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Based on observation and interview the facility failed to assure the folding room divider in the Computer Lab Room had a flame resistant finish. The facility failed to provide documentation for the flame spread rating. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 at 2:40 pm revealed, a plastic type folding room divider in the Computer Lab.

During an interview on 12-1-15 at 2:40 pm, Maintenance A confirmed the folding door and failed to provide any type of documentation for flame retardancy.

NFPA Standard:
Ceiling and wall materials shall be limited as specified in 2000 NFPA 101, 10.2.3 Existing materials may be Class A or Class B except that rooms protected by an approved, supervised automatic sprinkler system use of existing Class C finish shall be permitted within rooms separated from the exit access corridors in accordance with 19.3.6. New materials must be Class A except that new walls/ceilings shall be permitted to have Class A or Class B finish in individual rooms having a capacity of four persons. Newly installed corridor wall finish not exceeding 4 feet in height on the lower half of the wall shall be permitted to be Class A or Class B. 2000 NFPA 101, 19.3.3.

Based on observation and interview, the facility failed to ensure that corridor doors would resist the passage of smoke. This deficient practice had the potential to allow smoke or fire to migrate into exit corridors. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 1:36 am and 4:56 pm revealed:
1. The door to OR 2 failed to close and latch within the door frame.
2. The Sub Sterile door in OR 2 failed to close and latch within the door frame.
3. The doors to the Veranda on the 3rd floor were equipped with metal kick downs.
4. The door 3H165 to the Elevator Lobby failed to close and latch within the door frame.
5. The door 3H101 to the Beauty Shop failed to close and latch within the door frame.
6. The east Staff Elevator Lobby door next to Room 226 failed to close and latch within the door frame.
7. The door to Women ' s restroom across from 2H111 failed to close and latch within the door frame.
8. The door 2H113 to Family Education Room failed to close and latch within the door frame.

During an interview on 12-1-15 between 1:36 pm and 4:56 pm, Maintenance A confirmed all the findings.



29214

Based on observation and interview, the facility failed to ensure that corridor doors would resist the passage of smoke. This deficient practice had the potential to allow smoke or fire to migrate into exit corridors. The facility census was 48 patients.

Findings are:
Observations on 12-2-15 at 10:20 A.M. revealed the door to the cafeteria that opened to the corridor failed to close and latch within the door frame.

During an interview on 12-2-15 at 10:20 A.M., observation was acknowledged and verified by Maintenance C.

Based on observation and interview, the facility failed to maintain an exit door within the vertical opening. This deficient practice would allow smoke and gasses into the stair tower which would delay egress during a fire emergency. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 at 3:49 pm revealed, the stair door next to Room 208, failed to latch within the door frame when tested.

During an interview 12-1-15 at 3:49 pm, Maintenance A confirmed the findings.

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. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 1:56 pm and 4:19 pm revealed:
1. The smoke separation doors equipped with self-closing devices next to Room 301 failed to close and latch within the door frame.
2. The smoke separation doors equipped with self-closing devices next to Room 3H267 failed to close and latch within the door frame.
3. The smoke separation doors equipped with self-closing devices next to Room 2H132 failed to close and latch within the door frame.
4. The smoke separation doors equipped with self-closing devices next to Room 226 failed to close and latch within the door frame.

During an interview on 12-1-15 between 1:56 pm and 4:19 pm, Maintenance A confirmed the findings.

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 ensure that smoke separation doors were capable of resisting the passage of smoke. This deficient practice would allow smoke and gasses to spread. The facility census was 48 patients.

Findings are:

Observations on 12-1-15 at 4:20 pm revealed a smoke separation doors equipped with self-closing devices in the southwest respirator hallway failed to close and latch within the door frame.

During an interview on 12-1-15 at 4:20 pm, observations were acknowledged and verified by Maintenance B.

Based on observation and interview, the facility failed to maintain smoke resisting partitions and doors to separate hazard areas from other spaces in the facility. This deficient practice had the potential to allow smoke or fire to migrate out of the hazard rooms into exit corridors. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 1:36 pm and 4:55 pm revealed:
1. The storage room door in sub-sterile 2 room failed to close and latch within the door frame.
2. Door 1H269 to Soiled Linen failed to close and latch within the door frame.
3. Door 1H268 to Housekeeping failed to close and latch within the door frame.
4. Storage Room doors next to Room 306 had a gap greater than 1/8 inch between two doors.
5. Unsealed conduit chase in 3H165 Electrical Room
6. Storage Room doors 2H118 had a gap greater than 1/8 inch between two doors.

During an interview on 12-1-15 between 1:36 pm and 4:55 pm, Maintenance A confirmed all the findings.

Based on observation and staff interview, the facility failed to provide smoke resistant doors to hazard areas. This deficient practice had the potential to allow smoke or fire to migrate out of the hazard rooms into exit corridors. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 3:57 pm and 4:58 pm revealed:
1. The storage room door #1H478 in respiratory therapy failed to close and latch within the door frame.
2. The area in equipment storage room at west end of radiology measured 120ft2 and was not equipped with self-closing device.

During an interview on 12-1-15 between 3:57 pm and 4:58 pm, observations were acknowledged and verified by Maintenance B.

Based on observation and interview, the facility failed to provide a sidewalk to public way from doors marked as an exit and failed to provide delayed egress signage on magnetically locked doors. This deficient practice would delay egress during an emergency. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 at 10:15 am revealed:
1. No sidewalk from the Switch Gear Room exit door leading to public way.
2. No sidewalk from the Chiller exit door leading to public way.
3. Door 3H101 in the Beauty Shop provide a thumb lock, which took two motions to egress the room.
4. The double doors leading into Pharmacy were locked with a magnetic lock, the doors failed to provide delayed signage to have the ability to exit from the corridor.

During an interview on 12-1-15 at 10:47 am, Maintenance 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 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1

K 38
Based on observation and staff interview, the facility failed to maintain the doors in the path of egress so the exit hardware would release with no more than 15 pounds of pressure. Also, the facility allowed storage in the exit stair enclosure. These deficient practices had the potential to prevent occupants from exiting the facility during an emergency. Facility census was 48 residents.

Findings are:
Observation on 12/1/15 between 3:08 P.M. and 4:24 P.M. revealed:
1. While using a door pressure gauge to release the panic hardware for ER/Radiology Hallway ' s exterior exit, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.
2. While using a door pressure gauge to release the panic hardware for north exit door by ER director office, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.
3. Rugs and paint were stored in the stair enclosure.

During an interview on 12/1/15 between 3:08 P.M. and 4:24 P.M., observations were acknowledged and verified by Maintenance B.
NFPA Standard:

2000 ed. NFPA 1017.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.

Based on observation and interview, the facility failed to verify the illumination of the exit discharge, so that the failure of any single lighting fixture (bulb) would not leave the area in darkness, for all exits. This deficient practice would delay egress from the building. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 at 2:23 pm, revealed, the facility failed to provide a two bulb light fixture at the north OR exterior exit.

During an interview on 12-1-15 at 2:23 pm, Maintenance A confirmed the findings.

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

Based on observation and staff interview, the facility failed to provide a dual bulb light fixture in the means of egress. This deficient practice could leave the area in darkness when the single bulb failed. Facility census was 48.
Findings are:
Observation on 12-1-15 at 5:10 P.M. revealed a single bulb fixture outside by the radiology ' s north exit.
During an interview on 12-1-15 at 5:10 P.M., observations were acknowledged and verified by Maintenance B.

Based on observation and interview, the facility failed to maintain emergency lighting in the Switch Gear Room. This deficient practice could delay maintenance on equipment during a power outage and delay egress. The facility census was 48 patients .

Findings are:
Observations on 12-1-15 at 1:48 pm revealed, the emergency light in the switch gear room failed to light when test button was depressed.

During an interview on 12-1-15 at 1:48 pm, Maintenance A confirmed the light failed to operate.

NFPA Standard:
Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. 2000 NFPA 101, 7.9.2.1*

The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2

Based on observation and interview, the facility failed to provide exit signs for the required second exit throughout the facility. This deficient practice would delay or cause confusion during an emergency as occupants would not be aware of the exits. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 12:42 pm and 4:10 pm revealed:
1. While looking south in the OR corridor outside OR 3 no exit signage provided.
2. While looking east in the back OR corridor no exit signage provided.
3. While looking west in the corridor outside room 301 no exit signage provided.
4. While looking east in the corridor outside Prairie Room no exit signage provided.
5. While looking north in the corridor outside Room 2H254 no exit signage provided.
6. While looking east in the Pharmacy corridor the exit sign was not visible.

