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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed wall and ceiling penetrations. This affected three of twelve smoke compartments, and could result in the passage of smoke to other areas in the event of a fire.

Findings:

During a tour of the facility with staff, the walls and ceiling were observed.

1. On 8/2/17 at 2:20 p.m., the walls and ceiling in Room 621 Bathroom were observed. There were two approximately one-half inch diameter penetrations in the west wall.

2. On 8/2/17 at 2:45 p.m., the walls and ceiling in the 800 Wing Men's Bathroom were observed. There was an approximately one-half inch diameter penetration in the west wall by the sink.

3. On 8/2/17 at 2:50 p.m., the walls and ceiling in Room 816 were observed. There was an approximately one inch diameter penetration located in the ceiling by the sprinkler, next to the corridor door.

4. On 8/2/17 at 4:05 p.m., the walls and ceiling in Room 209 were observed. There was an approximately one quarter inch by 15 inches penetration in the south wall, where the wall had cracked and separated.

Based on observation and interview, the facility failed to maintain the self-closing doors in the exit passageway. This was evidenced by doors that were held-open with devices that were not connected to the Fire Alarm system (FAS). This affected four of twelve smoke compartments, and could potentially allow the spread of smoke into adjoining compartments.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.2.2.7* Any door in an exit passageway, stairway enclosure,
horizontal exit, smoke barrier, or hazardous area enclosure
shall be permitted to be held open only by an automatic release
device that complies with 7.2.1.8.2. The automatic sprinkler
system, if provided, and the fire alarm system, and the
systems required by 7.2.1.8.2, shall be arranged to initiate the
closing action of all such doors throughout the smoke compartment
or throughout the entire facility.

7.2.1.8 Self-Closing Devices.
7.2.1.8.1* A door leaf normally required to be kept closed
shall not be secured in the open position at any time and shall
be self-closing or automatic-closing in accordance with
7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
7.2.1.8.2 In any building of low or ordinary hazard contents,
as defined in 6.2.2.2 and 6.2.2.3, or where approved by the
authority having jurisdiction, door leaves shall be permitted to
be automatic-closing, provided that all of the following criteria
are met:
(1) Upon release of the hold-open mechanism, the leaf becomes
self-closing.
(2) The release device is designed so that the leaf instantly
releases manually and, upon release, becomes selfclosing,
or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated
by the operation of approved smoke detectors installed
in accordance with the requirements for smoke
detectors for door leaf release service in NFPA 72, National
Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the holdopen
mechanism is released and the door leaf becomes
self-closing.

Findings:

During a tour of the facility and interview with staff, the self-closing doors in the exit passageway were observed.

On 8/2/17 at 2:30 p.m., the cross corridor smoke barrier doors in the 600 wing were observed. The smoke barrier doors located at the Entrance were equipped with self-closing devices. The doors were held in the open position with magnetic devices that were not electronically interfaced with the automatic FAS. Upon interview, Staff 4 confirmed the finding.

Based on observation, the facility failed to maintain the hazardous areas. This was evidenced by hazardous area enclosure openings that were not equipped with self-closing devices on the doors and a penetration in one room. This affected three of twelve smoke compartments, and could result in a delay in containing smoke and/or fire to hazardous areas.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.2 Protection from Hazards.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction
(8) Laboratories employing flammable or combustible materials
in quantities less than those that would be considered
a severe hazard.

Findings:

During a facility tour with staff, the hazardous areas were observed.

1. On 8/2/17 at 2:52 p.m., Room 818 was observed. The room was used for storage and was greater than 50 square feet in size ( approximately 200 square feet). The room contained multiple combustible storage boxes within. The door was not equipped with a self-closing device.

2. On 8/2/17 at 2:54 p.m., Room 815 was observed. The room was used for storage and was greater than 50 square feet in size ( approximately 200 square feet). The room contained multiple combustible storage boxes and medical supplies within. The door was not equipped with a self-closing device.

