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Based on observation, interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the fire egress doors. The facility census was 14.

1. Review of the facility's inspection, testing and maintenance records for the 2018 year showed the records did not contain documentation of an annual inspection of the fire egress doors during the 12-month period.

During an interview on 4/23/19 at 9:29 A.M., the Maintenance Technician said he did not know of the requirement to conduct annual inspections of the egress doors.


Review of NFPA 101, 2012 Edition showed the following:
-7.1.10.2.1 showed no furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.
-19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
-7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7;
(2) Door assemblies in exit enclosures;
(3) Electrically controlled egress doors;
(4) Door assemblies with special locking arrangements subject to 7.2.1.6.
-7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
-7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
-7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting at exit discharge areas. In addition the facility failed to ensure all corridors are illuminated with emergency egress lights not controlled by light switches. The census was 14.


1. Observation on 4/22/19, during the facility tour showed no emergency lighting at any of the exit discharge areas.

During an interview on 4/22/19 at 2:28 P.M., the Maintenance Technician said exit discharge areas did not have emergency lighting.

NFPA 101, 2012 edition states "Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9".

2. Observation on 4/22/19, during the facility tour, all designated exit hallways contained switches controlling the emergency egress lighting fixtures.

During an interview on 4/22/19 at 2:45 P.M., the Maintenance Technician confirmed the observation.


19.2.8 Illumination of Means of Egress. Means of egress shall
be illuminated in accordance with Section 7.8.


7.8.1.2 Illumination of means of egress shall be continuous
during the time that the conditions of occupancy require that
the means of egress be available for use, unless otherwise provided
in 7.8.1.2.2.

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside two medication rooms and one pharmacy. The facility census was 14.

1. Observations on 4/22/19 and 4/23/19, during the facility tour, showed the following light fixtures in the building controlled by a light switch:

- Pharmacy;

- Med surge medication room;

- Outpatient medication room.


During an interview on 4/23/19 at 7:33 P.M., the Maintenance Director confirmed the observations.


NFPA 99, 2012 edition, section 6.4.2.2.4.2 states:

"6.4.2.2.4.2 The critical branch shall supply power for task illumination,
fixed equipment, select receptacles, and select power
circuits serving the following areas and functions related to patient
care:
(1) Critical care areas that utilize anesthetizing gases, task illumination,
select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles),
and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) 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, select receptacles, and select power circuits
for the following areas:
(a) General care beds with at least one duplex receptacle
per patient bedroom, and task illumination as required
by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power
circuits needed for effective facility operation, including
single-phase fractional horsepower motors, which are permitted
to be connected to the critical branch"

Based on observation and staff interview, the facility staff failed to ensure all designated exits were marked by exit signs. The facility census was 14.

1. Observation on 4/22/19, during the facility tour showed the front entrance corridor did not have visible exit signs when standing in the middle of the corridor.

Observation on 4/22/19, during the facility tour, showed the outpatient corridor, facing south, did not have any exit or directional signs.

Observation on 4/22/19, during the facility tour, showed the physical therapy entrance/exit did not have an exit sign.

Observation on 4/22/19, during the facility tour, showed the exit corridor off of the kitchen entrance, did not have a directional sign pointing evacuees to the physical therapy corridor.

During an interview on 4/22/19 at 2:44 P.M., the Maintenance Technician confirmed the observations.

NFPA 101, 2012 edition, section 7.10.1.5.1 states "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.

Based on observation and facility staff interview, the facility staff failed to provide a 1-hour rated separation between a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances) and designated exit corridors in the facility per NFPA (National Fire Protection Association) requirements. Failure to provide compliant hazardous area doors equipped with a self closing devices puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area. The facility census was 14.

1. Observation on 4/22/19, showed the following:

- The emergency room corridor soiled linen room door did not have a self closing device. Observation showed the room contained multiple bags of hazardous waste and soiled linen.

- The outpatient surgery corridor soiled linen room door did not have a self closing device. Observation showed the door did not latch or have a self closing device.

- The ICU soiled linen room door did not have a self closing device. Observation showed multiple bags of soiled linen. Observation showed the door did not latch.

- The med surge unit soiled linen room door did not have a self closing device. Observation showed the door did not latch.

During an interview on 4/22/19 at 3:41 P.M., the Maintenance Technician confirmed the observations.

19.3.2.1.1 An automatic extinguishing system, where used in
hazardous areas, shall be permitted to be in accordance with
19.3.5.9.

19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the
areas shall be separated from other spaces by smoke partitions
in accordance with Section 8.4.

