HospitalInspections.org

Based on observation and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Observations, on 07/31/13 between 10:00 AM and 11:00 AM, with the Facility Director and the Chief Nursing Officer revealed all of the smoke barriers extending above the ceiling located throughout the facility to be penetrated by pipes and wires. The smoke barriers would not resist the passage of smoke.

Interview, on 07/31/13 between 10:00 AM and 11:00 AM, with the Facility Director and the Chief Nursing Officer revealed they had just been made aware of the penetrations by an outside contractor.


Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure doors located in a smoke barrier would resist the passage of smoke.

The findings include:

Observation, on 07/31/13 at 10:42 AM, with the Facility Director and the Chief Nursing Officer revealed the cross corridor doors in the smoke barriers located in the Radiology Hall did not have self-closing devices installed on the doors. The doors and the frame had screw holes where the self-closers had been installed at some point, but had been removed.

Interview, on 07/31/13 at 10:42 AM, with the Facility Director and the Chief Nursing Officer revealed they did not know why the self-closing devices had been removed but they knew it was done many years ago.


Reference: NFPA 101 (2000 edition)

19.3.7.6*. Requires doors in smoke barriers to be self-closing and resist the passage of smoke.


Reference: NFPA 101 (2000 edition)

8.3.4.1* Doors in smoke barriers shall close the opening leaving
only the minimum clearance necessary for proper operation
and shall be without undercuts, louvers, or grilles.

Reference: NFPA 80 (1999 Edition)
Standard for Fire Doors 2-3.1.7
The clearance between the edge of the door on the pull side shall be 1/8 in. (+/-) 1/16 in. (3.18 mm (+/-) 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18mm) for wood doors.
Reference: NFPA 80 (1999 Edition)

2-4.1 Closing Devices.
2-4.1.1 Where there is an astragal or projecting latch bolt that
prevents the inactive door from closing and latching before
the active door closes and latches, a coordinating device shall
be used. A coordinating device shall not be required where
each door closes and latches independently of the other.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect three (3) of seven (7) smoke compartments, patients, staff and visitors. The facility has twenty five (25) certified beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed;

1) The storage of combustible paper, ABHR, and cleaning products, stored in an unrated closet located in the basement hall. The closet was added in the corridor, built out of wood and drywall and did not extend to the ceiling. This part of the facility is not sprinkler protected.
2) The dry storage room located in the kitchen did not have a self-closing device.
3) A storage area located in the kitchen behind the food prep area did not have a wall with a door to separate the combustible storage from the kitchen.
4) The Quality Risk Office did not have a self-closing device on the door and the room was filled with combustible storage.
5) The Radiology file room did not have a self-closing device installed on the door and the room was filled with combustible paper files.
6) The Registration Room did not have a self-closing device installed on the door and room was filled with combustible storage.

Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed they were unaware the storage areas needed to be separated from other use area, and self-closing devices were required on hazardous rooms.

Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
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 on observation and interview, it was determined the facility failed to meet the requirements of Protection of Laboratories in accordance with NFPA Standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure the laboratory was separate from the facility with smoke resisting partitions.

The findings include:

Observation, on 07/31/13 at 3:16 PM with the Facility Director and the Chief Nursing Officer revealed the smoke wall around the laboratory was not rated for one hour. The laboratory was not sprinkler protected.

Interview, on 07/31/13 at 3:16 PM with the Facility Director and the Chief Nursing Officer revealed they were not aware the laboratory was to be in a rated room.


Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
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 on observation and interview, it was determined the facility failed to ensure that a stairwell was maintained according to NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, visitors, and staff. The facility has twenty five (25) certified beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 at 1:57 PM, with the Facility Director and the Chief Nursing Officer revealed the ground floor landing of the enclosed maintenance stairwell was being used for the storage of metal folder chairs. Stairwells are required to be maintained free of items that may interfere from exiting the facility.

Interview, on 07/31/13 at 1:57 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware of the requirement.

Reference: NFPA 101 2000 edition

7.1.3.2.3*
An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)

7.2.2.5.3* Usable Space.
There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Based on observation and interview, it was determined the facility failed to ensure the exits were maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure the means of egress were free of obstructions and impediments.

The findings include:

Observation, on 07/31/13 at 3:01 PM, with the Facility Director and the Chief Nursing Officer revealed a power cord and data cables serving a Mobile MRI Trailer located in the parking lot outside the Med/Surge Exit. The cables would prevent wheel transportation devices from being able to exit the building safely. Further observation revealed a garden hose was also laying across the path of egress.

Interview, on 07/31/13 at 3:01 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the cables were blocking the path, but confirmed they would be an impediment to egress.


Reference: NFPA 101 (2000 edition)

7.1.10.1* Means of egress shall be continuously maintained
free of all obstructions or impediments to full instant use in
the case of fire or other emergency.
7.5.1.1 Exits shall be located and exit access shall be arranged
so that exits are readily accessible at all times.
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 on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect three (3) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to provide required illumination outside an exit for discharge.

The findings include:

Observation, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed the exit located in the Medical Records Hall, Surgery Exit, Med/Surge Exit, and the Swing Bed Exit did not have a light fixture installed outside to provide the required illumination for exit discharge.

Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the exits did not have the required illumination for egress lighting.


Reference NFPA 101 (2000 edition)


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


7.7 DISCHARGE FROM EXITS
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.
7.7.2
Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall be permitted to discharge through areas on the level of exit discharge, provided that the criteria of 7.7.2(1) through (3) are met:
(1) Such discharge shall lead to a free and unobstructed way to the exterior of the building, and such way is readily visible and identifiable from the point of discharge from the exit.
(2) The level of discharge shall be protected throughout by an approved, automatic sprinkler system in accordance with Section 9.7, or the portion of the level of discharge used for this purpose shall be protected by an approved, automatic sprinkler system in accordance with Section 9.7 and shall be separated from the nonsprinklered portion of the floor by a fire resistance rating meeting the requirements for the enclosure of exits (see 7.1.3.2.1).
Exception: The requirement of 7.7.2(2) shall not apply where the discharge area is a vestibule or foyer meeting all of the following:
(a) The depth from the exterior of the building shall not be more than 10 ft (3 m) and the length shall not be more than 30 ft (9.1 m).
(b) The foyer shall be separated from the remainder of the level of discharge by construction providing protection not less than the equivalent of wired glass in steel frames.
(c) The foyer shall serve only as means of egress and shall include an exit directly to the outside.
(3) The entire area on the level of discharge shall be separated from areas below by construction having a fire resistance rating not less than that required for the exit enclosure.
Exception No. 1: Levels below the level of discharge shall be permitted to be open to the level of discharge in an atrium in accordance with 8.2.5.6.
Exception No. 2: One hundred percent of the exits shall be permitted to discharge through areas on the level of exit discharge as provided in Chapters 22 and 23.
Exception No. 3: In existing buildings, the 50 percent limit on egress capacity shall not apply if the 50 percent limit on the required number of exits is met.
7.7.3
The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.
7.7.4
Doors, stairs, ramps, corridors, exit passageways, bridges, balconies, escalators, moving walks, and other components of an exit discharge shall comply with the detailed requirements of this chapter for such components.
7.7.5 Signs.
(See 7.2.2.5.4 and 7.2.2.5.5.)
7.7.6
Where approved by the authority having jurisdiction, exits shall be permitted to discharge to roofs or other sections of the building or an adjoining building where the following criteria are met:
(1) The roof construction has a fire resistance rating not less than that required for the exit enclosure.
(2) There is a continuous and safe means of egress from the roof.