3. On 8/2/17 at 3:45 p.m., the Medical Laboratory Room was observed. The corridor leading into the Phlebotomy section of the Laboratory Room was not equipped with a self-closing device.

4. On 8/2/17 at 3:50 p.m., the Medical Laboratory Storage Room was observed. There was an approximately one inch diameter penetration located in the ceiling above the storage shelves.

Based on observation and interview, the facility failed to maintain the fire alarm system. This was evidenced by a fire alarm circuit disconnecting means that was not distinctly marked. This affected 12 of 12 smoke compartments, and could result in a delay in identifying the proper circuit during an electrical emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72 National Fire Alarm and signaling Code, 2010 edition
Chapter 10 Fundamentals
10.1 Application.
10.1.1 The basic functions of a complete fire alarm or signaling
system shall comply with the requirements of this chapter.
10.1.2 The requirements of this chapter shall apply to systems,
equipment, and components addressed in Chapters 12,
14, 17, 18, 21, 23, 24, 26 and 27.
10.2 Purpose. The purpose of fire alarm and signaling systems
shall be primarily to provide notification of alarm, supervisory,
and trouble conditions; to alert the occupants; to summon
aid; and to control emergency control functions.
10.5.5.2 Circuit Identification and Accessibility.
10.5.5.2.1 The location of the dedicated branch circuit disconnecting
means shall be permanently identified at the control unit.
10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."
10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

Findings:

During a facility tour and interview with staff, the fire alarm system electrical circuit was observed.

On 8/2/17 at 4:10 p.m., the Fire Alarm Control Panel (FACP) Circuit Breaker 2 located in Med/Surgical Panel B was observed. The circuit breaker did not have a red marking and was
not marked for the FACP. Upon interview, Staff 4 confirmed that Breaker 2 was for the FACP.

Based on document review and interview, the facility failed to maintain interim fire measures. This was evidenced by failure to provide written protocol to ensure that if the fire alarm system was out of service for more than 4 hours in a 24 hour period, the authority having jurisdiction (AHJ) would be notified. This affected 12 of 12 smoke compartments, and could potentially result in the AHJ not able to exercise oversight if the fire alarm system should become inoperable.

Findings:

During document review and interview with staff, the interim fire measures and policy were reviewed.

On 8/2/17 at 10:45 a.m., the approved Fire Watch policy available for review did not include notification to the Department of Public Health if the fire alarm system was out of service for more than 4 hours in a 24 hour period. Upon interview, Staff 4 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the integrity of the automatic fire sprinkler system. This was evidenced by failure to perform and record monthly and quarterly inspections, maintain less than 18 inches of clearance, sprinklers with debris, and a water-flow alarm that took greater than 90 seconds to alarm. This affected 12 of 12 smoke compartments, and could result in the ineffective operation of the automatic fire sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.4 Detection, Alarm, and Communications Systems.
19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

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

19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected
throughout by an approved, supervised automatic
sprinkler system in accordance with Section 9.7, unless otherwise
permitted by 19.3.5.5.

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
9.7.5 Maintenance and Testing. All automatic sprinkler and
standpipe systems required by this Code shall be inspected,
tested, and maintained in accordance with NFPA 25, Standard
for the Inspection, Testing, and Maintenance of Water-Based Fire Protection
Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
4.3 Records
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
Chapter 5 Sprinkler Systems.
5.1.1 Minimum Requirements.
5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.
5.2.1 Sprinklers.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following
shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer
5.2.4 Gauges.
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
13.3.2 Inspection.
13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. 13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification
13.4 System Valves.
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected
as described in 13.4.1.1 and 13.4.1.2.
13.4.1.1* Alarm valves and system riser check valves shall be
externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being
maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition.
8.5.6* Clearance to Storage.
8.5.6.4 A minimum clearance to storage of less than 18 in.
(457 mm) between the top of storage and ceiling sprinkler
deflectors shall be permitted where proven by successful large scale
fire tests for the particular hazard.

