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Based on record review and interview, the facility failed to conduct load voltage tests on the fire alarm control panel batteries semiannually as required per NFPA 72, 1999 Edition, Table 7-3.2.¹ The deficiency could affect 4 of 4 first and second floor smoke compartments.

Findings include:

During record review on 6/17/15 at 12:30 p.m., the annual fire alarm panel test records were reviewed. The annual report completed on 10/14/14, indicated the load voltage testing had been done on the sealed lead-acid batteries for the alarm control panel. Load voltage tests were not competed six months prior to the annual test.¹

During an interview on 6/17/15 at 12:40 p.m., staff member A, facility manager/safety security officer, stated the load voltage tests were conducted once annually by the service contractor. Staff member A was neither aware nor could he produce documentation verifying the load voltage tests were conducted in March of 2014.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Table 7.3.2 (6)(d)(1) & (3); Requires sealed lead-acid type batteries to be replaced every four years and have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observation, record review, and interview, the facility failed to ensure the sprinkler system was installed with proper positioning to avoid obstruction to discharge per NFPA 13, 1999 Edition, Section 5-6.5.1.2 and Table 5-6.5.1.2. This deficiency could affect 2 of 2 penthouse smoke compartments.

Findings include:

During an observation on 6/17/15 at 2:00 p.m., the penthouse sprinkler system was inspected. The penthouse lacked sprinkler coverage between each support beam, as sprinkler coverage was located between every other support beam. The support beams measured 16 inches in depth and sprinkler coverage was not designed to spray beneath or above the support beams. Each support beam was hollow in design, but wrapped with a mesh burlap product and sprayed solid with a fire protectant, which acted as an obstruction for compete sprinkler coverage.¹ The distance from the sprinkler deflector to the support beams was three feet. The sprinkler heads would spray directly into the midpoint of the beams, and not 9.5 inches below the obstruction.

In an interview on 6/17/15 at 2:11 p.m., staff member A, facility manager/safety security officer, stated he was going to consult with the architect and sprinkler company to see why it had been designed that way.

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.1.2, Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).
Exception No. 1: Sprinklers shall be permitted to be spaced on opposite sides of obstructions not exceeding 4 ft (1.2 m) in width provided the distance from the centerline of the obstruction to the sprinklers does not exceed one-half the allowable distance permitted between sprinklers.
Exception No. 2: Obstructions located against the wall and that are not over 30 in. (762 mm) in width shall be permitted to be protected in accordance with Figure 5-6.5.1.2(b).
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)

Distance from Sprinklers Maximum Allowable
to Side of Obstruction (A) Distance of Deflector
Bottom of Obstruction
(in.) (B)
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 2 1/2
1 ft 6 in. to less than 2 ft 3 1/2
2 ft to less than 2 ft 6 in. 5 1/2
2 ft 6 in. to less than 3 ft 7 1/2
3 ft to less than 3 ft 6 in. 9 1/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 16 1/2
5 ft and greater 18
For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

Based on observation and interview, the facility failed to provide a placard for one portable fire extinguisher in the kitchen in accordance with NFPA 96, 1998 Edition, Section 7-2.1.1. The deficiency could affect 1 of 2 main level smoke compartments.

Findings include:

During an observation on 6/17/15 at 3:30 p.m., the kitchen K portable fire extinguisher did not have a placard stating to use the K extinguisher as a secondary backup to the installed kitchen hood automatic fire suppression system.¹

During an interview on 6/17/15 at 3:33 p.m., staff member A, facility manager/safety security officer, stated that he would get a placard in place which would serve the purpose.

¹ NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition, Section 7-2.1.1; A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

Based on observation and interview, the facility failed to assure that portable heaters were not in use in resident care and treatment areas per NFPA 101, 2000 Edition, Section 18.7.8.¹ This deficiency has the potential to affect all residents in 1 of 2 main level smoke compartments.

The findings include:

On 6/17/15 at 2:45 p.m., an electric portable space heater was observed plugged into a wall outlet in the laboratory receptionist office. Further observation of the electric heater confirmed that the element could exceed 212°F.

During an interview on 6/17/15 at 2:46 p.m., staff member A, facility manager/safety security officer, stated the heater was not allowed in the facility and promptly removed the item.

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 18.7.8 Portable Space-Heating Devices; Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Based on observation, the facility failed to conduct an annual bulk oxygen system inspection in accordance with NFPA 50, 1996 Edition, Sections 1-3 & 4-2.1. The deficiency had the potential to affect 2 of 2 main level and 2 of 2 upper level smoke compartments.

