.

Findings include:

During the facility tour conducted on 3/30/11 between 10:15 AM and 2:00 PM, observation revealed portable space heating devices located in the multipurpose room and the basement mechanical room. Interview with the Maintenance Engineer indicated the facility had no process to initially and annually test portable space heating devices used in non sleeping staff areas to ensure elements are less than 212 degrees F.

Actual NFPA Standard:

NFPA 101, the Life Safety Code, 2000 Edition

19.7.8 Portable Space-Heating Devices.
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).

Based upon observation and interview on 3/30/11 the facility failed to ensure oxygen cylinders were secured and stored in a safe manner. Failure to secure high pressure cylinders can result in physical damage and resulting overpressure events causing damage or injury. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

Observation of the Medical Gas Storage Room during the facility tour on 3/30/11 at 1:40 PM revealed ten "E" oxygen cylinders stored upright and unsecured inside the storage room. This deficient practice was observed by the surveyor and acknowledged by the Maintenance Engineer.

Actual NFPA standard:

NFPA 99 Health Care Facilities, 1999 Edition

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).

Based on record review and staff interview, it was determined the facility failed to ensure that the emergency power generator and transfer switch was tested as required with subsequent entries into a generator log. Failure to inspect and test the emergency power supply system (EPSS) regularly could affect system reliability in the facility. This deficient practice affected all residents and patients on the day of the survey. The hospital is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

Record review on 3/30/11 disclosed that the generator had been tested under load eight times in the last 12 months. When asked about weekly checks the Maintenance Engineer was not aware of the requirement for weekly inspections. Interview with the Maintenance Engineer revealed that the generator self exercised weekly with no load, and that the load test was conducted manually each month.

Actual NFPA Standard:
NFPA 110 Standard
6-3 Maintenance and Operational Testing.
6-3.1*
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.
6-3.2
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.
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4
A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-3.5*
Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required.
6-3.6*
Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

6-4 Operational Inspection and Testing.
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.3
Load tests of generator sets shall include complete cold starts.
6-4.4
Time delays shall be set as follows:
(a) Time delay on start: 1 second minimum
Exception: Gas turbine cycle: 0.5 second minimum.
(b) Time delay on transfer to emergency: no minimum required
(c) Time delay on restoration to normal: 5 minutes minimum (see A-4-2.4.7)
(d) Time delay on shutdown: 5 minutes minimum
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. 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.
6-4.6*
EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the off position.
Exception: Medium- and high-voltage circuit breakers for Level 1 system usage shall be exercised every 6 months and tested under simulated overload conditions every 2 years.
6-4.7
The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

Based upon record review and staff interview the facility failed to ensure a policy was in place to evacuate or safeguard occupants in the event of required fire protection systems being out of service. This deficient practice affected all patients, staff and visitors in the facility. The hospital is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

During the review of records portion of the survey, interview with the Maintenance Engineer revealed there was no policy in place to conduct a fire watch in the event of a fire alarm or sprinkler system being out of service for greater than four hours. When asked about such a policy the Maintenance Engineer was unaware of the requirements for a fire watch or a policy.

Actual NFPA standards:

LSC 101-2000

9.6.1.8*
Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

9.7.6.1
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Based upon observation and interview on 3/30/11 the facilty failed to ensure the two-hour fire separation door was maintained to be self closing. The propping open of a fire separation door prevents the door from providing the required fire separation, this practice will allow a fire to spread uncontrolled between occupancies. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

During the facility tour on 3/30/11 at approximately 1:35 PM, observation revealed two weighted balls propping open the self closing fire door between the hospital and the physical therapy room. This wall and door creates the occupancy separation between the hospital and the clinic. This observation was made by the surveyor and discussed with the Maintenance Engineer and Physical Therapist.

Actual NFPA Standard:
LSC 2000
19.1.1.4.1 Additions.
Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)
19.1.1.4.2
Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)
19.1.1.4.3
Doors in barriers required by 19.1.1.4.1 shall normally be kept closed.
Exception: Doors shall be permitted to be held open if they meet the requirements of 19.2.2.2.6.