NFPA 72 National Fire Alarm and signaling Code, 2010 edition
17.12.2* Activation of the initiating device shall occur within
90 seconds of waterflow at the alarm-initiating device when flow
occurs that is equal to or greater than that from a single sprinkler
of the smallest orifice size installed in the system.

Findings:

During a facility tour, document review,and interview with staff, the automatic fire sprinkler system was observed and records were requested.

1. On 8/2/17 at 1:50 p.m., the facility was observed with a wet automatic fire sprinkler system. The most current annual sprinkler report dated 5/19/16 was reviewed. A deficiency was noted for "no alarm within 90 seconds of water flow." The facility was not able to provide follow-up report for repair when requested. Upon interview, Staff 4 confirmed the finding.

2. On 8/2/17 at 1:55 p.m., no records for quarterly inspection and test were available for the first quarter 2017, third and forth quarters 2016-2017. Upon interview, Staff 4 confirmed the finding.

3. On 8/2/17 at 1:58 p.m., no record for monthly inspections of gauges and valves were available for review. Upon interview, Staff 2 confirmed the finding.

4. On 8/2/17 at 2:05 p.m., five of five sprinkler heads located under the Main Entrance roof over-hang were covered in debris.

5. On 8/2/17 at 2:40 p.m., the sprinkler head located outside under the 700 Wing Lobby exit canopy was covered in debris.

6. On 8/2/17 at 3:35 p.m., the sprinkler head in the Kitchen walk-in refrigerator was observed. The items on the top shelf were stored at approximately 9 inches beneath the pendant style sprinkler head, without maintaining the minimal 18 inches of clearance.

7. On 8/2/17 at 4 p.m., the sprinkler head located outside by the Family Care Wing east exit was observed. The sprinkler head was covered in debris.

8. On 8/2/17 at 4:25 p.m., four of four sprinkler heads under the Emergency Room Entrance roof overhang were covered in debris.

9. On 8/3/17 at 9:55 a.m., the Inspector Test Valve (ITV) water-flow alarm did not activate the Fire Alarm System (FAS) after 120 seconds from opening the valve during FAS testing. The ITV water-flow alarm was re-tested again. The FAS activated after 110 seconds from opening the valve, instead of at 90 seconds. Upon interview, Staff 4 confirmed the finding.

Based on document review and interview, the facility failed to maintain interim fire measures. This was evidenced by failure to provide written protocol to ensure that if the automatic sprinkler system was out of service for more than 10 hours in a 24 hour period, the authority having jurisdiction (AHJ) would be notified. This affected 12 of 12 smoke compartments, and could potentially result in the AHJ not able to exercise oversight if the sprinkler system should become inoperable.

During document review and interview with staff, the interim fire measures and policy were reviewed.

On 8/2/17 at 10:45 a.m., the approved Fire Watch policy was reviewed. The policy did not include notification to the Department of Public Health if the sprinkler system was out of service for more than 10 hours in a 24 hour period. Upon interview, Staff 4 confirmed the finding.

Based on observation, the facility failed to maintain the portable fire extinguishers. This was evidenced by a fire extinguisher that was obstructed from view and access. This affected one of twelve smoke compartments, and had the potential to result in the spread of smoke and/or fire due to a delay in locating or accessing the extinguisher.

NFPA 101 Life Safety Code, 2012 edition
19.3.5.12 Portable fire extinguishers shall be provided in all
health care occupancies in accordance with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section
of this Code, portable fire extinguishers shall be selected, installed,
inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010, edition.
6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured
from view.

Findings:

During a facility tour with staff, the portable fire extinguishers were observed.

On 8/2/17 at 3:52 p.m., a portable ABC-class fire extinguisher located under the counter in the Laboratory was obstructed from view and access by a chair that was stationed directly in front of it.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed corridor penetrations. This affected two of twelve smoke compartments, and could result in the passage of smoke to other areas in the event of a fire.

Findings:

During a tour of the facility with staff, the corridor walls and ceilings were observed.

