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Based on observation and staff interview, the facility fails to assure that any modification or additions to the facility complies with the Life Safety Code. Failure to submit plans for approval does not ensure the construction requirements are met. This would allow heat, smoke and fire products to travel into these areas in the event of a fire, affecting all patients, visitors and staff in 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 2 at the time of the survey.

Findings Include:

During the survey conducted on November 3, 2020 the following is observed

It was observed at 4:45 PM there has been a modular x-ray room addition to the back of the patient wing. There is a breezeway constructed to connect it to the existing hospital. This modular room is type V construction with no sprinkler system installed. The breezeway that connects the modular building to the existing hospital has no sprinkler protection and extends to cover the exit door from the patient wing. The modular building has installed detection and notification devices tied to the hospitals fire alarm system. No plans have been submitted to the OSFM for review of the addition.

Staff Maintenance 1 was present and acknowledged the findings.

Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)

Based on observation and staff interview the facility fails to ensure that all means of egress are free of all obstructions or impediments to a full instant use. This deficient practice could impede occupants from exiting in the event of a fire or other emergency situation, affecting patients, visitors and staff in 1 of 4 smoke zones including the dining area. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During the survey on November 3, 2020 the following is observed:

1. It was observed at 11:38 AM in the maintenance hall there are boxes of janitorial supplies siting by the door.
2. It was observed at 11:40 AM on the outside of the maintenance hall exit door there is scrap metal and used medical equipment obstructing sidewalk.

Staff Maintenance 1 was present and acknowledged the findings.

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

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

Based on observation the facility failed to provide emergency lighting in accordance with NFPA 101 (2012). This deficiency affects patients, staff and visitors in 3 of 4 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During the survey on November 3, 2020 the following observation is made:

1. It was observed at 3:57 PM the emergency light in the hallway by room 204 failed to illuminate. The backup power source for this light is the emergency generator.
2. It was observed at 4:31 PM the emergency light above the generator is hanging by the wires.

Staff Maintenance 1 was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Emergency lighting shall be provided in accordance with Section 7.9. 2012 NFPA 101, 19.2.9.1

Review of the following NFPA Standard revealed: Emergency illumination shall be provided for a minimum of 1 ½ 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 (l0.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 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 (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 ½ hours. A maximum-to minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. 2012 NFPA 101, 7.9.2.1

Based on document review and staff interview the facility fails to properly inspect and maintain their exit signs as required in Life Safety Code 101. The deficient practice would affect all patients, visitors and staff in 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of the survey.
Findings include:
During the survey conducted on November 3, 2020 the following deficiency is noted:
1. It was observed at 12:46 PM the exit light above the clinic entrance failed to illuminate when tested. 2. It was observed at 1:03 PM the exit light in the surgery hall is not illuminated.
Staff Maintenance 1 was present and acknowledged the findings.
NFPA Standard: NFPA 101 2012 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. 7.10.5.1* General. Every sign required by 7.10.1.2, 7.10.1.5, or 7.10.8.1, 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. 7.10.5.2.1 Every sign required to be illuminated by 7.10.6.3, 7.10.7, and 7.10.8.1 shall be continuously illuminated as required under the provisions of Section 7.8, unless otherwise provided in 7.10.5.2.2. 7.9.3 Periodic Testing of Emergency Lighting Equipment. 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum
of 11/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on staff interview and observation, the facility fails to install and maintain the Alcohol-Based Hand Rub dispensers in accordance with NFPA 101. The deficient practice would affect patients, visitors and staff in 1 of 4 smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the survey on November 3, 2020 the following deficiency is noted:

It was observed at 12:49 PM in the clinic by room #8 there was an ABH alcohol-based hand-rub dispenser installed above an outlet.

Staff Maintenance 1 was present and acknowledged the findings.

NFPA Standard: Life Safety Code 101 2012 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source.

Based on observation and staff interview the facility fails to provide a fire alarm system installed and maintained in accordance with NFPA 72. This deficient practice may result in the fire alarm system failing to notify patients, staff and visitors in the event of an emergency in 1 of 4 smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the survey on November 3, 2020 the following was observed:

It was observed at 4:13 PM in the Physical Therapy wing there are no fire alarm notification devices installed. There are rooms in this hall being used by staff to sleep in. Those rooms are 302, 304, 305, 306 and 307.

Staff Maintenance 1 was present and acknowledged the findings.

Fire Alarm - Notification
2012 EXISTING
Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals.
In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire.
19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1)

Based on observation, interview and record review, the facility failed to maintain and test the fire alarm system in accordance with NFPA 72 . Failure to maintain the fire alarm system in accordance with NFPA 72 can prevent the system from working as designed, components and initiating devices from working as designed and delaying notification of residents and staff in the event of a fire affecting all patients, visitors and staff in 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of this survey.