7.8 ILLUMINATION OF MEANS OF EGRESS
7.8.1 General.
7.8.1.1*
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 42. 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.
7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3*
The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.
7.8.1.4*
Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

Based on observation, and interview it was determined the facility failed to test emergency lighting in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to test emergency battery lighting for 90 minutes annually.

The findings include:

Observation, on 07/31/13 at 11:56 AM, with the Facility Director and the Chief Nursing Officer revealed the facility did not have documentation for the annual testing of emergency battery lighting located in the facility.

Interview, on 07/31/13 at 11:56 AM, with the Facility Director and Chief Nursing Officer revealed they were not aware documentation was to be kept for emergency battery light testing.

Observation, on 07/31/13 at 1:52 PM, with the Facility Director and the Chief Nursing Officer revealed the battery operated emergency lights located inside the generator enclosure, and in the transfer switch room did not function when tested.

Interview, on 07/31/13 at 1:52 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the emergency battery operated lights did not function.


Reference: NFPA 101 (2000 edition)
7.9.2.1* Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6
lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than
11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on observation and interview, it was determined the facility failed to ensure exit signs were maintained in accordance with NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 at 1:57 PM, with the Facility Director and the Chief Nursing Officer revealed the maintenance stairwell did not have proper exit signage to make the path of egress clearly recognizable. Further observation revealed the Swing Bed Exit did not have proper exit signage.

Interview, on 07/31/13 at 1:57 PM, with the Facility Director and Chief Nursing Officer revealed they had just been made aware by an independent contractor that the facility did not have proper exit signage.


Reference: NFPA 101 (2000 edition)


7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required.
Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.3 Exit Stair Door Tactile Signage.
Tactile signage shall be located at each door into an exit stair enclosure, and such signage shall read as follows:
EXIT
Signage shall comply with CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, and shall be installed adjacent to the latch side of the door 60 in. (152 cm) above the finished floor to the centerline of the sign.
Exception: This requirement shall not apply to existing buildings, provided that the occupancy classification does not change.
7.10.1.4* Exit Access.
Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.
7.10.1.5* Floor Proximity Exit Signs.
Where floor proximity exit signs are required in Chapters 11 through 42, signs shall be placed near the floor level in addition to those signs required for doors or corridors. These signs shall be illuminated in accordance with 7.10.5. Externally illuminated signs shall be sized in accordance with 7.10.6.1. The bottom of the sign shall be not less than 6 in. (15.2 cm) but not more than 8 in. (20.3 cm) above the floor. For exit doors, the sign shall be mounted on the door or adjacent to the door with the nearest edge of the sign within 4 in. (10.2 cm) of the door frame.
7.10.1.6* Floor Proximity Egress Path Marking.
Where floor proximity egress path marking is required in Chapters 11 through 42, a listed and approved floor proximity egress path marking system that is internally illuminated shall be installed within 8 in. (20.3 cm) of the floor. The system shall provide a visible delineation of the path of travel along the designated exit access and shall be essentially continuous, except as interrupted by doorways, hallways, corridors, or other such architectural features. The system shall operate continuously or at any time the building fire alarm system is activated. The activation, duration, and continuity of operation of the system shall be in accordance with 7.9.2.
7.10.1.7* Visibility.
Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
7.10.3* Sign Legend.
Signs required by 7.10.1 and 7.10.2 shall have the word EXIT or other appropriate wording in plainly legible letters.
7.10.4* Power Source.
Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.
7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.
7.10.5.2* Continuous Illumination.
Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception*: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.
7.10.6 Externally Illuminated Signs.
7.10.6.1* Size of Signs.
Externally illuminated signs required by 7.10.1 and 7.10.2, other than approved existing signs, shall have the word EXIT or other appropriate wording in plainly legible letters not less than 6 in. (15.2 cm) high with the principal strokes of letters not less than 3/4 in. (1.9 cm) wide. The word EXIT shall have letters of a width not less than 2 in. (5 cm), except the letter I, and the minimum spacing between letters shall be not less than 3/8 in. (1 cm). Signs larger than the minimum established in this paragraph shall have letter widths, strokes, and spacing in proportion to their height.
Exception No. 1: This requirement shall not apply to existing signs having the required wording in plainly legible letters not less than 4 in. (10.2 cm) high.
Exception No. 2: This requirement shall not apply to marking required by 7.10.1.3 and 7.10.1.5.
7.10.6.2* Size and Location of Directional Indicator.
The directional indicator shall be located outside of the EXIT legend, not less than 3/8 in. (1 cm) from any letter. The directional indicator shall be of a chevron type, as shown in Figure 7.10.6.2. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft (12.2 m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated.
Exception: This requirement shall not apply to approved existing signs.
Figure 7.10.6.2 Chevron-type indicator.

7.10.6.3* Level of Illumination.
Externally illuminated signs shall be illuminated by not less than 5 ft-candles (54 lux) at the illuminated surface and shall have a contrast ratio of not less than 0.5.
7.10.7 Internally Illuminated Signs.
7.10.7.1 Listing.
Internally illuminated signs, other than approved existing signs, or existing signs having the required wording in legible letters not less than 4 in. (10.2 cm) high, shall be listed in accordance with UL 924, Standard for Safety Emergency Lighting and Power Equipment.
Exception: This requirement shall not apply to signs that are in accordance with 7.10.1.3 and 7.10.1.5.
7.10.7.2* Photoluminescent Signs.
The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source as determined by the authority having jurisdiction. The charging light source shall be of a type specified in the product markings.
7.10.8 Special Signs.
7.10.8.1* No Exit.
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.


7.10.1.2* Exits. Exits, other than main exterior exit doors
that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction
of exit access.

Based on interview and fire drill record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure the fire drills were conducted quarterly at unexpected times.

The findings include:

Fire Drill review, on 07/31/13 at 11:30 AM, with Facility Director and the Chief Nursing Officer revealed the facility failed to conduct fire drills at unexpected times on all shifts. The facility conducted two drills on the same day for each quarter except the second quarter of 2012. Once the fire drill occurred, staff knew later in the day another fire drill was going to be performed. The facility has staff that work through the night, and these staff were not included in the drills. The facility has multiple shifts.

Interview, on 07/31/13 at 11:30 AM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the fire drills were not being conducted as required.


Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Reference: NFPA 101 Life Safety Code (2000 Edition).
19.7* OPERATING FEATURES
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1
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. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.
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 on observation and interview, the facility failed to maintain the fire alarm system per NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff, and visitors. The facility has twenty five (25) certified beds with a census of twelve (12) on the day of the survey. The facility failed to ensure manual fire pull stations were not blocked.

Findings include:

Observation, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed the manual pull stations located in the Kitchen and the Medical Records Room were blocked by storage.

Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the manual pull stations were blocked, but were aware of the requirement

Actual NFPA Standard: NFPA 101, 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.

Based on record review and interview, it was determined the facility failed to ensure smoke detectors were inspected and tested in accordance with NFPA Standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to provide documentation that a sensitivity test had been performed the smoke detectors.

