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Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 2 of 4 smoke zones. The facility has a capacity of 25 with a census of 8.

FINDINGS INCLUDE:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) The self closure is not latching the door to the door frame to the Nursery.

Staff A and Staff B were present and confirmed the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview, the facility failed to maintain doors to hazardous rooms in a fashion that allows it to close automatically in the event of an emergency. This condition would allow for the spread of smoke to the exit corridor, affecting 1 of 4 smoke zones. The facility has a capacity for 25 and a census of 8.

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM it is observed the corridor door is held open with a magnet that does not release with the fire alarm to the Housekeeping Storage closet that is over 50 sq ft in size.

Staff A and Staff B were present and confirmed the finding. Staff B realized when surveyor found the deficiency that the door could not stay open unless it released with the fire alarm.

NFPA Standard: Any building of low or ordinary hazard contents, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic closing, provided that the following criteria are met: Upon release of the hold-open mechanism, the door becomes self-closing. The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed. The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?. Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing. The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair. 2000 NFPA 101, 7.2.8.2

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 4 smoke zones. This facility has a capacity of 25 and a census of 4.

FINDINGS INCLUDE:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) There is no self closing device on the center Laundry room door.
--2) There is a gap between the double doors to the exit corridor to the north doors of Laundry.
--3) There is no self closing device on the over 50 sq ft room being used for medical supply storage,
--4) There is no self closing device on the over 50 sq ft room to Kitchen storage in the basement.
--5) The newly installed latching hardware is not latching the door to the door frame to the Lab.

Staff A and B were present and confirmed the finding. Staff B stated the latching hardware on the lab had recently been installed and will be worked on to make the door latch.

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

NFPA Standard: Hazardous areas without sprinkler protection require one-hour fire resistance rating construction and doors shall be 3/4 hour fire rated with self closer's and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation and staff interview the facility fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. This deficient practice affect 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) There is no normal illumination in the South stairwell. There is a battery back up light in the stairwell. Lighting in the stairwell can be turned off with a manual switch.
--2) There is no normal illumination provided in the south end of the basement.

Staff A and Staff B were present and confirmed the finding. Staff B stated they were not sure if the stairwell lighting was on the generator.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and staff interview the facility fails to assure directional and exit signs are properly displayed. This deficient practice fails to direct occupants to a safe path of egress in case of an emergency, affecting 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM it is observed the exit sign posted on the south smoke barrier doors in the basement have no continuous illumination or emergency lighting provided to illuminate the sign.

Staff A and Staff B were present and confirmed the finding. Staff A stated an exit sign supplied to the building electrical system may be installed at the smoke barrier doors.

NFPA standard: 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. 2000 NFPA 101, 7.10.2

Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent proper evacuation in a timely manner due to staff ' s inability to respond in the event of an emergency, affecting 4 out of 4 smoke zones. This facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) The fire drill conducted on 1/20/11 at 6:15 PM, is recorded as a 1st and 2nd shift fire drill.
--2) There was no fire drill conducted for the 1st shift of the second quarter of 2010.
--3) The fire drill conducted on 5/18/10 at 9:15 PM, is recorded as a 2nd and 3rd shift fire drill.
--4) There was no scenario recorded for the 2nd shift fire drill on 5/18/10. This same issue was cited on the fire survey dated 5/3/10.
--5) The fire drill conducted on 9/16/10 at 2:30 PM on 1st shift is recorded as a 1st and 2nd shift fire drill.
--6) The fire drill conducted on 7/27/10 at 12:40 AM is recorded as a 3rd shift fire drill.
--7) There was no scenario recorded for the 2nd shift fire drill 7/27/10 at 12:40 AM. This same issue was cited on the fire survey dated 5/3/10.
--8) There is no record of a fire drill being conducted on the 2nd shift of the fourth quarter of 2010.

Staff A and Staff B were present and confirmed the finding. Staff B stated there are two shifts only used for fire drills: first shift hours are 7:00 AM to 7:00 PM; and second shift hours are 7:00 PM to 7:00 AM.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation and staff interview the facility failed to ensure that a portable fire extinguisher is provided and maintained in accordance with NFPA 10. This deficient practice may prevent the portable fire extinguisher from being readily accessible in the event of a fire, affecting 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8..

