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Based upon observation and staff interview the facility is not ensuring that rated fire door assemblies are maintained in accordance with NFPA 80. This deficient practice of not ensuring rated doors are placarded with UL labels reduces the reliability of the doors to assure separation of occupancies, affecting approximately 2 patients and any visitors or staff in 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 7 at the time of this survey.

Findings include:

During the tour conducted on 08/24/18, at approximately 11:00 a.m., it is observed:

-- 1. South leaf of the 90-minute rated fire doors separating the Hospital from the LTCU and ALFs is missing the UL label. Findings also documented in the Fire Door Test Form dated 08/09/18 from the service vendor performing the annual inspection of fire doors.

Staff M-1 was present and acknowledged the observation.

NFPA Standard: Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (2010 NFPA 80)

Based on record review and staff interview the facility failed to assure the generator is inspected and tested in accordance with NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all residents in all smoke zones. The facility has a capacity of 25 and census of 7 at the time of this survey.

Findings include:

During the tour conducted on 08/24/18, between 10:30 a.m. and 11:30 a.m., a review of records for the last 5 quarters revealed that prior to August 1, 2018, documentation of weekly visual and monthly testing under load conditions did not reflect varying results for each of three phases; results appeared to be be duplicated from one inspection to another. No documented load bank testing within the last 12 months.

Staff M-1 was present and acknowledged the results of the records review.

Review of the following NFPA Standard revealed: EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1

Review of the following NFPA Standard revealed: A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer. 2010 NFPA 110, 8.3.4, 8.3.4.1
Review of the following NFPA Standard revealed: Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:

(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating. 2010 NFPA 110, 8.4.2

Review of the following NFPA Standard revealed: 8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.. 2010 NFPA 110, 8.4.2.3

Review of the following NFPA Standard revealed: For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. 8.4.9.5.2 For a diesel-powered EPS, loading shall be that which maintains the minimum exhaust gas temperatures as recommended by the manufacturer. 2010 NFPA 110, 8.4.9.5.1