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Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces by ensuring that doors are automatically closing or self-closing. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting approximately 8 patients, visitors and staff in three smoke zone. The facility has a capacity of 24 and census of 13 at the time of the survey.

Findings include:

During the survey the on December 31, 2019 the following was observed:

1. At 2:00 pm the following patient rooms are used as storage and the doors failed to self-close and latch upon drop test:114, 115, 116, 121, and 123.

2. At 2:45 pm the solid utility in SBH door failed to self-close and latch upon drop test.

During the survey the on January 2, 2020 at 9:30 am it was observed that the area on the Code footprint labeled as equipment storage in the ER has combustible storage that is approximately 70 square feet and is separated from the corridor by a curtain not by a smoke partition and a self-closing door as required.


Staff B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 19.2.2.2.7

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 19.3.6.3.5

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 7.2.1.8.1

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 19.3.2.1.5

Review of the following NFPA Standard revealed: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1

Review of the following NFPA Standard revealed: An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9. 2012 NFPA 101, 19.3.2.1.1

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 19.3.2.1.2

Based on observation and staff interview the facility fails to ensure that the width of corridors are clear or unobstructed that serve as exit access and maintained to provide the convenient removal of non-ambulatory patients. This deficient practice could impede occupants from exiting in the event of a fire or other emergency, affecting Staff and visitors in one smoke zone. The facility has a capacity of 24 and census of 13 at the time of the survey.

Findings include:

During the survey the following is on December 31, 2019 at 1:15 pm it is observed that Gift Shop has sale racks that are not fixed furniture and are not medical equipment that are placed in the corridor during business hours. All the furniture is moved into the gift shop when the gift shop is closed.

Staff B was present during and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:

(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2) Where corridor width is atleast 6ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in. (152.5 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c) The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5) Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5) (d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f) The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8. 2012 NFPA 101, 19.2.3.4

Based on observation, records review and staff interview the facility failed to ensure that task lighting is provided that is not switchable for adequate emergency task illumination. This deficient practice could result in the lack of task lighting during an interruption of power and does not ensure that the lighting fixtures are tested as required, affecting approximately 8 residents 3 smoke zones. The facility has a capacity of 24 with a census of 13 at the time of survey.

Findings include:

During the survey the following is observed:

1. On December 31, 2019, at 11:25 am it is observed that the emergency light in the maintenance room failed to illuminate upon test. It is also not on the monthly and annual testing documentation provided.

2. On December 31, 2019 at 2:10 pm it is observed that the emergency task illumination in the medication preparation room in the SBH area is powered from the diesel generator. This illumination is provided with a wall switch that when operated leaves the medication preparation room without lighting.

3. On January 2, 2020 at 11:00 am it is observed that the emergency task illumination in the medication preparation room in the Surgery area is powered from the diesel generator. This illumination is provided with a wall switch that when operated leaves the medication preparation room without lighting.


Staff B was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Emergency lighting shall be provided in accordance with Section 7.9. 2012 NFPA 101, 19.2.9.1

Review of the following NFPA Standard revealed: Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. 7.9.3.1.1

Testing of required emergency lighting systems shall be permitted to be conducted as follows:

(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1 (2).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2012 NFPA 101, 7.9.3.1

Review of the following NFPA Standard revealed: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following:

(1) Failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities
2012 NFPA 101, 7.9.2.2

Review of the following NFPA Standard revealed: Task illumination battery charger for battery powered lighting unit(s) and selected receptacles at the generator set and essential transfer switch locations. 2011 NFPA 70, 517.32 (E)

Review of the following NFPA Standard revealed: Delayed-Automatic Connections to Equipment Branch. The following equipment shall be permitted to be connected to the equipment branch and shall be arranged for delayed-automatic connection to the alternate power source:
(1) Task illumination and select receptacles in the following:
(a) Patient care rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor luminaires)
(2) Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms
(3) Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms
(4) Smoke control and stair pressurization systems
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood
2012 NFPA 99, 6.5.2.2.3.3

Based on observation, record review and staff interview the facility failed to provide documentation of a visual inspection of exit signs throughout the facility and failed to mark doors that are not an exit with the appropriate signage. The deficient practice of not inspecting exit signs monthly, and marking non-exit doors correctly, fails to ensure that the signs will remain illuminated in the event of an emergency so that occupants of the building will be directed to the exit path and could delay egress in the event of an emergency. This deficiency affects all patients in all smoke zones. The facility has a capacity of 24 with a census of 13 at the time of survey.

