HospitalInspections.org

Based on observation and interview, the facility failed to ensure that doors opening onto the corridors were not blocked open. This deficient practice would allow smoke and fire to migrate into the exit corridor. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 11:03 am and 12:05 pm revealed:
1. A portable x-ray machine was blocking the door to Mamo.
2. A brown paper grocery bag was stored in front of the Business Office door.

During an interview on 8-4-16 at 11:03 am and 12:05 pm, Facilities Staff A confirmed the items blocking the door and removed them.

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 and CMS S&C Letter 07-1

Based on observation and interview, the facility failed to provide "No Exit" signs on the exterior doors leading to the enclosed courtyard and the ambulance bay exterior door. This deficient practice had the potential to allow the doors to be mistaken as exit access from the building. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 10:43 am and 11:20 am revealed:
1. The glass doors leading into the enclosed courtyard failed to be identified by a "NO Exit" sign.
2. The glass doors leading into the ambulance bay failed to be identified by a "NO Exit" sign.

During an interview on 8-4-16 at 10:43 am and 11:20 am, Facilities Staff A confirmed that no "NO Exit" signs were provided on the doors.

NFPA Standard:
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO EXIT
Such sign shall have the word NO in letters 2 in. high with a stroke width of 3/8 in. and the word EXIT in letters 1 in. high, with the word EXIT below the word NO. 2000 NFPA 101, 7.10.4.1

Based on observation and interview, the facility failed to ensure that smoke separation doors were capable of resisting the passage of smoke. This deficient practice would allow smoke and gasses to spread throughout the exit corridor. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 11:08 am revealed the west smoke door leading into the OR corridor hit the locking device and failed to be smoke tight.

During an interview on 8-4-16 at 11:08 am, Facilities Staff A confirmed the door failed to be smoke tight.

NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 19.3.7.6*.

Based on observation and interview, the facility failed to maintain the doors to hazardous areas so they would provide a smoke resistant partition from the corridor. This deficient practice would allow fire and smoke to migrate out of the hazard areas into the exiting corridors which could render the corridor useless for evacuation. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 between 10:41 am and 12:25 pm revealed:
1. The Bathhouse door, across from Room 30 which was equipped with a self-closing device failed to close and latch within the doorframe.
2. The door to Maintenance Storage room had 12 inch by 12 inch louvers.
3. The door to the Generator Room was blocked open with a wooden block.
4. The door to the Air Handlers was blocked open with a paint can.
5. A storage area in the basement measuring 30 feet by 12 feet, failed to be separated from the exit corridor by any type of construction.
6. The Medical Records room measured over 100 square feet, and failed to provide a self-closing device on the door.

During an interview on 8-4-16 between 10:41 am and 12:05 pm, and Facilities Staff A confirmed the findings.

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 interview, this facility allowed the use of more than one locking / latching device on a door within a means of egress. This deficient practice would prohibit or delay egress for staff during an emergency. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 11:13 am revealed:
1. The smoke doors leading from the OR corridor into the main corridor were equipped with a thumb lock in addition to the regular door hardware.
2. The door hardware was located higher than 48 inches from the finished floor.

During an interview on 8-4-16 at 11:13 am, Facilities Staff A confirmed the findings.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations. 2000 NFPA 101, 7.2.1.5.4*

Based on observation and interview, the facility failed to provide illumination of the exit discharge to the public way so that the failure of any single lighting fixture (bulb) did not leave the area in darkness for the area. This deficient practice could leave the path of egress in darkness which would delay or cause confusion during exiting. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 between 11:13 am and 12:00 pm revealed:
1. The west exit door next to Room 32 failed to provide egress lighting to public way.
2. The sidewalk egress path to the public way from the exit door near the Nurses Station failed to provide egress lighting to public way.

During an interview on 8-4-16 between 11:13 am and 12:00 pm, Facilities Staff A confirmed the lack of lighting.

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

7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3*
The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.

Based on observation and interview, the facility failed to provide an exit sign for the second required exit in the Clinic. This deficient practice could delay or cause confusion during an emergency as occupants would not be aware of the exit. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 12:25 pm revealed, the facility failed to provide an exit sign at the Nurses Station located in the Clinic to direct occupants to the exit.

During an interview on 8-4-16 at 12:25 pm, Facilities Staff A confirmed that no exit sign was provided.