During an interview on 12-1-15 between 12:42 pm and 4:10 pm, Maintenance A confirmed the lack of exit signage.

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

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs. 2000 NFPA 101, 7.10.1.4

Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000 NFPA 101, 7.10.1.2

Based on record review and staff interview, the facility failed to conduct fire drills quarterly on each shift and failed to provide documentation from the facility ' s fire alarm monitoring service that showed that a signal was received for each fire drill conducted. This had the potential to affect staff preparation and experience to respond to a fire emergency. The facility census was 48.

Findings are:

Record review of the fire drill report on 12-2-15 between 10:27 am and 10:47 am revealed:
1. The facility failed to provide documentation from the central monitoring services that a fire alarm signal was transmitted for each fire drill.
2. There was no fire drill that was conducted for 3rd shift, 1st quarter of 2015.


During an interview on 12-2-15 between 10:27 am and 10:47 am, findings of documentation review were acknowledged and verified by Maintenance B.

NFPA Standard:

NFPA 101, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on record review and staff interview, the facility failed to conduct fire drills quarterly on each shift to familiarize facility personnel and failed to provide documentation from the facility ' s fire alarm monitoring service that showed a signal was received for each fire drill conducted. This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility census was 48.

Findings are:

Record review of the fire drill report on 12-2-15 between 10:27 am and 10:47 am revealed:
1. The facility failed to provide documentation from the central monitoring services for each fire drill.
2. There was no fire drill that was conducted for 3rd shift, 1st quarter of 2015.


During an interview on 12-2-15 between 10:27 am and 10:47 am, findings of documentation review were acknowledged and verified by Maintenance B.

NFPA Standard:

NFPA 101, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on observation, record review and staff interview, the facility failed to provide complete documentation for the annual fire alarm system inspection as required by NFPA 72 and failed to maintain the fire alarm annunciators in working condition. The deficient practice increased the potential that the fire alarm would fail to operate during a fire. This facility census was 48.

Findings are:

Record review of the facility's fire alarm inspection report on 7/10/15, at 11:01 A.M., revealed the report did not list the type and quantity of all activation devices, circuits, and supervisory devices, the method of testing, and the results of the tests.

During an interview on 7/10/15, at 11:01 A.M., findings of documentation review were acknowledged and verified by Maintenance B.

Observation on 12-2-15 at 9:31 A.M. revealed the fire alarm annunciator panel at Same Day Service was not working as designed.

During an interview on 12-2-15 at 9:31 A.M., observations were acknowledged and verified by Maintenance C.


NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2, including: Date, Test frequency, Name of property, Address, Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number, Name, address, and representative of approving agency, Designation of the detector(s) tested, for example, " Tests performed in accordance with Section _. " , Functional test of detectors, Functional test of required sequence of operations, Check of all smoke detectors, Loop resistance for all fixed-temperature, line-type heat detectors, Other tests as required by equipment manufacturers, Other tests as required by the authority having jurisdiction, Signatures of tester and approved authority representative, Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place). 1999 NFPA 72, 7-5.2.2

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

NFPA 72 1999 ed.

5-5.3.2.1.6 DACT Transmission Channels.
5-5.3.2.1.6.1 A DACT shall employ one of the following combinations of transmission channels:
(1) Two telephone lines (numbers)
(2) One telephone line (number) and one cellular telephone connection
(3) One telephone line (number) and a one-way radio system
(4) One telephone line (number) equipped with a derived local channel
(5) One telephone line (number) and a one-way private radio alarm system
(6) One telephone line (number) and a private microwave radio system
(7) One telephone line (number) and a two-way RF multiplex system

Based on observation, record review and staff interview, the facility failed to provide complete documentation for the annual fire alarm system inspection as required by NFPA 72. The deficient practice increased the potential that the fire alarm would fail to operate during a fire. This facility census was 48.

Findings are:

Record review of the facility's fire alarm inspection report on 7/10/15, at 11:01 A.M., revealed the report did not list the type and quantity of all activation devices, circuits, and supervisory devices, the method of testing, and the results of the tests.

During an interview on 7/10/15, at 11:01 A.M., findings of documentation review were acknowledged and verified by Maintenance B.

Observation on 12-2-15 at 9:31 A.M. revealed the annunciator at the Same Day Service was not working as designed.

During an interview on 12-2-15 at 9:31 A.M., findings of documentation review were acknowledged and verified by Maintenance C.


NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2, including: Date, Test frequency, Name of property, Address, Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number, Name, address, and representative of approving agency, Designation of the detector(s) tested, for example, " Tests performed in accordance with Section _. " , Functional test of detectors, Functional test of required sequence of operations, Check of all smoke detectors, Loop resistance for all fixed-temperature, line-type heat detectors, Other tests as required by equipment manufacturers, Other tests as required by the authority having jurisdiction, Signatures of tester and approved authority representative, Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place). 1999 NFPA 72, 7-5.2.2

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

NFPA 72 1999 ed.

5-5.3.2.1.6 DACT Transmission Channels.
5-5.3.2.1.6.1 A DACT shall employ one of the following combinations of transmission channels:
(1) Two telephone lines (numbers)
(2) One telephone line (number) and one cellular telephone connection
(3) One telephone line (number) and a one-way radio system
(4) One telephone line (number) equipped with a derived local channel
(5) One telephone line (number) and a one-way private radio alarm system
(6) One telephone line (number) and a private microwave radio system
(7) One telephone line (number) and a two-way RF multiplex system

Based on observation and interview, the facility failed to provide an outside window in all patient rooms. This deficient practice would not allow for appropriate rescue and ventilation of the room. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 at 3:36 pm and 3:39 pm revealed:
1. Patient room 201 failed to provide an outside window.
2. Patient room 213 failed to provide an outside window.

During an interview on 12-1-15 at 3:36 pm and 3:39 pm, Maintenance A confirmed the findings.

NFPA Standard:
2000 NFPA, 19.3.8
Every patient sleeping room shall have an outside window or outside door. The allowable sill height shall not exceed 36 in. (91 cm) above the floor.
Exception No. 1: Newborn nurseries and rooms intended for occupancy for less than 24 hours, such as those housing obstetrical labor beds, recovery beds, and observation beds in the emergency department.
Exception No. 2: Windows in atrium walls shall be considered outside windows for the purposes of this requirement.

Based on observation and interview, the facility failed to provide one-hour fire separation around a fire pump and the fire pump components. This condition would allow a fire outside the room where the fire pump was located to disable the pump. Facility census was 48 patients.

Findings are:
Observation on 12-1-15 at 3:22 pm revealed, the fire pump in the Fire Pump Room failed to have a one-hour fire separation around the fire pump and its components so they were separated from the Mechanical Room.

During an interview on 12-1-15 at 3:22 pm, Maintenance A confirmed the fire pump was not one-hour fire separated.

NFPA Standard:
Indoor fire pump units shall be separated from all other areas of the building by 2-hour fire-rated construction.
Exception No. 1: The pumps outlined in 2-7.1.2.
Exception No. 2: In buildings protected with an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, the separation requirement shall be reduced to 1-hour fire-rated construction. 1999, NFPA 20, 2-7.1.1

Based on observation and interview, the facility failed to maintain all sprinkler heads throughout the facility in accordance with their llisting and failed to ensure all upright sprinkler heads located near the ceilings were installed within the required clearance range. This condition could prevent a fire from being suppressed by the sprinkler system. The facility census was 48 patients

Findings are:
Observations on 12-1-15 between 11:37 am revealed:
1. A missing sprinkler head escutcheon plate failed to be replaced on the flush-type sprinkler head in Room 2H266.
2. The upright sprinkler heads in 3H191 were located more than 12 inches from the ceiling.
3. The upright sprinkler heads in 2H132 were located more than 12 inches from the ceiling.
4. The upright sprinkler heads in 2H131 were located more than 12 inches from the ceiling.
5. The upright sprinkler heads in 2H108B were located more than 12 inches from the ceiling and failed to be located under a 4 foot duct.
6. The upright sprinkler heads in 2H409B were located more than 12 inches from the ceiling.
7. The upright sprinkler heads in the various other Mechanical areas and Fire Pump room were located more than 12 inches from the ceiling.

During an interview on 12-1-14 between 11:37 am and 4:45 pm, Maintenance A confirmed the findings.

NFPA Standard:
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. NFPA 13, 1999, 3-2.7.2*

Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).
Exception: Ceiling-type sprinklers (concealed, recessed, and flush types) shall be permitted to have the operating element above the ceiling and the deflector located nearer to the ceiling where installed in accordance with their listing. NFPA 13 1999, 5-6.4.1.1



29214

Based on record review, observation and staff interview, the facility failed to ensure the required automatic fire sprinkler systems were continuously maintained in reliable operating condition. This deficient practice could prevent the fire suppression system from extinguishing a fire as designed. The facility census was 48.