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) There is no class K type fire extinguisher in the kitchen for grease laden vapor fires. This is a 2nd year citation.
--2) There is a stethoscope hanging on the fire extinguisher, and a coat rack obstructing the fire extinguisher by Procedure room 1. This was corrected at time of survey.

Staff A and Staff B were present and confirmed the finding. Staff B stated their fire extinguisher company informed the facility they do not need a Class K type due to their kitchen hood is not a UL listed hood and they are only required to have a portable extinguisher that is the same as their fire suppression system which is a ABC extinguisher that is mounted in the kitchen.


NFPA Standard: 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. 1998 NFPA 10, 1-6.3

Based on observation and staff interview the facility failed to assure dampers are installed in ventilation ducts in storage rooms. The failure to supply dampers could result in the passage of smoke or fire from a hazardous room to other areas of the building affecting 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) There is an AC ventilation duct with no damper in the non-sprinkled room 41 that is being used for medical supply storage.
--2) There is no damper in the AC ventilation duct in the non-sprinkled Used Equipment room storage in the basement and in the basement Supply room.
--3) There is no damper in the AC ventilation duct in the non-sprinkled Clean Linen that is attached to Laundry and the door between the two rooms is held open with a laundry cart.
--4) There is no damper in the AC ventilation duct in the non-sprinkled Kitchen storage room in the basement.


NFPA Standard: Egress corridors in health care shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas. 1999 NFPA 90 A, 2-3.11.1

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 1 of 4 smoke zones. This facility has a capacity of 25 with a census of 8 at the time of the survey.

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM it is observed the exit stairwell hand railing is loose from the wall in the north exit egress stairwell.

Staff A and Staff B were present and confirmed the finding. Staff B stated the railing will be tightened.

NFPA Standards: Stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 in. (76 cm) of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path of travel. 2000 NFPA 101 , 7.2.2.4.2

Based on observation and staff interview the facility failed to ensure that empty and full oxygen cylinders were not stored in the same rack. This deficient practice could cause an empty cylinder to be retrieved in an emergency situation, affecting 1 of 4 smoke zones. The facility has a capacity 25 and a census of 8.

Findings Include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM it is observed there is one unsecured empty oxygen tank that is not placed in a rack, and is stored in the full oxygen storage room in the basement.

Staff A and Staff B were present and confirmed the finding. Staff B moved the empty tank and placed it outside into the empty oxygen storage area.

NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on a review of records and staff interview, the facility fails to conduct and properly document testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator. The deficient practice affects 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 8.

FINDINGS INCLUDE:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) The recently installed annunciator panel for the generator is a light bulb indicator light that illuminates if the generator fails, there is also no audible alarm at the nurses station.
--2) There is no October 2010 generator load test recorded.


NFPA Standard: A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: Individual visual signals shall indicate: when the emergency power source is operating to supply power to load and when the battery charger is malfunctioning. Individual visual signals plus an audible signal shall warn of the following engine-generator alarm conditions: low oil pressure, low water temperature, excessive water temperature, low fuel (main fuel storage tank contains less than a 3-hour supply), over crank (failed to start), and over speed. Where a regular workstation will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions occur, but need not display these conditions individually. 1999 NFPA 99, 3-4.1.1.15, 3-5.1, 3-6.1 and NFPA 110


NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

Based on observation and staff interview the facility failed to ensure that extension cords and
power strips are not being used as permanent wiring. This deficient practice could cause an electrical fire or the equipment to fail in the event the equipment overloads the capacity of the power strip or extension cord, affecting 1 out of 4 smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM it is observed there is a suction machine and a scope machine plugged into a non-secured power strip that is laying on the floor in Procedure room 1.

Staff A and Staff B were present and confirmed the finding. Staff B was unaware there was a power strip in use with medical equipment.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 2 of 4 smoke zones. The facility has a capacity of 25 with a census of 8.

FINDINGS INCLUDE:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) The self closure is not latching the door to the door frame to the Nursery.