The findings include:

Smoke detector record review, on 07/31/13 at 11:57 AM, with the Facility Director and the Chief Nursing Officer revealed the facility did not have documentation of a Smoke Detector Sensitivity Test being performed on the fire alarm smoke detectors within the last two years.

Interview, on 07/31/13 at 11:57 AM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the facility did not have a current sensitivity test on the fire alarm smoke detectors.


Reference: NFPA 72 (1999 edition)

7-3.2.1* Detector sensitivity shall be checked within 1 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.
To ensure that each smoke detector is within its listed and
marked sensitivity range, it shall be tested using any of the following
methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction
Detectors found to have a sensitivity outside the listed and
marked sensitivity range shall be cleaned and recalibrated or
be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors
referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured
using any device that administers an unmeasured concentration
of smoke or other aerosol into the detector.

Based on observation and interview, it was determined that the facility failed to maintain the installation of portable fire extinguishers per NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

Findings include:

Observation, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed the wall mounted, portable fire extinguishers located in the Kitchen, and the Radiology Hall was mounted above five (5) feet from the floor.

Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed that they were not aware of the installation requirements for wall mounted portable fire extinguishers.


Reference NFPA 10 (1998 Edition).

1-6.10 Fire extinguishers having a gross weight
not exceeding 40 lb (18.14 kg) shall be
installed so that the top of the fire
extinguisher is not more than 5 ft (1.53 m)
above the floor. Fire extinguishers having a
gross weight greater than 40 lb (18.14 kg)
(except wheeled types) shall be so installed
that the top of the fire extinguisher is not
more than 3 1/2 ft (1.07 m) above the floor.
In no case shall the clearance between the
bottom of the fire extinguisher and the floor
be less than 4 in. (10.2 cm).

Based on record review and interview, it was determined the facility failed to ensure kitchen hood extinguishing system would activate the fire alarm. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure the kitchen hood suppression system was connected to the fire alarm and gas shut off.

The findings include:

Kitchen Hood Inspection, on 07/31/13 at 11:15 AM, with the Facility Director and the Chief Nursing Officer revealed the kitchen hood suppression system was not connected to the facilities fire alarm or gas shut off. The contractor that inspected the kitchen hood had noted in the memos of the test results that the hood was not compliant. Further observation revealed the means for manual activation was not located in the egress path.

Interview, on 07/31/13 at 11:15 AM with the Facility Director and the Chief Nursing Officer revealed they were aware the hood was not connected to the fire alarm and the gas shut off, however they did not have a plan in place to have the system upgraded. Further interview revealed they were not aware the means for manual activation was to be located in the path of egress.

NFPA 96 (1998 edition)
7-6.2 Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation shall activate the fire alarm signaling system.

Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed a portable space heater located in the Transcriptionist Office, and the Med/Surge Nurses' Station. The facility failed to ensure portable heaters did not exceed 212 degrees.

Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the heaters element could not exceed 212?F in non-sleeping, staff, and employee areas.


Reference: NFPA 101 (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 non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212?F (100?C).

Based on observation and interview, it was determined the facility failed to maintain exit access in accordance with NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure the means of egress was free of all obstructions or impediments.

The findings include:

Observations, on 07/31/13 at 1:40 PM, with the Facility Director and the Chief Nursing Officer revealed a tool cart and metal bars used in the Therapy Department were being stored in the Medical Records Hall. Further observation revealed a trash cart stored in the Basement Hall by the exit door.

Interview, on 07/31/13 at 1:40 PM, with the Facility Director and the Chief Nursing Officer revealed they did not know why the items were in the egress corridors.

Reference: NFPA 101 (2000 Edition)
Means of Egress Reliability 7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, it was determined the facility failed to ensure trash collection receptacles with capacities greater than 32 gallon were stored in accordance with NFPA standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 at 1:48 PM, with the Facility Director and the Chief Nursing Officer revealed a trash can with a capacity of over thirty two (32) gallons was left unattended in the basement hall next to the exit door.

Interview, on 07/31/13 at 1:48 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware of the requirement for trash receptacles with capacities greater than thirty two (32) gallons.


19.7.5.5
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Based on fire damper testing record review, and interview, it was determined the facility failed to ensure fire/smoke dampers were maintained in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to provide documentation that the smoke/fire dampers were tested within the last four (4) years.

The findings include:

Fire damper testing record review, on 07/31/13 at 11:20 AM with the Facility Director and the Chief Nursing Officer revealed the facility did not have documentation that fire/smoke dampers had been tested within the last four (4) years.

Interview, on 07/31/13 at 11:20 AM, with the Facility Director and the Chief Nursing Officer revealed they were not aware of the requirements for fire/smoke damper testing.


Reference: NFPA 90A (1999 edition)

3-4.7 Maintenance. At least every 4 years, fusible links (where
applicable) shall be removed; all dampers shall be operated to
verify that they fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.

Based on observation and interview, it was determined the facility failed to maintain doors within a required means of egress, in accordance with NFPA standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff, and visitors. The facility has twenty five (25) certified beds with a census of twelve (12) on the day of the survey.

The findings include:

Observations, on 07/31/13 at 2:11 PM, with the Facility Director and the Chief Nursing Officer revealed unapproved hold open devices (door wedges) holding the doors to the Kitchen open to the dining room

Interviews, on 07/31/13 at 2:11 PM, with the Facility Director and the Chief Nursing Officer revealed they had just became aware the hold open devices (door wedges) were prohibited

Reference: NFPA 101 (2000 Edition)

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.



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 on observation and interview, it was determined the facility failed to meet the requirements continuing safety education and supervision for Laboratories in accordance with NFPA Standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure safety training was conducted annually.

The findings include:

Observations, on 07/31/13 at 3:16 PM with the Facility Director and the Chief Nursing Officer revealed the Laboratory did not conduct safety training or have documentation for the annual review of the laboratory safety procedures.

Interview, on 07/31/13 at 3:16 PM with the Facility Director and the Chief Nursing Officer revealed they were not aware of the requirement.


Reference:

NFPA 99 (1999 Edition).

10.2.1.4.2 The safety officer shall also supervise the periodic education of laboratory personnel including the following:
(1) New employee orientation
(2) The nature of combustible and flammable liquids and gases
(3) First aid
(4) Fire fighting
(5) The use of protective equipment
(6) Unsafe conditions observed or reported
The laboratory safety officer shall prepare and supervise the proper completion of a safety checklist that can be preserved for the record.
The laboratory safety officer shall supervise operations and equipment related to safe operations and practices, including such items as the following:
(1) Ventilating provisions
(2) Fire protection apparatus
(3) Periodic flushing of sinks, emergency showers, and eye wash units
(4) Shelf stocks and storage of flammable and combustible materials and caustic and corrosive liquids shall be reviewed at appropriate, regular intervals

Based on observation and interviews it was determined the facility failed to properly store flammable and combustible liquids in accordance with NFPA standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff and visitors. The facility has twenty five (25) certified beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 at 2:14 PM, with the Facility Director and the Chief Nursing Officer revealed three (3) cans of gel fuel stored in an unrated storage room located in the Dining Room outside the Kitchen. These items were stored on an open table top. All flammable materials shall be stored in a flammable proof cabinet if stored in the facility.

