HospitalInspections.org

Based on observation and staff interview, the facility failed to separate hazardous areas from the exit corridor. This deficient practice would allow smoke and fire to migrate throughout the exit corridor affecting all residents, staff, and visitors in the corridor. Facility census was 10.

Findings are:

Observations during the facility tour on 9-23-15 at 2:40 pm revealed the door for housekeeping soiled utility next to pharmacy failed to positive latch within the door frame.

During an interview on 9-23-15 at 2:40 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, facility failed to ensure exit access was arranged that exits was readily accessible at all times. This deficient practice could cause a delay in evacuating the building in the event of an emergency affecting all residents, staff, and visitors. The facility census was 10 residents.

Findings are:

Observations during the facility tour on 9-23-15 between 2:05 pm and 2:47 pm revealed:
1. The power doors in the front lobby did not have a sign install stating " IN EMERGENCY PUSH TO OPEN" .


During an interview on 9-23-15 between 2:05 pm and 2:47 pm, observation was acknowledged and verified by Maintenance A.

NFPA Standard:
NFPA 101, 2000 ed., 19.2.1
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

2000 NFPA 101, 7.2.1.9.1
Where means of egress doors are operated by power upon the approach of a person or doors with power-assisted manual operation, the design shall be such that, in the event of power failure, the door opens manually to allow egress travel or closes where necessary to safeguard the means of egress. The forces required to open such doors manually shall not exceed those required in 7.2.1.4.5, except that the force required to set the door in motion shall not exceed 50 lbf (222 N). The door shall be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4). On the egress side of each door, there shall be a readily visible, durable sign that reads as follows:
IN EMERGENCY, PUSH TO OPEN
The sign shall be in letters not less than 1 in. (2.5 cm) high on a contrasting background.
Exception No. 1: Sliding, power-operated doors in exit access serving an occupant load of fewer than 50 that manually open in the direction of door travel with forces not exceeding those required in 7.2.1.4.5 shall not be required to have a swing-out feature. The required sign shall read as follows:
IN EMERGENCY, SLIDE TO OPEN
Exception No. 2*: In the emergency breakout mode, a door leaf located within a two-leaf opening shall be exempt from the minimum 32-in. (81-cm) single-leaf requirement of 7.2.1.2.3, provided that the clear width of the single leaf is not less than 30 in. (76 cm).
Exception No. 3: For a biparting sliding door in the emergency breakout mode, a door leaf located within a multiple-leaf opening shall be exempt from the minimum 32-in. (81-cm) single-leaf requirement of 7.2.1.2.3 if a clear opening of not less than 32 in. (81 cm) is provided by all leafs broken out.
Exception No. 4: Doors complying with 7.2.1.14 shall be permitted to be used.
Exception No. 5: This requirement shall not apply where otherwise provided in Chapters 22 and 23

Based on record review and staff interview, the facility failed to conduct fire drills in accordance with NFPA 101. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility census was 10.

Findings are:

Record review of the fire drill report on 9-23-15 at 3:15 pm revealed that the facility had failed to conduct any fire drills for the 4th quarter of 2014 and 1st quarter of 2015. Also, the facility failed to provide any documentation from the central monitoring services showing the signals were received.

During an interview on 9-23-15 at 3:15 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standard:
NFPA 101, 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.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association 72. This deficient practice would delay the response time of emergency responders in the event of a fire affecting all residents, staff, and visitors. Facility census was 69.

Findings are:

Documentation review of the automatic fire alarm reports on 9-23-15 at 3:22 pm revealed that biennial smoke sensitivity test was not completed.

During an interview on 9-23-15 at 3:22 pm, observation was acknowledged and verified by Maintenance A.

NFPA Standard:

NFPA 101, 2000 ed. 9.6.1.4* A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with applicable requirements of NFPA 70 (National Electictrical Code) and NFPA 72 (National Fire Alarm Code)

NFPA 72, 1999 ed., 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.

Based on record review and staff interview, the facility failed to ensure the required automatic fire sprinkler systems are continuously maintained in reliable operating condition. This deficient practice could prevent the fire suppression system from extinguishing a fire as designed affecting all residents, visitors, and staff. The facility census was 10 residents.

Findings are:


Documentation review of the fire sprinkler system on 9-23-15 at 2:29 pm revealed that the facility failed to do a quarterly flow test for the 1st quarter of 2015.

During an interview on 9-23-15 at 2:29 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standard:
1999 NFPA 13, 12.1
A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

1999 NFPA 13, 5-6.6
The clearance between the deflector and the top of storage shall be 18 inches or greater.

Based on observation and staff interview the facility failed to ensure that the fire extinguishers were readily accessible and immediately available in the event of a fire. This deficient practice would delay the extinguishment of a fire affecting all residents, staff, and visitors in the area. The facility census was 10.