Findings include:

During record review on December 30, 2019, it is revealed that there is no documentation available for review for the monthly inspection of exit signs throughout the facility that are powered by the emergency generator.

Based on observation on December 31, 2019 at 1:45 pm it is observed that the two enclosed courts have signs stating, "not an exit" And are not marked with the appropriately sized "NO EXIT" signage.


Staff B was present during record review and acknowledged the findings.

Review of the following NFPA Standard revealed: Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. 2012 NFPA 101, 19.2.10.1

Review of the following NFPA Standard revealed: Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 43 for individual occupancies, the signs, other than approved self-luminous signs and listed photoluminescent signs in accordance with 7.10.7.2 shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration. 2012 NFPA 101, 7.10.4

Review of the following NFPA Standard revealed: Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.l.3. 2012 NFPA 101, 7.10.9.1


Review of the following NFPA Standard revealed: Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2012 NFPA 101, 7.9.3.1

Review of the following NFPA Standard revealed: Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:

NO
EXIT

The NO EXIT sign shall have the word NO in letters 2in. (51 mm) high, with a stroke width of 3/8 in. (9.5mm), and the word EXIT in letters 1 in. (25 mm) high, with the word EXIT below the word NO, unless such sign is an approved existing sign. 2012 NFPA 101, 7.10.8.3.1 and 7.10.8.3.2.

Based on observation and record review, the facility failed to provide documentation of the fire alarm system semiannual inspection as required by NFPA 72. The absence of complete, verifiable documentation of the Fire alarm system's inspection maintenance and testing fails to ensure reliability of the alarm system in the event of an emergency, affecting all staff, visitors and patients in all smoke zones. The facility has a capacity of 24 and census of 13 at the time of the survey.

Findings include:

During record review on December 30, 2019 it is revealed that no documentation is available for review for the semiannual inspections for the fire alarm system and its components as required by table 14.3.1 of NFPA 72, 2010 edition.

Based on observation on December 31, 2019 at 12:35 pm it is observed that the head cover is missing on the smoke detector in the data 2 room.

Staff B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 2012 NFPA 101, 19.3.4.1

Review of the following NFPA Standard revealed: Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 2012 NFPA 101, 4.6.12.4

Review of the following NFPA Standard revealed: To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2012 NFPA 101, 9.6.1.5

Review of the following NFPA Standard revealed: 14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Test of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction. Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction. Extended intervals shall not exceed 18 months. The visual inspection shall be made to ensure that there are no changes that affect equipment performance. 2010 NFPA 72, 14.3.1.

Based on observation, staff interview, and record review the facility failed to provide a sprinkler system installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems. Failing to meet the requirement to provide an automatic fire sprinkler system in accordance with the requirements of NPFA 13 may not prevent fire growth, affecting staff and visitors in one smoke zone. The facility has a capacity of 24 with a census of 13 at the time of survey.

Findings include:

During the survey on January 2, 2020 at 9:55 am it is observed that there is no sprinkler protection installed in the approximately 60 square foot cooler in the kitchen storage area. There is a head installed above the cooler.

Staff B was present at the time of observation and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 19.3.5.1

Review of the following NFPA Standard revealed: 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
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2012 NFPA 101, 9.7.1.1

Review of the following NFPA Standard revealed: The requirements for spacing, location, and position of sprinklers shall be based on the following principles:

(1) Sprinklers shall be installed throughout the premises.
(2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler.
(3) Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution.
(4) Sprinklers shall be permitted to be omitted from areas specifically allowed by this standard.
(5) When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
(6) Clearance between sprinklers and ceilings exceeding the maximums specified in this standard shall be permitted, provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.
(7) Furniture, such as portable wardrobe units, cabinets, trophy cases, and similar features not intended for occupancy, does not require sprinklers to be installed in them. This type of feature shall be permitted to be attached to the finished structure. 2010 NFPA 13, 8.1.1

Review of the following NFPA Standard revealed: Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3. 2010 NFPA 13, 8.5.5.3

Review of the following NFPA Standard revealed: Automatic sprinklers shall not be obstructed by auxiliary devices, piping, insulation, and so forth, from detecting fire or from proper distribution of water. 2010 NFPA 13, 7.7.1.4

Review of the following NFPA Standard revealed: Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2 and 8.5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Sidewall sprinklers shall be installed no closer than 4 ft (1.2 m) from light fixtures or similar obstructions. The distance between light fixtures or similar obstructions located more than 4 ft (1.2 m) from the sprinkler shall be in conformity with Table 8.7.5.1.3 and Figure 8.7.5.1.3.
2010 NFPA 13, 8.7.5.1.1 through 8.7.5.1.3

Based on observation and interview the facility fails to ensure that the facility's automatic sprinkler system is being inspected, tested and maintained in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all patients in all smoke zones. The facility has a capacity of 24 and census of 13 at the time of the survey.