Interview, on 07/31/13 at 2:14 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the gel fuel cans were being stored in the unrated storage room.

NFPA 99,
10-7.2.1* Flammable and Combustible liquids shall be used from and stored in approved containers in accordance with, NFPA 30- 4.3.3

Storage cabinets that meet at least one of the following sets of requirements shall be acceptable for storage of liquids:
(a) Storage cabinets that are designed and constructed to limit the internal temperature at the center of the cabinet and 1 in. (25 mm) from the top of the cabinet to not more than 325?F (162.8?C), when subjected to a 10-minute fire test that simulates the fire exposure of the standard time-temperature curve specified in NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials, shall be acceptable. All joints and seams shall remain tight and the door shall remain securely closed during the test.

Based on generator testing record review and interview, it was determined the facility failed to ensure the emergency generator was maintained in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Generator testing record review, on 7/31/13 at 12:00 PM, with the Facility Director and the Chief Nursing Officer revealed the generator was not being run monthly for thirty (30) minutes. A fifteen minute run was documented on 01/28/13 and the next documented run by the facility was on 07/24/13 which the generator was documented to have run for thirty five (35) minutes. An annual load bank by an outside contractor was performed on 03/15/13 and the generator ran for four (4) hours.

Interview, on 7/31/13 at 12:00 PM, with the Facility Director and the Chief Nursing Officer revealed they felt like the generator was run monthly and it was a documentation error.



Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction

6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established

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.

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.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Observations, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed;

1) Storage of combustible materials within three (3) feet of electrical panels located in the Transfer Switch Room.
2) A power strip was plugged into an extension cord located in the Transcriptionist Office.
3) A refrigerator was plugged into an extension cord located in the Medical Records Office.
4) A microwave, toaster, and coffer maker were plugged into an extension cord located in the Radiology Break Room.
5) A freezer and hydrocolator were plugged into a power strip located in the Therapy Department.
6) The hydrocolator located in the Therapy Department was not plugged into a ground fault (GFCI) protected outlet.
7) Electrical breaker boxes located in the corridor by the cross corridor doors to Radiology, did not have a cover that would protect the electrical breaker to prevent tampering.


Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware of the misuse of the power strip, and extension cords. Further interview revealed they were not aware the hydrocolator was to be plugged into a ground fault protected (GFCI) outlet, or electrical breaker boxes were to be locked to prevent tampering.






Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.



Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 70 400-8
( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Reference: NFPA 70 (1999 edition)

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.



110-26. Spaces

About Electrical Equipment. Sufficient access and working space shall be provided and maintained around all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

Reference: NFPA 70 (1999 edition)


Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.


Reference NFPA 70 (1999) edition
National Electric Code, relating to ground fault protection for electric outlets near sinks in resident rooms. NFPA: 70 210.8 Receptacles installed under the exceptions to 210.8(A)(5) shall not be considered as meeting the requirements of 210.52(G).
(6) Kitchens - where the receptacles are installed to serve the countertop surfaces
(7) Wet bar sinks - where the receptacles are installed to serve the countertop surfaces and are located within 1.8 m (6 ft) of the outside edge of the wet bar sink.


Reference NFPA 70 (1999 edition)
210.8 Ground-Fault Circuit-Interrupter Protection for Personnel.
FPN: See 215.9 for ground-fault circuit-interrupter protection for personnel on feeders.
(A) Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in (1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms
(2) Garages, and also accessory buildings that have a floor located at or below grade level not intended as habitable rooms and limited to storage areas, work areas, and areas of similar use
Exception No. 1: Receptacles that are not readily accessible.
Exception No. 2: A single receptacle or a duplex receptacle for two appliances located within dedicated space for each appliance that, in normal use, is not easily moved from one place to another and that is cord-and-plug connected in accordance with 400.7(A)(6), (A)(7), or (A)(8).
Receptacles installed under the exceptions to 210.8(A)(2) shall not be considered as meeting the requirements of 210.52(G).
(3) Outdoors
Exception: Receptacles that are not readily accessible and are supplied by a dedicated branch circuit for electric snow-melting or deicing equipment shall be permitted to be installed in accordance with the applicable provisions of Article 426.
(4) Crawl spaces - at or below grade level
(5) Unfinished basements - for purposes of this section, unfinished basements are defined as portions or areas of the basement not intended as habitable rooms and limited to storage areas, work areas, and the like
Exception No. 1: Receptacles that are not readily accessible.
Exception No. 2: A single receptacle or a duplex receptacle for two appliances located within dedicated space for each appliance that, in normal use, is not easily moved from one place to another and that is cord-and-plug connected in accordance with 400.7(A)(6), (A)(7), or (A)(8).
Exception No. 3: A receptacle supplying only a permanently installed fire alarm or burglar alarm system shall not be required to have ground-fault circuit-interrupter protection.
Receptacles installed under the exceptions to 210.8(A)(5) shall not be considered as meeting the requirements of 210.52(G).
(6) Kitchens - where the receptacles are installed to serve the countertop surfaces
(7) Wet bar sinks - where the receptacles are installed to serve the countertop surfaces and are located within 1.8 m (6 ft) of the outside edge of the wet bar sink.
(8) Boathouses
(B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in (1), (2), and (3) shall have ground-fault circuit-interrupter protection for personnel:
(1) Bathrooms
(2) Rooftops
Exception: Receptacles that are not readily accessible and are supplied from a dedicated branch circuit for electric snow-melting or deicing equipment shall be permitted to be installed in accordance with the applicable provisions of Article 426.
(406.8 Receptacles in Damp or Wet Locations.
(A) Damp Locations. A receptacle installed outdoors in a location protected from the weather or in other damp locations shall have an enclosure for the receptacle that is weatherproof when the receptacle is covered (attachment plug cap not inserted and receptacle covers closed).
An installation suitable for wet locations shall also be considered suitable for damp locations.
A receptacle shall be considered to be in a location protected from the weather where located under roofed open porches, canopies, marquees, and the like, and will not be subjected to a beating rain or water runoff.
(B) Wet Locations.
(1) 15- and 20-Ampere Outdoor Receptacles. 15- and 20-ampere, 125- and 250-volt receptacles installed outdoors in a wet location shall have an enclosure that is weatherproof whether or not the attachment plug cap is inserted.
(2) Other Receptacles. All other receptacles installed in a wet location shall comply with (a) or (b):
(a) A receptacle installed in a wet location where the product intended to be plugged into it is not attended while in use (e.g., sprinkler system controller, landscape lighting, holiday lights, and so forth) shall have an enclosure that is weatherproof with the attachment plug cap inserted or removed.
(b) A receptacle installed in a wet location where the product intended to be plugged into it will be attended while in use (e.g., portable tools, and so forth) shall have an enclosure that is weatherproof when the attachment plug is removed.
(C) Bathtub and Shower Space. A receptacle shall not be installed within a bathtub or shower space.

3) Kitchens

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Policy and Procedure review, on 07/31/13 at 3:30 PM, with the Facility Director and the Chief Nursing Officer revealed the facility failed to provide a written policy outlining an approved fire watch system in the event the fire alarm or sprinkler system is shut down for four (4) or more hours in a twenty four (24) hour period.