Observation on 9-23-15 at 2:51 pm, revealed a ladder obstructing access to the fire extinguisher in the utility room .

During an interview on 9-23-15 at 2:51 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standard:
1998 ed. NFPA 10, 1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Based on record review and staff interview, the facility failed to provide current annual boiler inspection certification for the boiler. This failure would increase the probability of boiler failure and affected all residents in the facility. Facility census was 10 residents.

Findings are:
Record review of the boiler certificate on 9-23-15 at 2:17 pm revealed 3 boilers in boiler room was last inspected in November of 2013.

During an interview on 9-23-15 at 2:17 pm, observations were acknowledged and verified by Maintenance A.


Regulation: NBIA 48-701 - 48-743

48-722. State boiler inspector; inspection; exception; contract with authorized inspection agency; certification.
(1) Except as provided in subsections (3) and (4) of this section, the state boiler inspector shall inspect or cause to be inspected at least once every twelve months all boilers required to be inspected by the Boiler Inspection Act to determine whether the boilers are in a safe and satisfactory condition and properly constructed and maintained for the purpose for which the boiler is used, except that (a) hobby boilers, steam farm traction engines, portable and stationary show engines, and portable and stationary show boilers, which are not otherwise exempted from the act pursuant to section 48-726 , shall be subject to inspection at least once every twenty-four months and (b) the commissioner may, by rule and regulation, establish inspection periods for pressure vessels of more than twelve months, but not to exceed the inspection period recommended in the National Board Inspection Code or the American Petroleum Institute Pressure Vessel Inspection Code API-510 for pressure vessels being used for similar purposes. In order to ensure that inspections are performed in a timely manner, the department may contract with an authorized inspection agency to perform any inspection authorized under the Boiler Inspection Act. If the department contracts with an authorized inspection agency to perform inspections, such contract shall be in writing and shall contain an indemnification clause wherein the authorized inspection agency agrees to indemnify and defend the department for loss occasioned by negligent or tortious acts committed by special inspectors employed by such authorized inspection agency when performing inspections on behalf of the department.
(2) No boilers required to be inspected by the act shall be operated without valid and current certification pursuant to rules and regulations adopted and promulgated by the commissioner in accordance with the requirements of the Administrative Procedure Act. The owner of any boiler installed after September 2, 1973, shall file a manufacturer's data report covering the construction of such boiler with the state boiler inspector. Such reports shall be used to assist the state boiler inspector in the certification of boilers. No boiler required to be inspected by the Boiler Inspection Act shall be operated at any type of public gathering or show without first being inspected and certified as to its safety by the state boiler inspector or a special inspector commissioned pursuant to section 48-731 . Antique engines with boilers may be brought into the state from other states without inspection, but inspection as provided in this section shall be made and the boiler certified as safe before being operated.
(3) The commissioner may, by rule and regulation, waive the inspection of unfired pressure vessels registered with the State of Nebraska if the commissioner finds that the owner or user of the unfired pressure vessel follows a safety inspection and repair program that is based upon nationally recognized standards.
(4) A boiler that is used as a water heater to supply potable hot water and that is not otherwise exempt from inspection under the act pursuant to section 48-726 shall be subject to inspection at least once every twenty-four months in accordance with a schedule of inspection established by the commissioner by rule and regulation.
Source:Laws 1943, c. 112, § 2(1), p. 392; R.S.1943, § 48-702 ; Laws 1961, c. 235, § 5, p. 698; Laws 1971, LB 886, § 1; Laws 1973, LB 481, § 1; R.S.1943, (1984), § 48-702 ; Laws 1987, LB 462, § 4; Laws 1995, LB 438, § 2; Laws 1997, LB 641, § 2; Laws 1998, LB 395, § 13; Laws 1999, LB 66, § 2; Laws 2007, LB226, § 2; Laws 2009, LB627, § 1.Effective Date: August 30, 2009

Based on record review and staff interview, the facility failed to conduct a monthly test on the generator for at least 30 minutes with the generator under at least 30% of the nameplate load rating or conducting an annual load bank test. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator does not ensure proper operation and prompt repair affecting all residents, staff, and visitors. Facility census was 10.
Findings are:

Record review conducted on 9-24-15 at 2:55 pm of the facility ' s generator inspection testing and maintenance records revealed that facility is unable to do a monthly load test with a 30% of the nameplate rating for at least 30 minutes with an additional cool-down period and was unable to provide evidence of an annual load bank test in lieu of the 30% monthly test.

