HospitalInspections.org

Reference NFPA 13 Section 1-5.1
Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.

Reference NFPA 25, 1-4.2
The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

Reference NFPA 25, 1-4.4
The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.


Based on record review, observation and staff interview, the facility failed to ensure the fire sprinkler system and its components are installed and maintained in accordance with NFPA 25, (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems) and NFPA 13 (Standard for the Installation of Sprinkler Systems). This deficient practice could result in an unreliable Sprinkler System operation in the event of fire, which presents a risk of potential harm to all three (3) patients in the facility as identified by a list of patients provided by the Maintenance Director on 03/13/12 at 11:20 am, and all staff and visitors of the facility. The findings are:



A. On 03/13/12 at 9:30 am, review of the facility maintenance record dated 11/07/11 of the sprinkler system revealed the facility was not fully sprinkled. Noted in the comments section of the record was "Control valve not lock" and "no gauges." The sprinkler system record dated 06/30/11 noted in the comments section that it "does not comply with NFPA standards."

B. On 03/13/12 at 9:38 a m, review of the facility's record of the New Mexico Fire Marshal office "FIRE & LIFE SAFETY INSPECTION REPORT" dated 02/07/12 indicated that "the entire building is required to be protected with a sprinkler system, see NFPA 101 1991 table 13-1.6.2." The same report continued and included "The sprinkler system shall not be connected to the hallway standpipe valve and shall connected to an independent water supply other than the buildings domestic water system."

C. On 03/14/12 at 9:08 a m, the surveyor observed that the sprinkler system is supplied by the buildings main water supply and not an independent source as required. A flow alarm or back-flow preventer were not in evidence for the sprinkler system as required.

D. On 03/14/12 at 9:35 a m, when asked why the system was not in compliance, the Maintenance Director stated that it's been needed but the facility has been trying to get a new building and they were waiting to see what happens.

E. On 03/14/12 at 11:45 a m, the Administrator, Maintenance Director and other Hospital staff members acknowledged the above findings at the exit conference.

8-2* Inspection.
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

8-2.1
All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. In addition to these requirements, the specific inspection requirements of the applicable NFPA standard shall also be followed.

8-2.2
Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer ' s recommendations.
Exception: Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinkler or spray nozzles.



Based on observation, record review and staff interview, the facility failed to ensure cooking facilities are protected by UL-300 standards (wet system) in accordance with NFPA 96 (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). The findings are:


A. On 03/13/12 at 9:43 a m, review of the facility maintenance records for the range hood system dated 11/07/11 showed the range hood system was a wet system.

1. On 03/14/12 at 10:00 a m, the surveyor observed a dry chemical range hood system within the main kitchen. This system was not the UL-300 standards (wet system) the documentation indicated it was.

B. On 03/13/12 at 10:02 a m, when asked why the documentation indicated the range hood system as being a wet system, the Director of Maintenance stated he did not have an answer for that.

C. On 03/14/12 at 11:45 a m, the Administrator, Maintenance Director and other Hospital staff members acknowledged the above finding at the exit conference.

NFPA 99:
3-4.4.2 Record keeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1. * Test Criteria. 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.
2. Test Conditions. 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.
3. Test Personnel. 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.

NFPA 110:
Section 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.

NFPA 110, Chapter 6, Routine Maintenance and Operational Testing
(Requirements for Weekly, Monthly, Semi-annually, Annually, and every 2 years are explained.)





Based on record review, observation and staff interview, the facility failed to ensure that the specific gravity of the battery cells for the emergency generator used to protect residents during times of primary power failure was being tested monthly as required in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). This deficient practice could result in the battery's failure to provide power to start the generator in the event of a power failure, which presents a risk of potential harm to all three (3) patients in the facility identified by a list of patients provided by the Director of Maintenance on 03/13/12 at 11:20 am. The findings are:


A. On 03/13/12 at 10:21 am, review of the generator log book revealed the specific gravity of the battery was being tested as required. All six battery cells where shown with a correlating specific gravity number for every week for the twelve (12) months from 03/11 to 03/12.

1. On 03/14/12 at 10:15 am, when testing the facility's generator, the Maintenance Director was asked where the battery for the generator was located. After several minutes of looking for the battery, the surveyor had to show the Maintenance Director where it was located. In order to access the battery a protective cover plate [requiring a tool to remove] needed to be removed. Once the protective plate was removed, the surveyor observed that the battery was a sealed maintenance-free battery, which does not have the ability to test the specific gravity of the cells of the battery.

B. On 03/14/12 at 10:24 am, when asked who was responsible for taking the readings for the specific gravity, the Maintenance Director stated that he rotated the duty to different people on his staff.

C. On 03/14/12 at 10:45 a m, when the Maintenance Director was asked why the documentation showed the specific gravity testing being conducted when the battery was not capable of providing the information that was being recorded, he stated that the documents were not falsified and his only explanation was that his staff must have placed the wrong number in the space provided for the specific gravity reading.

D. On 03/14/12 at 11:45 a m, the Administrator, Maintenance Director and other Hospital staff members acknowledged the above finding at the exit conference.

Reference NFPA 13 Section 1-5.1
Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.

