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Based on observation and staff interview, the facility failed to provide walls free from holes and penetrations. This deficient practice would allow smoke products to travel from room to room and into the attic area, affecting all patients and residents in 1 of 1 smoke zone. The facility has a capacity of 25 and census of 6 at the time of the survey.

Findings include:

During the survey on February 11, 2019 the following observations were made

1) 2:42 p.m. It was observed in Pt room 105 there are (3) 5/8 diameter penetration holes in the north wall above the sink.

2) 3:14 p.m. It was observed in the soiled linen room there are multiple penetration holes in the east and north walls.

3) 3:17 p.m. It was observed in patient room 112 there is a large crack in the closet wall along the east wall.

Staff member M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. (2012) NFPA 101, 19.3.1.

Review of the following NFPA Standard revealed: Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. (2012) NFPA 101, 19.3.1.1

Review of the following NFPA Standard revealed: Unprotected vertical openings in accordance with 8.6.9.1 shall be permitted. (2012) NFPA 101, 19.3.1.2

Review of the following NFPA Standard revealed: 8.4.4 Penetrations. The provisions of 8.4.4 shall govern the materials and methods of construction used to protect through penetrations and membrane penetrations of smoke partitions.

Review of the following NFPA Standard revealed: .4.4.1 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a smoke partition shall be protected by a system or material that is capable of limiting the transfer of smoke.

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants from exiting in the event of a fire or other emergency situation, affecting patients, residents and staff in 1 of 1 smoke zone. The facility has a capacity of 25 with a census of 6 at the time of survey.

Findings include:

During the survey on February 11, 2019 the following is observed:

1) 2:22 p.m. It was observed in the west corridor there are multiple wheel chairs being stored in the hallway blocking the egress pathway.

Staff member M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:

(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2) Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in. (152.5 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c) The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5) (d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8. 2012 NFPA 101, 19.2.3.4

Based on observation and staff interview the facility failed to provide continuous illumination of floors and other walking surfaces to values of at least 1 ft. candle (10 lux) measured at the floor. This deficient practice does not insure that exit path will be illuminated continuously and will delay egress, affecting staff only in 1 of 1 smoke zone. The facility has a capacity of 25 and census of 6 at the time of the survey.

Findings include:

During the survey on February 11, 2019 the following observations were made:

2:19 p.m. It was observed in the scope cleansing room the emergency light does not illuminate upon test.

Staff Member M1 was present and acknowledged the finding.

Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.

Based on observation, interview and record review, the facility failed to provide and maintain complete documentation of annual inspection and testing of the fire alarm system in accordance with NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all patients, residents, visitors and staff in 1 of 1 smoke zone. The facility has a capacity of 25 with a census of 6 at the time of this survey.

Findings include:

During the survey on February 11, 2019 the following observation was made:

It was observed during the documentation review of the previous (3) years of fire alarm testing and inspection, the inspection report from Absolute Protection dated: March 7, 2018 does not list all devices (magnetic door hold open devices) on the fire alarm initiating, and notification system that are being tested, their location, address and disposition of Pass or Fail.

Staff member M1 was present and acknowledged the findings.

NFPA Standard: 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 and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

NFPA Standard: A complete record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested. If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year. 2010 NFPA 72 10.18.3

NFPA Standard: Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 2010 NFPA 72, 14.4.5.3

Based on observation, record review and interview the facility fails to ensure that the facility's automatic sprinkler system is installed, maintained and tested in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will be properly prepared in the event of a fire, affecting all patients and residents in 1 of 1 smoke zone. The facility has a capacity of 25 and census of 6 at the time of the survey.

Findings include:

During the survey on February 11, 2019 the following observations were made:

1) No documented monthly visual inspections of the automatic fire sprinkler system.

2) It was observed there is no documentation of a 1st quarter 2018 sprinkler testing.

3) 2:34 p.m. it was observed in the emergency room the (2) south sprinkler heads are loaded with dust.

Staff member M1 was present and acknowledged the results of the records review.

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per 2012 NFPA 101, 9.7.5.

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 2012 NFPA 101 4.6.12.1

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 2012 NFPA 101, 4.6.12.1

Based on interview and record review, this facility is not assuring that a complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four-hour period. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice would affect all occupants of the building, including patients, residents, visitors and staff in 1 of 1 smoke zones. The facility has a capacity of 25 with a census of 6 at the time of this survey.

Findings include:

During the survey on February 11, 2019 the following observations were made:

1) It was observed during the documentation review it was observed the fire watch policy does not contain the (2011) NFPA 25 information requiring the facility to make notifications when the sprinkler system is out of service for more than 10 hours in a 24-hour period.

2) It was observed during the documentation review the fire watch policy does not contain the (2011) NFPA 25 information regarding who should be contacted in the event the sprinkler system is down for over 10 hours in a 24-hour period.

Staff Member M1 was present and acknowledged the findings.