Findings include:

Record review conducted December 30, 2019 of the facility's sprinkler inspection, testing and maintenance records revealed that the following:

1. There is no documentation available for review for the weekly inspection and testing of the sprinkler system's electric jockey pump.

2. There is no documentation available for review for the weekly inspection and testing of the sprinkler system's Diesel fire pump.

3. There is no documentation available for review for the monthly inspection of sprinkler gauges throughout the facility.

4. There is no documentation available for review for the annual inspection of back flow prevention devices that are connected to the fire sprinkler systems throughout the facility.


Based on observation on December 31, 2019 at 11:30 am there is a sprinkler head in the pharmacy that has a storage shelf that is located within 18 inches of the head.



Staff A was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: Gauges on dry, preaction, and deluge systems shall be
inspected weekly to ensure that normal air and water pressures are being maintained. Where air pressure supervision is connected to a constantly attended location, gauges shall be inspected monthly.2011 NFPA 25, 5.2.4.2 and 5.2.4.3

Review of the following NFPA Standard revealed: Waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage. 2011 NFPA 25, 5.2.5

Review of the following NFPA Standard revealed: Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 2011 NFPA 25, 5.3.3.1

Review of the following NFPA Standard revealed: Sprinklers manufactured using fast-response elements that have been in service for 20 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals. 2011 NFPA 25, 5.3.1.1.1.3

Review of the following NFPA Standard revealed: Testing waterflow alarm devices on dry pipe, preaction, or deluge systems shall be accomplished by using the bypass connection. 2011 NFPA 25, 5.3.3.5

Review of the following NFPA Standard revealed: Each control valve shall be operated annually through its full range and returned to its normal position. Post indicator valves shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicator and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming. 2011 NFPA 25, 13.3.3.1 through 13.3.3.3

Review of the following NFPA Standard revealed: Record Keeping and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location. 2012 NFPA 101, 9.7.8

Review of the following NFPA Standard revealed: The purpose of inspection shall be to verify that the pump assembly appears to be in operating condition and is free from physical damage. The pertinent visual observations specified in the following checklists shall be performed weekly:
(1) Pump house conditions:
(a) Heat is adequate, not less than 40°F (4.4°C) [70°F (21°C)] for pump room with diesel pumps without engine heaters.
(b) Ventilating louvers are free to operate.

(2) Pump system conditions:
(a) Pump suction and discharge and bypass valves are fully open.
(b) Piping is free of leaks.
(c) Suction line pressure gauge reading is within acceptable range.
(d) System line pressure gauge reading is within acceptable range.
(e) Suction reservoir is full.
(f) Wet pit suction screens are unobstructed and in place.

(3) Electrical system conditions:
(a) Controller pilot light (power on) is illuminated.
(b) Transfer switch normal pilot light is illuminated.
(c) Isolating switch is closed - standby (emergency) source.
(d) Reverse phase alarm pilot light is off, or normal phase rotation pilot light is on.
(e) Oil level in vertical motor sight glass is within acceptable range.

(4) Diesel engine system conditions:
(a) Fuel tank is two-thirds full.
(b) Controller selector switch is in auto position.
(c) Batteries' (2) voltage readings are within acceptable range.
(d) Batteries' (2) charging current readings are within acceptable range.
(e) Batteries' (2) pilot lights are on or battery failure (2) pilot lights are off.
(f) All alarm pilot lights are off.
(g) Engine running time meter is reading.
(h) Oil level in right angle gear drive is within acceptable range.
(i) Crankcase oil level is within acceptable range.
(j) Cooling water level is within acceptable range.
(k) Electrolyte level in batteries is within acceptable range.
(l) Battery terminals are free from corrosion.
(m) Water-jacket heater is operating.