Findings include:

During the survey on November 3, 2020 the following was observed:

1. At 10:07 AM during documentation review there is no documentation of the magnetic door holders that are tied to the fire alarm system being tested on the 2019 and 2020 reports.
2. At 10:13 AM during documentation review there is no documentation of a semi-annual fire alarm inspection, testing and maintenance.

Staff Maintenance 1 was present and acknowledged the findings.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

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

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

Based on observation and staff interview, this facility failed to install a complete automatic sprinkler system as required by the Life Safety Code. This facility is a one-story building composed of combustible construction and is required to be completely sprinklered. This deficient practice affects all patients, visitors and staff in 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 2 at the time of this survey.

Findings Include:

During the survey conducted on November 3, 2020 the following is observed

It was observed at 4:45 PM there has been a modular x-ray room addition to the back of the patient wing. There is a breezeway constructed connecting it to the existing hospital. No sprinkler protection is provided for the breezeway or x-ray building.

Staff Maintenance 1 was present and acknowledged the findings.

NFPA Standard: NFPA 101, 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in
One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in
Residential Occupancies up to and Including Four Stories in
Height

NFPA Standard: NFPA 13 (2010), 8.15.7* Exterior Roofs, Canopies, Porte-Cocheres, Balconies, Decks, or Similar Projections.
8.15.7.1 Unless the requirements of 8.15.7.2, 8.15.7.3, or 8.15.7.4 are met, sprinklers shall be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding 4 ft (1.2 m) in width.
8.15.7.2* Sprinklers shall be permitted to be omitted where the canopies, roofs, porte-cocheres, balconies, decks, or similar projections are constructed with materials that are noncombustible, limited-combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant- Treated Wood and Fire-Retardant Coatings for Building Materials.
8.15.7.3 Sprinklers shall be permitted to be omitted from below the canopies, roofs, porte-cocheres, balconies, decks, or similar projections of combustible construction, provided the exposed finish material on the roofs, canopies, or porte-cocheres are noncombustible, limited-combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials, and the roofs, canopies, or porte-cocheres contain only sprinklered concealed spaces or any of the following unsprinklered combustible concealed spaces:

Based on observation, record review and interview the facility fails to ensure that the automatic sprinkler system is installed, maintained and tested in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will be properly prepared in the event of a fire, affecting all residents in 4 of 4 smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the survey on November 3, 2020 the following observations were made:

1. It was observed at 11:46 AM by the maintenance office the sprinkler is missing the escutcheon.
2. It was observed at 11:57 AM in the mail room the sprinkler head has been painted.
3. It was observed at 1:11 PM in the sprinkler riser room no sprinkler head wrench is located with the spare sprinkler heads.

Staff Maintenance 1 was present and acknowledged the findings.

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Review of the following NFPA Standard revealed: Sprinklers shall be inspected from the floor level annually. 2011 NFPA 25, 5.2.1.1

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients, staff and visitors in 4 of 4 smoke zones. The facility has a capacity of 25 and a census of 2.

Findings include:

During the survey on November 3, 2020 the following observations were made

At 11:01 AM during documentation review of the fire drills for the previous (5) quarters the fire drills there are multiple fire drills held at the end of the month.

Staff Maintenance 1 was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8

Based on observation and staff interview the facility failed to provide corridors safe from excessive combustible decorations. Failure to keep doors and walls free from excessive combustible decorations can provide additional fuels than can ignite in the event of a fire in escape pathways. This deficiency affects patients, visitor and staff in 1 of 4 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of survey.

Findings include:

During the survey on November 3, 2020 the following observations were made:

It was observed at 12:29 PM the corridor side of the lab supply closet door is completely covered with combustible decorations.

Staff Maintenance 1 was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Combustible Decorations
Combustible decorations shall be prohibited unless one of the following is met:
o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product.
o Decorations meet NFPA 701.
o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289.
o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4).
o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present.
19.7.5.6

Based upon a review of records and staff interview, the facility failed to provide a medical gas system in accordance with NFPA 99 standard for Health Care Facilities. The deficient practice reduces the reliability of the medical gas system affecting all patients within the facility in 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of this survey.

Findings include:

During the routine survey on November 3, 2020 the following observations were made:

It was observed at 4:42 PM the fenced in medical gas supply tank located near the parking lot at the rear of the hospital is not properly marked with "Medical Gases, NO Smoking or Open Flame" signs.

Staff Maintenance 1 was present and acknowledged the findings.