NFPA Standard: Where the inspection, testing, and maintenance of standpipe and hose systems results or involves a system that is out of service, the impairment procedures outlined in Chapter 15 shall be followed. 2011 NFPA 25 6.1.6

NFPA Standard: The following procedures shall be implemented; the extent and expected duration of the impairment shall be determined; the areas or buildings involved have been inspected and the increased risks determined; recommendations submitted to management or the property owner or designated representative. Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: evacuation of the building or portion of the building affected by the system out of service; an approved fire watch; establishment of a temporary water supply; establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire; the fire department has been notified; the insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified; the supervisors in the areas to be affected have been notified; tag impairment system has been implemented. (See Section 15.3.); all necessary tools and materials have been assembled on the impairment site. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should be looking for fire, and other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2011 NFPA 25, 15.5.2

NFPA Standard: Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

Based on observation and staff interview the facility fails to assure fire extinguishers have been selected, installed and maintained in accordance with NFPA 10. This deficiency practice fails to ensure that fire extinguishers will be maintained and in proper working condition when needed in the event of a fire emergency, affecting all residents and staff in 1 of 1 smoke zone. The facility has a capacity of 25 with a census of 6 at the time of survey.

Findings include:

During the survey February 11, 2019 the following observations were made:

1) 2:11 p.m. It was observed in the C/T building the fire extinguishers (2) do not have current annual inspection tag. Last completed March 2017.

Staff member M1 was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2012 NFPA 101, 9.7.4.1

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting all patients and residents in 1 of 1 smoke zone. The facility has a capacity of 25 and a census of 6.

Findings include:

During the survey on February 11, 2019 the following is observed:

1) 2:54 p.m. It was observed in patient room 105 the corridor door will not close and latch because the door hits the bed.
2) 2:58 p.m. It was observed the corridor door to patient room 110 will not latch when closed.
3) 3:02 p.m. It was observed in room 111 there is a rubber chock holding the door open.
4) 3:12 p.m. It was observed in the south office there is a 1/4 diameter hole above the door handle.

Staff Member M1 was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13/4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes
2012 NFPA 101, 19.3.6.3.1

Review of the following NFPA Standard revealed: Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.
2012 NFPA 101, 19.3.6.3.5

Review of the following NFPA Standard revealed: Doors shall not be held open by devices other
than those that release when the door is pushed or pulled. 2012 NFPA 101, 19.3.6.3.10

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NAPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting all patients, residents, visitors and staff in 1 of 1 smoke zone. The facility has a capacity of 25 with a census of 6 at the time of this survey.

Findings include:

During the survey on February 11, 2019 the following was observed:

1) 1:40 p.m. It was observed in the northeast office there is a multi-plug extension cord was in use.

2) 1:43 p.m. It was observed in the business office there are (3) daisy chained power strips along the east wall.

3) 1:51 p.m. It was observed in the reimbursement office there is a power strip plugged into a multi-plug adapter.

4) 2:01 p.m. It was observed in the maintenance office there are daisy chained power strips on computer systems.

5) 2:05 p.m. it was observed in the lab the electronically receptacles are over the sink with no GFCI.

6) 2:28 p.m. It was observed in x-ray room there is a multi-plug extension cord in use.

7) 2:35 p.m. It was observed in the boiler room there is a multi-plug extension cord in use on the west wall.

8) 3:05 p.m. It was observed in the south office there are daisy chained power strips under the north desk.

9) 3:08 p.m. It was observed in sprinkler riser room there are (2) open junction boxes on the north wall with exposed electrical wire splices.

Staff Member M1 was present and acknowledged the finding.

Review of the following NAPA Standard revealed: Electrical wiring and equipment shall be in accordance with NAPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.1.2

Based upon interview and record review, the facility fails to provide a complete written plan for the evacuation of the building's smoke zone directly affected by fire. The deficient practice affects all residents, patients, visitors and staff in 1 of 1 smoke zone. The facility has a capacity of 25 with a census of 6.

Findings include:

During the survey on February 11, 2019 the following observations were made:

1) It was observed during the documentation review of the fire procedures policy the procedure does not include staff response to alarms - staff responsibilities - who has the responsibility of calling 911, isolating the fire area, and evacuation of the smoke zone.

2) It was observed during the documentation review of the fire policy and procedure there are no documented records to show that employees and staff are being trained on the proper procedures to perform in a fire emergency.

Staff member M1 was present and acknowledged the findings.

NFPA Standard: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. 2012. NFPA 101, 18/19.7.1.1

NFPA Standard: A written health care occupancy fire safety plan shall provide for all of the following: (1) use of alarms; (2) transmission of alarms to fire department; (3) emergency phone call to fire department; (4) response to alarms; (5) isolation of fire; (6) evacuation of immediate area; (7) evacuation of smoke compartment; (8) preparation of floors and building for evacuation; (9) extinguishment of fire. 2012 NFPA 101 18/19.7.2.2

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients & residents in 1 of 1 smoke zone. The facility has a capacity of 25 and a census of 6.