Findings are:

A.

Observation 12-1-15 between 4:15 P.M. and 5:52 P.M. revealed:
1. A fire sprinkler head in gift shop was missing an escutcheon ring.
2. A fire sprinkler head in old pain clinic #2 was missing an escutcheon ring.
3. A fire sprinkler head radiology storage room was 12 inches away from the storage.
4. The bathroom in CT had joint compound on the fire sprinkler head.



During an interview on 12-1-15 between 4:15 P.M. and 5:52 P.M., observations were acknowledged and verified by Maintenance B.

B.
Observation 12-2-15 between 9:47 A.M. and 9:59 P.M. revealed:
1. Two fire sprinkler heads in the southeast area of the kitchen were covered with foreign debris.
2. A fire sprinkler head in northwest area of the kitchen had an escutcheon ring that was not in place and the sprinkler head was covered with foreign debris.
3. A fire sprinkler head in the northeast area of the kitchen had an escutcheon ring that was missing.

During an interview on 12-2-15 between 9:47 A.M. and 9:59 P.M., observations were acknowledged and verified by Maintenance C.

C.

Record Review of the fire sprinkler report on 12-2-15 at 1:05 P.M., revealed that the facility failed to conduct a 5 year test on all fire sprinkler gauges or have the gauges replaced. Also, the facility failed to conduct a 5 year internal inspection on all fire sprinkler alarm valves and their associated strainers, filters, and restriction orifices.

During an interview on 12-2-15 at 1:05 P.M., findings of documentation review were acknowledged and verified by Maintenance B.

Based on record review, observation and staff interview, the facility failed to ensure the required automatic fire sprinkler system was continuously maintained in reliable operating condition. This deficient practice could prevent the fire suppression system from extinguishing a fire as designed. The facility census was 48.

Findings are:

Observation 12-1-15 at 3:28 P.M. revealed a fire sprinkler head in staff locker room # 1H145B was missing an escutcheon ring.

During an interview on 12-1-15 at 3:28 P.M, observations were acknowledged and verified by Maintenance B.

Record Review of the fire sprinkler report on 12-2-15 at 1:05 P.M., revealed that the facility failed to conduct a 5 year test on all fire sprinkler gauges or have the gauges replaced. Also, the facility failed to conduct a 5 year internal inspection on all fire sprinkler alarm valves and their associated strainers, filters, and restriction orifices.

During an interview on 12-2-15 at 1:05 P.M., findings of documentation review were acknowledged and verified by Maintenance B.

Based on observation and staff interview the facility failed to provide a placard for the Class K fire extinguisher that stated that the fire protection system shall be activated prior to using the fire extinguisher. This deficient practice would lead to a misuse of the fire extinguisher preventing the fire from being extinguished. The facility census was 48.
Findings are:
Observation on 12-2-15 at 9:57 A.M. revealed the Class K fire extinguisher in the kitchen and in the cafeteria did not have a placard that stated that the fire protection system shall be activated prior to using the fire extinguisher.
During an interview on 12-2-15 at 9:57 A.M., observations were acknowledged and verified by Maintenance C.

NFPA Standard:
NFPA 10 1998 ed. 2-3.2.1 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on record review, observation and staff interview the facility failed to ensure that all internal seams and joints of the hood and exhaust system for the commercial cooking equipment were sealed and grease tight. The facility failed to inspect the extinguishing system and exhaust system every 6 months. This deficient practice could prevent the fire extinguishing equipment from extinguishing a fire as designed. The facility census was 48.

Findings are:

A.
Record review of extinguishing system reports and exhausts system report on 12/1/15 at 11:00 A.M. revealed:
1. The exhausts system report on 4-13-15 stated that the system was cleaned but not inspected.
2. The exhausts system report on 4-13-15 stated the hood duct was inaccessible. The facility could not verify this complication.
3. The extinguishing system inspections were conducted on 3-16-15 and 10-6-15 and were not completed within 6 months.

During an interview on 2/1/15 at 11:00 A.M., findings of documentation review were acknowledged and verified by Maintenance B.

B.

Observation on 12/2/15 at 10:15 A.M. revealed the hood and exhaust system in the kitchen and cafeteria had internal seams and joints that were not all sealed and grease tight. The sealant was either removed or loose.

During an interview on 12/2/15 at 10:15 A.M., observation was acknowledged and verified by Maintenance C.

NFPA Standard

NFPA 96, 1999 ed. 2.1.2
All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood ' s lower outermost perimeter. Internal hood joints seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made greasetight.

Based on observation and interview, this facility did not provide unobstructed corridors that provide a clear path of egress. Exiting corridors shall be fee of obstructions to provide a reliable means of egress. This deficient practice can limit and/or delay evacuation in the event of an emergency. This facility census was 48 patients.

Findings are:
Observation on 12-1-15 at 11:45 am of the C-Section corridor revealed the corridor was being obstructed by soiled instrument cart, baby camera machine, mop and bucket.

During an interview 12-1-15 at 11:45 am, Maintenance A confirmed the findings

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on record review and staff interview, the facility failed to have the bulk oxygen storage inspected annually by a qualified representative of the equipment owner. Facility census was 48

Findings are:

Record review of the Bulk Oxygen Storage Inspection on 12-2-15 at 12:32 pm revealed that an inspection was completed on 9-18-14 and on 10-29-15.

During an interview on 12-2-15 at 12:32 pm, findings of documentation review were acknowledged and verified by Maintenance B.

NFPA Standard:

Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner. 2001 NFPA 50, 4.2.1

A. Based on documentation review, observation and interview, the facility failed to have the Level 1 emergency generator installed in accordance with NFPA 110, 1999 edition by not having the generator installed in a separate room separated from the rest of the building by a minimum of two-hour fire-rated construction and failed to have an emergency generator shut down switch outside the area of the generators. The facility census was 48 patients.

Findings are:
Observation on 12-1-15 at 1:32 pm revealed the facility failed to provide a manual shutdown for the generators.

Documentation review of the facility's original blueprints on 12-1-15 at 1:32 pm indicated the room housing the emergency generators provided a one-hour fire resistane rating with 45 minute fire rated doors.

During an interview on 12-1-15 at 1:32 pm, Maintenance A confirmed the facility failed to provide a manual shutdown and verified the generator room was separated by only one-hour fire resistance rating as indicated on the blueprints.

NFPA Standard:
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 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, 5-2.1

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*

A.

Based on observation and interview, the facility failed to provide a self-closing door for a hazard area. This deficient practice had the potential to allow smoke or fire to migrate out of the hazard rooms into exit corridors.

Findings are:

Observations on 12-1-15 at 2:01 pm revealed the door to the store room was not self-closing.

During an interview on 12-1-15 at 2:01 pm, observations were acknowledged and verified by Maintenance B.

B.

Based on record review and staff interview, the facility failed to conduct required weekly inspections of the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This deficient practice increased the potential that the generator would fail to run during loss of power.

Findings are:

Record review of the emergency generator inspection and testing log on 12-1-15 at 2:15 pm revealed that the electrical system, air/exhaust system, lubrication system, generator engine and battery system failed to be inspected and documented weekly. Also, the monthly load test failed to be conducted and documented monthly.

During an interview on 12-1-15 at 2:15 pm, findings of documentation review were acknowledged and verified by Maintenance B.

Based on observation and interview, the facility failed to provide corridor doors that would resist the passage of smoke and gases. These deficient practices have the potential to allow smoke to migrate throughout the exit corridors, which would delay egress in the event of a fire.

Findings are:

Observations on 12-1-15 at 11:30 am revealed the east exit door from the lab failed to latch within the door frame when closed.

During an interview on 12-1-15 at 11:30 am, Maintenance B confirmed all the findings.

Based on observation and staff interview, the facility failed to ensure emergency lighting was operable at all times. The lack of illumination in the event of loss of power would prevent occupants from evacuating the facility during an emergency.

Findings are:

Observations on 12-1-15 at 11:40 A.M. revealed that the emergency light in west hall by room #455 failed to work when the test button was depressed.

During an interview on 12-1-15 at 11:40 A.M., observations were acknowledged and verified by Maintenance B.

NFPA Standard:
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.3

Based on observation, record review, and staff interview, the facility failed to ensure the required automatic fire sprinkler system was continuously maintained in reliable operating condition. This deficient practice could prevent the fire suppression system from extinguishing a fire as designed.

Findings are:

Observation on 12-1-15 at 1:20 P.M. revealed two corroded sprinkler heads in the pool room and one escutcheon ring missing from a sprinkler head in the north store room.