NFPA Standard:
Means of egress shall have signs in accordance with Section 7.10. 2000 NFPA 101, 19.2.10.1

Based on record review and staff interview, the facility failed to conduct fire drills under varying conditions by not spacing drills at least one hour apart between each quarter, on each shift for 2 of 3 shifts, and failed to conduct a fire drill quarterly on each shift. This deficient practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response for all residents. The deficient practice had the potential to affect all occupants. The facility census was 3 patients.

Findings are:
Fire drill documentation review on 8-4-16 at 2:20 pm revealed:
1. The first shift fire drills were conducted at 1:55pm, 3:15pm, 2:45pm and 1:55pm
2. The second shift fire drills were conducted at 3:42pm, 3:54pm and 2:53pm
3. The facility failed to conduct a 2nd shift fire drill during the 2nd quarter of 2016.

During an interview on 8-4-16 at 2:20 pm, Facilities A confirmed all the findings.

NFPA Standard:
The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan. 2000 NFPA 101, 19.7.2.1

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. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on observations and interview, the facility failed to provide a fire alarm notification device in the enclosed interior courtyard. The lack of fire alarm notification devices could cause a fire emergency to go undetected by occupants in the OR and courtyard because of the inability to hear and see the alarm device. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 10:54 am and 11:15 am revealed:
1. The facility failed to provide an audible/visual fire alarm notification device in the enclosed interior courtyard.
2. The facility failed to provide an audible/visual fire alarm notification device in the OR corridor.

During an interview on 8-4-16 at 10:54 am and 11:15 am, Facilities Staff A confirmed the lack of notification device.

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, and NFPA 72. 2000 NFPA 101, 9.6.1.4

Based on observation and interview, the facility failed to maintain the required clearance from the sprinkler head in closets. This deficient practice would delay the response of the sprinkler head and affect the spray pattern which could lead to a larger fire that could spread outside of the room into the exit corridor. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 10:12 am revealed:
1. Items on the top shelf of the Custodial closet next to Room 31 encroached into the required clear space for the sprinkler head.

During an interview on 8-4-16 at 10:12 am, Facilities Staff A confirmed the findings.

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

Based on observation and interview, the facility failed to provide protected egress corridors by using the corridors as a return air plenum for the heating and air system. The deficient practice pulled heated/cooled air from the resident rooms to heat/cool the corridors, which could spread smoke, fire and gasses throughout the exit corridor and render the corridor impassable. The facility census was 3 patients.

Findings are:
Observation on 8-4-16, between 10:30 am and 12:45 pm, revealed the facility air handling systems in the hospital corridors were supplying cool air to the patient rooms. The air conditioning (and heating) source for the corridors of the facility also came from the patient rooms. The system was not designed as a balanced system with equal supply/exhaust from the resident rooms and an equal supply/exhaust from the corridors, resulting in the corridor being used as a plenum.

During an interview on 8-4-16 between 10:30 am and 12:45 pm, Facilities Staff A confirmed the corridor was being used as a plenum.

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 90A, 2-3.11.1

Based on observation and interview, the facility failed to ensure empty and full oxygen tanks were identified to prevent confusion when choosing tanks in an emergency. The facility census was 6 patients.

Findings are:
Observation on 8-4-16 at 10:13 am revealed, the Oxygen Storage room contained empty oxygen cylinders and full cylinders. The cylinders were not identified as full or empty.

During an interview on 8-4-16 at 10:13 am, Facilities Staff A confirmed the lack of identification for the cylinders.

NFPA Standard:
If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. 1999 NFPA 99, 4.3.5.2.2

A. Based on documentation, observation and interview, the facility failed to provide a manual stop station outside the area of the generator. This deficient practice had the potential to affect all occupants of the facility. The facility census was 3 patients.

Findings are:
Observation on 8-4-16 at 12:32 pm revealed, the facility failed to provide a remote manual shutdown for the generator.

During an interview on 8-4-16 at 12:32 pm, Facilities Staff A confirmed the facility failed to provide a manual shutdown.

NFPA Standard:
All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.1999 NFPA 110, 3-5.5.6*



B. Based on observation and interview, the facility failed to house the emergency generator in an area separated from the rest of the facility by two-hour fire rated construction. The facility failed to provide documentation of required ventilation, combustion air and intake air required for operation of the generator. The facility allowed storage of combustible materials in the same room housing the emergency generator. These deficient practices increased the potential for damage to the generator from a fire originating in the room. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 1:12 pm revealed:
1. The generator room failed to provide a 2 hour fire rated separation from the rest of the facility.
2. The generator was housed in an open room with facilities storage supplies.
3. Normal electrical service was in the same room as the generator.
4. The facility failed to verify adequate ventilation for operation of the generator.
5. The facility failed to verify adequate combustion air for the operation of the generator.
6. The facility failed to verify air intake and discharge foroperation of the generator.