Findings include:

The medical gas storeroom was observed on 6/17/15 at 1:00 p.m. The amount of stored and hooked to manifold oxygen would qualify the area as a bulk oxygen system as it exceeded 20,000 cubic feet of oxygen.¹

The stored and hooked to manifold oxygen included:
28 "E" size oxygen cylinders; 28 x 24 cubic feet (cu. ft.) per E cylinder = 672 cu. ft. of oxygen
4 liquid oxygen containers; 4 x 5010 cubic feet of oxygen per container = 20,040 cu. ft. of oxygen
12 oxygen "K" cylinder connected to the reserve system and in storage; 12 x 249 cu. ft of oxygen per K cylinder = 2,988 cu. ft. of oxygen

Total oxygen stored and hooked to manifold oxygen is: 672 + 20,040 + 2,988 = 23,700 cu. ft. of oxygen.

During an interview on 6/17/15 at 1:05 p.m., staff member A, facility manager/safety security officer, stated he did not realize that they had exceeded 20,000 cubic feet of oxygen.

¹ NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, 1.3 Definitions, Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

² NFPA 50, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition, Articles 110-3 and 400-10. These deficiencies could affect 2 of 2 main level and 2 of 2 upper level smoke compartments.

Findings include:

1. During an observation on 6/17/15 at 1:45 p.m., a broken power strip was discovered in payroll.¹ The power strip flexible cord was broken at the plug exposing colored wiring.¹

2. During an observation on 6/17/15 at 2:03 p.m., in room 2112-1, two power strips were found connected in series.²

3. During an observation on 6/17/15 at 4:02 p.m., in the emergency room (ER), a power strip was found dangling and not supported. The power strip was not long enough to sit flat on the floor.² ³

4. During an observation on 6/17/15 at 4:04 p.m., in room 1049, a power strip cord was found dangling and not properly supported. The power strip was not long enough to sit flat on the floor.² ³

¹ NFPA 70 National Electrical Code, 1999 Edition, Article 110-3. Examination, Identification, Installation, and Use of Equipment; (a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment.

² CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

³ NFPA 70, 1999 Edition, Article 400-10; Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

Based on record review and interview, the facility failed to conduct load voltage tests on the fire alarm control panel batteries semiannually as required per NFPA 72, 1999 Edition, Table 7-3.2.¹ The deficiency could affect 4 of 4 first and second floor smoke compartments.

Findings include:

During record review on 6/17/15 at 12:30 p.m., the annual fire alarm panel test records were reviewed. The annual report completed on 10/14/14, indicated the load voltage testing had been done on the sealed lead-acid batteries for the alarm control panel. Load voltage tests were not competed six months prior to the annual test.¹

During an interview on 6/17/15 at 12:40 p.m., staff member A, facility manager/safety security officer, stated the load voltage tests were conducted once annually by the service contractor. Staff member A was neither aware nor could he produce documentation verifying the load voltage tests were conducted in March of 2014.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Table 7.3.2 (6)(d)(1) & (3); Requires sealed lead-acid type batteries to be replaced every four years and have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observation, record review, and interview, the facility failed to ensure the sprinkler system was installed with proper positioning to avoid obstruction to discharge per NFPA 13, 1999 Edition, Section 5-6.5.1.2 and Table 5-6.5.1.2. This deficiency could affect 2 of 2 penthouse smoke compartments.

Findings include:

During an observation on 6/17/15 at 2:00 p.m., the penthouse sprinkler system was inspected. The penthouse lacked sprinkler coverage between each support beam, as sprinkler coverage was located between every other support beam. The support beams measured 16 inches in depth and sprinkler coverage was not designed to spray beneath or above the support beams. Each support beam was hollow in design, but wrapped with a mesh burlap product and sprayed solid with a fire protectant, which acted as an obstruction for compete sprinkler coverage.¹ The distance from the sprinkler deflector to the support beams was three feet. The sprinkler heads would spray directly into the midpoint of the beams, and not 9.5 inches below the obstruction.

In an interview on 6/17/15 at 2:11 p.m., staff member A, facility manager/safety security officer, stated he was going to consult with the architect and sprinkler company to see why it had been designed that way.