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

Based on observation and facility staff interview, the facility staff failed to provide and maintain one of one kitchen range hood in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition requirements. The facility census was 14.

1. Observation on 4/22/19, during the facility tour, showed the range hood did not have a an enclosed metal container to collect grease from the drip tray.

During an interview on 4/22/19 at 3:24 P.M, the Maintenance Technician confirmed the observation.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 6.2.4.1 states: "Grease filters shall be equipped with a grease drip-tray beneath their lower edges.

Based on observation and facility staff interview, the facility failed to ensure that one of one fire alarm systems was installed per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was 14.

1. Observation on 4/22/19 and 4/23/19, during the facility tour, showed all exit corridors did not have complete smoke detector coverage.

During an interview on 4/22/19 at 2:30 P.M., the Maintenance Technician confirmed the observation.

Refer to National Fire Protection Association 72, 2010 edition, section 17.5.3.2

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and staff interview, the facility failed to install manual pull stations at exit doorways. The facility census was 14.

1. Observation on 4/22/19 and 4/23/19 showed the following exit doorways did not have manual pull stations.

- Front entrance/exit

- Physical therapy entrance/exit

- ICU corridor exit

- Cafeteria exit

- Exit door across from vending machine area

During an interview on 4/22/19 at 2:40 P.M., the Maintenance Director confirmed the observation.

NFPA 72,2010 edition, section 17.14.6 states " Manual fire alarm boxes shall be located within 60 in. (1.52m) of the exit doorway opening at each exit on each floor".

Based on observation and facility staff interview, the facility failed to secure the fire alarm control panel against unauthorized use. The facility census was 14.

1. Observation on 4/22/19, during the facility tour, showed the fire alarm control panel in the breakroom on the med surge unit. Observation showed the fire alarm control panel accessible to all staff, visitors, etc. Observation showed directions on how to silence the alarm posted on the wall next to the fire alarm control panel.

During an interview on 4/22/19 at 4:55 P.M., the Maintenance Director said that fire alarm control panel is accessible to unauthorized people.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Section 10.11.5.2 states: " The means shall be key operated or located within a locked cabinet, or arranged to provide equivalent protection against unauthorized use.

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection per NFPA 72, National Fire Alarm and Signaling Code. The facility census was 14.

Observations on 4/22/19, during the facility tour, showed the following room/areas open to the corridor open to the designated exit corridor. Observation showed the rooms/areas did not have smoke detector coverage:

- Vending machine room;

- Admissions waiting room;

- Patient administrations office

- ICU/OR waiting room.

During an interview on 4/22/19 at 2:36 P.M., the Maintenance Director confirmed the observations.

NFPA 101, 2012 edition states "Smoke detection systems are provided in spaces open to the corridors as required by 19.3.6.1".

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on staff interview and record review, facility staff failed to inspect the wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 14.

Record review on 4/23/19 did not show the following inspections:


-5 year internal pipe inspection.

During an interview on 4/23/19 at 9:00 A.M., the Maintenance Technician said the sprinkler system was installed 20 years ago. The Maintenance Technician said that a five year internal pipe inspection was never conducted.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on observation and staff interview, the facility failed to ensure corridor walls extended to the underside of the roofdeck of the floor above. The facility census was 14.

1. Observation on 4/23/19, during the facility tour, showed corridor walls did not extend to the underside of the roofdeck on the south side 1st floor exit corridor. Observation showed no separation between the exit corridor and accounts office, restrooms, and family support division office. Observation showed the area did not have sprinkler coverage.

During an interview on 4/23/19 at 8:02 A.M., the Maintenance Technician confirmed the observation.

NFPA 101, 2012 edition, section 19.3.6.2.1 states "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 and 19.3.6.2.8."

Based on observation and facility staff interview, facility staff failed to ensure . Facility staff failed to ensure corridor doors resisted the passage of smoke and positively latched when closed. These deficient practices have the potential to affect all patients, staff and visitors. Failure to ensure corridor doors positively latched when closed and resist the passage of smoke has the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. This facility had a capacity of 14.

1. Observation on 4/22/19 and 4/23/19 during the building tour, showed the following doors with flushbolts:

-Med Surge breakroom;

-Outpatient breakroom.

During an interview on 4/22/19 at 4:30 P.M., the Maintenance Director confirmed the observations.

* Rollar Latches prohibited by CMS regulations

2. Observation on 4/22/19 and 4/23/19, during the building tour, showed the following corridor doors did not resist the passage of smoke or positively latch when closed:

- Lab door on 1st floor;

- Patient accounts door;

- 3rd floor equipment room;

-Family support office.