Reference NFPA 25, 1-4.2
The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.

Reference NFPA 25, 1-4.4
The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.


Based on record review, observation and staff interview, the facility failed to ensure the fire sprinkler system and its components are installed and maintained in accordance with NFPA 25, (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems) and NFPA 13 (Standard for the Installation of Sprinkler Systems). This deficient practice could result in an unreliable Sprinkler System operation in the event of fire, which presents a risk of potential harm to all three (3) patients in the facility as identified by a list of patients provided by the Maintenance Director on 03/13/12 at 11:20 am, and all staff and visitors of the facility. The findings are:



A. On 03/13/12 at 9:30 am, review of the facility maintenance record dated 11/07/11 of the sprinkler system revealed the facility was not fully sprinkled. Noted in the comments section of the record was "Control valve not lock" and "no gauges." The sprinkler system record dated 06/30/11 noted in the comments section that it "does not comply with NFPA standards."

B. On 03/13/12 at 9:38 a m, review of the facility's record of the New Mexico Fire Marshal office "FIRE & LIFE SAFETY INSPECTION REPORT" dated 02/07/12 indicated that "the entire building is required to be protected with a sprinkler system, see NFPA 101 1991 table 13-1.6.2." The same report continued and included "The sprinkler system shall not be connected to the hallway standpipe valve and shall connected to an independent water supply other than the buildings domestic water system."

C. On 03/14/12 at 9:08 a m, the surveyor observed that the sprinkler system is supplied by the buildings main water supply and not an independent source as required. A flow alarm or back-flow preventer were not in evidence for the sprinkler system as required.

D. On 03/14/12 at 9:35 a m, when asked why the system was not in compliance, the Maintenance Director stated that it's been needed but the facility has been trying to get a new building and they were waiting to see what happens.

E. On 03/14/12 at 11:45 a m, the Administrator, Maintenance Director and other Hospital staff members acknowledged the above findings at the exit conference.

8-2* Inspection.
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

8-2.1
All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. In addition to these requirements, the specific inspection requirements of the applicable NFPA standard shall also be followed.

8-2.2
Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper operation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer ' s recommendations.
Exception: Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinkler or spray nozzles.



Based on observation, record review and staff interview, the facility failed to ensure cooking facilities are protected by UL-300 standards (wet system) in accordance with NFPA 96 (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). The findings are:


A. On 03/13/12 at 9:43 a m, review of the facility maintenance records for the range hood system dated 11/07/11 showed the range hood system was a wet system.

1. On 03/14/12 at 10:00 a m, the surveyor observed a dry chemical range hood system within the main kitchen. This system was not the UL-300 standards (wet system) the documentation indicated it was.

B. On 03/13/12 at 10:02 a m, when asked why the documentation indicated the range hood system as being a wet system, the Director of Maintenance stated he did not have an answer for that.

C. On 03/14/12 at 11:45 a m, the Administrator, Maintenance Director and other Hospital staff members acknowledged the above finding at the exit conference.

NFPA 99:
3-4.4.2 Record keeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1. * Test Criteria. 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.
2. Test Conditions. 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.
3. Test Personnel. 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.

NFPA 110:
Section 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.

NFPA 110, Chapter 6, Routine Maintenance and Operational Testing
(Requirements for Weekly, Monthly, Semi-annually, Annually, and every 2 years are explained.)





Based on record review, observation and staff interview, the facility failed to ensure that the specific gravity of the battery cells for the emergency generator used to protect residents during times of primary power failure was being tested monthly as required in accordance with NFPA 99 (Health Care Facilities) and NFPA 110 (Standard for Emergency and Standby Power Systems). This deficient practice could result in the battery's failure to provide power to start the generator in the event of a power failure, which presents a risk of potential harm to all three (3) patients in the facility identified by a list of patients provided by the Director of Maintenance on 03/13/12 at 11:20 am. The findings are:


A. On 03/13/12 at 10:21 am, review of the generator log book revealed the specific gravity of the battery was being tested as required. All six battery cells where shown with a correlating specific gravity number for every week for the twelve (12) months from 03/11 to 03/12.

1. On 03/14/12 at 10:15 am, when testing the facility's generator, the Maintenance Director was asked where the battery for the generator was located. After several minutes of looking for the battery, the surveyor had to show the Maintenance Director where it was located. In order to access the battery a protective cover plate [requiring a tool to remove] needed to be removed. Once the protective plate was removed, the surveyor observed that the battery was a sealed maintenance-free battery, which does not have the ability to test the specific gravity of the cells of the battery.

B. On 03/14/12 at 10:24 am, when asked who was responsible for taking the readings for the specific gravity, the Maintenance Director stated that he rotated the duty to different people on his staff.

C. On 03/14/12 at 10:45 a m, when the Maintenance Director was asked why the documentation showed the specific gravity testing being conducted when the battery was not capable of providing the information that was being recorded, he stated that the documents were not falsified and his only explanation was that his staff must have placed the wrong number in the space provided for the specific gravity reading.

D. On 03/14/12 at 11:45 a m, the Administrator, Maintenance Director and other Hospital staff members acknowledged the above finding at the exit conference.