Interview, on 07/31/13 at 3:30 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the facility did not have an approved fire watch policy.



Reference; NFPA 101 (2000 edition)
9.7.6* Sprinkler System Shutdown.
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.

Reference; NFPA 101 (2000 edition)
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.

Based on observation and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Observations, on 07/31/13 between 10:00 AM and 11:00 AM, with the Facility Director and the Chief Nursing Officer revealed all of the smoke barriers extending above the ceiling located throughout the facility to be penetrated by pipes and wires. The smoke barriers would not resist the passage of smoke.

Interview, on 07/31/13 between 10:00 AM and 11:00 AM, with the Facility Director and the Chief Nursing Officer revealed they had just been made aware of the penetrations by an outside contractor.


Reference: NFPA 101 (2000 Edition).

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure cross -corridor doors located in a smoke barrier would resist the passage of smoke in accordance with NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure doors located in a smoke barrier would resist the passage of smoke.

The findings include:

Observation, on 07/31/13 at 10:42 AM, with the Facility Director and the Chief Nursing Officer revealed the cross corridor doors in the smoke barriers located in the Radiology Hall did not have self-closing devices installed on the doors. The doors and the frame had screw holes where the self-closers had been installed at some point, but had been removed.

Interview, on 07/31/13 at 10:42 AM, with the Facility Director and the Chief Nursing Officer revealed they did not know why the self-closing devices had been removed but they knew it was done many years ago.


Reference: NFPA 101 (2000 edition)

19.3.7.6*. Requires doors in smoke barriers to be self-closing and resist the passage of smoke.


Reference: NFPA 101 (2000 edition)

8.3.4.1* Doors in smoke barriers shall close the opening leaving
only the minimum clearance necessary for proper operation
and shall be without undercuts, louvers, or grilles.

Reference: NFPA 80 (1999 Edition)
Standard for Fire Doors 2-3.1.7
The clearance between the edge of the door on the pull side shall be 1/8 in. (+/-) 1/16 in. (3.18 mm (+/-) 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18mm) for wood doors.
Reference: NFPA 80 (1999 Edition)

2-4.1 Closing Devices.
2-4.1.1 Where there is an astragal or projecting latch bolt that
prevents the inactive door from closing and latching before
the active door closes and latches, a coordinating device shall
be used. A coordinating device shall not be required where
each door closes and latches independently of the other.

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect three (3) of seven (7) smoke compartments, patients, staff and visitors. The facility has twenty five (25) certified beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed;

1) The storage of combustible paper, ABHR, and cleaning products, stored in an unrated closet located in the basement hall. The closet was added in the corridor, built out of wood and drywall and did not extend to the ceiling. This part of the facility is not sprinkler protected.
2) The dry storage room located in the kitchen did not have a self-closing device.
3) A storage area located in the kitchen behind the food prep area did not have a wall with a door to separate the combustible storage from the kitchen.
4) The Quality Risk Office did not have a self-closing device on the door and the room was filled with combustible storage.
5) The Radiology file room did not have a self-closing device installed on the door and the room was filled with combustible paper files.
6) The Registration Room did not have a self-closing device installed on the door and room was filled with combustible storage.

Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed they were unaware the storage areas needed to be separated from other use area, and self-closing devices were required on hazardous rooms.

Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
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 on observation and interview, it was determined the facility failed to meet the requirements of Protection of Laboratories in accordance with NFPA Standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure the laboratory was separate from the facility with smoke resisting partitions.

The findings include:

Observation, on 07/31/13 at 3:16 PM with the Facility Director and the Chief Nursing Officer revealed the smoke wall around the laboratory was not rated for one hour. The laboratory was not sprinkler protected.

Interview, on 07/31/13 at 3:16 PM with the Facility Director and the Chief Nursing Officer revealed they were not aware the laboratory was to be in a rated room.


Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
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 on observation and interview, it was determined the facility failed to ensure that a stairwell was maintained according to NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, visitors, and staff. The facility has twenty five (25) certified beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 at 1:57 PM, with the Facility Director and the Chief Nursing Officer revealed the ground floor landing of the enclosed maintenance stairwell was being used for the storage of metal folder chairs. Stairwells are required to be maintained free of items that may interfere from exiting the facility.

Interview, on 07/31/13 at 1:57 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware of the requirement.

Reference: NFPA 101 2000 edition

7.1.3.2.3*
An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)

7.2.2.5.3* Usable Space.
There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Based on observation and interview, it was determined the facility failed to ensure the exits were maintained in accordance with NFPA standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure the means of egress were free of obstructions and impediments.

The findings include:

Observation, on 07/31/13 at 3:01 PM, with the Facility Director and the Chief Nursing Officer revealed a power cord and data cables serving a Mobile MRI Trailer located in the parking lot outside the Med/Surge Exit. The cables would prevent wheel transportation devices from being able to exit the building safely. Further observation revealed a garden hose was also laying across the path of egress.

Interview, on 07/31/13 at 3:01 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the cables were blocking the path, but confirmed they would be an impediment to egress.


Reference: NFPA 101 (2000 edition)

7.1.10.1* Means of egress shall be continuously maintained
free of all obstructions or impediments to full instant use in
the case of fire or other emergency.
7.5.1.1 Exits shall be located and exit access shall be arranged
so that exits are readily accessible at all times.
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 on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect three (3) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to provide required illumination outside an exit for discharge.

The findings include:

Observation, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed the exit located in the Medical Records Hall, Surgery Exit, Med/Surge Exit, and the Swing Bed Exit did not have a light fixture installed outside to provide the required illumination for exit discharge.

Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the exits did not have the required illumination for egress lighting.


Reference NFPA 101 (2000 edition)


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


7.7 DISCHARGE FROM EXITS
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.
7.7.2
Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall be permitted to discharge through areas on the level of exit discharge, provided that the criteria of 7.7.2(1) through (3) are met:
(1) Such discharge shall lead to a free and unobstructed way to the exterior of the building, and such way is readily visible and identifiable from the point of discharge from the exit.
(2) The level of discharge shall be protected throughout by an approved, automatic sprinkler system in accordance with Section 9.7, or the portion of the level of discharge used for this purpose shall be protected by an approved, automatic sprinkler system in accordance with Section 9.7 and shall be separated from the nonsprinklered portion of the floor by a fire resistance rating meeting the requirements for the enclosure of exits (see 7.1.3.2.1).
Exception: The requirement of 7.7.2(2) shall not apply where the discharge area is a vestibule or foyer meeting all of the following:
(a) The depth from the exterior of the building shall not be more than 10 ft (3 m) and the length shall not be more than 30 ft (9.1 m).
(b) The foyer shall be separated from the remainder of the level of discharge by construction providing protection not less than the equivalent of wired glass in steel frames.
(c) The foyer shall serve only as means of egress and shall include an exit directly to the outside.
(3) The entire area on the level of discharge shall be separated from areas below by construction having a fire resistance rating not less than that required for the exit enclosure.
Exception No. 1: Levels below the level of discharge shall be permitted to be open to the level of discharge in an atrium in accordance with 8.2.5.6.
Exception No. 2: One hundred percent of the exits shall be permitted to discharge through areas on the level of exit discharge as provided in Chapters 22 and 23.
Exception No. 3: In existing buildings, the 50 percent limit on egress capacity shall not apply if the 50 percent limit on the required number of exits is met.
7.7.3
The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.
7.7.4
Doors, stairs, ramps, corridors, exit passageways, bridges, balconies, escalators, moving walks, and other components of an exit discharge shall comply with the detailed requirements of this chapter for such components.
7.7.5 Signs.
(See 7.2.2.5.4 and 7.2.2.5.5.)
7.7.6
Where approved by the authority having jurisdiction, exits shall be permitted to discharge to roofs or other sections of the building or an adjoining building where the following criteria are met:
(1) The roof construction has a fire resistance rating not less than that required for the exit enclosure.
(2) There is a continuous and safe means of egress from the roof.

