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Based on observation and record review, the facility failed to maintain a minimum 18 inches clear distance between storage and ceiling mounted automatic sprinkler heads in accordance with NFPA 8.5.6.1 in one of one laboratory closets and failed to conduct the last quarterly inspection of the automatic sprinkler system in accordance with NFPA 25. This deficient practice potentially affects the sprinkler coverage of combustibles stored in combustible packaging in a confined area. The facility census was 10.

Findings included:

1. Observation on 08/11/14 at 2:40 PM showed numerous boxes of cardboard and paper packaged lab supplies stacked on top shelves to within four inches of the ceiling and the automatic sprinkler head serving the small storage closet. Due to the confined space of the room, high stacked items on the top shelf would directly impede the intended spray pattern of the fire suppression system.

During an interview on 08/11/14 at 2:45 PM Staff C, Maintenance Supervisor, agreed with the observation and stated that he did not know if there was a facility policy that addressed sprinkler clearance in confined enclosures.

2. Record review on 08/12/14 at 9:00 AM, showed no quarterly inspections on the facility's partial automatic sprinkler system during the past 12 months. The last annual inspection, flow test and service was completed by an outside contractor on 05/30/14.

During an interview on 08/12/14 at 9:00 AM Staff DDD, Assistant Maintenance Worker, stated that they checked the valves monthly, but he did not think they had a procedure or were doing quarterly inspections.

NFPA 25 (National Fire Protection Association) lists perscriptive data for frequency of inspection activities. Quarterly inspections should include alarm devices, hydraulic nameplate, and inspection of sprinkler heads for signs of leakage, corrosion or impedements.

Based on observation, record review and interview, the facility failed to show documentation that the generator was being load tested at least annually and was receiving appropriate preventive maintenance in accordance with NFPA 110 to ensure reliability of the facility's single source of emergency power. The deficient practice of unreliable emergency power resources affects the entire facility, patients and staff by potentially impeding their performance of their duties. The facility census was 10.

Observation on 08/11/14 at 3:00 PM showed the facility generator nameplate rating was 650 Kilowatts (kW) and emergency power transferred through three transfer switches.

Record review on 08/12/14 of facility generator maintenance showed no preventive maintenance reports during the past 12 months for the 650 Kilowatt diesel-fueled generator, except for a hand-written maintenance checklist for the months of May through July 2014, used for recording engine performance data.

During interview on 08/11/14 at 4:00 PM, Staff C stated that he or his assistant does weekly preventive maintenance checks and monthly 30 minute exercise runs, and records the data on the log sheet. He stated that he did not know if the generator used more than 30 percent of the facility load and did not have any information or record of annual tests under full supplementary load brought in by an outside vendor. He stated that he had only been in charge of maintenance for one year and did not have any documentation on preventive maintenance to the engine, such as periodic changes of engine oil, oil filters, air filters, and cooling system.

During a telephone interview on 08/19/14, at 9:15 AM, Staff C stated that he could not find a contract with the service company that installed the generator.

Based on observation and interview, the facility failed to maintain a clear width and work area in accordance with The National Electrical Code (NFPA 70), section 110.26 that requires a minimum 30 inches clear working space be provided for equipment that is likely to require examination, servicing, adjustments, or maintenance while energized. This deficient practice of electrical safety and the associated fire hazard puts facility staff and maintenance workers at unnecessary risk. The facility census was 10.

Findings included:

1. Observation on 08/11/14 at 2:48 PM showed a handcart loaded with packages of light bulbs and combustible paper packing materials in electrical equipment closet A202. With the handcart in the room, there was less than 18 inches clear working area in front of the closed electrical panels.

During an interview on 08/11/14 at 2:48 PM, Staff C confirmed the observation and stated that he did not have a policy that governed the safe work area for electrical equipment. He stated that he would find a more suitable area to store the light bulbs and handcart.

The National Electrical Code (NFPA 70) requires in section 110.26 that adequate working space be provided for equipment that is likely to require examination, servicing, adjustments, or maintenance while energized. The minimum depth of the working space in front of equipment is normally three feet but is increased to four feet for electrical equipment operating between 151-600 volts, nominal, to ground under certain conditions. The width of the working space is required to be the width of the electrical equipment, but not less than 30 inches. The height of the working space is required to be the height of the electrical equipment, but not less than 6 ½ feet. The working space is required to be clear space and cannot be used for storage.