(5) Steam system conditions: Steam pressure gauge reading is within acceptable range.
2011 NFPA 25, 8.2

Review of the following NFPA Standard revealed: A weekly test of fire pump assemblies shall be conducted
without flowing water. The weekly test shall be conducted by starting the pump
automatically. The electric pump shall run a minimum of 10 minutes. The diesel pump shall run a minimum of 30 minutes. A valve installed to open as a safety feature shall be
permitted to discharge water. The automatic weekly test timer shall be permitted to
be substituted for the starting procedure.
Weekly Tests: Qualified operating personnel shall be in attendance
during the weekly pump operation. The pertinent visual observations or adjustments specified in the following checklists shall be conducted while the pump is running:

(1) Pump system procedure:
(a) Record the system suction and discharge pressure gauge readings.
(b) Check the pump packing glands for slight discharge.
(c) Adjust gland nuts if necessary.
(d) Check for unusual noise or vibration.
(e) Check packing boxes, bearings, or pump casing for overheating.
(f) Record the pump starting pressure.

(2) Electrical system procedure:
(a) Observe the time for motor to accelerate to full speed.
(b) Record the time controller is on first step (for reduced
voltage or reduced current starting).
(c) Record the time pump runs after starting (for automatic
stop controllers).

(3) Diesel engine system procedure:
(a) Observe the time for engine to crank.
(b) Observe the time for engine to reach running speed.
(c) Observe the engine oil pressure gauge, speed indicator, water, and oil temperature indicators periodically while engine is running.
(d) Record any abnormalities.
(e) Check the heat exchanger for cooling waterflow.
(4) Steam system procedure:
(a) Record the steam pressure gauge reading.
(b) Observe the time for turbine to reach running speed.
2011 NFPA 25, 8.3

Based on observation and record review the facility fails to provide a smoke barrier with continuity through the space above the ceiling grid. This deficient practice will increase the travel distance from any point in the compartment to a door in the next nearest barrier, affecting approximately 8 patients, visitors and staff in two smokes. The facility has a capacity of 24 and census of 13 at the time of the survey.

Findings include:

On January 2, 2020 at 12:00 pm the following is observed

1. The smoke barrier separating fire area of the ER from the rest of the facility as documented on the Code footprint provided to OSFM and dated 3/23/10 is not completed.

2. The facility informed the surveyor that the code foot print that was provided, and is the most recent, is not accurate. The facility is not maintaining 5 smoke barriers that divide the facility into 6 zones but rather 3 barriers that divide the facility in to 4 smoke zones. Other minor discrepancies were noted such as walls and doors, not in barriers where they were not actually constructed.


Staff B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum ½ 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. 2012 NFPA 101, 19.3.7.3

Review of the following NFPA Standard revealed: Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. 2012 NFPA 101, 8.5.2.1 and 8.5.2.2

Review of the following NFPA Standard revealed: The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers. 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. 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. 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 112 in. (13 mm), measured between the edge of the membrane and the sprinkler. 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. 2012 NFPA 101, 8.5.6.1 through 8.5.6.5

Based on observation and staff interview, the facility failed to provide documentation proving a water heater requiring a boiler inspection has been inspected and certified. Failure to comply with the State's inspection requirements could result in a hazardous condition due improper installation or the malfunction of a heat-producing appliance, affecting approximately 8 patients in one smoke zones. The facility has a capacity of 24 and census of 13 at the time of the survey.

Findings include:

During the survey on January 2, 2020 the following is observed:

1. At 10:00 am that a 100-gallon capacity water heater has been installed in basement boiler room on 10/30/19 and this water heater has not been inspected and received a boiler certificate from the Office of the Fire Marshal.

Staff B was present during the survey and acknowledged the findings.

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting outpatient, visitors, and staff in 2 smoke zones. The facility has a capacity of 24 with a census of 13 at the time of survey.

Findings Include:


During the survey on December 31, 2019 at 11:10 am it is observed that there is an outlet in the maintenance office that is missing a cover.

During the survey on January 2, 2020 the following is observed:


1. At 9:30 am there is a night time phone ringer that is plugged into a UPS batter back up that is above the ceiling. The outlet installed in the ceiling grid has the flexible cord for the UPS running from under the ceiling to above the ceiling where the UPS battery backup that is located on the ceiling grid.

2. At 11:15 am there are open junction boxes in the ceiling above the Lab back door with an outlet that has a battery back up installed and sitting on the ceiling grid.