During an interview on 8-4-16 at 1:12 pm, Facilities Staff A confirmed the findings.

NFPA Standard:
1999 NFPA 110, 5-2.1
The EPS shall be installed in a separate room for Level 1 installations. EPSS equipment shall be permitted to be installed in this room. The room shall have a minimum 2-hour fire rating or shall be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local building codes. No other equipment, including architectural appurtenances, except those that serve this space, shall be permitted in this room.

1999 NFPA 110, 5-2.2
EPSS equipment shall not be installed in the same room where the normal electrical service equipment is installed.
Exception: Transfer switches shall be permitted to be installed in the normal electrical service room where twice the clearance required by Article 110.16(a) of NFPA 70, National Electrical Code, exists between equipment enclosures.

1999 NFPA 110, 5-7.2
Adequate ventilation shall be provided to prevent temperatures or temperature rises in the EPS and related accessory equipment that exceed the recommendations of the manufacturer.

1999 NFPA 110, 5-7.3
For the EPS equipment room, the ventilation or cooling equipment, or both, shall be sized so that the ambient temperature shall not exceed the EPS equipment manufacturer ' s criteria or allowable maximum temperatures.

1999 NFPA 110, 5-7.4
Adequate combustion air shall be supplied to the EPS equipment.

1999 NFPA 110, 5-7.5
Consideration shall be given to designing and sizing an air intake louver and air discharge louver system, either gravity or motor operated, so that the proper pressure control and airflows are provided. Dampers and louver restrictions shall be considered in sizing the room ventilation requirements.

1999 NFPA 110, 5-11.1
The room in which the EPS equipment is located shall not be used for storage purposes.


C. Based on observation and interview, the facility failed to assure that the audible alarm for the fueling of the generator was operable. This deficient practice would not alert personnel and would allow the tank to be overfilled. The facility census was 3 patients.

Findings are:
Observations on 8-5-16 at 3:20 pm revealed, that the audible alarm for the fueling of the generator failed to operate when tested.

During an interview on 8-5-16 at 3:20 pm, Facilities Staff A confirmed the findings.

NFPA Standard:
(e) Means shall be provided to prevent overfilling by sounding an alarm when the liquid level in the tank reaches 90 percent of capacity and by automatically stopping delivery of liquid to the tank when the liquid level in the tank reaches 95 percent of capacity. In no case shall these provisions restrict or interfere with the proper functioning of the normal vent or the emergency vent. 2000 NFPA 30, 2.3.2.3.3

Based on observation and interview, the facility failed to post "oxygen in use" signage at areas where oxygen was being administered. This deficient practice failed to alert persons entering the area to use extra caution with devices that could be a source of ignition and increased the potential for ignition of a fire. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 10:25 am revealed:
1. An oxygen concentrator was located in Resident Room 28 and the facility failed to provide oxygen in use signage on the door.

During an interview on 8-4-16 at 10:25 am, Facilities Staff A confirmed the lack of signage on the doors.

NFPA Standard:
"No smoking" signs required when oxygen is in use. 2000 NFPA 101, 19.7.4(1).

Precautionary signs, readable from a distance of 5 feet, shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means. 1999 NFPA 99, 8-6.4.2

Based on documentation review and interview, the facility failed to document the test methods used to determine and confirm the generator was tested to 30% of its load rating. This deficient practice would not ensure the generator could provide the required electrical power during an emergency. The facility census was 3 patients.

Findings are:
Documentation review on 8-4-16 at 2:00 pm revealed that the facility documented the amps reading at 1-100.

During an interview on 8-4-16 at 2:00 pm, Facilities Staff A stated that the gauge fluctuates from 0 to 100 amps, and that 100 amps is always used to determine the percentage of load.

NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
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
The date and time of day for required testing shall be decided by the owner, based on facility operations

Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and interview, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. The facility failed to have transfer switches identified. These deficient practices had the potential to affect all patients of the facility by affecting the egress lighting and emergency systems of the facility. The facility census is 3 patients.