1. On 8/2/17 at 2:15 p.m., the walls and ceiling in the 600 Corridor were observed. There was an approximately three inches by one inch penetration located in the ceiling by an outside exit.

2. On 8/2/17 at 4:12 p.m., the walls and ceiling in the Medical/Surgical Corridor were observed. There was an approximately one inch diameter penetration located in the ceiling next to the sprinkler by the Nursing Station.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that were obstructed from fully closing and latching. This affected two of twelve smoke compartments, and could result in the inability to contain smoke and/or fire to a room.

Findings:

During a tour of the facility with staff, the corridor doors were observed.

1. On 8/2/17 at 3:55 p.m., the back door to the Emergency Room was observed. The door was equipped with a self-closing device. The door was held-open to the fullest extent and allowed to close. The door failed to fully close and latch.

2. On 8/2/17 at 4:07 p.m., the corridor door to Room 25 was observed. The door was equipped with a self-closing device. The door was held-open to the fullest extent and allowed to close. The door failed to fully close and latch.

Based on observation and interview, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by penetrations in the smoke barrier walls. This affected two of twelve smoke compartments, and could potentially allow the spread of smoke and/or fire to other areas of the facility in the event of emergency.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1)This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a)Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b)Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.
8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.
8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.
8.5.6.4 Where sprinklers penetrate a single membrane of a fire resistance-rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 1/2 in. (13 mm), measured between the edge of the membrane and the sprinkler.
8.5.6.5 Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be securely set in the smoke barrier, and the space between the item and the sleeve shall be filled with a material capable of restricting the transfer of smoke.

Findings:

During a facility tour and interview with staff, the smoke barrier walls were observed.

On 8/2/17 at 3:40 p.m., the smoke barrier wall located in the attic above the door to Room 402 was observed. There was an approximately one inch by three inches penetration in the lower center area of the wall with a pipe traveling through it. Upon interview, Staff 4 confirmed the finding.

Based on observation, the facility failed to maintain the electrical wiring and connections. This was evidenced by missing an electrical outlet cover-plate. This affected one of twelve smoke compartments, and could potentially result in electrical shock, or the ignition of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of section 9.1
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition.
406.6 Receptacle Faceplates (Cover Plates). Receptacle
faceplates shall be installed so as to completely cover the
opening and seat against the mounting surface.
Receptacle faceplates mounted inside a box having a
recess-mounted receptacle shall effectively close the opening
and seat against the mounting surface.

Findings:

During a tour of the facility with Staff, the electrical wiring and connections were observed.

On 8/2/17 at 2:08 p.m., Office 402 was observed with an electrical duplex outlet that was missing a cover plate.

Based on record review and interview, the facility failed to maintain the Heating, Ventilating, and Air-Conditioning (HVAC) system. This was evidenced by failure to provide a current smoke/fire damper testing and service report. This affected 12 of 12 smoke compartments, and could result in the spread of smoke and/or fire to other locations of the facility due to a malfunctioning damper.

NFPA 101. Life Safety Code, 2012 Edition
19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply
with the provisions of Section 9.2 and shall be installed in
accordance with the manufacturer ' s specifications, unless otherwise
modified by 19.5.2.2.

9.2 Heating, Ventilating, and Air-Conditioning.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and
Related Equipment. Air-conditioning, heating, ventilating
ductwork, and related equipment shall be in accordance with
NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, or NFPA 90B, Standard for the Installation of
Warm Air Heating and Air-Conditioning Systems, as applicable, unless
such installations are approved existing installations,
which shall be permitted to be continued in service.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition.
5.4.8 Maintenance.
5.4.8.1 Fire dampers and ceiling dampers shall be maintained
in accordance with NFPA 80, Standard for Fire Doors and
Other Opening Protective's.