Gas and Vacuum Piped Systems - Central Supply System Identification and Labeling
Containers, cylinders and tanks are designed, fabricated, tested, and marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. Locations containing only oxygen or medical air have doors labeled with "Medical Gases, NO Smoking or Open Flame." Locations containing other gases have doors labeled "Positive Pressure Gases, NO Smoking or Open Flame, Room May Have Insufficient Oxygen, Open Door and Allow Room to Ventilate Before Opening."
5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99)

Based on observation, interview, and review of records, the hospital failed to ensure that the medical gas system is maintained in accordance with the National Fire Protection Association (NFPA) 99 which resulted in an Immediate Jeopardy (IJ - a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments or death to a patient) finding. This deficient practice failed to ensure patients are being provided with the minimum amount of medical gas flow from the wall outlet. The deficient practice affects patients in (2) treatment rooms in the hospital. The facility has 25 certified beds and at the time of the survey had a census of 2 patients.

Findings Include:

Documentation review during a routine survey at 11:02 AM on November 3, 2020 of the annual Medical (Med) Gas Testing Report from a medical gas testing company dated June 2, 2020 showed the following deficiencies:

1. Medical Gas Outlet in room 203 low minimum flow due to possible obstruction of the outlet.
2. Medical Gas Outlet in room 209 low minimum flow due to possible obstruction of the outlet.

The regional maintenance director received this inspection report by mid-June 2020.

There is no documentation that the facility repaired or replaced either of the outlets since receiving this inspection report.

During an interview on November 3, 2020 at 11:05 AM, the Facility Maintenance Director (FMD) said that he had not seen the report prior to getting it for documentation review by the Fire Marshal Inspector. The FMD indicated that he had taken those outlets apart and cleaned them multiple times during the past couple of years. The FMD also indicated that he was planning on replacing them due to a complaint last week from the nursing staff. Nursing staff had told FMD that when the oxygen equipment was plugged into outlet in room 203 it began leaking.

Following the document review, contact was made with representatives from Evergreen Medical Services. The supervisor from the medical gas testing company advised that he had been onsite during that inspection. During interview with the Supervisor he indicated that the outlets in 203 and 209 had failed during previous annual testing due to low flow rates caused by possible obstructions in the outlets. After the phone interview the 2018 and 2019 Medical Gas Testing Reports were reviewed. The reports showed that room 203 had failed in both reports due to low flow of 2.0 SFCM and room 209 had also failed both with 1.5 SFCM. The minimum SFCM flow from the outlets is 3.5 SFCM. Room 203 has been in use by patients requiring use of medical gas since the June 2, 2020 testing. The room 209 has not been used but has been turned into a COVID-19 treatment room.

The facility/FMD were notified at 3:30 PM on November 3, 2020 that these deficiencies represent an Immediate Jeopardy.

The hospital removed the IJ on November 3, 2020 at 3:41 PM when they submitted a plan to close rooms 203 and 209 to patients and to notify staff that those rooms were out of service until the med gas outlets were repaired.

The plan of removal also included the following:
The med gas repair company will arrive at Sedan City Hospital on 11/06/2020.
The Identified Deficiencies will be repaired and in full compliance.
The Identified Deficiencies include the low flow of medical gas in patient rooms 203 and 206.
Once the repairs are made, the med gas repair company will provide the hospital with a full report that documents the corrections.
Once the report is received by the hospital, it will be reported immediately to the Kansas State Fire Marshal Office.


Review of the following NFPA Standard revealed: Medical Air Systems shall have operational pressure testing for their piped medical air systems. (NFPA 99) 5.1.12.3.10
Review of the following NFPA Standard revealed: 5.1.12.3.10 Operational Pressure Test. Operational pressure tests shall be performed at each station outlet/inlet or terminal where the user makes connections and disconnections.
5.1.12.3.10.1 Tests shall be performed with the gas of system designation or the operating vacuum.
5.1.12.3.10.2 All gas outlets with a gauge pressure of 345 kPa (50 psi), including, but not limited to, oxygen, nitrous oxide, medical air, and carbon dioxide, shall deliver 100 SLPM (3.5 SCFM) with a pressure drop of not more than 35 kPa (5 psi) and static pressure of 345 kPa to 380 kPa (50 psi to 55 psi).

Based on observation, interview, and review of records, the hospital failed to ensure that the generator is installed and monitored in accordance with the National Fire Protection Association (NFPA) 99 and (NFPA) 110 which resulted in an Immediate Jeopardy (IJ - a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments or death to a patient) finding. The hospital failed to provide an annunciator panel for the generator that provides emergency power to the hospital during an emergency is reliable. The deficient practice affects all patients, visitors and staff in the hospital. The facility has 25 certified beds and at the time of the survey had a census of 2 patients.


Findings include:

During the survey on November 3rd, 2020 the following is observed:

It was observed at 3:54 PM during interview with the facility maintenance director revealed the emergency generator located in the lower level boiler room does not have a remote annunciator panel installed. Not having a annuniciator panel installed that is connected to the generator would prevent staff from being notified when the generator was in trouble. The generator provides backup emergency power to the emergency and exit lighting, all red outlets and switches and everything in (2) emergency rooms.