Findings are:
Observations on 8-4-16 between 10:00 am and 1:30 pm revealed:
1. The transfer switches failed to be identified.
2. Facility failed to confirm what electrical panels provided life safety, critical and equipment circuits.
3. Electrical panel boxes throughout the facility have intermixed systems within the branches.

During an interview on 8-4-16 between 10:00 am and 1:30 pm, Facilities Staff A confirmed the findings.

NFPA Standard:
NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure Facilities (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on observation and interview, the facility failed to ensure electrical receptacles in all the patient rooms were identified to be on the critical branch of the generator and failed to provide the required amount of receptacles connected to the emergency power supply. This deficient practice would affect all patients during an electrical outage or medical treatment. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 between 10:46 am and 11:20 pm revealed:
1. 19 of 19 Patient Rooms failed to identify receptacles that were on the generator.
2. 19 of 19 Patient Rooms failed to provide four receptacles, which were on the critical branch of the generator.

During an interview on 8-4-16 between 10:46 am and 11:20 pm, Facilities Staff A confirmed all the findings

NFPA Standard:
The number of receptacles shall be determined by the intended use of the patient care areas in accordance with 4.3.2.2.6.2(A) through 4.3.2.2.6.2(D). 1999 NFPA 99, 3-3.2.1.2

(d)Receptacles.
1.* Types of Receptacles. Each power receptacle shall provide at least one separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug despite electrical and mechanical abuse. Special receptacles (such as four-pole units providing an extra pole for redundant grounding or ground continuity monitoring; or locking-type receptacles; or, where required for reduction of electrical noise on the grounding circuit, receptacles in which the grounding terminals are purposely insulated from the receptacle yoke) shall be permitted.

(A) Receptacles for Patient Bed Locations in General Care Areas. Each patient bed location shall be provided with a minimum of four receptacles (or two duplex receptacles).(B) Receptacles for Patient Bed Locations in Critical Care Areas. Each patient bed location shall be provided with a minimum of six receptacles (or three duplex receptacles).

Based on record review and interview, the facility failed to assure that a policy was in place regarding all the procedures to be taken in the event that the sprinkler system was out of service for more than 4 hours in a 24-hour period. The lack of written policies and procedures could result in staff failing to implement interim measures in the event of an emergency. This facility census was 3 patients.

Findings are:
Documentation review on 8-4-16 at 1:47 pm revealed:
1. The facility's policy failed to include notification of the local fire department immediately.
2. The facility's policy failed to include notification of the monitoring company immediately.
3. The facility's policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facility's policy failed to include that the individual conducting the fire watch shall be trained to recognize a fire hazard and the use of an extinguisher.
5. The facility's policy failed to state the Nebraska Department of Health and Human Services and the Nebraska Fire Marshal should be notified of the impairment.

During an interview on 8-4-16 at 1:47 pm, Facilities Staff A confirmed the lack of information on the policy.

NFPA Standard:
When a required sprinkler system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

NFPA Standard:
The following procedures shall be implemented: the extent and expected duration of the impairment shall be determined; the area or buildings involved shall be inspected and the increased risks determined; and recommendations submitted to management or building owner/manager. Where a required fire protection system is out of service for more than 4 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: evacuation of the building affected by the system out of service; an approved fire watch; establishment of a temporary water supply; implementation of a program to eliminate potential ignition sources and limit the amount of fuel available; notification of the fire department; the insurance carrier, the alarm company, building owner/manager, and other AHJ ' s; notification of the supervisors in the affected areas; a tag impairment system has been implemented; all necessary tools and materials have been assembled on the site for preplanned impairments. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should be looking for fire, and other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 1998 NFPA 25, 11-5

Based on record review and interview, the facility failed to assure a policy was in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than 4 hours in a 24-hour period. The lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency. This facility census was 3 patients.

Findings are:
Documentation review on 8-4-16 at 1:47 pm revealed:
1. The facility's policy failed to include notification of the monitoring company immediately.
2. The facility's policy failed to include that the individual conducting the fire watch shall have no other duties.
3. The facility's policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facility's policy failed to include that the individual conducting the fire watch shall be trained to recognize a fire hazard and the use of an extinguisher.

During an interview on 8-4-16 at 1:47 pm, Facilities Staff A confirmed the lack of information on the policy.