19.2.2.2.6*
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Based upon observation and testing on 3/30/11 the facility failed to ensure that corridor doors closed and latched securely. This deficient practice allows products of combustion to move freely between rooms and the exit access corridor compromising egress. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

During the facility tour on 3/30/11 between 10:15 AM and 1:45 PM corridor doors were tested and the following were observed to not close and latch securely; Room 104 has a roller latch, room 101 is off-set and would not close and latch, the janitor closet would not close and latch, the shower room would not close and latch. In addition when the door to the clean utility was closed the door knob would not release the latch, due to loose hardware. Testing was conducted by the surveyor and witnessed by the Maintenance Engineer.

Actual NFPA standard:
LSC 2000
19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service. Roller latches are prohibited by 42 CFR 482.41

Based upon observation and interview on 3/30/11 the facility failed to ensure that hazardous area doors automatically or self closed. This deficient practice allows products of combustion to move freely between hazardous areas and the exit access corridor compromising egress. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

1) During the facility tour on 3/30/11 between 10:15 AM and 1:45 PM hazardous area doors were observed to have hinged drop-down door props holding open; the Pantry door and the main storage room. In addition several other self closing doors were observed to be held open similarly, defeating the door closures. This was observed by surveyor and acknowledged as a common practice by the Maintenance Engineer.

2) During the facility tour on 3/30/11 between 10:15 AM and 1:45 PM the hazardous area door on the basement storage room was observed to not be equipped with a self closing device. This hazardous area was adjacent to the only means of egress from the basement. This was observed by surveyor and acknowledged by the Maintenance Engineer.

3) During the facility tour on 3/30/11 between 10:15 AM and 1:45 PM the hazardous area door on the laundry room was observed to not self close and latch. This was observed by surveyor and acknowledged by the Maintenance Engineer as needing adjustment.


Actual NFPA standard:
LSC 2000
19.2.2.2.6*
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based upon observation and interview on 3/30/11 the facility failed to ensure exit discharge was unobstructed to a public way. Failure to provide accessible exit discharge prevents egress to a safe area by wheelchairs, beds and mobility impaired persons. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

During the facility tour on 3/30/11 at 11:05 AM observation revealed the hard surfaced exit discharge from the patient wing did not connect to a public way or parking area, there was approximately 20 feet of grassy surface to cross before a hard surface area was available. This was observed by the surveyor and acknowledged as a potential problem during snow and wet weather by the Maintenance Engineer.

Actual NFPA Standard:

19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.7.1*
Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Based upon record review and interview conducted on 3/30/11 the facility failed to ensure fire drills were conducted at least once per shift per quarter during the last 12 months. Failure to train personnel in emergency procedures could result in panic and confusion in a true emergency. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

During the record review conducted on 3/30/11 between 10:15 AM and 11:00 AM records were not available to demonstrate that drills were conducted at least once per shift, per quarter. Records indicated only two drills had been conducted on 7/09/10 and on 3/30/11. No other drill records could be presented. This deficient practice was acknowledged by the Director of Nursing and the Administrator during the exit conference.

Actual NFPA standard:
LSC 2000

19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based upon record review and interview on 3/30/11 the facility failed to ensure the fire alarm system was maintained in a reliable operating condition. Failure to maintain the fire alarm system could result in an increased time to identify and control a fire. The facility was licensed for 10 with a census of one on the day of the survey.

Findings include:


During the review of facilty records on 3/30/11 at approximately 10:45 AM the facility was unable to produce a record of an annual inspection/testing being conducted within the last 12 months of the fire alarm/detection system. Review of the Sprinkler system inspection report dated 9/23/10, indicated a problem was identified in the tamper switch signal to the fire alarm control panel, and the water flow system restore feature. This is indicative of a communication problem within the fire alarm control panel and initiating devices. There was no record of this problem being corrected.

Actual NFPA standard:

9.6.1.4
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.5
All systems and components shall be approved for the purpose for which they are installed.
9.6.1.6
Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.
9.6.1.7*
To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

Based upon observation, record review and interview the facility failed to test and maintain the automatic sprinkler system in a reliable operating condition in accordance with NFPA 25. This deficient practice could result in the system not being fully functional during an emergency, this practice affected all residents, patients and staff present on the day of the survey. The hospital is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

1) Interview with the Maintenance Engineer on 3/30/11 revealed no system was in place to conduct quarterly inspections and flow alarm testing of the sprinkler system. No records were not available to document quarterly inspection and testing.