During the survey on November 4th, 2020 the following is observed:

During an interview at 11:45 AM, the Facility Maintenance Director (FMD) said that he does not remember an annunciator ever being installed. The FMD indicated that in the past there was a red light located at the nurse station that came on when the generator was on. This red light could not be located during inspection. The Administrator called the regional maintenance director for contact information for a generator repair contractor. The Administrator made contact with a generator repair contractor to schedule the installation of the annunciator panel.

The facility/FMD and the Administrator were notified at 2:00 PM on November 4, 2020 that this deficiency represents an Immediate Jeopardy.

The hospital removed the IJ on November 4, 2020 at 5:00 PM when they submitted a plan to place an employee in the generator room 24/7 until an annunciator panel could be installed. This employee will be in radio contact with the nurse station.

The plan of removal also included the following:
Hospital staff will be performing a monthly load test and all weekly checks on the generator daily.
Hospital staff will be stationed in the generator room 24/7 until annunciator panel is installed. Staff at the generator will be in radio contact with the nurse station.
The generator repair contractor will be at the facility no later than November 13, 2020 to install an annunciator panel at the nurse station for the generator.


Electrical Systems - Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Based on observation, interview, and review of records, the hospital failed to ensure that the generator is tested in accordance with the National Fire Protection Association (NFPA) 110 which resulted in an Immediate Jeopardy (IJ - a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments or death to a patient) finding. The facility didn't provide complete documentation of ITM during monthly load testing of the emergency generator. This deficient practice failed to ensure reliable source of emergency power is being delivered to the life safety systems during a loss of power. The deficient practice affects all patients, visitors and staff in the hospital. The facility has 25 certified beds and at the time of the survey had a census of 2 patients.


Findings include:

During the survey on November 3rd, 2020 the following is observed:

1. At 11:10 AM during documentation review for a routine survey the facility failed to document the amperage and voltage of monthly generator tests. This practice fails to show the generator is being exercised with the available EPSS load for 30 minutes or until the oil pressure and water temperature has stabilized.
2. At 11:12 AM during documentation review for a routine survey the facility failed to perform 36 month 4-hr. load bank test on the natural gas-powered emergency generator.

During the survey on November 4th, 2020 the following is observed:

3. It was observed at 10:43 AM during a generator load test the amperage gauges located on the transfer switch failed to show any amperage is being produced by the generator. With no amperage being shown on the gauges it does ensure the transfer switch is operating properly.


During an interview on November 4, 2020 at 11:45 AM, the Facility Maintenance Director (FMD) said that he does not remember the gauges working. FMD also indicated that he was unaware that during monthly load testing that amps and volts for each phase of the generator needed to be documented. The Administrator called the regional maintenance director for contact information for a generator repair contractor. The Administrator made contact with the generator repair contractorto schedule a service visit to repair or replace the gauges for the generator. The generator provides backup emergency power to the emergency and exit lighting, all red outlets and switches and everything in (2) emergency rooms.


The facility/FMD and the Administrator were notified at 2:00 PM on November 4, 2020 that this deficiency represents an Immediate Jeopardy.

The hospital removed the IJ on November 4, 2020 at 5:00 PM when they submitted a plan to place an employee in the generator room 24/7 until the gauges could be repaired or replaced. This employee will be in radio contact with the nurse station.

The plan of removal also included the following:
Hospital staff will be performing a monthly load test and all weekly checks on the generator daily.
Hospital staff will be stationed in the generator room 24/7 until the gauges are repaired or replaced. Staff at the generator will be in radio contact with the nurse station.
The generator repair company will be at the facility no later than November 13, 2020 to repair or replace the gauges.

NFPA 110
8.4.2.4 Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and the oil pressure have stabilized.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 99, Health Care Facility Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting patients and staff in 1 of 4 smoke zones. This facility has a capacity of 25 with a census of 2 at the time of this survey.

Findings include:


During the survey conducted on November 3, 2020 it is observed:

It was observed at 4:12 PM in the physical therapy room 308 there is a power strip plugged into the wall hanging by the cord.

Staff Maintenance 1 was present and acknowledged the findings.

NFPA Standard: 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. 2012 NFPA 101, 9.1.2

NFPA Standard: Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

NFPA Standard: NFPA 70 2011, 400.8 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 Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage.

Based on observation the facility fails to maintain and store oxygen cylinders in a safe environment. This deficient practice affects patients, staff and visitors in 1 of 4 smoke zones. The facility has a capacity of 25 and census of 2 at the time of the survey.

Findings include:

During the survey on November 3, 2020 the following is observed:

1. It was observed at 4:36 PM in the med gas room there are (2) e-cylinders sitting on the floor unsecured.
2. It was observed at 4:37 PM in the med gas room the e-cylinders are not being segregated from empty or full cylinders.

Staff Maintenance 1 was present and acknowledged the findings.

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

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

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

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