NFPA Standard:
When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on observation and interview, the facility failed to ensure that doors opening onto the corridors were not blocked open. This deficient practice would allow smoke and fire to migrate into the exit corridor. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 11:03 am and 12:05 pm revealed:
1. A portable x-ray machine was blocking the door to Mamo.
2. A brown paper grocery bag was stored in front of the Business Office door.

During an interview on 8-4-16 at 11:03 am and 12:05 pm, Facilities Staff A confirmed the items blocking the door and removed them.

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 and CMS S&C Letter 07-1

Based on observation and interview, the facility failed to provide "No Exit" signs on the exterior doors leading to the enclosed courtyard and the ambulance bay exterior door. This deficient practice had the potential to allow the doors to be mistaken as exit access from the building. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 10:43 am and 11:20 am revealed:
1. The glass doors leading into the enclosed courtyard failed to be identified by a "NO Exit" sign.
2. The glass doors leading into the ambulance bay failed to be identified by a "NO Exit" sign.

During an interview on 8-4-16 at 10:43 am and 11:20 am, Facilities Staff A confirmed that no "NO Exit" signs were provided on the doors.

NFPA Standard:
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO EXIT
Such sign shall have the word NO in letters 2 in. high with a stroke width of 3/8 in. and the word EXIT in letters 1 in. high, with the word EXIT below the word NO. 2000 NFPA 101, 7.10.4.1

Based on observation and interview, the facility failed to ensure that smoke separation doors were capable of resisting the passage of smoke. This deficient practice would allow smoke and gasses to spread throughout the exit corridor. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 11:08 am revealed the west smoke door leading into the OR corridor hit the locking device and failed to be smoke tight.

During an interview on 8-4-16 at 11:08 am, Facilities Staff A confirmed the door failed to be smoke tight.

NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 19.3.7.6*.

Based on observation and interview, the facility failed to maintain the doors to hazardous areas so they would provide a smoke resistant partition from the corridor. This deficient practice would allow fire and smoke to migrate out of the hazard areas into the exiting corridors which could render the corridor useless for evacuation. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 between 10:41 am and 12:25 pm revealed:
1. The Bathhouse door, across from Room 30 which was equipped with a self-closing device failed to close and latch within the doorframe.
2. The door to Maintenance Storage room had 12 inch by 12 inch louvers.
3. The door to the Generator Room was blocked open with a wooden block.
4. The door to the Air Handlers was blocked open with a paint can.
5. A storage area in the basement measuring 30 feet by 12 feet, failed to be separated from the exit corridor by any type of construction.
6. The Medical Records room measured over 100 square feet, and failed to provide a self-closing device on the door.

During an interview on 8-4-16 between 10:41 am and 12:05 pm, and Facilities Staff A confirmed the findings.

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 interview, this facility allowed the use of more than one locking / latching device on a door within a means of egress. This deficient practice would prohibit or delay egress for staff during an emergency. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 11:13 am revealed:
1. The smoke doors leading from the OR corridor into the main corridor were equipped with a thumb lock in addition to the regular door hardware.
2. The door hardware was located higher than 48 inches from the finished floor.

During an interview on 8-4-16 at 11:13 am, Facilities Staff A confirmed the findings.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations. 2000 NFPA 101, 7.2.1.5.4*

Based on observation and interview, the facility failed to provide illumination of the exit discharge to the public way so that the failure of any single lighting fixture (bulb) did not leave the area in darkness for the area. This deficient practice could leave the path of egress in darkness which would delay or cause confusion during exiting. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 between 11:13 am and 12:00 pm revealed:
1. The west exit door next to Room 32 failed to provide egress lighting to public way.
2. The sidewalk egress path to the public way from the exit door near the Nurses Station failed to provide egress lighting to public way.

During an interview on 8-4-16 between 11:13 am and 12:00 pm, Facilities Staff A confirmed the lack of lighting.

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

7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3*
The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.

Based on observation and interview, the facility failed to provide an exit sign for the second required exit in the Clinic. This deficient practice could delay or cause confusion during an emergency as occupants would not be aware of the exit. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 12:25 pm revealed, the facility failed to provide an exit sign at the Nurses Station located in the Clinic to direct occupants to the exit.

During an interview on 8-4-16 at 12:25 pm, Facilities Staff A confirmed that no exit sign was provided.

