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Based on observation, the facility failed to maintain its building construction by having penetrations through a wall and ceiling. Penetrations through walls and ceilings establish conditions conducive to the spread of fire, smoke and heat to other sections of the facility.

Finding:

On June 27, 2012 between 9:53 a.m. and 10:24 a.m., the evaluator observed two open 4 inch diameter EMT TT577 sleeves penetrating the wall of a communications room in the basement.

At 10:41 a.m., there were five ? inch diameter penetrations through the ceiling of the reception area.

Based on observation, the facility failed to ensure a corridor door closed. In the event of a fire, closed corridor doors can contain the spread of smoke

Finding:

On June 26, 2012 at 12:30 p.m., the evaluator observed the kitchen corridor door failed to fully close and positively latch.

Based on observation, the facility failed to maintain a hazardous area separated from other spaces by obstructing a door from closing and having a penetration through a wall. Doors that do not self-close and compromised construction by penetrations at hazardous area separations establish conditions conducive to the rapid spread of fire, smoke and heat to other sections of the facility.

Findings:

On June 26, 27 and 28, 2012, the evaluator observed the corridor door of the laundry room (a hazardous area) was continuously obstructed from closing by a wedge placed under the front of the door. The laundry room measured 156 square feet and housed one washing machine and one natural gas fueled dryer.

On June 27, 2012 at 9:53 a.m., there was a penetration around a pipe through the laundry room wall.

Based on record review, the facility failed to provide supporting documentation that the staff participated in fire drills, at least quarterly, on each shift. Success for any fire emergency plan is based on planning, training and practice. Continuous participation of staff on all shifts in fire drills assists in ensuring the staff on all shifts are familiar with the facility's fire emergency plan and are prepared to put it in effect in the event of a fire emergency. The staff's level of training and familiarity with the facility's fire emergency plan affects all the patients and occupants of the facility.

Finding:

On June 27, 2012, accompanied by the maintenance supervisor, record review of the facility's fire drill reports for the period of June 8, 2012 to June 27, 2012, revealed there were no fire drill reports documenting the staff from the 7:00 p.m. to 7:00 a.m. shift participated in a fire drills for the second and third quarters of 2011.

NFPA 72 National Fire Alarm Code 1999 Edition

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

This standard was not met as evidenced by:

Finding:

Based on interview and record review, the facility failed to maintain the fire alarm system in accordance with NFPA 70 National Electrical Code and NFPA 72 by not correcting a deficiency found during the annual fire alarm service/test.
On June 27, 2012, accompanied by the maintenance supervisor, record review revealed the annual fire alarm service/test report dated March 21, 2012, indicated a deficiency that all alarms show up as zone 2 waterflow, instead of zone 1, 2 general.
On June 27, 2012, between 11:53 a.m. and 12:17 p.m., a test of the facility's fire alarm system was conducted that included the manual fire alarm boxes and smoke detectors located on the ground floor and basement, and also included a waterflow test and shut off valve tamper test. Review of the central monitoring activity report of the test listed all the alarms from the devices tested as "fire alarm commercial fire waterflow."
During an interview, the maintenance supervisor stated "we've signed an agreement to fix it and we are waiting for them to fix it."
The facility had a contract, signed June 8, 2012, with a fire alarm company to investigate why alarms show up as zone 2 waterflow instead of zone 1 and 2 general alarm.

Based on record review, the facility failed to inspect and test the automatic sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 edition by not inspecting and testing components of the sprinkler system at an annual frequency in accordance with Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance. Testing and inspection of the automatic sprinkler system helps to ensure the system will function as designed.

Finding:

On June 27, 2012, accompanied by the maintenance engineer, record review revealed there was no record of a current annual inspection and test of the automatic sprinkler system. Review of the sprinkler system testing record revealed the last inspection and test of the automatic sprinkler system was conducted on July 19, 2009, during the 5 year test.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems 1999 Edition

3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Based on record review, the facility failed to provide documented evidence that for fusible link held dampers, at least every 4 years fusible links were removed, dampers were operated to verify they fully closed, that the latch was checked and moving parts were lubricated. Dampers are designed to operate in the event of a fire to stop the passage of fire and smoke through the buildings heating, ventilation and air conditioning (HVAC) system.

This standard was not met as evidenced by:

Finding:

On June 27, 2012, accompanied by the maintenance supervisor, record review revealed there was no documented evidence of maintenance to the facility's dampers to ensure the dampers close automatically and remained closed upon the operation of the listed fusible links.