NFPA 80, Standard for Fire Doors and Other Opening Protective's, 2010 edition.
19.3.4 Documentation. All inspections and testing shall be
documented, indicating the location of the fire damper, date(s)
of inspection, name of inspector, and deficiencies discovered.
The documentation shall have a space to indicate when and how
the deficiencies were corrected.
19.4.1.1
19.4* Periodic Inspection and Testing.
19.4.1 Each damper shall be tested and inspected 1 year after
installation.
19.4.1.1 The test and inspection frequency shall then be every
4 years, except in hospitals, where the frequency shall be every
6 years.

Findings:

During document review and interview with staff, the HVAC damper testing/service records were requested for review.

On 8/2/17 at 1:30 p.m., the current report for service and testing of smoke/fire dampers was requested. Upon interview, Staff 4 confirmed that there was no current testing/inspection report available for review. The last damper testing and inspection service was unknown.

Based on record review and interview, the facility failed to determine the risk category classification of building systems. This was evidenced by no documentation of a building systems risk assessment. This affected 12 of 12 smoke compartments, and could result in a prolonged duration of unsafe conditions due to insufficient assessment of the building systems.

NFPA 99, Health Care Facilities Code, 2012 Edition.
4.1 Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.
4.1.1 Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.
4.1.2 Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code.
4.1.3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code.
4.1.4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code.
4.2 Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure.
4.3 Application. The Category definitions in Chapter 4 shall apply to Chapters 5 through 11.
Chapter 5 Gas and Vacuum Systems
Chapter 6 Electrical Systems
Chapter 9 Heating, Ventilation, and Air Conditioning (HVAC)
Chapter 10 Electrical Equipment
Chapter 11 Gas Equipment

Findings:

During record review and interview with staff, a risk assessment corresponding to building systems was requested.

On 8/2/17 at 11 a.m., no risk assessment related to the failure of the building systems addressed in NFPA 99 was provided. Upon interview, Staff 1 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the emergency power supply system (EPSS). This was evidenced by failure to perform monthly battery electrolyte specific gravity testing and recording. This affected 12 of 12 smoke compartments, and could result in a loss of power due to a generator malfunction during an emergency power outage.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities, Utilities shall comply with the provisions of section 9.1
19.5.1.1 Utilities shall comply with the provisions of section 9.1
9.1.3.1 Emergency Generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition.
Chapter 8 Routine Maintenance and
Operational Testing
8.1* General.
8.1.1 The routine maintenance and operational testing program
shall be based on all of the following:
(1) Manufacturer's recommendations
(2) Instruction manuals
(3) Minimum requirements of this chapter
(4) The authority having jurisdiction
8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following: (1)The date of the maintenance report (2)Identification of the servicing personnel (3)Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4)Testing of any repair for the time as recommended by the manufacturer

8.3.7.1 Maintenance of lead-acid batteries shall include the
monthly testing and recording of electrolyte specific gravity. Battery
conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.

Findings:

During a facility tour, document review, and interview with staff, the EPSS was observed and records were requested and reviewed.

On 8/2/17 at 12:05 p.m., the facility was observed with a 250 kilowatt diesel generator that was equipped with 6 of 6 lead acid batteries. There was no documentation available for monthly Electrolyte Specific Gravity or conductivity testing for the batteries. Upon interview, Staff 4 confirmed the finding.

Based on observation, the facility failed to maintain the oxygen storage. This was evidenced by failure to maintain the minimal required signage on enclosure doors, and failure to secure the doors against unauthorized entry. This affected one of twelve smoke compartments, and could result in the unsafe and unauthorized use of oxygen.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
11.3.4 Signs.
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Findings:

During a tour of the facility with staff, the oxygen storage was observed.

1. On 8/2//17 at 3:16 p.m., the inside Oxygen Storage Room was observed. The room enclosure door was not equipped with a locking device to secure against unauthorized entry.

There was no sign posted on the door to indicate, "Oxygen stored within-No Smoking."

2. On 8/2/17 at 3:18 p.m., the Emergency Technician Oxygen Storage Room was observed. The room enclosure door did not have a sign posted to indicate, "Oxygen stored within-No Smoking."