During an interview on 4/22/19 at 2:42 P.M., the Maintenance Technician confirmed the observations.

19.3.6.3* Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than
required enclosures of vertical openings, exits, or hazardous
areas shall be doors constructed to resist the passage of smoke
and shall be constructed of materials such as the following:
(1) 13.4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

19.3.6.3.2 The requirements of 19.3.6.3.1 shall not apply
where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink
closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required
to comply with 19.3.6.3.1.

(2) In smoke compartments protected throughout by an approved,
supervised automatic sprinkler system in accordance
with 19.3.5.7, the door construction materials requirements
of 19.3.6.3.1 shall not be mandatory, but the doors
shall be constructed to resist the passage of smoke.

19.3.6.3.10* Doors shall not be held open by devices other
than those that release when the door is pushed or pulled.

19.3.6.3.5* Doors shall be provided with a means for keeping
the door closed that is acceptable to the authority having jurisdiction,
and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully
closed if a force of 5 lbf (22 N) is applied at the latch edge
of the door.
(2) Roller latches shall be prohibited on corridor doors in
buildings not fully protected by an approved automatic
sprinkler system in accordance with 19.3.5.7.

19.3.6.3.13 Dutch doors shall be permitted where they conform
to 19.3.6.3 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a
latching device.
(2) The meeting edges of the upper and lower leaves are
equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous
areas, the doors comply with NFPA80, Standard for Fire

Based on observation and staff interview, the facility failed to install automatic smoke dampers in smoke barrier walls where the HVAC duct work penetrated the smoke barrier wall. This effects two of six smoke barrier walls. The facility census was 14.

1. Observation on 4/23/19 during the facility tour, showed the 1st floor barrier wall, near the x-ray room, did not have an automatic smoke damper in barrier wall. Observation showed the HVAC duct work penetrated the barrier wall. Observation showed the 1st floor did not have sprinkler coverage.

Observation on 4/23/19, during the facility tour, showed the 2nd floor barrier wall, going into the med surge unit, did not have an automatic smoke damper in the barrier wall. Observation showed the HVAC duct work penetrated the barrier wall. Observation showed the zone did not have sprinkler coverage.

During an interview on 4/23/19 at 8:16 A.M., the Maintenance Technician said the duct work penetrating the barrier walls did not have smoke dampers.

NFPA 101, 2012 edition, section 8.5.5.2 states "Where a smoke barrier is penetrated by a duct or air-transfer opening, a smoke damper designed and tested in accordance with the requirements of ANSI/UL 555S, Standard of smoke dampers, shall be installed. Where a smoke barrier is also constructed as a fire barrier , a combination fire/smoke damper designed and tested in accordance with the requirements of ANSI/UL 555, standard for fire dampers, and ANSI /UL 555S, Standard for smoke dampers, shall be installed.

Based on observation and facility staff interview, the facility staff failed to ensure the building ventilation system was installed according to NFPA 90B, Standard for the Installation of Warm Heating and Air-Conditioning and Ventilating Systems, 2012 edition and NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition. In addition, the facility staff failed to ensure soiled linen rooms in the facility were adequately vented and kept under relative negative pressure. The census was 14.

1. Observation on 4/22/19, during the building tour, showed a stand-alone room air conditioner in the conference room. Additional observation showed the warm air exhaust flexible duct penetrated the suspended ceiling and exhausted the air into the interstitial space between the ceiling and the floor deck .

During an interview on 4/22/19 at 3:34 P..M., the Maintenance Director confirmed the observation.

NFPA 101, 2012 edition, Section 19.5.2 states:

"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.

Refer to NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, 2012 edition, Section 4.2.4 thru 4.2.4.2 and Section 4.3.3.1 for additional information.

2. Observation on 4/22/19, during the facility tour, showed the soiled linen room located on the med surge unit did not have exhaust ventilation.

Observation on 4/22/19, during the facility tour, showed the soiled linen room located on the outpaitent surgery corridor did not have exhaust ventilation.

During an interview on 4/22/19 at 4:57 P.M., the Maintenance Director confirmed the observation.

Based on observation and interview the facility failed to provide window blinds that were flame resistant in accordance with provisions of NFPA 101, 10.3. The facility census was 14.

1. Observations on 4/22/19 and 4/23/19, during the Life Safety Code tour, showed window blinds throughout the facility did not have identification that showed them as being flame retardant.

NFPA Standard: Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as /demonstrated by testing in accordance with NFPA 701. 2012 NFPA 101.