Staff A and Staff B were present and confirmed the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview, the facility failed to maintain doors to hazardous rooms in a fashion that allows it to close automatically in the event of an emergency. This condition would allow for the spread of smoke to the exit corridor, affecting 1 of 4 smoke zones. The facility has a capacity for 25 and a census of 8.

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM it is observed the corridor door is held open with a magnet that does not release with the fire alarm to the Housekeeping Storage closet that is over 50 sq ft in size.

Staff A and Staff B were present and confirmed the finding. Staff B realized when surveyor found the deficiency that the door could not stay open unless it released with the fire alarm.

NFPA Standard: Any building of low or ordinary hazard contents, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic closing, provided that the following criteria are met: Upon release of the hold-open mechanism, the door becomes self-closing. The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed. The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?. Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing. The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair. 2000 NFPA 101, 7.2.8.2

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 4 smoke zones. This facility has a capacity of 25 and a census of 4.

FINDINGS INCLUDE:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) There is no self closing device on the center Laundry room door.
--2) There is a gap between the double doors to the exit corridor to the north doors of Laundry.
--3) There is no self closing device on the over 50 sq ft room being used for medical supply storage,
--4) There is no self closing device on the over 50 sq ft room to Kitchen storage in the basement.
--5) The newly installed latching hardware is not latching the door to the door frame to the Lab.

Staff A and B were present and confirmed the finding. Staff B stated the latching hardware on the lab had recently been installed and will be worked on to make the door latch.

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

NFPA Standard: Hazardous areas without sprinkler protection require one-hour fire resistance rating construction and doors shall be 3/4 hour fire rated with self closer's and positive latches. 2000 NFPA 101, 19.3.2.1

Based on observation and staff interview the facility fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. This deficient practice affect 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) There is no normal illumination in the South stairwell. There is a battery back up light in the stairwell. Lighting in the stairwell can be turned off with a manual switch.
--2) There is no normal illumination provided in the south end of the basement.

Staff A and Staff B were present and confirmed the finding. Staff B stated they were not sure if the stairwell lighting was on the generator.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and staff interview the facility fails to assure directional and exit signs are properly displayed. This deficient practice fails to direct occupants to a safe path of egress in case of an emergency, affecting 1 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

FINDINGS INCLUDE:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM it is observed the exit sign posted on the south smoke barrier doors in the basement have no continuous illumination or emergency lighting provided to illuminate the sign.

Staff A and Staff B were present and confirmed the finding. Staff A stated an exit sign supplied to the building electrical system may be installed at the smoke barrier doors.

NFPA standard: 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. 2000 NFPA 101, 7.10.2

Based on record review and staff interview the facility failed to assure that fire drills are held at least quarterly on each shift. This deficient practice may prevent proper evacuation in a timely manner due to staff ' s inability to respond in the event of an emergency, affecting 4 out of 4 smoke zones. This facility has a capacity of 25 with a census of 8.

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) The fire drill conducted on 1/20/11 at 6:15 PM, is recorded as a 1st and 2nd shift fire drill.
--2) There was no fire drill conducted for the 1st shift of the second quarter of 2010.
--3) The fire drill conducted on 5/18/10 at 9:15 PM, is recorded as a 2nd and 3rd shift fire drill.
--4) There was no scenario recorded for the 2nd shift fire drill on 5/18/10. This same issue was cited on the fire survey dated 5/3/10.
--5) The fire drill conducted on 9/16/10 at 2:30 PM on 1st shift is recorded as a 1st and 2nd shift fire drill.
--6) The fire drill conducted on 7/27/10 at 12:40 AM is recorded as a 3rd shift fire drill.
--7) There was no scenario recorded for the 2nd shift fire drill 7/27/10 at 12:40 AM. This same issue was cited on the fire survey dated 5/3/10.
--8) There is no record of a fire drill being conducted on the 2nd shift of the fourth quarter of 2010.

Staff A and Staff B were present and confirmed the finding. Staff B stated there are two shifts only used for fire drills: first shift hours are 7:00 AM to 7:00 PM; and second shift hours are 7:00 PM to 7:00 AM.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation and staff interview the facility failed to ensure that a portable fire extinguisher is provided and maintained in accordance with NFPA 10. This deficient practice may prevent the portable fire extinguisher from being readily accessible in the event of a fire, affecting 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8..