2) During record review on 3/30/11 of sprinkler testing documentation, no records were available to document five year testing of gauges.

3) During record review on 3/30/11 of sprinkler testing documentation, no records were available to document analysis of potential obstructions nor an obstruction investigation.

4) During the facility tour on 3/30/11 observation revealed two sprinkler heads in the basement stairwell with evidence of paint on the fusible links.

These observations were acknowledged by the Maintenance Engineer who stated he was unaware of the specific regulations in regards to sprinkler systems.

Actual NFPA Standard:

NFPA 25, 1999 Edition
2-1 General.
This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.
2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7* Hydraulic Nameplate.
The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

10-2.1*
To ensure that piping remains clear of all obstructive foreign matter, an obstruction investigation shall be conducted for system or yard main piping wherever any of the following conditions exist:
(a) Defective intake for fire pumps taking suction from open bodies of water
(b) The discharge of obstructive material during routine water tests
(c) Foreign materials in fire pumps, in dry pipe valves, or in check valves
(d) Foreign material in water during drain tests or plugging of inspector ' s test connection(s)
(e) Plugged sprinklers
(f) Plugged piping in sprinkler systems dismantled during building alterations
(g) Failure to flush yard piping or surrounding public mains following new installations or repairs
(h) A record of broken public mains in the vicinity
(i) Abnormally frequent false tripping of a dry pipe valve(s)
(j) A system that is returned to service after an extended shutdown (greater than 1 year)
(k) There is reason to believe that the sprinkler system contains sodium silicate or highly corrosive fluxes in copper systems
(l) A system has been supplied with raw water via the fire department connection.

10-2.2* Obstruction Prevention.
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

A-10-2 (informational only)
For effective control and extinguishment of fire, automatic sprinklers should receive an unobstructed flow of water. Although the overall performance record of automatic sprinklers has been very satisfactory, there have been numerous instances of impaired efficiency because sprinkler piping or sprinklers were plugged with pipe scale, mud, stones, or other foreign material. If the first sprinklers to open in a fire are plugged, the fire in that area cannot be extinguished or controlled by prewetting of adjacent combustibles. In such a situation, the fire can grow to an uncontrollable size, resulting in greater fire damage and excessive sprinkler operation and even threatening the structural integrity of the building, depending on the number of plugged sprinklers and fire severity.
Keeping the inside of sprinkler system piping free of scale, silt, or other obstructing material is an integral part of an effective loss prevention program.

2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Based upon observation and interview on 3/30/11 the facility failed to ensure portable fire extinguishers were inspected and maintained in accordance with NFPA 10. Failure to maintain operable extinguishers could allow incipient fires to spread. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

1) During the facility tour on 3/30/11 between 10:45 AM and 1:45 PM observation revealed that fire extinguishers located in the Laboratory, X-Ray, and Basement storage room, had no record of annual service and testing. This was observed by the surveyor and acknowledged by the Maintenance Engineer who indicated they were missed because they were behind locked doors.

2) During the facility tour on 3/30/11 between 10:45 AM and 1:45 PM observation revealed that fire extinguishers located throughout the building were not being checked monthly and annotated on the affixed tag in accordance with NFPA 10. When asked, the Maintenance Engineer was not aware of this requirement.