7.8 ILLUMINATION OF MEANS OF EGRESS
7.8.1 General.
7.8.1.1*
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 42. 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.
7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3*
The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.
7.8.1.4*
Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

Based on observation, and interview it was determined the facility failed to test emergency lighting in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to test emergency battery lighting for 90 minutes annually.

The findings include:

Observation, on 07/31/13 at 11:56 AM, with the Facility Director and the Chief Nursing Officer revealed the facility did not have documentation for the annual testing of emergency battery lighting located in the facility.

Interview, on 07/31/13 at 11:56 AM, with the Facility Director and Chief Nursing Officer revealed they were not aware documentation was to be kept for emergency battery light testing.

Observation, on 07/31/13 at 1:52 PM, with the Facility Director and the Chief Nursing Officer revealed the battery operated emergency lights located inside the generator enclosure, and in the transfer switch room did not function when tested.

Interview, on 07/31/13 at 1:52 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the emergency battery operated lights did not function.


Reference: NFPA 101 (2000 edition)
7.9.2.1* Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6
lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than
11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on observation and interview, it was determined the facility failed to ensure exit signs were maintained in accordance with NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 at 1:57 PM, with the Facility Director and the Chief Nursing Officer revealed the maintenance stairwell did not have proper exit signage to make the path of egress clearly recognizable. Further observation revealed the Swing Bed Exit did not have proper exit signage.

Interview, on 07/31/13 at 1:57 PM, with the Facility Director and Chief Nursing Officer revealed they had just been made aware by an independent contractor that the facility did not have proper exit signage.


Reference: NFPA 101 (2000 edition)


7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required.
Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.3 Exit Stair Door Tactile Signage.
Tactile signage shall be located at each door into an exit stair enclosure, and such signage shall read as follows:
EXIT
Signage shall comply with CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, and shall be installed adjacent to the latch side of the door 60 in. (152 cm) above the finished floor to the centerline of the sign.
Exception: This requirement shall not apply to existing buildings, provided that the occupancy classification does not change.
7.10.1.4* Exit Access.
Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.
7.10.1.5* Floor Proximity Exit Signs.
Where floor proximity exit signs are required in Chapters 11 through 42, signs shall be placed near the floor level in addition to those signs required for doors or corridors. These signs shall be illuminated in accordance with 7.10.5. Externally illuminated signs shall be sized in accordance with 7.10.6.1. The bottom of the sign shall be not less than 6 in. (15.2 cm) but not more than 8 in. (20.3 cm) above the floor. For exit doors, the sign shall be mounted on the door or adjacent to the door with the nearest edge of the sign within 4 in. (10.2 cm) of the door frame.
7.10.1.6* Floor Proximity Egress Path Marking.
Where floor proximity egress path marking is required in Chapters 11 through 42, a listed and approved floor proximity egress path marking system that is internally illuminated shall be installed within 8 in. (20.3 cm) of the floor. The system shall provide a visible delineation of the path of travel along the designated exit access and shall be essentially continuous, except as interrupted by doorways, hallways, corridors, or other such architectural features. The system shall operate continuously or at any time the building fire alarm system is activated. The activation, duration, and continuity of operation of the system shall be in accordance with 7.9.2.
7.10.1.7* Visibility.
Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
7.10.3* Sign Legend.
Signs required by 7.10.1 and 7.10.2 shall have the word EXIT or other appropriate wording in plainly legible letters.
7.10.4* Power Source.
Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.
7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.
7.10.5.2* Continuous Illumination.
Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception*: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.
7.10.6 Externally Illuminated Signs.
7.10.6.1* Size of Signs.
Externally illuminated signs required by 7.10.1 and 7.10.2, other than approved existing signs, shall have the word EXIT or other appropriate wording in plainly legible letters not less than 6 in. (15.2 cm) high with the principal strokes of letters not less than 3/4 in. (1.9 cm) wide. The word EXIT shall have letters of a width not less than 2 in. (5 cm), except the letter I, and the minimum spacing between letters shall be not less than 3/8 in. (1 cm). Signs larger than the minimum established in this paragraph shall have letter widths, strokes, and spacing in proportion to their height.
Exception No. 1: This requirement shall not apply to existing signs having the required wording in plainly legible letters not less than 4 in. (10.2 cm) high.
Exception No. 2: This requirement shall not apply to marking required by 7.10.1.3 and 7.10.1.5.
7.10.6.2* Size and Location of Directional Indicator.
The directional indicator shall be located outside of the EXIT legend, not less than 3/8 in. (1 cm) from any letter. The directional indicator shall be of a chevron type, as shown in Figure 7.10.6.2. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft (12.2 m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated.
Exception: This requirement shall not apply to approved existing signs.
Figure 7.10.6.2 Chevron-type indicator.

7.10.6.3* Level of Illumination.
Externally illuminated signs shall be illuminated by not less than 5 ft-candles (54 lux) at the illuminated surface and shall have a contrast ratio of not less than 0.5.
7.10.7 Internally Illuminated Signs.
7.10.7.1 Listing.
Internally illuminated signs, other than approved existing signs, or existing signs having the required wording in legible letters not less than 4 in. (10.2 cm) high, shall be listed in accordance with UL 924, Standard for Safety Emergency Lighting and Power Equipment.
Exception: This requirement shall not apply to signs that are in accordance with 7.10.1.3 and 7.10.1.5.
7.10.7.2* Photoluminescent Signs.
The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source as determined by the authority having jurisdiction. The charging light source shall be of a type specified in the product markings.
7.10.8 Special Signs.
7.10.8.1* No Exit.
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.


7.10.1.2* Exits. Exits, other than main exterior exit doors
that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction
of exit access.

Based on interview and fire drill record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure the fire drills were conducted quarterly at unexpected times.

The findings include:

Fire Drill review, on 07/31/13 at 11:30 AM, with Facility Director and the Chief Nursing Officer revealed the facility failed to conduct fire drills at unexpected times on all shifts. The facility conducted two drills on the same day for each quarter except the second quarter of 2012. Once the fire drill occurred, staff knew later in the day another fire drill was going to be performed. The facility has staff that work through the night, and these staff were not included in the drills. The facility has multiple shifts.

Interview, on 07/31/13 at 11:30 AM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the fire drills were not being conducted as required.


Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Reference: NFPA 101 Life Safety Code (2000 Edition).
19.7* OPERATING FEATURES
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1
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. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.
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 on observation and interview, the facility failed to maintain the fire alarm system per NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff, and visitors. The facility has twenty five (25) certified beds with a census of twelve (12) on the day of the survey. The facility failed to ensure manual fire pull stations were not blocked.