During an interview on 9-24-15 at 2:55 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standards:
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
c) The date and time of day for required testing shall be decided by the owner, based on facility operations 1999 NPPA 110, 6-4.2

Based on observation and staff interview, the facility failed to separate hazardous areas from the exit corridor. This deficient practice would allow smoke and fire to migrate throughout the exit corridor affecting all residents, staff, and visitors in the corridor. Facility census was 10.

Findings are:

Observations during the facility tour on 9-23-15 at 2:40 pm revealed the door for housekeeping soiled utility next to pharmacy failed to positive latch within the door frame.

During an interview on 9-23-15 at 2:40 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, facility failed to ensure exit access was arranged that exits was readily accessible at all times. This deficient practice could cause a delay in evacuating the building in the event of an emergency affecting all residents, staff, and visitors. The facility census was 10 residents.

Findings are:

Observations during the facility tour on 9-23-15 between 2:05 pm and 2:47 pm revealed:
1. The power doors in the front lobby did not have a sign install stating " IN EMERGENCY PUSH TO OPEN" .


During an interview on 9-23-15 between 2:05 pm and 2:47 pm, observation was acknowledged and verified by Maintenance A.

NFPA Standard:
NFPA 101, 2000 ed., 19.2.1
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

2000 NFPA 101, 7.2.1.9.1
Where means of egress doors are operated by power upon the approach of a person or doors with power-assisted manual operation, the design shall be such that, in the event of power failure, the door opens manually to allow egress travel or closes where necessary to safeguard the means of egress. The forces required to open such doors manually shall not exceed those required in 7.2.1.4.5, except that the force required to set the door in motion shall not exceed 50 lbf (222 N). The door shall be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4). On the egress side of each door, there shall be a readily visible, durable sign that reads as follows:
IN EMERGENCY, PUSH TO OPEN
The sign shall be in letters not less than 1 in. (2.5 cm) high on a contrasting background.
Exception No. 1: Sliding, power-operated doors in exit access serving an occupant load of fewer than 50 that manually open in the direction of door travel with forces not exceeding those required in 7.2.1.4.5 shall not be required to have a swing-out feature. The required sign shall read as follows:
IN EMERGENCY, SLIDE TO OPEN
Exception No. 2*: In the emergency breakout mode, a door leaf located within a two-leaf opening shall be exempt from the minimum 32-in. (81-cm) single-leaf requirement of 7.2.1.2.3, provided that the clear width of the single leaf is not less than 30 in. (76 cm).
Exception No. 3: For a biparting sliding door in the emergency breakout mode, a door leaf located within a multiple-leaf opening shall be exempt from the minimum 32-in. (81-cm) single-leaf requirement of 7.2.1.2.3 if a clear opening of not less than 32 in. (81 cm) is provided by all leafs broken out.
Exception No. 4: Doors complying with 7.2.1.14 shall be permitted to be used.
Exception No. 5: This requirement shall not apply where otherwise provided in Chapters 22 and 23

Based on record review and staff interview, the facility failed to conduct fire drills in accordance with NFPA 101. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility census was 10.

Findings are:

Record review of the fire drill report on 9-23-15 at 3:15 pm revealed that the facility had failed to conduct any fire drills for the 4th quarter of 2014 and 1st quarter of 2015. Also, the facility failed to provide any documentation from the central monitoring services showing the signals were received.

During an interview on 9-23-15 at 3:15 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standard:
NFPA 101, 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.

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association 72. This deficient practice would delay the response time of emergency responders in the event of a fire affecting all residents, staff, and visitors. Facility census was 69.

Findings are:

Documentation review of the automatic fire alarm reports on 9-23-15 at 3:22 pm revealed that biennial smoke sensitivity test was not completed.

During an interview on 9-23-15 at 3:22 pm, observation was acknowledged and verified by Maintenance A.

NFPA Standard:

NFPA 101, 2000 ed. 9.6.1.4* A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with applicable requirements of NFPA 70 (National Electictrical Code) and NFPA 72 (National Fire Alarm Code)

NFPA 72, 1999 ed., 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.

Based on record review and staff interview, the facility failed to ensure the required automatic fire sprinkler systems are continuously maintained in reliable operating condition. This deficient practice could prevent the fire suppression system from extinguishing a fire as designed affecting all residents, visitors, and staff. The facility census was 10 residents.

Findings are:


Documentation review of the fire sprinkler system on 9-23-15 at 2:29 pm revealed that the facility failed to do a quarterly flow test for the 1st quarter of 2015.

During an interview on 9-23-15 at 2:29 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standard:
1999 NFPA 13, 12.1
A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

1999 NFPA 13, 5-6.6
The clearance between the deflector and the top of storage shall be 18 inches or greater.

Based on observation and staff interview the facility failed to ensure that the fire extinguishers were readily accessible and immediately available in the event of a fire. This deficient practice would delay the extinguishment of a fire affecting all residents, staff, and visitors in the area. The facility census was 10.