During an interview on 12-1-15 at 1:20 P.M., observations were acknowledged and verified by Maintenance B.

Record review of the fire sprinkler report on 12-1-15 at 1:18 P.M. revealed:
1. There was no report for the quarterly flow test.
2. There was no annuall inspection report for the fire sprinkler system.
3. There was no 5 year internal pipe, valves and gauges inspection report.

During an interview on 12-1-15 at 1:18 P.M., findings of documentation review were acknowledged and verified by Maintenance B.

Based on record review and staff interview, the facility failed to conduct required weekly inspections of the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This deficient practice increased the potential that the generator would fail to run during loss of power.

Findings are:

Record review of the emergency generator inspection and testing log on 12-1-15 at 2:15 pm revealed that the electrical system, air/exhaust system, lubrication system, generator engine and battery system failed to be inspected and documented weekly. Also, the monthly load test failed to be inspected and documented monthly.

During an interview on 12-1-15 at 2:15 pm, findings of documentation review were acknowledged and verified by Maintenance B.

Based on documentation review and interview, the facility failed to verify the generator transferred from normal power to generator power in 10 seconds or less of a general power outage. This deficient practice affected the entire building emergency lighting system and all the building occupants. The facility census was 48 patients.

Findings are:
Documentation review on 12-1-15 at 4:20 pm revealed, the facility failed to document the time to transfer from normal power to generator power.

During an interview on 12-1-15 at 4:20 pm, Maintenance A confirmed that the generator testing documentation failed to be complete.

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 separate the circuits of 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. This deficient practice had the potential to affect all patients, staff and visitors of the facility and affected operation of the egress lighting and emergency systems of the facility. The facility census is 48 patients.

Findings are:
Observations on 12-2-15 between 11:31 am and 2:30 pm revealed:
1. Life Safety loads connected to the Critical branch panel box 3CL2 in room 3H190
2. Life Safety loads connected to the Critical branch panel box 3CH2 in room 2H407
3. Life Safety and Equipment loads connected to the Critical branch panel box 1CL1 in room 1H493
4. Life Safety, Equipment and normal loads connected to the Critical branch panel box 1CL2 in room 1H116
5. Life Safety loads connected to the Equipment branch panel box PIEQ2L in the Main Electrical Room.
6. Life Safety loads connected to the Critical branch panel box 2CL4 in room 2H407
7. Life Safety loads connected to the Normal branch panel box 2NL4 in room 2H407
8. Life Safety loads connected to the Critical branch panel box 3CL1 in room 3H161
9. Emergency lighting and egress lighting for the OR Suite could not be located in any electrical panel boxes located in the sterile core area.

During an interview on 12-2-15 between 11:31 am and 2:30 pm, Maintenance 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 maintenance (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 prohibit the use of extension cords and electrical adaptors, and failed to provide schedules and directories to identify circuits in panel boxes. This deficient practice could increase the potential for an electrical fire or delay turning off power to a specific location. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 2:47 pm and 3:40 pm revealed:
1. Extension cord and a three way electrical adaptor in Office 3H171.
2. Missing panel schedule and no label for the north east panel box in Room 3H190.
3. Missing panel schedule in panel box 2CL-3 in Room 2H259.

During an interview on 12-1-15 between 2:47 pm and 3:40, Maintenance A confirmed the findings.

Regulations:
Nebraska State Fire Marshal Official State Interpretation- 08-01

NFPA Standard:
(e) Identification. Where a building or structure is supplied by more than one service, or any combination of branch circuits, feeders, and services, a permanent plaque or directory shall be installed at each service disconnect location denoting all other services, feeders, and branch circuits supplying that building or structure and the area served by each. See Section 225-37. 1999 NFPA 70, 225-37

Based on observation and interview, the facility allowed the use of unapproved surge protectors. This deficient practice could increase the potential for an electrical fire or delay turning off power to a specific location. The facility census was 48.

Findings are:
Observations on 12-1-15 at 3:50 pm revealed an unapproved surge protector being used in Pulmonary Function Therapy room #1H482.

During an interview on 12-1-15 at 3:50 pm and 3:40, observations were acknowledged and verified by Maintenance B.

Based on record review and staff interview, the facility fire watch policy failed to include information on how often an individual would inspect the affected areas when the fire sprinkler system was out service for more than 4 hours in a 24 hour period. Also, the facility failed to indicate that the individual conducting fire watch had no other assigned duties. These deficient practices could allow a fire to go undetected. Facility census was 48.

Findings are:

Record review of the fire watch policy on 12-2-15 at 2:00 P.M. revealed the fire watch policy did not contain information on how often an individual would complete inspection rounds of the affected areas when a fire watch was initiated. Also, the fire watch policy did not indicate that the individual conducting fire watch had no other assigned duties.

During an interview on 12-2-15 at 2:00 P.M., findings of documentation review were acknowledged and verified by Maintenance A.

NFPA Standard
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1

Nebraska Fire Marshal Interpretation 05-01
The approved firewatch shall contain the following:
1. The authority having jurisdiction and the local fire department shall be notified immediately,
2. The individual(s) conducting the firewatch shall have no other assigned duties,
3. The individual(s) conducting the firewatch shall be trained to recognize fire hazards, know the procedures for occupant and fire department notification and occupant evacuation,
4. The individual(s) conducting the firewatch has access to all portions of the building,
5. The individual(s) conducting the firewatch shall walk through the affected area(s) at intervals not exceeding 30 minutes, (this may be altered depending on the size of the building and with the approval of the authority having jurisdiction)

Based on record review and staff interview, the facility fire watch policy failed to include information on how often an individual would inspect the affected areas when the fire sprinkler system was out service for more than 4 hours in a 24 hour period. Also, the facility failed to indicate that the individual conducting fire watch had no other assigned duties. These deficient practices could allow a fire to go undetected. Facility census was 48.

Findings are:

Record review of the fire watch policy on 12-2-15 at 2:00 P.M. revealed the fire watch policy did not contain information on how often an individual would complete inspection rounds of the affected areas when a fire watch was initiated. Also, the fire watch policy did not indicate that the individual conducting fire watch had no other assigned duties.

During an interview on 12-2-15 at 2:00 P.M., findings of documentation review were acknowledged and verified by Maintenance A.

NFPA Standard
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1

Nebraska Fire Marshal Interpretation 05-01
The approved firewatch shall contain the following:
1. The authority having jurisdiction and the local fire department shall be notified immediately,
2. The individual(s) conducting the firewatch shall have no other assigned duties,
3. The individual(s) conducting the firewatch shall be trained to recognize fire hazards, know the procedures for occupant and fire department notification and occupant evacuation,
4. The individual(s) conducting the firewatch has access to all portions of the building,
5. The individual(s) conducting the firewatch shall walk through the affected area(s) at intervals not exceeding 30 minutes, (this may be altered depending on the size of the building and with the approval of the authority having jurisdiction)

Based on record review and staff interview, the facility fire watch policy failed to include information on how often an individual would inspect the affected areas when the fire alarm system was out service for more than 4 hours in a 24 hour period. Also, the facility failed to indicate that the individual conducting fire watch had no other assigned duties. These deficient practices could allow a fire to go undetected. Facility census was 48.

Findings are:

Record review of the fire watch policy on 12-2-15 at 2:00 P.M. revealed the fire watch policy did not contain information on how often an individual would complete inspection rounds of the affected areas when a fire watch was initiated. Also, the fire watch policy did not indicate that the individual conducting fire watch had no other assigned duties.

During an interview on 12-2-15 at 2:00 P.M., findings of documentation review were acknowledged and verified by Maintenance A.

NFPA Standard
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1

Nebraska Fire Marshal Interpretation 05-01
The approved firewatch shall contain the following:
1. The authority having jurisdiction and the local fire department shall be notified immediately,
2. The individual(s) conducting the firewatch shall have no other assigned duties,
3. The individual(s) conducting the firewatch shall be trained to recognize fire hazards, know the procedures for occupant and fire department notification and occupant evacuation,
4. The individual(s) conducting the firewatch has access to all portions of the building,
5. The individual(s) conducting the firewatch shall walk through the affected area(s) at intervals not exceeding 30 minutes, (this may be altered depending on the size of the building and with the approval of the authority having jurisdiction)

Based on observation and interview the facility failed to assure the folding room divider in the Computer Lab Room had a flame resistant finish. The facility failed to provide documentation for the flame spread rating. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 at 2:40 pm revealed, a plastic type folding room divider in the Computer Lab.

During an interview on 12-1-15 at 2:40 pm, Maintenance A confirmed the folding door and failed to provide any type of documentation for flame retardancy.