Findings include:

During the survey on February 11, 2019 the following observations were made:

1) It was observed during documentation review of the previous five quarters of fire drills none of the fire drills on any shift in 2018 have a documented scenario.
2) It was observed during the documentation review of the previous five quarters of fire drills the is no supporting documentation that the fire alarm was ever tested during a fire drill or on the following morning. Fire drills were held on the following dates during day shift hours: 1/16/18, 3/2018, 5/3/18, 7/17/18 and 10/11/18. Fire drills were held during the night shift hours on the following dates: 2/20/18, 4/19/18, 6/20/18, 8/13/18 and 11/17/18.

Staff member M1 was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 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. and
6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8

Based upon a review of records and staff interview the facility is not inspecting and maintaining fire-rated door assemblies in compliance with NFPA 80. This deficient practice could prevent the ability of the facility to properly confine smoke and prevent fire from spreading to other areas of the building. This deficient practice would affect all patients, residents, visitors, and staff in 1 of 1 smoke zone. The facility has a capacity of 25 with a census of 6 at the time of this survey.


Findings include:


During the survey conducted on February 11, 2019 the following deficiency is noted:


1) It was observed during documentation review the double fire rated 90-minute fire doors in the south hall were annually inspected by Blue Star Contracting, LLC on 11/15/2018. There is no documentation of repair for the following discrepancies: a) The door clearances between the doors and the frame are in excess of 1/8". b) The labels on the frame is missing or has been painted over. c) The door closure's need to be adjusted. d) The fire rated doors do not have any positive latching hardware. e) The fire rated doors have no panic hardware installed.


Staff member M1 was present and acknowledged the findings.


NFPA Standard: NFPA 80 2010 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in the surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7 (6) The self-closing device is operational; that is, the active door completely closes when operated from the open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.

Based on observation and interview, the facility fails to prohibit the use of portable space heating devices within the patient care areas. Additionally, the facility fails to assure that heating elements do not exceed 212 degrees Fahrenheit in the business office area. The deficient practice would affect all patients/residents, visitors and staff in 1 of 1 smoke zone. This facility has a capacity of 25 and a census of 6 patients at the time of the survey.

Findings include:

During the survey conducted on February 11, 2019 the following is observed:

3:03 p.m. It was observed in the south office within the patient/resident care area there is a portable electric heater in use under the desk. The heater was left on with combustibles within 30" of the front of the heater.

Staff member M1 was present and acknowledged the finding.

NFPA Standard: Prohibits the use of portable space heating devices in healthcare occupancies except for nonresident and staff sleeping areas with heating elements that exceed 212 degrees. 2012 NFPA 101, 18/19.7.8

Based upon observation and staff interview, the facility fails to test, inspect and maintain the emergency generator per NFPA 110. This deficient practice could result in the generator working as it was designed in an emergency. The deficient practice could affect all patients, residents and any staff or visitors in 1 of 1 smoke zone. The facility has a capacity of 25 with a census of 6 at the time of this survey.

Findings include:

During the survey conducted on February 11, 2019 the following was observed.

1) It was observed during documentation review there was no documented 30-minute monthly load test for the month of November 2018.

2) It was observed during the documentation review the facility does not have a statement of reasonable reliability of the natural gas delivery. The letter should have a brief description that supports the statement regarding the reliability that there is a low probability of interruption of the natural gas. The letter must also provide a brief description that supports the statement regarding the low probability of interruption and the signature of technical personnel from the natural gas vendor.

3) 2:32 p.m. It was observed there is no remote emergency shut-off provided for the natural gas generator.

Staff Member M1 was present and acknowledged the observation.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

Based on observation the facility fails to segregate full and empty oxygen cylinders and provide appropriate sign on the oxygen room door. This deficient practice affects all patients and residents in 1 of 1 smoke zone. The facility has a capacity of 25 and census of 6 at the time of the survey.

Findings include:

During the survey on February 11, 2019 the following is observed:

1) 2:46 p.m. it was observed in the oxygen storage room there is no labeling for full or empty cylinders.

2) 2:49 p.m. It was observed there is no sign on the oxygen storage room to indicate what is contained within.

Staff M1 was present and acknowledged the findings.

Review of the following NFPA standard revealed: Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. When the facility employs cylinders with integral pressure gauge, it shall establish the threshold pressure at which a cylinder is considered empty. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. (NFPA 99), 11.4

Review of the following NFPA standard revealed: Containers shall be stored, used, and operated in accordance with the manufacturer's instructions and labeling. Containers shall not be placed in the following areas: (1) Where they can be tipped over by the movement of a door (2) Where they interfere with foot traffic (3) Where they are subject to damage from falling objects (4) Where exposed to open flames and high-temperature. (NFPA 99), 11.7.3

Review of the following NFPA standard revealed: A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. (NFPA 99), 11.4

Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour. (NFPA 99) 11.3.2.3