NFPA Standard:
Means of egress shall have signs in accordance with Section 7.10. 2000 NFPA 101, 19.2.10.1

Based on record review and staff interview, the facility failed to conduct fire drills under varying conditions by not spacing drills at least one hour apart between each quarter, on each shift for 2 of 3 shifts, and failed to conduct a fire drill quarterly on each shift. This deficient practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response for all residents. The deficient practice had the potential to affect all occupants. The facility census was 3 patients.

Findings are:
Fire drill documentation review on 8-4-16 at 2:20 pm revealed:
1. The first shift fire drills were conducted at 1:55pm, 3:15pm, 2:45pm and 1:55pm
2. The second shift fire drills were conducted at 3:42pm, 3:54pm and 2:53pm
3. The facility failed to conduct a 2nd shift fire drill during the 2nd quarter of 2016.

During an interview on 8-4-16 at 2:20 pm, Facilities A confirmed all the findings.

NFPA Standard:
The proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan. 2000 NFPA 101, 19.7.2.1

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. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2

Based on observations and interview, the facility failed to provide a fire alarm notification device in the enclosed interior courtyard. The lack of fire alarm notification devices could cause a fire emergency to go undetected by occupants in the OR and courtyard because of the inability to hear and see the alarm device. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 10:54 am and 11:15 am revealed:
1. The facility failed to provide an audible/visual fire alarm notification device in the enclosed interior courtyard.
2. The facility failed to provide an audible/visual fire alarm notification device in the OR corridor.

During an interview on 8-4-16 at 10:54 am and 11:15 am, Facilities Staff A confirmed the lack of notification device.

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, and NFPA 72. 2000 NFPA 101, 9.6.1.4

Based on observation and interview, the facility failed to maintain the required clearance from the sprinkler head in closets. This deficient practice would delay the response of the sprinkler head and affect the spray pattern which could lead to a larger fire that could spread outside of the room into the exit corridor. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 10:12 am revealed:
1. Items on the top shelf of the Custodial closet next to Room 31 encroached into the required clear space for the sprinkler head.

During an interview on 8-4-16 at 10:12 am, Facilities Staff A confirmed the findings.

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

Based on observation and interview, the facility failed to provide protected egress corridors by using the corridors as a return air plenum for the heating and air system. The deficient practice pulled heated/cooled air from the resident rooms to heat/cool the corridors, which could spread smoke, fire and gasses throughout the exit corridor and render the corridor impassable. The facility census was 3 patients.

Findings are:
Observation on 8-4-16, between 10:30 am and 12:45 pm, revealed the facility air handling systems in the hospital corridors were supplying cool air to the patient rooms. The air conditioning (and heating) source for the corridors of the facility also came from the patient rooms. The system was not designed as a balanced system with equal supply/exhaust from the resident rooms and an equal supply/exhaust from the corridors, resulting in the corridor being used as a plenum.

During an interview on 8-4-16 between 10:30 am and 12:45 pm, Facilities Staff A confirmed the corridor was being used as a plenum.

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 90A, 2-3.11.1

Based on observation and interview, the facility failed to ensure empty and full oxygen tanks were identified to prevent confusion when choosing tanks in an emergency. The facility census was 6 patients.

Findings are:
Observation on 8-4-16 at 10:13 am revealed, the Oxygen Storage room contained empty oxygen cylinders and full cylinders. The cylinders were not identified as full or empty.

During an interview on 8-4-16 at 10:13 am, Facilities Staff A confirmed the lack of identification for the cylinders.

NFPA Standard:
If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. 1999 NFPA 99, 4.3.5.2.2

A. Based on documentation, observation and interview, the facility failed to provide a manual stop station outside the area of the generator. This deficient practice had the potential to affect all occupants of the facility. The facility census was 3 patients.

Findings are:
Observation on 8-4-16 at 12:32 pm revealed, the facility failed to provide a remote manual shutdown for the generator.

During an interview on 8-4-16 at 12:32 pm, Facilities Staff A confirmed the facility failed to provide a manual shutdown.

NFPA Standard:
All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.
For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.1999 NFPA 110, 3-5.5.6*



B. Based on observation and interview, the facility failed to house the emergency generator in an area separated from the rest of the facility by two-hour fire rated construction. The facility failed to provide documentation of required ventilation, combustion air and intake air required for operation of the generator. The facility allowed storage of combustible materials in the same room housing the emergency generator. These deficient practices increased the potential for damage to the generator from a fire originating in the room. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 1:12 pm revealed:
1. The generator room failed to provide a 2 hour fire rated separation from the rest of the facility.
2. The generator was housed in an open room with facilities storage supplies.
3. Normal electrical service was in the same room as the generator.
4. The facility failed to verify adequate ventilation for operation of the generator.
5. The facility failed to verify adequate combustion air for the operation of the generator.
6. The facility failed to verify air intake and discharge foroperation of the generator.