NFPA Standard:
Ceiling and wall materials shall be limited as specified in 2000 NFPA 101, 10.2.3 Existing materials may be Class A or Class B except that rooms protected by an approved, supervised automatic sprinkler system use of existing Class C finish shall be permitted within rooms separated from the exit access corridors in accordance with 19.3.6. New materials must be Class A except that new walls/ceilings shall be permitted to have Class A or Class B finish in individual rooms having a capacity of four persons. Newly installed corridor wall finish not exceeding 4 feet in height on the lower half of the wall shall be permitted to be Class A or Class B. 2000 NFPA 101, 19.3.3.

Based on observation and interview, the facility failed to ensure that corridor doors would resist the passage of smoke. This deficient practice had the potential to allow smoke or fire to migrate into exit corridors. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 1:36 am and 4:56 pm revealed:
1. The door to OR 2 failed to close and latch within the door frame.
2. The Sub Sterile door in OR 2 failed to close and latch within the door frame.
3. The doors to the Veranda on the 3rd floor were equipped with metal kick downs.
4. The door 3H165 to the Elevator Lobby failed to close and latch within the door frame.
5. The door 3H101 to the Beauty Shop failed to close and latch within the door frame.
6. The east Staff Elevator Lobby door next to Room 226 failed to close and latch within the door frame.
7. The door to Women ' s restroom across from 2H111 failed to close and latch within the door frame.
8. The door 2H113 to Family Education Room failed to close and latch within the door frame.

During an interview on 12-1-15 between 1:36 pm and 4:56 pm, Maintenance A confirmed all the findings.



29214

Based on observation and interview, the facility failed to ensure that corridor doors would resist the passage of smoke. This deficient practice had the potential to allow smoke or fire to migrate into exit corridors. The facility census was 48 patients.

Findings are:
Observations on 12-2-15 at 10:20 A.M. revealed the door to the cafeteria that opened to the corridor failed to close and latch within the door frame.

During an interview on 12-2-15 at 10:20 A.M., observation was acknowledged and verified by Maintenance C.

Based on observation and interview, the facility failed to maintain an exit door within the vertical opening. This deficient practice would allow smoke and gasses into the stair tower which would delay egress during a fire emergency. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 at 3:49 pm revealed, the stair door next to Room 208, failed to latch within the door frame when tested.

During an interview 12-1-15 at 3:49 pm, Maintenance A confirmed the findings.

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. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 1:56 pm and 4:19 pm revealed:
1. The smoke separation doors equipped with self-closing devices next to Room 301 failed to close and latch within the door frame.
2. The smoke separation doors equipped with self-closing devices next to Room 3H267 failed to close and latch within the door frame.
3. The smoke separation doors equipped with self-closing devices next to Room 2H132 failed to close and latch within the door frame.
4. The smoke separation doors equipped with self-closing devices next to Room 226 failed to close and latch within the door frame.

During an interview on 12-1-15 between 1:56 pm and 4:19 pm, Maintenance A confirmed the findings.

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 ensure that smoke separation doors were capable of resisting the passage of smoke. This deficient practice would allow smoke and gasses to spread. The facility census was 48 patients.

Findings are:

Observations on 12-1-15 at 4:20 pm revealed a smoke separation doors equipped with self-closing devices in the southwest respirator hallway failed to close and latch within the door frame.

During an interview on 12-1-15 at 4:20 pm, observations were acknowledged and verified by Maintenance B.

Based on observation and interview, the facility failed to maintain smoke resisting partitions and doors to separate hazard areas from other spaces in the facility. This deficient practice had the potential to allow smoke or fire to migrate out of the hazard rooms into exit corridors. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 1:36 pm and 4:55 pm revealed:
1. The storage room door in sub-sterile 2 room failed to close and latch within the door frame.
2. Door 1H269 to Soiled Linen failed to close and latch within the door frame.
3. Door 1H268 to Housekeeping failed to close and latch within the door frame.
4. Storage Room doors next to Room 306 had a gap greater than 1/8 inch between two doors.
5. Unsealed conduit chase in 3H165 Electrical Room
6. Storage Room doors 2H118 had a gap greater than 1/8 inch between two doors.

During an interview on 12-1-15 between 1:36 pm and 4:55 pm, Maintenance A confirmed all the findings.

Based on observation and staff interview, the facility failed to provide smoke resistant doors to hazard areas. This deficient practice had the potential to allow smoke or fire to migrate out of the hazard rooms into exit corridors. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 3:57 pm and 4:58 pm revealed:
1. The storage room door #1H478 in respiratory therapy failed to close and latch within the door frame.
2. The area in equipment storage room at west end of radiology measured 120ft2 and was not equipped with self-closing device.

During an interview on 12-1-15 between 3:57 pm and 4:58 pm, observations were acknowledged and verified by Maintenance B.

Based on observation and interview, the facility failed to provide a sidewalk to public way from doors marked as an exit and failed to provide delayed egress signage on magnetically locked doors. This deficient practice would delay egress during an emergency. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 at 10:15 am revealed:
1. No sidewalk from the Switch Gear Room exit door leading to public way.
2. No sidewalk from the Chiller exit door leading to public way.
3. Door 3H101 in the Beauty Shop provide a thumb lock, which took two motions to egress the room.
4. The double doors leading into Pharmacy were locked with a magnetic lock, the doors failed to provide delayed signage to have the ability to exit from the corridor.

During an interview on 12-1-15 at 10:47 am, Maintenance 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 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. 2000 NFPA 101, 7.7.1

K 38
Based on observation and staff interview, the facility failed to maintain the doors in the path of egress so the exit hardware would release with no more than 15 pounds of pressure. Also, the facility allowed storage in the exit stair enclosure. These deficient practices had the potential to prevent occupants from exiting the facility during an emergency. Facility census was 48 residents.

Findings are:
Observation on 12/1/15 between 3:08 P.M. and 4:24 P.M. revealed:
1. While using a door pressure gauge to release the panic hardware for ER/Radiology Hallway ' s exterior exit, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.
2. While using a door pressure gauge to release the panic hardware for north exit door by ER director office, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.
3. Rugs and paint were stored in the stair enclosure.

During an interview on 12/1/15 between 3:08 P.M. and 4:24 P.M., observations were acknowledged and verified by Maintenance B.
NFPA Standard:

2000 ed. NFPA 1017.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.

Based on observation and interview, the facility failed to verify the illumination of the exit discharge, so that the failure of any single lighting fixture (bulb) would not leave the area in darkness, for all exits. This deficient practice would delay egress from the building. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 at 2:23 pm, revealed, the facility failed to provide a two bulb light fixture at the north OR exterior exit.

During an interview on 12-1-15 at 2:23 pm, Maintenance A confirmed the findings.

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

Based on observation and staff interview, the facility failed to provide a dual bulb light fixture in the means of egress. This deficient practice could leave the area in darkness when the single bulb failed. Facility census was 48.
Findings are:
Observation on 12-1-15 at 5:10 P.M. revealed a single bulb fixture outside by the radiology ' s north exit.
During an interview on 12-1-15 at 5:10 P.M., observations were acknowledged and verified by Maintenance B.

Based on observation and interview, the facility failed to maintain emergency lighting in the Switch Gear Room. This deficient practice could delay maintenance on equipment during a power outage and delay egress. The facility census was 48 patients .

Findings are:
Observations on 12-1-15 at 1:48 pm revealed, the emergency light in the switch gear room failed to light when test button was depressed.

During an interview on 12-1-15 at 1:48 pm, Maintenance A confirmed the light failed to operate.

NFPA Standard:
Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. 2000 NFPA 101, 7.9.2.1*

The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2

Based on observation and interview, the facility failed to provide exit signs for the required second exit throughout the facility. This deficient practice would delay or cause confusion during an emergency as occupants would not be aware of the exits. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 12:42 pm and 4:10 pm revealed:
1. While looking south in the OR corridor outside OR 3 no exit signage provided.
2. While looking east in the back OR corridor no exit signage provided.
3. While looking west in the corridor outside room 301 no exit signage provided.
4. While looking east in the corridor outside Prairie Room no exit signage provided.
5. While looking north in the corridor outside Room 2H254 no exit signage provided.
6. While looking east in the Pharmacy corridor the exit sign was not visible.

During an interview on 12-1-15 between 12:42 pm and 4:10 pm, Maintenance A confirmed the lack of exit signage.

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

Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs. 2000 NFPA 101, 7.10.1.4

Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000 NFPA 101, 7.10.1.2

Based on record review and staff interview, the facility failed to conduct fire drills quarterly on each shift and failed to provide documentation from the facility ' s fire alarm monitoring service that showed that a signal was received for each fire drill conducted. This had the potential to affect staff preparation and experience to respond to a fire emergency. The facility census was 48.