Based on observation and record review, the facility failed to maintain a minimum 18 inches clear distance between storage and ceiling mounted automatic sprinkler heads in accordance with NFPA 8.5.6.1 in one of one laboratory closets and failed to conduct the last quarterly inspection of the automatic sprinkler system in accordance with NFPA 25. This deficient practice potentially affects the sprinkler coverage of combustibles stored in combustible packaging in a confined area. The facility census was 10.

Findings included:

1. Observation on 08/11/14 at 2:40 PM showed numerous boxes of cardboard and paper packaged lab supplies stacked on top shelves to within four inches of the ceiling and the automatic sprinkler head serving the small storage closet. Due to the confined space of the room, high stacked items on the top shelf would directly impede the intended spray pattern of the fire suppression system.

During an interview on 08/11/14 at 2:45 PM Staff C, Maintenance Supervisor, agreed with the observation and stated that he did not know if there was a facility policy that addressed sprinkler clearance in confined enclosures.

2. Record review on 08/12/14 at 9:00 AM, showed no quarterly inspections on the facility's partial automatic sprinkler system during the past 12 months. The last annual inspection, flow test and service was completed by an outside contractor on 05/30/14.

During an interview on 08/12/14 at 9:00 AM Staff DDD, Assistant Maintenance Worker, stated that they checked the valves monthly, but he did not think they had a procedure or were doing quarterly inspections.

NFPA 25 (National Fire Protection Association) lists perscriptive data for frequency of inspection activities. Quarterly inspections should include alarm devices, hydraulic nameplate, and inspection of sprinkler heads for signs of leakage, corrosion or impedements.

Based on observation, record review and interview, the facility failed to show documentation that the generator was being load tested at least annually and was receiving appropriate preventive maintenance in accordance with NFPA 110 to ensure reliability of the facility's single source of emergency power. The deficient practice of unreliable emergency power resources affects the entire facility, patients and staff by potentially impeding their performance of their duties. The facility census was 10.

Observation on 08/11/14 at 3:00 PM showed the facility generator nameplate rating was 650 Kilowatts (kW) and emergency power transferred through three transfer switches.

Record review on 08/12/14 of facility generator maintenance showed no preventive maintenance reports during the past 12 months for the 650 Kilowatt diesel-fueled generator, except for a hand-written maintenance checklist for the months of May through July 2014, used for recording engine performance data.

During interview on 08/11/14 at 4:00 PM, Staff C stated that he or his assistant does weekly preventive maintenance checks and monthly 30 minute exercise runs, and records the data on the log sheet. He stated that he did not know if the generator used more than 30 percent of the facility load and did not have any information or record of annual tests under full supplementary load brought in by an outside vendor. He stated that he had only been in charge of maintenance for one year and did not have any documentation on preventive maintenance to the engine, such as periodic changes of engine oil, oil filters, air filters, and cooling system.

During a telephone interview on 08/19/14, at 9:15 AM, Staff C stated that he could not find a contract with the service company that installed the generator.

Based on observation and interview, the facility failed to maintain a clear width and work area in accordance with The National Electrical Code (NFPA 70), section 110.26 that requires a minimum 30 inches clear working space be provided for equipment that is likely to require examination, servicing, adjustments, or maintenance while energized. This deficient practice of electrical safety and the associated fire hazard puts facility staff and maintenance workers at unnecessary risk. The facility census was 10.

Findings included:

1. Observation on 08/11/14 at 2:48 PM showed a handcart loaded with packages of light bulbs and combustible paper packing materials in electrical equipment closet A202. With the handcart in the room, there was less than 18 inches clear working area in front of the closed electrical panels.

During an interview on 08/11/14 at 2:48 PM, Staff C confirmed the observation and stated that he did not have a policy that governed the safe work area for electrical equipment. He stated that he would find a more suitable area to store the light bulbs and handcart.

The National Electrical Code (NFPA 70) requires in section 110.26 that adequate working space be provided for equipment that is likely to require examination, servicing, adjustments, or maintenance while energized. The minimum depth of the working space in front of equipment is normally three feet but is increased to four feet for electrical equipment operating between 151-600 volts, nominal, to ground under certain conditions. The width of the working space is required to be the width of the electrical equipment, but not less than 30 inches. The height of the working space is required to be the height of the electrical equipment, but not less than 6 ½ feet. The working space is required to be clear space and cannot be used for storage.