1.) NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition

3-2.9.1 A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or have been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types of temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100 degrees Fahrenheit (38 degrees Celsius).

3-2.9.3 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:

(1) For systems having less than 300 sprinklers - not fewer than 6 sprinklers
(2) For systems with 300 to 1000 sprinklers - not fewer than 12 sprinklers
(3) For systems with over 1000 sprinklers - not fewer than 24 sprinklers


NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition

2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees Fahrenheit (38 degrees Celsius).

2-4.1.5 The stock of spare sprinklers shall be as follows:
(a) For protected facilities having under 300 sprinklers - no fewer than 6 sprinklers
(b) For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers
(c) For protected facilities having over 1000 sprinklers - no fewer than 24 sprinklers

These requirements were not met as evidenced by:

Based on observation and interview, the facility failed to ensure spare sprinklers representative of each sprinkler type installed at the facility were maintained at the facility. In the event a sprinkler needs to be replaced because it has operated or has been damaged, spare sprinklers that are immediately available help to put the system back into service without delay.

Finding:

On June 27, 2012, between 9:45 a.m. and 10:24 a.m., accompanied by the maintenance supervisor, the evaluator observed common type bimetal recessed pendant sprinkler heads and frangible bulb pendant sprinkler heads in the basement, and waxed corrosion resistant sprinkler heads at the exterior of the building.

During a check of the spare sprinkler box, the evaluator observed
the box contained four fusible link upright sprinkler heads, a chemical pellet pendant sprinkler head and a fusible link pendant sprinkler head. There were no bimetal pendant sprinkler heads, frangible bulb pendant sprinkler heads and waxed corrosion resistant sprinkler heads in the box.

During an interview the maintenance supervisor stated he was not aware of any other spare sprinkler heads in the facility.


2.) NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition

6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:

(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced

Based on record review and interview, the facility failed to provide documented evidence of corrective action to an unsatisfactory condition found during a generator service.

Findings:

On June 27, 2012, accompanied by the maintenance supervisor, review of a generator service report dated April 5, 2012, revealed the service technician indicated "engine belts to be change, with coolant and new water pump, and new bat (battery) to be installed".

The service report dated May 17, 2012, indicated the installation of a new water pump and the service report dated June 21 2012 indicated a new battery was installed. There was no documentation of the engine belts being changed.

During an interview, the maintenance supervisor stated there was no documentation the engine belts had been changed.

1.) NFPA 70 National Electrical Code 1999 edition
110-26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(a) Working space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.

(1) Depth of Working Space. The depth of working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a) Working Spaces

Nominal Voltage to Ground 0-150
Condition 1 3 ft Minimum Clear Distance
Condition 2 3 ft Minimum Clear Distance
Condition 3 3 ft Minimum Clear Distance

Nominal Voltage to Ground 151-600
Condition 1 3 ft Minimum Clear Distance
Condition 2 3 1/2 ft Minimum Clear Distance
Condition 3 4 ft Minimum Clear Distance

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors and hinged panels.

(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.

(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

(e) Headroom. The minimum headroom of working spaces about service equipment, switchboards, panelboards, or motor control centers shall be 6 1/2 ft (1.98 m). Where the electrical equipment exceeds 6 1/2 ft (1.98 m) in height, the minimum headroom shall not be less than the height of the equipment.

These Requirements were not met as evidenced by:

Based on observation, the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70, National Electrical Code. NFPA 70 contains provisions necessary for safety and its purpose is the practical safeguarding of persons and property from hazards arising from the use of electricity. Electrical panels contain circuit breakers designed to trip and stop the flow of current to specific circuits and appliances. Easy unobstructed access to electrical panels is essential to promptly respond to an electrical emergency.

Finding:

On June 26 and 27, 2012, the evaluator observed a water cooler/dispenser and a paper towel dispenser located in front of electrical panel located in the kitchen.

On June 27, 2012, between 10:41 a.m. and 11:10 a.m., the water cooler/dispenser and paper towel dispenser obstructed opening of the panel door by the maintenance supervisor.


2.) NFPA 70 National Electrical Code 1999 Edition

370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

This requirement was not met as evidenced by:

Based on observation, the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70 by not having a cover on an electrical receptacle. NFPA 70 contains provisions necessary for safety and its purpose is the practical safeguarding of persons and property from hazards arising from the use of electricity. Electrical cover plates on electrical receptacles protect from accidental contact of electrical wires.

Finding:

On January 26, 2012 at 11:13 a.m., the evaluator observed an electrical receptacle in the main lobby was missing its cover plate.