During an interview on 8-4-16 at 1:12 pm, Facilities Staff A confirmed the findings.

NFPA Standard:
1999 NFPA 110, 5-2.1
The EPS shall be installed in a separate room for Level 1 installations. EPSS equipment shall be permitted to be installed in this room. The room shall have a minimum 2-hour fire rating or shall be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local building codes. No other equipment, including architectural appurtenances, except those that serve this space, shall be permitted in this room.

1999 NFPA 110, 5-2.2
EPSS equipment shall not be installed in the same room where the normal electrical service equipment is installed.
Exception: Transfer switches shall be permitted to be installed in the normal electrical service room where twice the clearance required by Article 110.16(a) of NFPA 70, National Electrical Code, exists between equipment enclosures.

1999 NFPA 110, 5-7.2
Adequate ventilation shall be provided to prevent temperatures or temperature rises in the EPS and related accessory equipment that exceed the recommendations of the manufacturer.

1999 NFPA 110, 5-7.3
For the EPS equipment room, the ventilation or cooling equipment, or both, shall be sized so that the ambient temperature shall not exceed the EPS equipment manufacturer ' s criteria or allowable maximum temperatures.

1999 NFPA 110, 5-7.4
Adequate combustion air shall be supplied to the EPS equipment.

1999 NFPA 110, 5-7.5
Consideration shall be given to designing and sizing an air intake louver and air discharge louver system, either gravity or motor operated, so that the proper pressure control and airflows are provided. Dampers and louver restrictions shall be considered in sizing the room ventilation requirements.

1999 NFPA 110, 5-11.1
The room in which the EPS equipment is located shall not be used for storage purposes.


C. Based on observation and interview, the facility failed to assure that the audible alarm for the fueling of the generator was operable. This deficient practice would not alert personnel and would allow the tank to be overfilled. The facility census was 3 patients.

Findings are:
Observations on 8-5-16 at 3:20 pm revealed, that the audible alarm for the fueling of the generator failed to operate when tested.

During an interview on 8-5-16 at 3:20 pm, Facilities Staff A confirmed the findings.

NFPA Standard:
(e) Means shall be provided to prevent overfilling by sounding an alarm when the liquid level in the tank reaches 90 percent of capacity and by automatically stopping delivery of liquid to the tank when the liquid level in the tank reaches 95 percent of capacity. In no case shall these provisions restrict or interfere with the proper functioning of the normal vent or the emergency vent. 2000 NFPA 30, 2.3.2.3.3

Based on observation and interview, the facility failed to post "oxygen in use" signage at areas where oxygen was being administered. This deficient practice failed to alert persons entering the area to use extra caution with devices that could be a source of ignition and increased the potential for ignition of a fire. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 at 10:25 am revealed:
1. An oxygen concentrator was located in Resident Room 28 and the facility failed to provide oxygen in use signage on the door.

During an interview on 8-4-16 at 10:25 am, Facilities Staff A confirmed the lack of signage on the doors.

NFPA Standard:
"No smoking" signs required when oxygen is in use. 2000 NFPA 101, 19.7.4(1).

Precautionary signs, readable from a distance of 5 feet, shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means. 1999 NFPA 99, 8-6.4.2

Based on documentation review and interview, the facility failed to document the test methods used to determine and confirm the generator was tested to 30% of its load rating. This deficient practice would not ensure the generator could provide the required electrical power during an emergency. The facility census was 3 patients.

Findings are:
Documentation review on 8-4-16 at 2:00 pm revealed that the facility documented the amps reading at 1-100.

During an interview on 8-4-16 at 2:00 pm, Facilities Staff A stated that the gauge fluctuates from 0 to 100 amps, and that 100 amps is always used to determine the percentage of load.

NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
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
The date and time of day for required testing shall be decided by the owner, based on facility operations

Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and interview, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. The facility failed to have transfer switches identified. These deficient practices had the potential to affect all patients of the facility by affecting the egress lighting and emergency systems of the facility. The facility census is 3 patients.