Findings are:

Record review of the fire drill report on 12-2-15 between 10:27 am and 10:47 am revealed:
1. The facility failed to provide documentation from the central monitoring services that a fire alarm signal was transmitted for each fire drill.
2. There was no fire drill that was conducted for 3rd shift, 1st quarter of 2015.


During an interview on 12-2-15 between 10:27 am and 10:47 am, findings of documentation review were acknowledged and verified by Maintenance B.

NFPA Standard:

NFPA 101, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on record review and staff interview, the facility failed to conduct fire drills quarterly on each shift to familiarize facility personnel and failed to provide documentation from the facility ' s fire alarm monitoring service that showed a signal was received for each fire drill conducted. This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility census was 48.

Findings are:

Record review of the fire drill report on 12-2-15 between 10:27 am and 10:47 am revealed:
1. The facility failed to provide documentation from the central monitoring services for each fire drill.
2. There was no fire drill that was conducted for 3rd shift, 1st quarter of 2015.


During an interview on 12-2-15 between 10:27 am and 10:47 am, findings of documentation review were acknowledged and verified by Maintenance B.

NFPA Standard:

NFPA 101, 19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Based on observation, record review and staff interview, the facility failed to provide complete documentation for the annual fire alarm system inspection as required by NFPA 72 and failed to maintain the fire alarm annunciators in working condition. The deficient practice increased the potential that the fire alarm would fail to operate during a fire. This facility census was 48.

Findings are:

Record review of the facility's fire alarm inspection report on 7/10/15, at 11:01 A.M., revealed the report did not list the type and quantity of all activation devices, circuits, and supervisory devices, the method of testing, and the results of the tests.

During an interview on 7/10/15, at 11:01 A.M., findings of documentation review were acknowledged and verified by Maintenance B.

Observation on 12-2-15 at 9:31 A.M. revealed the fire alarm annunciator panel at Same Day Service was not working as designed.

During an interview on 12-2-15 at 9:31 A.M., observations were acknowledged and verified by Maintenance C.


NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2, including: Date, Test frequency, Name of property, Address, Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number, Name, address, and representative of approving agency, Designation of the detector(s) tested, for example, " Tests performed in accordance with Section _. " , Functional test of detectors, Functional test of required sequence of operations, Check of all smoke detectors, Loop resistance for all fixed-temperature, line-type heat detectors, Other tests as required by equipment manufacturers, Other tests as required by the authority having jurisdiction, Signatures of tester and approved authority representative, Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place). 1999 NFPA 72, 7-5.2.2

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

NFPA 72 1999 ed.

5-5.3.2.1.6 DACT Transmission Channels.
5-5.3.2.1.6.1 A DACT shall employ one of the following combinations of transmission channels:
(1) Two telephone lines (numbers)
(2) One telephone line (number) and one cellular telephone connection
(3) One telephone line (number) and a one-way radio system
(4) One telephone line (number) equipped with a derived local channel
(5) One telephone line (number) and a one-way private radio alarm system
(6) One telephone line (number) and a private microwave radio system
(7) One telephone line (number) and a two-way RF multiplex system

Based on observation, record review and staff interview, the facility failed to provide complete documentation for the annual fire alarm system inspection as required by NFPA 72. The deficient practice increased the potential that the fire alarm would fail to operate during a fire. This facility census was 48.

Findings are:

Record review of the facility's fire alarm inspection report on 7/10/15, at 11:01 A.M., revealed the report did not list the type and quantity of all activation devices, circuits, and supervisory devices, the method of testing, and the results of the tests.

During an interview on 7/10/15, at 11:01 A.M., findings of documentation review were acknowledged and verified by Maintenance B.

Observation on 12-2-15 at 9:31 A.M. revealed the annunciator at the Same Day Service was not working as designed.

During an interview on 12-2-15 at 9:31 A.M., findings of documentation review were acknowledged and verified by Maintenance C.


NFPA Standard:
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2, including: Date, Test frequency, Name of property, Address, Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number, Name, address, and representative of approving agency, Designation of the detector(s) tested, for example, " Tests performed in accordance with Section _. " , Functional test of detectors, Functional test of required sequence of operations, Check of all smoke detectors, Loop resistance for all fixed-temperature, line-type heat detectors, Other tests as required by equipment manufacturers, Other tests as required by the authority having jurisdiction, Signatures of tester and approved authority representative, Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place). 1999 NFPA 72, 7-5.2.2

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

NFPA 72 1999 ed.

5-5.3.2.1.6 DACT Transmission Channels.
5-5.3.2.1.6.1 A DACT shall employ one of the following combinations of transmission channels:
(1) Two telephone lines (numbers)
(2) One telephone line (number) and one cellular telephone connection
(3) One telephone line (number) and a one-way radio system
(4) One telephone line (number) equipped with a derived local channel
(5) One telephone line (number) and a one-way private radio alarm system
(6) One telephone line (number) and a private microwave radio system
(7) One telephone line (number) and a two-way RF multiplex system

Based on observation and interview, the facility failed to provide an outside window in all patient rooms. This deficient practice would not allow for appropriate rescue and ventilation of the room. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 at 3:36 pm and 3:39 pm revealed:
1. Patient room 201 failed to provide an outside window.
2. Patient room 213 failed to provide an outside window.

During an interview on 12-1-15 at 3:36 pm and 3:39 pm, Maintenance A confirmed the findings.

NFPA Standard:
2000 NFPA, 19.3.8
Every patient sleeping room shall have an outside window or outside door. The allowable sill height shall not exceed 36 in. (91 cm) above the floor.
Exception No. 1: Newborn nurseries and rooms intended for occupancy for less than 24 hours, such as those housing obstetrical labor beds, recovery beds, and observation beds in the emergency department.
Exception No. 2: Windows in atrium walls shall be considered outside windows for the purposes of this requirement.

Based on observation and interview, the facility failed to provide one-hour fire separation around a fire pump and the fire pump components. This condition would allow a fire outside the room where the fire pump was located to disable the pump. Facility census was 48 patients.

Findings are:
Observation on 12-1-15 at 3:22 pm revealed, the fire pump in the Fire Pump Room failed to have a one-hour fire separation around the fire pump and its components so they were separated from the Mechanical Room.

During an interview on 12-1-15 at 3:22 pm, Maintenance A confirmed the fire pump was not one-hour fire separated.

NFPA Standard:
Indoor fire pump units shall be separated from all other areas of the building by 2-hour fire-rated construction.
Exception No. 1: The pumps outlined in 2-7.1.2.
Exception No. 2: In buildings protected with an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, the separation requirement shall be reduced to 1-hour fire-rated construction. 1999, NFPA 20, 2-7.1.1

Based on observation and interview, the facility failed to maintain all sprinkler heads throughout the facility in accordance with their llisting and failed to ensure all upright sprinkler heads located near the ceilings were installed within the required clearance range. This condition could prevent a fire from being suppressed by the sprinkler system. The facility census was 48 patients

Findings are:
Observations on 12-1-15 between 11:37 am revealed:
1. A missing sprinkler head escutcheon plate failed to be replaced on the flush-type sprinkler head in Room 2H266.
2. The upright sprinkler heads in 3H191 were located more than 12 inches from the ceiling.
3. The upright sprinkler heads in 2H132 were located more than 12 inches from the ceiling.
4. The upright sprinkler heads in 2H131 were located more than 12 inches from the ceiling.
5. The upright sprinkler heads in 2H108B were located more than 12 inches from the ceiling and failed to be located under a 4 foot duct.
6. The upright sprinkler heads in 2H409B were located more than 12 inches from the ceiling.
7. The upright sprinkler heads in the various other Mechanical areas and Fire Pump room were located more than 12 inches from the ceiling.

During an interview on 12-1-14 between 11:37 am and 4:45 pm, Maintenance A confirmed the findings.

NFPA Standard:
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. NFPA 13, 1999, 3-2.7.2*

Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).
Exception: Ceiling-type sprinklers (concealed, recessed, and flush types) shall be permitted to have the operating element above the ceiling and the deflector located nearer to the ceiling where installed in accordance with their listing. NFPA 13 1999, 5-6.4.1.1



29214

Based on record review, observation and staff interview, the facility failed to ensure the required automatic fire sprinkler systems were continuously maintained in reliable operating condition. This deficient practice could prevent the fire suppression system from extinguishing a fire as designed. The facility census was 48.

Findings are:

A.