Actual NFPA standard:
LSC 101 - 2000
19.3.5.6
Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1*
Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition
4-1.2
The procedure for inspection and maintenance of fire extinguishers varies considerably. Minimal knowledge is necessary to perform a monthly " quick check " or inspection in order to follow the inspection procedure as outlined in Section 4-3. A trained person who has undergone the instructions necessary to reliably perform maintenance and has the manufacturer ' s service manual shall service the fire extinguishers not more than 1 year apart, as outlined in Section 4-4.
4-2.1 Inspection.
A " quick check " that a fire extinguisher is available and will operate. It is intended to give reasonable assurance that the fire extinguisher is fully charged and operable. This is done by verifying that it is in its designated place, that it has not been actuated or tampered with, and that there is no obvious or physical damage or condition to prevent its operation.
4-2.2 Maintenance.
A thorough examination of the fire extinguisher. It is intended to give maximum assurance that a fire extinguisher will operate effectively and safely. It includes a thorough examination and any necessary repair or replacement. It will normally reveal if hydrostatic testing or internal maintenance is required.
4-3.1* Frequency.
Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.2* Procedures.
Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Based upon observation and interview conducted on 3/30/11, the facility failed to ensure portable space heating device elements did not exceed 212 degrees Fahrenheit. This deficient practice is considered a significant risk due to the history of fires caused by space heaters. The hospital is licensed for 10 beds with a census of one on the day of the survey.

Findings include:

During the facility tour conducted on 3/30/11 between 10:15 AM and 2:00 PM, observation revealed portable space heating devices located in the multipurpose room and the basement mechanical room. Interview with the Maintenance Engineer indicated the facility had no process to initially and annually test portable space heating devices used in non sleeping staff areas to ensure elements are less than 212 degrees F.

Actual NFPA Standard:

NFPA 101, the Life Safety Code, 2000 Edition

19.7.8 Portable Space-Heating Devices.
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).

Based upon observation and interview on 3/30/11 the facility failed to ensure oxygen cylinders were secured and stored in a safe manner. Failure to secure high pressure cylinders can result in physical damage and resulting overpressure events causing damage or injury. The facility is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

Observation of the Medical Gas Storage Room during the facility tour on 3/30/11 at 1:40 PM revealed ten "E" oxygen cylinders stored upright and unsecured inside the storage room. This deficient practice was observed by the surveyor and acknowledged by the Maintenance Engineer.

Actual NFPA standard:

NFPA 99 Health Care Facilities, 1999 Edition

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).

Based on record review and staff interview, it was determined the facility failed to ensure that the emergency power generator and transfer switch was tested as required with subsequent entries into a generator log. Failure to inspect and test the emergency power supply system (EPSS) regularly could affect system reliability in the facility. This deficient practice affected all residents and patients on the day of the survey. The hospital is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

Record review on 3/30/11 disclosed that the generator had been tested under load eight times in the last 12 months. When asked about weekly checks the Maintenance Engineer was not aware of the requirement for weekly inspections. Interview with the Maintenance Engineer revealed that the generator self exercised weekly with no load, and that the load test was conducted manually each month.

Actual NFPA Standard:
NFPA 110 Standard
6-3 Maintenance and Operational Testing.
6-3.1*
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.
6-3.2
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.
6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4
A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-3.5*
Transfer switches shall be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required.
6-3.6*
Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

6-4 Operational Inspection and Testing.
6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1
Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2
Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.3
Load tests of generator sets shall include complete cold starts.
6-4.4
Time delays shall be set as follows:
(a) Time delay on start: 1 second minimum
Exception: Gas turbine cycle: 0.5 second minimum.
(b) Time delay on transfer to emergency: no minimum required
(c) Time delay on restoration to normal: 5 minutes minimum (see A-4-2.4.7)
(d) Time delay on shutdown: 5 minutes minimum
6-4.5
Level 1 and Level 2 transfer switches shall be operated monthly. 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.
6-4.6*
EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the off position.
Exception: Medium- and high-voltage circuit breakers for Level 1 system usage shall be exercised every 6 months and tested under simulated overload conditions every 2 years.
6-4.7
The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

Based upon record review and staff interview the facility failed to ensure a policy was in place to evacuate or safeguard occupants in the event of required fire protection systems being out of service. This deficient practice affected all patients, staff and visitors in the facility. The hospital is licensed for 10 beds and had a census of one on the day of the survey.

Findings include:

During the review of records portion of the survey, interview with the Maintenance Engineer revealed there was no policy in place to conduct a fire watch in the event of a fire alarm or sprinkler system being out of service for greater than four hours. When asked about such a policy the Maintenance Engineer was unaware of the requirements for a fire watch or a policy.

Actual NFPA standards:

LSC 101-2000

9.6.1.8*
Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

9.7.6.1
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.