Based on interview and record review the facility failed to develop a maintenance program for the medical gas, vacuum, WAGD (Waste Anesthetic Gas Disposal), or support gas system within the facility. . The facility census was 14.

1. Review of the facility maintenance program documentation did not show the facility had a program in place which includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets, and an inspection and maintenance schedule for this system.

During an interview on 4/23/19 at 9:43 A.M., the Maintenance Technician said he/she did not know about the maintenance program for the medical gas, vacuum, WAGD, or support gas system requirements.

Section 5.1.14.2.2.1 of the National Fire Protection Association (NFPA 99) states: Health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

Based on observation and facility staff interview, the facility staff failed to provide a remote annunciator panel (a panel providing information on the condition and problems with the emergency generator) for one of one emergency generators at a constantly attended location. This facility census was 14.

1. Observation on 4/22/19, during the facility tour, did not show a remote annunciator panel for the emergency generator in a constantly attended location.

During an interview on 4/22/19 at 4:30 P.M., the Maintenance Technician said the facility did not have a remote annunciator panel.

6.4.1.1.17 Alarm Annunciator. A remote annunciator that is
storage battery powered shall be provided to operate outside of
the generating room in a location readily observed by operating
personnel at a regular work station (see 700.12 of NFPA 70, National
Electrical Code). The annunciator shall be hard-wired to indicate
alarm conditions of the emergency or auxiliary power
source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating
to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to
warn of an engine-generator alarm condition shall indicate
the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in
6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains
less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

6.4.1.1.17.1* A remote, common audible alarm shall be provided
as specified in 6.4.1.1.17.4 that is powered by the storage
battery and located outside of the EPS service room at a work
site observable by personnel. [110:5.6.6]

6.4.1.1.17.2 An alarm-silencing means shall be provided, and
the panel shall include repetitive alarm circuitry so that, after
the audible alarm has been silenced, it reactivates after the
fault condition has been cleared and has to be restored to its
normal position to be silenced again. [110:5.6.6.1]

6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA110, a
manual alarm-silencing means shall be permitted that silences
the audible alarm after the occurrence of the alarm condition,
provided such means do not inhibit any subsequent alarms from
sounding the audible alarm again without further manual action.
[110:5.6.6.2]

6.4.1.1.17.4 Individual alarm indication to annunciate any of
the conditions listed in Table 6.4.1.1.16.2 shall have the following
characteristics:
(1) It shall be battery powered.
(2) It shall be visually indicated.
(3) It shall have additional contacts or circuits for a common
audible alarm that signals locally and remotely when any
of the itemized conditions occurs.
(4) It shall have a lamp test switch(es) to test the operation of
all alarm lamps.

6.4.1.1.17.5 Acentralized computer system (e.g., building automation
system) shall not be permitted to be substituted for
the alarm annunciator in 6.4.1.1.17 but shall be permitted to
be used to supplement the alarm annunciator.

6.4.1.2 Battery. Battery systems shall meet all requirements of
Article 700 of NFPA 70, National Electrical Code.


Table 6.4.1.1.16.2 Safety Indications and Shutdowns
Level 1
Indicator Function (at Battery Voltage) CV S RA
(a) Overcrank X X X
(b) Low water temperature X - X
(c) High engine temperature pre-alarm X - X
(d) High engine temperature X X X
(e) Low lube oil pressure pre-alarm X - X
(f) Low lube oil pressure X X X
(g) Overspeed X X X
(h) Low fuel main tank X - X
(i) Low coolant level X O X
(j) EPS supplying load X - -
(k) Control switch not in automatic
position
X - X
(l) High battery voltage X - -
(m) Low cranking voltage X - X
(n) Low voltage in battery X - -
(o) Battery charger ac failure X - -
(p) Lamp test X - -
(q) Contacts for local and remote
common alarm
X - X
(r) Audible alarm-silencing switch - - X
(s) Low starting air pressure X - -
(t) Low starting hydraulic pressure X - -
(u) Air shutdown damper when used X X X
(v) Remote emergency stop - X -
CV: Control panel-mounted visual. S: Shutdown of EPS indication.
RA: Remote audible. X: Required. O: Optional.
Notes:
(1) Item (p) shall be provided, but a separate remote audible signal shall
not be required when the regular work site in 5.6.6 of NFPA110, Standard
for Emergency and Standby Power Systems, is staffed 24 hours a day.
(2) Item (b) is not required for combustion turbines.
(3) Item (r) or (s) is required only where used as a starting method.
(4) Item (j): EPS ac ammeter shall be permitted for this function.
(5) All required CV functions shall be visually annunciated by a remote,
common visual indicator.
(6) All required functions indicated in the RAcolumn shall be annunciated
by a remote, common audible alarm as required in 5.6.5.2(4) of
NFPA 110.
(7) Item (i) requires a low gas pressure alarm on gaseous systems.
(8) Item (b) must be set at 11°C (20°F) below the regulated temperature
determined by the EPS manufacturer, as required in 5.3.1 of
NFPA 110.