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) There is no class K type fire extinguisher in the kitchen for grease laden vapor fires. This is a 2nd year citation.
--2) There is a stethoscope hanging on the fire extinguisher, and a coat rack obstructing the fire extinguisher by Procedure room 1. This was corrected at time of survey.

Staff A and Staff B were present and confirmed the finding. Staff B stated their fire extinguisher company informed the facility they do not need a Class K type due to their kitchen hood is not a UL listed hood and they are only required to have a portable extinguisher that is the same as their fire suppression system which is a ABC extinguisher that is mounted in the kitchen.


NFPA Standard: 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. 1998 NFPA 10, 1-6.3

Based on observation and staff interview the facility failed to assure dampers are installed in ventilation ducts in storage rooms. The failure to supply dampers could result in the passage of smoke or fire from a hazardous room to other areas of the building affecting 2 of 4 smoke zones. The facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) There is an AC ventilation duct with no damper in the non-sprinkled room 41 that is being used for medical supply storage.
--2) There is no damper in the AC ventilation duct in the non-sprinkled Used Equipment room storage in the basement and in the basement Supply room.
--3) There is no damper in the AC ventilation duct in the non-sprinkled Clean Linen that is attached to Laundry and the door between the two rooms is held open with a laundry cart.
--4) There is no damper in the AC ventilation duct in the non-sprinkled Kitchen storage room in the basement.


NFPA Standard: Egress corridors in health care shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas. 1999 NFPA 90 A, 2-3.11.1

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 1 of 4 smoke zones. This facility has a capacity of 25 with a census of 8 at the time of the survey.

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM it is observed the exit stairwell hand railing is loose from the wall in the north exit egress stairwell.

Staff A and Staff B were present and confirmed the finding. Staff B stated the railing will be tightened.

NFPA Standards: Stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 in. (76 cm) of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path of travel. 2000 NFPA 101 , 7.2.2.4.2

Based on observation and staff interview the facility failed to ensure that empty and full oxygen cylinders were not stored in the same rack. This deficient practice could cause an empty cylinder to be retrieved in an emergency situation, affecting 1 of 4 smoke zones. The facility has a capacity 25 and a census of 8.

Findings Include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM it is observed there is one unsecured empty oxygen tank that is not placed in a rack, and is stored in the full oxygen storage room in the basement.

Staff A and Staff B were present and confirmed the finding. Staff B moved the empty tank and placed it outside into the empty oxygen storage area.

NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on a review of records and staff interview, the facility fails to conduct and properly document testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator. The deficient practice affects 4 of 4 smoke zones. The facility has a capacity of 25 with a census of 8.

FINDINGS INCLUDE:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM the following is observed:

--1) The recently installed annunciator panel for the generator is a light bulb indicator light that illuminates if the generator fails, there is also no audible alarm at the nurses station.
--2) There is no October 2010 generator load test recorded.


NFPA Standard: A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: Individual visual signals shall indicate: when the emergency power source is operating to supply power to load and when the battery charger is malfunctioning. Individual visual signals plus an audible signal shall warn of the following engine-generator alarm conditions: low oil pressure, low water temperature, excessive water temperature, low fuel (main fuel storage tank contains less than a 3-hour supply), over crank (failed to start), and over speed. Where a regular workstation will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions occur, but need not display these conditions individually. 1999 NFPA 99, 3-4.1.1.15, 3-5.1, 3-6.1 and NFPA 110


NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

Based on observation and staff interview the facility failed to ensure that extension cords and
power strips are not being used as permanent wiring. This deficient practice could cause an electrical fire or the equipment to fail in the event the equipment overloads the capacity of the power strip or extension cord, affecting 1 out of 4 smoke zones. This facility has a capacity of 25 and a census of 8.

Findings include:

During the tour on 2/3/11 between 12:00 PM and 4:45 PM it is observed there is a suction machine and a scope machine plugged into a non-secured power strip that is laying on the floor in Procedure room 1.

Staff A and Staff B were present and confirmed the finding. Staff B was unaware there was a power strip in use with medical equipment.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8