3. At 11.45 am there are multiple open junction boxes in the ceiling above outpatient pulmonary rehabilitation.

Staff B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 9.1.2

Review of the following NFPA Standard revealed: Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in 210.23(A) through (D) and as summarized in 210.24 and Table 210.24. 2011 NFPA 70, 210.23

Review of the following NFPA Standard revealed Raceways, cable assemblies, boxes, cabinets, and fittings shall be securely fastened in place. Support wires that do not provide secure support shall not be permitted as the sole support. Support wires and associated fittings that provide secure support and that are installed in addition to the ceiling grid support wires shall be permitted as the sole support. Where independent support wires are used, they shall be secured at both ends. Cables and raceways shall not be supported by ceiling grids. 2011 NFPA 70, 300.11

Based on observation and interview the facility failed to prevent the use of combustible decorations. This deficient practice will allow rapid flame spread across the room and allow fire products to grow rapidly, affecting approximately 5 patients, visitors and staff in 2 smoke zones. The facility has a capacity of 24 and census of 13 at the time of the survey.

Findings include:

During the survey on December 31 the following is observed.

1. At 11:45 am there is a candle in the billing office area near the pharmacy.

2. At 11:55 am the Christmas tree in the front lobby has no documentation available for review showing that it is noncombustible. The documentation provided said "CAUTION, Risk of fire"


Staff B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:

(l) They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.
(2) The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests/or Flame Propagation a/Textiles and Films.
(3) The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20 kW ignition source.
(4) The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:

(a) Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 19.7.5.6(b), (c), or (d).
(b) Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
(c) Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system in accordance with Section 9.7.
(d) Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms, having a capacity not exceeding four persons, in a smoke compartment that is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
(5) They are decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present. 2012 NFPA 101, 19.7.5.6

Based on observation and staff interview the facility is not ensuring that fire and smoke rated doors and assemblies are inspected and tested annually. This deficient practice of not ensuring fire and smoke rated doors and assemblies are inspected and tested annually, prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting all patients, visitors, and staff in all smoke zones. The facility has a capacity of 24 with a census of 13 patients at the time of the survey.

Findings include:

During document review on December 30, 2019 it is revealed that there is no documentation available for review that the fire and smoke rated doors and assemblies are inspected and tested annually.

Based on observation on December 31, 2019 at 12:25 pm the ICU east rated doors failed to close and latch upon drop test. The code footprint provided to OSFM and dated 3/23/2010 shows that this is a rated wall.

Based on observation on January 2, 2020 at 9:35 am it is revealed that there is no annual inspection or testing available for review for the two rolling fire rated doors (one is in the registration area and one is in the X-ray area).

Staff B present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 8O, 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. 2012 NFPA 101, 7.2.1.15.2

Review of the following NFPA Standard revealed: Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 2010 NFPA 80, 5.2.1

Review of the following NFPA Standard revealed: Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting. 2010 NFPA 80, 5.2.3.1 and 5.2.3.2

Based on record review and staff interview the facility failed to assure that portable space heaters being used within the facility are code compliant. This deficient practice could cause a fire due to excessive heat, affecting approximately 13 residents/patients in all smoke zones. The facility has a capacity of 24 with a census of 13 at the time of survey.

Findings include:

During the survey on December 31, 2019 at 11:40 it is observed that a portable space heater is in use in the pharmacy. The documentation that is provided states that the exterior of the heater will not exceed 149 degrees. The documentation does not address the heating element to indicate that the heating element will not exceed 212 degrees Fahrenheit. It was revealed that these heaters are in use in office spaces throughout the facility.

Staff B was present at the time of observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:

(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (l00°C). 2012 NFPA 101, 19.7.8

During a review of records and staff interview the facility failed to ensure that an annual maintenance inspection is completed of the piped in medical gas and vacuum piped systems in accordance with NFPA 99 2012 Health Care Facilities edition; this failure adversely affect all patients in all smoke zones. The facility has a capacity of 24 with a census of 13 patients at the time of the survey.


Findings include:

Background

Based in record review on December 30, 2019 at approximately 2:00 pm the state agency's life safety inspector, who was preforming a routine healthcare survey, observed that the facilities piped medical gas system has not been inspected since it was put into operation in 2011.

This deficient practice resulted in the LSC inspector of the Office of the state Fire Marshal notifying the Hospitals administration that the Centers for Medicare and Medicaid services (CMS) identified this as an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more of the requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) on 12/30/19 at approximately 3:30 pm. The Immediate Jeopardy was remediated by the facility providing a signed document stating that they would not use the Medical Gas system until it was inspected by a qualified medical gas inspector. The facility moved all patients to portable oxygen bottles and concentrators and had the a medical gas inspection conducted the next morning by qualified personal who approved the system for the medical center to return to normal operating procedures

Staff B was present at the time of the observation and acknowledged the findings, Staff C was informed of the finding during the records review.