Findings include:

Observation, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed the manual pull stations located in the Kitchen and the Medical Records Room were blocked by storage.

Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the manual pull stations were blocked, but were aware of the requirement

Actual NFPA Standard: NFPA 101, 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.

Based on record review and interview, it was determined the facility failed to ensure smoke detectors were inspected and tested in accordance with NFPA Standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to provide documentation that a sensitivity test had been performed the smoke detectors.

The findings include:

Smoke detector record review, on 07/31/13 at 11:57 AM, with the Facility Director and the Chief Nursing Officer revealed the facility did not have documentation of a Smoke Detector Sensitivity Test being performed on the fire alarm smoke detectors within the last two years.

Interview, on 07/31/13 at 11:57 AM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the facility did not have a current sensitivity test on the fire alarm smoke detectors.


Reference: NFPA 72 (1999 edition)

7-3.2.1* Detector sensitivity shall be checked within 1 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.
To ensure that each smoke detector is within its listed and
marked sensitivity range, it shall be tested using any of the following
methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction
Detectors found to have a sensitivity outside the listed and
marked sensitivity range shall be cleaned and recalibrated or
be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors
referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured
using any device that administers an unmeasured concentration
of smoke or other aerosol into the detector.

Based on observation and interview, it was determined that the facility failed to maintain the installation of portable fire extinguishers per NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

Findings include:

Observation, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed the wall mounted, portable fire extinguishers located in the Kitchen, and the Radiology Hall was mounted above five (5) feet from the floor.

Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed that they were not aware of the installation requirements for wall mounted portable fire extinguishers.


Reference NFPA 10 (1998 Edition).

1-6.10 Fire extinguishers having a gross weight
not exceeding 40 lb (18.14 kg) shall be
installed so that the top of the fire
extinguisher is not more than 5 ft (1.53 m)
above the floor. Fire extinguishers having a
gross weight greater than 40 lb (18.14 kg)
(except wheeled types) shall be so installed
that the top of the fire extinguisher is not
more than 3 1/2 ft (1.07 m) above the floor.
In no case shall the clearance between the
bottom of the fire extinguisher and the floor
be less than 4 in. (10.2 cm).

Based on record review and interview, it was determined the facility failed to ensure kitchen hood extinguishing system would activate the fire alarm. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure the kitchen hood suppression system was connected to the fire alarm and gas shut off.

The findings include:

Kitchen Hood Inspection, on 07/31/13 at 11:15 AM, with the Facility Director and the Chief Nursing Officer revealed the kitchen hood suppression system was not connected to the facilities fire alarm or gas shut off. The contractor that inspected the kitchen hood had noted in the memos of the test results that the hood was not compliant. Further observation revealed the means for manual activation was not located in the egress path.

Interview, on 07/31/13 at 11:15 AM with the Facility Director and the Chief Nursing Officer revealed they were aware the hood was not connected to the fire alarm and the gas shut off, however they did not have a plan in place to have the system upgraded. Further interview revealed they were not aware the means for manual activation was to be located in the path of egress.

NFPA 96 (1998 edition)
7-6.2 Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation shall activate the fire alarm signaling system.

Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed a portable space heater located in the Transcriptionist Office, and the Med/Surge Nurses' Station. The facility failed to ensure portable heaters did not exceed 212 degrees.

Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the heaters element could not exceed 212?F in non-sleeping, staff, and employee areas.


Reference: NFPA 101 (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 non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212?F (100?C).

Based on observation and interview, it was determined the facility failed to maintain exit access in accordance with NFPA standards. The deficiency had the potential to affect two (2) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to ensure the means of egress was free of all obstructions or impediments.

The findings include:

Observations, on 07/31/13 at 1:40 PM, with the Facility Director and the Chief Nursing Officer revealed a tool cart and metal bars used in the Therapy Department were being stored in the Medical Records Hall. Further observation revealed a trash cart stored in the Basement Hall by the exit door.

Interview, on 07/31/13 at 1:40 PM, with the Facility Director and the Chief Nursing Officer revealed they did not know why the items were in the egress corridors.

Reference: NFPA 101 (2000 Edition)
Means of Egress Reliability 7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, it was determined the facility failed to ensure trash collection receptacles with capacities greater than 32 gallon were stored in accordance with NFPA standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 at 1:48 PM, with the Facility Director and the Chief Nursing Officer revealed a trash can with a capacity of over thirty two (32) gallons was left unattended in the basement hall next to the exit door.

Interview, on 07/31/13 at 1:48 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware of the requirement for trash receptacles with capacities greater than thirty two (32) gallons.


19.7.5.5
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Based on fire damper testing record review, and interview, it was determined the facility failed to ensure fire/smoke dampers were maintained in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey. The facility failed to provide documentation that the smoke/fire dampers were tested within the last four (4) years.

The findings include:

Fire damper testing record review, on 07/31/13 at 11:20 AM with the Facility Director and the Chief Nursing Officer revealed the facility did not have documentation that fire/smoke dampers had been tested within the last four (4) years.

Interview, on 07/31/13 at 11:20 AM, with the Facility Director and the Chief Nursing Officer revealed they were not aware of the requirements for fire/smoke damper testing.


Reference: NFPA 90A (1999 edition)

3-4.7 Maintenance. At least every 4 years, fusible links (where
applicable) shall be removed; all dampers shall be operated to
verify that they fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.

Based on observation and interview, it was determined the facility failed to maintain doors within a required means of egress, in accordance with NFPA standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff, and visitors. The facility has twenty five (25) certified beds with a census of twelve (12) on the day of the survey.

The findings include:

Observations, on 07/31/13 at 2:11 PM, with the Facility Director and the Chief Nursing Officer revealed unapproved hold open devices (door wedges) holding the doors to the Kitchen open to the dining room

Interviews, on 07/31/13 at 2:11 PM, with the Facility Director and the Chief Nursing Officer revealed they had just became aware the hold open devices (door wedges) were prohibited

Reference: NFPA 101 (2000 Edition)

19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.



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 on observation and interviews it was determined the facility failed to properly store flammable and combustible liquids in accordance with NFPA standards. The deficiency had the potential to affect one (1) of seven (7) smoke compartments, patients, staff and visitors. The facility has twenty five (25) certified beds with a census of twelve (12) on the day of the survey.

The findings include:

Observation, on 07/31/13 at 2:14 PM, with the Facility Director and the Chief Nursing Officer revealed three (3) cans of gel fuel stored in an unrated storage room located in the Dining Room outside the Kitchen. These items were stored on an open table top. All flammable materials shall be stored in a flammable proof cabinet if stored in the facility.

Interview, on 07/31/13 at 2:14 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the gel fuel cans were being stored in the unrated storage room.

NFPA 99,
10-7.2.1* Flammable and Combustible liquids shall be used from and stored in approved containers in accordance with, NFPA 30- 4.3.3

Storage cabinets that meet at least one of the following sets of requirements shall be acceptable for storage of liquids:
(a) Storage cabinets that are designed and constructed to limit the internal temperature at the center of the cabinet and 1 in. (25 mm) from the top of the cabinet to not more than 325?F (162.8?C), when subjected to a 10-minute fire test that simulates the fire exposure of the standard time-temperature curve specified in NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials, shall be acceptable. All joints and seams shall remain tight and the door shall remain securely closed during the test.