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.1.2, Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).
Exception No. 1: Sprinklers shall be permitted to be spaced on opposite sides of obstructions not exceeding 4 ft (1.2 m) in width provided the distance from the centerline of the obstruction to the sprinklers does not exceed one-half the allowable distance permitted between sprinklers.
Exception No. 2: Obstructions located against the wall and that are not over 30 in. (762 mm) in width shall be permitted to be protected in accordance with Figure 5-6.5.1.2(b).
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)

Distance from Sprinklers Maximum Allowable
to Side of Obstruction (A) Distance of Deflector
Bottom of Obstruction
(in.) (B)
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 2 1/2
1 ft 6 in. to less than 2 ft 3 1/2
2 ft to less than 2 ft 6 in. 5 1/2
2 ft 6 in. to less than 3 ft 7 1/2
3 ft to less than 3 ft 6 in. 9 1/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 16 1/2
5 ft and greater 18
For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

Based on observation and interview, the facility failed to provide a placard for one portable fire extinguisher in the kitchen in accordance with NFPA 96, 1998 Edition, Section 7-2.1.1. The deficiency could affect 1 of 2 main level smoke compartments.

Findings include:

During an observation on 6/17/15 at 3:30 p.m., the kitchen K portable fire extinguisher did not have a placard stating to use the K extinguisher as a secondary backup to the installed kitchen hood automatic fire suppression system.¹

During an interview on 6/17/15 at 3:33 p.m., staff member A, facility manager/safety security officer, stated that he would get a placard in place which would serve the purpose.

¹ NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition, Section 7-2.1.1; A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

Based on observation and interview, the facility failed to assure that portable heaters were not in use in resident care and treatment areas per NFPA 101, 2000 Edition, Section 18.7.8.¹ This deficiency has the potential to affect all residents in 1 of 2 main level smoke compartments.

The findings include:

On 6/17/15 at 2:45 p.m., an electric portable space heater was observed plugged into a wall outlet in the laboratory receptionist office. Further observation of the electric heater confirmed that the element could exceed 212°F.

During an interview on 6/17/15 at 2:46 p.m., staff member A, facility manager/safety security officer, stated the heater was not allowed in the facility and promptly removed the item.

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 18.7.8 Portable Space-Heating Devices; Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Based on observation, the facility failed to conduct an annual bulk oxygen system inspection in accordance with NFPA 50, 1996 Edition, Sections 1-3 & 4-2.1. The deficiency had the potential to affect 2 of 2 main level and 2 of 2 upper level smoke compartments.

Findings include:

The medical gas storeroom was observed on 6/17/15 at 1:00 p.m. The amount of stored and hooked to manifold oxygen would qualify the area as a bulk oxygen system as it exceeded 20,000 cubic feet of oxygen.¹

The stored and hooked to manifold oxygen included:
28 "E" size oxygen cylinders; 28 x 24 cubic feet (cu. ft.) per E cylinder = 672 cu. ft. of oxygen
4 liquid oxygen containers; 4 x 5010 cubic feet of oxygen per container = 20,040 cu. ft. of oxygen
12 oxygen "K" cylinder connected to the reserve system and in storage; 12 x 249 cu. ft of oxygen per K cylinder = 2,988 cu. ft. of oxygen

Total oxygen stored and hooked to manifold oxygen is: 672 + 20,040 + 2,988 = 23,700 cu. ft. of oxygen.

During an interview on 6/17/15 at 1:05 p.m., staff member A, facility manager/safety security officer, stated he did not realize that they had exceeded 20,000 cubic feet of oxygen.

¹ NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, 1.3 Definitions, Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

² NFPA 50, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition, Articles 110-3 and 400-10. These deficiencies could affect 2 of 2 main level and 2 of 2 upper level smoke compartments.

Findings include:

1. During an observation on 6/17/15 at 1:45 p.m., a broken power strip was discovered in payroll.¹ The power strip flexible cord was broken at the plug exposing colored wiring.¹

2. During an observation on 6/17/15 at 2:03 p.m., in room 2112-1, two power strips were found connected in series.²

3. During an observation on 6/17/15 at 4:02 p.m., in the emergency room (ER), a power strip was found dangling and not supported. The power strip was not long enough to sit flat on the floor.² ³

4. During an observation on 6/17/15 at 4:04 p.m., in room 1049, a power strip cord was found dangling and not properly supported. The power strip was not long enough to sit flat on the floor.² ³

¹ NFPA 70 National Electrical Code, 1999 Edition, Article 110-3. Examination, Identification, Installation, and Use of Equipment; (a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment.

² CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

³ NFPA 70, 1999 Edition, Article 400-10; Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.