Findings are:
Observations on 8-4-16 between 10:00 am and 1:30 pm revealed:
1. The transfer switches failed to be identified.
2. Facility failed to confirm what electrical panels provided life safety, critical and equipment circuits.
3. Electrical panel boxes throughout the facility have intermixed systems within the branches.

During an interview on 8-4-16 between 10:00 am and 1:30 pm, Facilities Staff A confirmed the findings.

NFPA Standard:
NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure Facilities (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on observation and interview, the facility failed to ensure electrical receptacles in all the patient rooms were identified to be on the critical branch of the generator and failed to provide the required amount of receptacles connected to the emergency power supply. This deficient practice would affect all patients during an electrical outage or medical treatment. The facility census was 3 patients.

Findings are:
Observations on 8-4-16 between 10:46 am and 11:20 pm revealed:
1. 19 of 19 Patient Rooms failed to identify receptacles that were on the generator.
2. 19 of 19 Patient Rooms failed to provide four receptacles, which were on the critical branch of the generator.

During an interview on 8-4-16 between 10:46 am and 11:20 pm, Facilities Staff A confirmed all the findings

NFPA Standard:
The number of receptacles shall be determined by the intended use of the patient care areas in accordance with 4.3.2.2.6.2(A) through 4.3.2.2.6.2(D). 1999 NFPA 99, 3-3.2.1.2

(d)Receptacles.
1.* Types of Receptacles. Each power receptacle shall provide at least one separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug despite electrical and mechanical abuse. Special receptacles (such as four-pole units providing an extra pole for redundant grounding or ground continuity monitoring; or locking-type receptacles; or, where required for reduction of electrical noise on the grounding circuit, receptacles in which the grounding terminals are purposely insulated from the receptacle yoke) shall be permitted.

(A) Receptacles for Patient Bed Locations in General Care Areas. Each patient bed location shall be provided with a minimum of four receptacles (or two duplex receptacles).(B) Receptacles for Patient Bed Locations in Critical Care Areas. Each patient bed location shall be provided with a minimum of six receptacles (or three duplex receptacles).

Based on record review and interview, the facility failed to assure that a policy was in place regarding all the procedures to be taken in the event that the sprinkler system was out of service for more than 4 hours in a 24-hour period. The lack of written policies and procedures could result in staff failing to implement interim measures in the event of an emergency. This facility census was 3 patients.

Findings are:
Documentation review on 8-4-16 at 1:47 pm revealed:
1. The facility's policy failed to include notification of the local fire department immediately.
2. The facility's policy failed to include notification of the monitoring company immediately.
3. The facility's policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facility's policy failed to include that the individual conducting the fire watch shall be trained to recognize a fire hazard and the use of an extinguisher.
5. The facility's policy failed to state the Nebraska Department of Health and Human Services and the Nebraska Fire Marshal should be notified of the impairment.

During an interview on 8-4-16 at 1:47 pm, Facilities Staff A confirmed the lack of information on the policy.

NFPA Standard:
When a required sprinkler system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

NFPA Standard:
The following procedures shall be implemented: the extent and expected duration of the impairment shall be determined; the area or buildings involved shall be inspected and the increased risks determined; and recommendations submitted to management or building owner/manager. Where a required fire protection system is out of service for more than 4 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: evacuation of the building affected by the system out of service; an approved fire watch; establishment of a temporary water supply; implementation of a program to eliminate potential ignition sources and limit the amount of fuel available; notification of the fire department; the insurance carrier, the alarm company, building owner/manager, and other AHJ ' s; notification of the supervisors in the affected areas; a tag impairment system has been implemented; all necessary tools and materials have been assembled on the site for preplanned impairments. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should be looking for fire, and other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 1998 NFPA 25, 11-5

Based on record review and interview, the facility failed to assure a policy was in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than 4 hours in a 24-hour period. The lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency. This facility census was 3 patients.

Findings are:
Documentation review on 8-4-16 at 1:47 pm revealed:
1. The facility's policy failed to include notification of the monitoring company immediately.
2. The facility's policy failed to include that the individual conducting the fire watch shall have no other duties.
3. The facility's policy failed to include that the individual conducting the fire watch shall have access to all portions of the building.
4. The facility's policy failed to include that the individual conducting the fire watch shall be trained to recognize a fire hazard and the use of an extinguisher.

During an interview on 8-4-16 at 1:47 pm, Facilities Staff A confirmed the lack of information on the policy.

NFPA Standard:
When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8