Observation 12-1-15 between 4:15 P.M. and 5:52 P.M. revealed:
1. A fire sprinkler head in gift shop was missing an escutcheon ring.
2. A fire sprinkler head in old pain clinic #2 was missing an escutcheon ring.
3. A fire sprinkler head radiology storage room was 12 inches away from the storage.
4. The bathroom in CT had joint compound on the fire sprinkler head.



During an interview on 12-1-15 between 4:15 P.M. and 5:52 P.M., observations were acknowledged and verified by Maintenance B.

B.
Observation 12-2-15 between 9:47 A.M. and 9:59 P.M. revealed:
1. Two fire sprinkler heads in the southeast area of the kitchen were covered with foreign debris.
2. A fire sprinkler head in northwest area of the kitchen had an escutcheon ring that was not in place and the sprinkler head was covered with foreign debris.
3. A fire sprinkler head in the northeast area of the kitchen had an escutcheon ring that was missing.

During an interview on 12-2-15 between 9:47 A.M. and 9:59 P.M., observations were acknowledged and verified by Maintenance C.

C.

Record Review of the fire sprinkler report on 12-2-15 at 1:05 P.M., revealed that the facility failed to conduct a 5 year test on all fire sprinkler gauges or have the gauges replaced. Also, the facility failed to conduct a 5 year internal inspection on all fire sprinkler alarm valves and their associated strainers, filters, and restriction orifices.

During an interview on 12-2-15 at 1:05 P.M., findings of documentation review were acknowledged and verified by Maintenance B.

Based on record review, observation and staff interview, the facility failed to ensure the required automatic fire sprinkler system was continuously maintained in reliable operating condition. This deficient practice could prevent the fire suppression system from extinguishing a fire as designed. The facility census was 48.

Findings are:

Observation 12-1-15 at 3:28 P.M. revealed a fire sprinkler head in staff locker room # 1H145B was missing an escutcheon ring.

During an interview on 12-1-15 at 3:28 P.M, observations were acknowledged and verified by Maintenance B.

Record Review of the fire sprinkler report on 12-2-15 at 1:05 P.M., revealed that the facility failed to conduct a 5 year test on all fire sprinkler gauges or have the gauges replaced. Also, the facility failed to conduct a 5 year internal inspection on all fire sprinkler alarm valves and their associated strainers, filters, and restriction orifices.

During an interview on 12-2-15 at 1:05 P.M., findings of documentation review were acknowledged and verified by Maintenance B.

Based on observation and staff interview the facility failed to provide a placard for the Class K fire extinguisher that stated that the fire protection system shall be activated prior to using the fire extinguisher. This deficient practice would lead to a misuse of the fire extinguisher preventing the fire from being extinguished. The facility census was 48.
Findings are:
Observation on 12-2-15 at 9:57 A.M. revealed the Class K fire extinguisher in the kitchen and in the cafeteria did not have a placard that stated that the fire protection system shall be activated prior to using the fire extinguisher.
During an interview on 12-2-15 at 9:57 A.M., observations were acknowledged and verified by Maintenance C.

NFPA Standard:
NFPA 10 1998 ed. 2-3.2.1 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on record review, observation and staff interview the facility failed to ensure that all internal seams and joints of the hood and exhaust system for the commercial cooking equipment were sealed and grease tight. The facility failed to inspect the extinguishing system and exhaust system every 6 months. This deficient practice could prevent the fire extinguishing equipment from extinguishing a fire as designed. The facility census was 48.

Findings are:

A.
Record review of extinguishing system reports and exhausts system report on 12/1/15 at 11:00 A.M. revealed:
1. The exhausts system report on 4-13-15 stated that the system was cleaned but not inspected.
2. The exhausts system report on 4-13-15 stated the hood duct was inaccessible. The facility could not verify this complication.
3. The extinguishing system inspections were conducted on 3-16-15 and 10-6-15 and were not completed within 6 months.

During an interview on 2/1/15 at 11:00 A.M., findings of documentation review were acknowledged and verified by Maintenance B.

B.

Observation on 12/2/15 at 10:15 A.M. revealed the hood and exhaust system in the kitchen and cafeteria had internal seams and joints that were not all sealed and grease tight. The sealant was either removed or loose.

During an interview on 12/2/15 at 10:15 A.M., observation was acknowledged and verified by Maintenance C.

NFPA Standard

NFPA 96, 1999 ed. 2.1.2
All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood ' s lower outermost perimeter. Internal hood joints seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made greasetight.

Based on observation and interview, this facility did not provide unobstructed corridors that provide a clear path of egress. Exiting corridors shall be fee of obstructions to provide a reliable means of egress. This deficient practice can limit and/or delay evacuation in the event of an emergency. This facility census was 48 patients.

Findings are:
Observation on 12-1-15 at 11:45 am of the C-Section corridor revealed the corridor was being obstructed by soiled instrument cart, baby camera machine, mop and bucket.

During an interview 12-1-15 at 11:45 am, Maintenance A confirmed the findings

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on record review and staff interview, the facility failed to have the bulk oxygen storage inspected annually by a qualified representative of the equipment owner. Facility census was 48

Findings are:

Record review of the Bulk Oxygen Storage Inspection on 12-2-15 at 12:32 pm revealed that an inspection was completed on 9-18-14 and on 10-29-15.

During an interview on 12-2-15 at 12:32 pm, findings of documentation review were acknowledged and verified by Maintenance B.

NFPA Standard:

Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner. 2001 NFPA 50, 4.2.1

A. Based on documentation review, observation and interview, the facility failed to have the Level 1 emergency generator installed in accordance with NFPA 110, 1999 edition by not having the generator installed in a separate room separated from the rest of the building by a minimum of two-hour fire-rated construction and failed to have an emergency generator shut down switch outside the area of the generators. The facility census was 48 patients.

Findings are:
Observation on 12-1-15 at 1:32 pm revealed the facility failed to provide a manual shutdown for the generators.

Documentation review of the facility's original blueprints on 12-1-15 at 1:32 pm indicated the room housing the emergency generators provided a one-hour fire resistane rating with 45 minute fire rated doors.

During an interview on 12-1-15 at 1:32 pm, Maintenance A confirmed the facility failed to provide a manual shutdown and verified the generator room was separated by only one-hour fire resistance rating as indicated on the blueprints.

NFPA Standard:
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 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, 5-2.1

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*

A.

Based on observation and interview, the facility failed to provide a self-closing door for a hazard area. This deficient practice had the potential to allow smoke or fire to migrate out of the hazard rooms into exit corridors.

Findings are:

Observations on 12-1-15 at 2:01 pm revealed the door to the store room was not self-closing.

During an interview on 12-1-15 at 2:01 pm, observations were acknowledged and verified by Maintenance B.

B.

Based on record review and staff interview, the facility failed to conduct required weekly inspections of the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This deficient practice increased the potential that the generator would fail to run during loss of power.

Findings are:

Record review of the emergency generator inspection and testing log on 12-1-15 at 2:15 pm revealed that the electrical system, air/exhaust system, lubrication system, generator engine and battery system failed to be inspected and documented weekly. Also, the monthly load test failed to be conducted and documented monthly.

During an interview on 12-1-15 at 2:15 pm, findings of documentation review were acknowledged and verified by Maintenance B.

Based on observation and interview, the facility failed to provide corridor doors that would resist the passage of smoke and gases. These deficient practices have the potential to allow smoke to migrate throughout the exit corridors, which would delay egress in the event of a fire.

Findings are:

Observations on 12-1-15 at 11:30 am revealed the east exit door from the lab failed to latch within the door frame when closed.

During an interview on 12-1-15 at 11:30 am, Maintenance B confirmed all the findings.

Based on observation and staff interview, the facility failed to ensure emergency lighting was operable at all times. The lack of illumination in the event of loss of power would prevent occupants from evacuating the facility during an emergency.

Findings are:

Observations on 12-1-15 at 11:21 A.M. revealed 2 emergency lights in east hall behind the reception ' s desk failed to work when the test button was depressed.

During an interview on 12-1-15 at 11:21 A.M., observations were acknowledged and verified by Maintenance B.

NFPA Standard:
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.3

Based on observation and staff interview, the facility failed to ensure emergency lighting was operable at all times. The lack of illumination in the event of loss of power would prevent occupants from evacuating the facility during an emergency.

Findings are:

Observations on 12-1-15 at 11:40 A.M. revealed that the emergency light in west hall by room #455 failed to work when the test button was depressed.

During an interview on 12-1-15 at 11:40 A.M., observations were acknowledged and verified by Maintenance B.

NFPA Standard:
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.3

Based on observation, record review, and staff interview, the facility failed to ensure the required automatic fire sprinkler system was continuously maintained in reliable operating condition. This deficient practice could prevent the fire suppression system from extinguishing a fire as designed.