Based on observation and staff interview facility staff failed to provide an emergency stop switch away from the generator set location. The facility census was 14.

1. Observation on 4/22/19, during the facility tour, showed the emergency generator's emergency stop switch located on the generator set.

During an interview on 4/22/19 at 4:30 P.M., the Maintenance Technician confirmed the observation.


NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition states:

5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

8.4.2* Diesel generator sets in service shall be exercised at
least once monthly, for a minimum of 30 minutes, using one
of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures
as recommended by the manufacturer
(2) Under operating temperature conditions and at not less
than 30 percent of the EPS nameplate kW rating

8.4.2.1 The date and time of day for required testing shall be
decided by the owner, based on facility operations.

8.4.2.2 Equivalent loads used for testing shall be automatically
replaced with the emergency loads in case of failure of
the primary source.

8.4.2.3 Diesel-powered EPS installations that do not meet the
requirements of 8.4.2 shall be exercised monthly with the available
EPSS load and shall be exercised annually with supplemental
loads at not less than 50 percent of the EPS nameplate kW
rating for 30 continuous minutes and at not less than 75 percent
of the EPS nameplate kWrating for 1 continuous hour for a total
test duration of not less than 1.5 continuous hours.

8.3 Maintenance and Operational Testing.

8.3.1* The EPSS shall be maintained to ensure to a reasonable
degree that the system is capable of supplying service within the
time specified for the type and for the time duration specified for
the class.

8.3.2 A routine maintenance and operational testing program
shall be initiated immediately after the EPSS has passed
acceptance tests or after completion of repairs that impact the
operational reliability of the system.

8.3.2.1 The operational test shall be initiated at an ATS and
shall include testing of each EPSS component on which maintenance
or repair has been performed, including the transfer of
each automatic and manual transfer switch to the alternate
power source, for a period of not less than 30 minutes under
operating temperature.

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

8.3.5* Transfer switches shall be subjected to a maintenance and
testing program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.6 Paralleling gear shall be subject to an inspection, testing,
and maintenance program that includes all of the following
operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive
contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.7* Storage batteries, including electrolyte levels or battery
voltage, used in connection with systems shall be inspected
weekly and maintained in full compliance with manufacturer ' s
specifications.

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.

8.3.7.2 Defective batteries shall be replaced immediately
upon discovery of defects.

8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

8.4 Operational Inspection and Testing.

8.4.1* EPSSs, including all appurtenant components, shall be
inspected weekly and exercised under load at least monthly.

8.4.6 Transfer switches shall be operated monthly.

8.4.6.1 The monthly test of a transfer switch shall consist of
electrically operating the transfer switch from the standard position
to the alternate position and then a return to the standard
position.

7.2.4* Minimizing the possibility of damage resulting from interruptions
of the emergency source shall be a design consideration
for EPSS equipment.

A.7.2.4 When installing the EPSS equipment and related
auxiliaries, environmental considerations should be given,
particularly with regard to the installation of the fuel tanks
and exhaust lines, or the EPS building, or both.
To protect against disruption of power in the facility, it is recommended
that the transfer switch be located as close to the load
as possible. The following are examples of external influences:
(1) Natural conditions
(a) Storms
(b) Floods
(c) Earthquakes
(d) Tornadoes
(e) Hurricanes
(f) Lightning
(g) Ice storms
(h) Wind
(i) Fire
(2) Human-caused conditions
(a) Vandalism
(b) Sabotage
(c) Other similar occurrences
(3) Material and equipment failures
For natural conditions, EPSS design should consider the
"100-year storm" flooding level or the flooding level predicted

Based on observation, the facility staff failed to ensure and surge protectors met NFPA requirements. The facility census was 14.


Observations on 4/22/2019 and 4/23/19, during the facility tour, showed unrated surge protectors in the following areas:

- Administration offices

- Family support office

- Physical therapy office

- Patient accounts office

- Outpatient surgery


Refer to NFPA 70, National Electrical Code, 2011 edition, Article 400.8 for additional information.