Observation on 9-23-15 at 2:51 pm, revealed a ladder obstructing access to the fire extinguisher in the utility room .

During an interview on 9-23-15 at 2:51 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standard:
1998 ed. NFPA 10, 1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

Based on record review and staff interview, the facility failed to provide current annual boiler inspection certification for the boiler. This failure would increase the probability of boiler failure and affected all residents in the facility. Facility census was 10 residents.

Findings are:
Record review of the boiler certificate on 9-23-15 at 2:17 pm revealed 3 boilers in boiler room was last inspected in November of 2013.

During an interview on 9-23-15 at 2:17 pm, observations were acknowledged and verified by Maintenance A.


Regulation: NBIA 48-701 - 48-743

48-722. State boiler inspector; inspection; exception; contract with authorized inspection agency; certification.
(1) Except as provided in subsections (3) and (4) of this section, the state boiler inspector shall inspect or cause to be inspected at least once every twelve months all boilers required to be inspected by the Boiler Inspection Act to determine whether the boilers are in a safe and satisfactory condition and properly constructed and maintained for the purpose for which the boiler is used, except that (a) hobby boilers, steam farm traction engines, portable and stationary show engines, and portable and stationary show boilers, which are not otherwise exempted from the act pursuant to section 48-726 , shall be subject to inspection at least once every twenty-four months and (b) the commissioner may, by rule and regulation, establish inspection periods for pressure vessels of more than twelve months, but not to exceed the inspection period recommended in the National Board Inspection Code or the American Petroleum Institute Pressure Vessel Inspection Code API-510 for pressure vessels being used for similar purposes. In order to ensure that inspections are performed in a timely manner, the department may contract with an authorized inspection agency to perform any inspection authorized under the Boiler Inspection Act. If the department contracts with an authorized inspection agency to perform inspections, such contract shall be in writing and shall contain an indemnification clause wherein the authorized inspection agency agrees to indemnify and defend the department for loss occasioned by negligent or tortious acts committed by special inspectors employed by such authorized inspection agency when performing inspections on behalf of the department.
(2) No boilers required to be inspected by the act shall be operated without valid and current certification pursuant to rules and regulations adopted and promulgated by the commissioner in accordance with the requirements of the Administrative Procedure Act. The owner of any boiler installed after September 2, 1973, shall file a manufacturer's data report covering the construction of such boiler with the state boiler inspector. Such reports shall be used to assist the state boiler inspector in the certification of boilers. No boiler required to be inspected by the Boiler Inspection Act shall be operated at any type of public gathering or show without first being inspected and certified as to its safety by the state boiler inspector or a special inspector commissioned pursuant to section 48-731 . Antique engines with boilers may be brought into the state from other states without inspection, but inspection as provided in this section shall be made and the boiler certified as safe before being operated.
(3) The commissioner may, by rule and regulation, waive the inspection of unfired pressure vessels registered with the State of Nebraska if the commissioner finds that the owner or user of the unfired pressure vessel follows a safety inspection and repair program that is based upon nationally recognized standards.
(4) A boiler that is used as a water heater to supply potable hot water and that is not otherwise exempt from inspection under the act pursuant to section 48-726 shall be subject to inspection at least once every twenty-four months in accordance with a schedule of inspection established by the commissioner by rule and regulation.
Source:Laws 1943, c. 112, § 2(1), p. 392; R.S.1943, § 48-702 ; Laws 1961, c. 235, § 5, p. 698; Laws 1971, LB 886, § 1; Laws 1973, LB 481, § 1; R.S.1943, (1984), § 48-702 ; Laws 1987, LB 462, § 4; Laws 1995, LB 438, § 2; Laws 1997, LB 641, § 2; Laws 1998, LB 395, § 13; Laws 1999, LB 66, § 2; Laws 2007, LB226, § 2; Laws 2009, LB627, § 1.Effective Date: August 30, 2009

Based on record review and staff interview, the facility failed to conduct a monthly test on the generator for at least 30 minutes with the generator under at least 30% of the nameplate load rating or conducting an annual load bank test. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator does not ensure proper operation and prompt repair affecting all residents, staff, and visitors. Facility census was 10.
Findings are:

Record review conducted on 9-24-15 at 2:55 pm of the facility ' s generator inspection testing and maintenance records revealed that facility is unable to do a monthly load test with a 30% of the nameplate rating for at least 30 minutes with an additional cool-down period and was unable to provide evidence of an annual load bank test in lieu of the 30% monthly test.

During an interview on 9-24-15 at 2:55 pm, observations were acknowledged and verified by Maintenance A.

NFPA Standards:
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
c) The date and time of day for required testing shall be decided by the owner, based on facility operations 1999 NPPA 110, 6-4.2