Findings are:

Observation on 12-1-15 at 1:20 P.M. revealed two corroded sprinkler heads in the pool room and one escutcheon ring missing from a sprinkler head in the north store room.

During an interview on 12-1-15 at 1:20 P.M., observations were acknowledged and verified by Maintenance B.

Record review of the fire sprinkler report on 12-1-15 at 1:18 P.M. revealed:
1. There was no report for the quarterly flow test.
2. There was no annuall inspection report for the fire sprinkler system.
3. There was no 5 year internal pipe, valves and gauges inspection report.

During an interview on 12-1-15 at 1:18 P.M., findings of documentation review were acknowledged and verified by Maintenance B.

Based on record review and staff interview, the facility failed to conduct required weekly inspections of the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. This deficient practice increased the potential that the generator would fail to run during loss of power.

Findings are:

Record review of the emergency generator inspection and testing log on 12-1-15 at 2:15 pm revealed that the electrical system, air/exhaust system, lubrication system, generator engine and battery system failed to be inspected and documented weekly. Also, the monthly load test failed to be inspected and documented monthly.

During an interview on 12-1-15 at 2:15 pm, findings of documentation review were acknowledged and verified by Maintenance B.

Based on documentation review and interview, the facility failed to verify the generator transferred from normal power to generator power in 10 seconds or less of a general power outage. This deficient practice affected the entire building emergency lighting system and all the building occupants. The facility census was 48 patients.

Findings are:
Documentation review on 12-1-15 at 4:20 pm revealed, the facility failed to document the time to transfer from normal power to generator power.

During an interview on 12-1-15 at 4:20 pm, Maintenance A confirmed that the generator testing documentation failed to be complete.

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 separate the circuits of 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. This deficient practice had the potential to affect all patients, staff and visitors of the facility and affected operation of the egress lighting and emergency systems of the facility. The facility census is 48 patients.

Findings are:
Observations on 12-2-15 between 11:31 am and 2:30 pm revealed:
1. Life Safety loads connected to the Critical branch panel box 3CL2 in room 3H190
2. Life Safety loads connected to the Critical branch panel box 3CH2 in room 2H407
3. Life Safety and Equipment loads connected to the Critical branch panel box 1CL1 in room 1H493
4. Life Safety, Equipment and normal loads connected to the Critical branch panel box 1CL2 in room 1H116
5. Life Safety loads connected to the Equipment branch panel box PIEQ2L in the Main Electrical Room.
6. Life Safety loads connected to the Critical branch panel box 2CL4 in room 2H407
7. Life Safety loads connected to the Normal branch panel box 2NL4 in room 2H407
8. Life Safety loads connected to the Critical branch panel box 3CL1 in room 3H161
9. Emergency lighting and egress lighting for the OR Suite could not be located in any electrical panel boxes located in the sterile core area.

During an interview on 12-2-15 between 11:31 am and 2:30 pm, Maintenance 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 maintenance (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 prohibit the use of extension cords and electrical adaptors, and failed to provide schedules and directories to identify circuits in panel boxes. This deficient practice could increase the potential for an electrical fire or delay turning off power to a specific location. The facility census was 48 patients.

Findings are:
Observations on 12-1-15 between 2:47 pm and 3:40 pm revealed:
1. Extension cord and a three way electrical adaptor in Office 3H171.
2. Missing panel schedule and no label for the north east panel box in Room 3H190.
3. Missing panel schedule in panel box 2CL-3 in Room 2H259.

During an interview on 12-1-15 between 2:47 pm and 3:40, Maintenance A confirmed the findings.

Regulations:
Nebraska State Fire Marshal Official State Interpretation- 08-01

NFPA Standard:
(e) Identification. Where a building or structure is supplied by more than one service, or any combination of branch circuits, feeders, and services, a permanent plaque or directory shall be installed at each service disconnect location denoting all other services, feeders, and branch circuits supplying that building or structure and the area served by each. See Section 225-37. 1999 NFPA 70, 225-37

Based on observation and interview, the facility allowed the use of unapproved surge protectors. This deficient practice could increase the potential for an electrical fire or delay turning off power to a specific location. The facility census was 48.

Findings are:
Observations on 12-1-15 at 3:50 pm revealed an unapproved surge protector being used in Pulmonary Function Therapy room #1H482.

During an interview on 12-1-15 at 3:50 pm and 3:40, observations were acknowledged and verified by Maintenance B.

Based on record review and staff interview, the facility fire watch policy failed to include information on how often an individual would inspect the affected areas when the fire sprinkler system was out service for more than 4 hours in a 24 hour period. Also, the facility failed to indicate that the individual conducting fire watch had no other assigned duties. These deficient practices could allow a fire to go undetected. Facility census was 48.

Findings are:

Record review of the fire watch policy on 12-2-15 at 2:00 P.M. revealed the fire watch policy did not contain information on how often an individual would complete inspection rounds of the affected areas when a fire watch was initiated. Also, the fire watch policy did not indicate that the individual conducting fire watch had no other assigned duties.

During an interview on 12-2-15 at 2:00 P.M., findings of documentation review were acknowledged and verified by Maintenance A.

NFPA Standard
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1

Nebraska Fire Marshal Interpretation 05-01
The approved firewatch shall contain the following:
1. The authority having jurisdiction and the local fire department shall be notified immediately,
2. The individual(s) conducting the firewatch shall have no other assigned duties,
3. The individual(s) conducting the firewatch shall be trained to recognize fire hazards, know the procedures for occupant and fire department notification and occupant evacuation,
4. The individual(s) conducting the firewatch has access to all portions of the building,
5. The individual(s) conducting the firewatch shall walk through the affected area(s) at intervals not exceeding 30 minutes, (this may be altered depending on the size of the building and with the approval of the authority having jurisdiction)

Based on record review and staff interview, the facility fire watch policy failed to include information on how often an individual would inspect the affected areas when the fire sprinkler system was out service for more than 4 hours in a 24 hour period. Also, the facility failed to indicate that the individual conducting fire watch had no other assigned duties. These deficient practices could allow a fire to go undetected. Facility census was 48.

Findings are:

Record review of the fire watch policy on 12-2-15 at 2:00 P.M. revealed the fire watch policy did not contain information on how often an individual would complete inspection rounds of the affected areas when a fire watch was initiated. Also, the fire watch policy did not indicate that the individual conducting fire watch had no other assigned duties.

During an interview on 12-2-15 at 2:00 P.M., findings of documentation review were acknowledged and verified by Maintenance A.

NFPA Standard
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1

Nebraska Fire Marshal Interpretation 05-01
The approved firewatch shall contain the following:
1. The authority having jurisdiction and the local fire department shall be notified immediately,
2. The individual(s) conducting the firewatch shall have no other assigned duties,
3. The individual(s) conducting the firewatch shall be trained to recognize fire hazards, know the procedures for occupant and fire department notification and occupant evacuation,
4. The individual(s) conducting the firewatch has access to all portions of the building,
5. The individual(s) conducting the firewatch shall walk through the affected area(s) at intervals not exceeding 30 minutes, (this may be altered depending on the size of the building and with the approval of the authority having jurisdiction)

Based on record review and staff interview, the facility fire watch policy failed to include information on how often an individual would inspect the affected areas when the fire alarm system was out service for more than 4 hours in a 24 hour period. Also, the facility failed to indicate that the individual conducting fire watch had no other assigned duties. These deficient practices could allow a fire to go undetected. Facility census was 48.

Findings are:

Record review of the fire watch policy on 12-2-15 at 2:00 P.M. revealed the fire watch policy did not contain information on how often an individual would complete inspection rounds of the affected areas when a fire watch was initiated. Also, the fire watch policy did not indicate that the individual conducting fire watch had no other assigned duties.

During an interview on 12-2-15 at 2:00 P.M., findings of documentation review were acknowledged and verified by Maintenance A.

NFPA Standard
Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction is notified, and the building is evacuated or an approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1

Nebraska Fire Marshal Interpretation 05-01
The approved firewatch shall contain the following:
1. The authority having jurisdiction and the local fire department shall be notified immediately,
2. The individual(s) conducting the firewatch shall have no other assigned duties,
3. The individual(s) conducting the firewatch shall be trained to recognize fire hazards, know the procedures for occupant and fire department notification and occupant evacuation,
4. The individual(s) conducting the firewatch has access to all portions of the building,
5. The individual(s) conducting the firewatch shall walk through the affected area(s) at intervals not exceeding 30 minutes, (this may be altered depending on the size of the building and with the approval of the authority having jurisdiction)