Based on generator testing record review and interview, it was determined the facility failed to ensure the emergency generator was maintained in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Generator testing record review, on 7/31/13 at 12:00 PM, with the Facility Director and the Chief Nursing Officer revealed the generator was not being run monthly for thirty (30) minutes. A fifteen minute run was documented on 01/28/13 and the next documented run by the facility was on 07/24/13 which the generator was documented to have run for thirty five (35) minutes. An annual load bank by an outside contractor was performed on 03/15/13 and the generator ran for four (4) hours.

Interview, on 7/31/13 at 12:00 PM, with the Facility Director and the Chief Nursing Officer revealed they felt like the generator was run monthly and it was a documentation error.



Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction

6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established

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.

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.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Observations, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed;

1) Storage of combustible materials within three (3) feet of electrical panels located in the Transfer Switch Room.
2) A power strip was plugged into an extension cord located in the Transcriptionist Office.
3) A refrigerator was plugged into an extension cord located in the Medical Records Office.
4) A microwave, toaster, and coffer maker were plugged into an extension cord located in the Radiology Break Room.
5) A freezer and hydrocolator were plugged into a power strip located in the Therapy Department.
6) The hydrocolator located in the Therapy Department was not plugged into a ground fault (GFCI) protected outlet.
7) Electrical breaker boxes located in the corridor by the cross corridor doors to Radiology, did not have a cover that would protect the electrical breaker to prevent tampering.


Interview, on 07/31/13 between 10:00 AM and 4:00 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware of the misuse of the power strip, and extension cords. Further interview revealed they were not aware the hydrocolator was to be plugged into a ground fault protected (GFCI) outlet, or electrical breaker boxes were to be locked to prevent tampering.






Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.



Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 70 400-8
( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Reference: NFPA 70 (1999 edition)

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.



110-26. Spaces

About Electrical Equipment. Sufficient access and working space shall be provided and maintained around all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

Reference: NFPA 70 (1999 edition)


Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.


Reference NFPA 70 (1999) edition
National Electric Code, relating to ground fault protection for electric outlets near sinks in resident rooms. NFPA: 70 210.8 Receptacles installed under the exceptions to 210.8(A)(5) shall not be considered as meeting the requirements of 210.52(G).
(6) Kitchens - where the receptacles are installed to serve the countertop surfaces
(7) Wet bar sinks - where the receptacles are installed to serve the countertop surfaces and are located within 1.8 m (6 ft) of the outside edge of the wet bar sink.


Reference NFPA 70 (1999 edition)
210.8 Ground-Fault Circuit-Interrupter Protection for Personnel.
FPN: See 215.9 for ground-fault circuit-interrupter protection for personnel on feeders.
(A) Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in (1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms
(2) Garages, and also accessory buildings that have a floor located at or below grade level not intended as habitable rooms and limited to storage areas, work areas, and areas of similar use
Exception No. 1: Receptacles that are not readily accessible.
Exception No. 2: A single receptacle or a duplex receptacle for two appliances located within dedicated space for each appliance that, in normal use, is not easily moved from one place to another and that is cord-and-plug connected in accordance with 400.7(A)(6), (A)(7), or (A)(8).
Receptacles installed under the exceptions to 210.8(A)(2) shall not be considered as meeting the requirements of 210.52(G).
(3) Outdoors
Exception: Receptacles that are not readily accessible and are supplied by a dedicated branch circuit for electric snow-melting or deicing equipment shall be permitted to be installed in accordance with the applicable provisions of Article 426.
(4) Crawl spaces - at or below grade level
(5) Unfinished basements - for purposes of this section, unfinished basements are defined as portions or areas of the basement not intended as habitable rooms and limited to storage areas, work areas, and the like
Exception No. 1: Receptacles that are not readily accessible.
Exception No. 2: A single receptacle or a duplex receptacle for two appliances located within dedicated space for each appliance that, in normal use, is not easily moved from one place to another and that is cord-and-plug connected in accordance with 400.7(A)(6), (A)(7), or (A)(8).
Exception No. 3: A receptacle supplying only a permanently installed fire alarm or burglar alarm system shall not be required to have ground-fault circuit-interrupter protection.
Receptacles installed under the exceptions to 210.8(A)(5) shall not be considered as meeting the requirements of 210.52(G).
(6) Kitchens - where the receptacles are installed to serve the countertop surfaces
(7) Wet bar sinks - where the receptacles are installed to serve the countertop surfaces and are located within 1.8 m (6 ft) of the outside edge of the wet bar sink.
(8) Boathouses
(B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in (1), (2), and (3) shall have ground-fault circuit-interrupter protection for personnel:
(1) Bathrooms
(2) Rooftops
Exception: Receptacles that are not readily accessible and are supplied from a dedicated branch circuit for electric snow-melting or deicing equipment shall be permitted to be installed in accordance with the applicable provisions of Article 426.
(406.8 Receptacles in Damp or Wet Locations.
(A) Damp Locations. A receptacle installed outdoors in a location protected from the weather or in other damp locations shall have an enclosure for the receptacle that is weatherproof when the receptacle is covered (attachment plug cap not inserted and receptacle covers closed).
An installation suitable for wet locations shall also be considered suitable for damp locations.
A receptacle shall be considered to be in a location protected from the weather where located under roofed open porches, canopies, marquees, and the like, and will not be subjected to a beating rain or water runoff.
(B) Wet Locations.
(1) 15- and 20-Ampere Outdoor Receptacles. 15- and 20-ampere, 125- and 250-volt receptacles installed outdoors in a wet location shall have an enclosure that is weatherproof whether or not the attachment plug cap is inserted.
(2) Other Receptacles. All other receptacles installed in a wet location shall comply with (a) or (b):
(a) A receptacle installed in a wet location where the product intended to be plugged into it is not attended while in use (e.g., sprinkler system controller, landscape lighting, holiday lights, and so forth) shall have an enclosure that is weatherproof with the attachment plug cap inserted or removed.
(b) A receptacle installed in a wet location where the product intended to be plugged into it will be attended while in use (e.g., portable tools, and so forth) shall have an enclosure that is weatherproof when the attachment plug is removed.
(C) Bathtub and Shower Space. A receptacle shall not be installed within a bathtub or shower space.

3) Kitchens

Based on interview and facility policy and procedure review, the facility failed to develop a fire watch policy in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of seven (7) smoke compartments, patients, staff, and visitors. The facility is certified for twenty five (25) beds with a census of twelve (12) on the day of the survey.

The findings include:

Policy and Procedure review, on 07/31/13 at 3:30 PM, with the Facility Director and the Chief Nursing Officer revealed the facility failed to provide a written policy outlining an approved fire watch system in the event the fire alarm or sprinkler system is shut down for four (4) or more hours in a twenty four (24) hour period.

Interview, on 07/31/13 at 3:30 PM, with the Facility Director and the Chief Nursing Officer revealed they were not aware the facility did not have an approved fire watch policy.



Reference; NFPA 101 (2000 edition)
9.7.6* Sprinkler System Shutdown.
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.

Reference; NFPA 101 (2000 edition)
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.