Review of the following NFPA Standard revealed: Medical Gas. Medical gas storage and administration
areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: Paragraph 5.1.14.4.3 through 5.1.14.4.9 and 5.1.13
through 5.1.15 shall apply to existing health care facilities. 2012 NFPA 99, 5.1.1.6

Review of the following NFPA Standard revealed: An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity. Central supply systems for nonflammable medical
gases shall conform to the following:

(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.

A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be
implemented. 5.1.14.4.7 Procedures, as specified, shall be established for the following:

(1) Maintenance program for the medical air compressor supply system in accordance with the manufacturer's recommendations
(2) Facility testing and calibration procedure that ensures carbon monoxide monitors are calibrated at least annually
or more often if recommended by the manufacturer
(3) Maintenance program for both the medical-surgical vacuum piping system and the secondary equipment attached to medical-surgical vacuum station inlets to ensure the continued good performance of the entire
medical-surgical vacuum system
(4) Maintenance program for the WAGD system to ensure performance

Audible and visual alarm indicators shall meet the following requirements:

(1) They shall be periodically tested to determine that they are functioning properly.
(2) Records of the test shall be maintained until the next test is performed.

Medical-surgical vacuum station inlet terminal performance, as required in 5.1.12.3.10.4, shall be tested as follows:

(1) On a regular preventive maintenance schedule as determined by the facility maintenance staff
(2) Based on flow of free air (Nl/min or SCFM) into a station inlet while simultaneously checking the vacuum level
2012 NFPA 99, 5.1.14.4.3 through 5.1.14.4.9

During a review of records and staff interview the facility failed to ensure that an annual inspection is completed of the piped in medical gas and vacuum piped systems in accordance with NFPA 99 2012 Health Care Facilities edition; this failure adversely affect all patients in all smoke zones. The facility has a capacity of 24 with a census of 13 patients at the time of the survey.

Findings include:

On Monday December 30th, 2019, the Office of the State Fire Marshal conducted a routine state licensure inspection of Girard Medical Center # 171376 located at 320 North Hospital Dr in Kansas. At approximately 2:00 PM; it is observed that the facilities failed to have an annual inspection for the piped in medical gas system. Staff member B provided the surveyor paperwork form a medial gas vendor which had a calendar date of 2011, Staff member B said the system hasn't been inspected annually since install in 2011.

This deficient practice resulted in the LSC inspector of the Office of the state Fire Marshal notifying the Hospitals administration that the Centers for Medicare and Medicaid services (CMS) identified this as an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more of the requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) on 12/30/19 at approximately 3:30 pm. The Immediate Jeopardy was remediated by the facility providing a signed document stating that they would not use the Medical Gas system until it was inspected by a qualified medical gas inspector. The facility moved all patients to portable oxygen bottles and concentrators and had the a medical gas inspection conducted the next morning by qualified personal who approved the system for the medical center to return to normal operating procedures


Staff B was present at the time of the observation and acknowledged the findings, Staff C was informed of the finding during the records review.


Review of the following NFPA Standard revealed: Medical Gas. Medical gas storage and administration
areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows:

(1)Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point

(2) Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4) Instrument air source - filter condition
(5) Manifold sources (including systems complying with 5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems - delivery pressure
(8) Valves - labeling
(9) Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11) Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks

2012 NFPA 99, 5.1.14.2.3.1

Review of the following NFPA Standard revealed: An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity. Central supply systems for nonflammable medical
gases shall conform to the following:

(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.

A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be
implemented. 5.1.14.4.7 Procedures, as specified, shall be established for the following:

(1) Maintenance program for the medical air compressor supply system in accordance with the manufacturer's recommendations
(2) Facility testing and calibration procedure that ensures carbon monoxide monitors are calibrated at least annually
or more often if recommended by the manufacturer
(3) Maintenance program for both the medical-surgical vacuum piping system and the secondary equipment attached to medical-surgical vacuum station inlets to ensure the continued good performance of the entire
medical-surgical vacuum system
(4) Maintenance program for the WAGD system to ensure performance

Audible and visual alarm indicators shall meet the following requirements:

(1) They shall be periodically tested to determine that they are functioning properly.
(2) Records of the test shall be maintained until the next test is performed.

Medical-surgical vacuum station inlet terminal performance, as required in 5.1.12.3.10.4, shall be tested as follows:

(1) On a regular preventive maintenance schedule as determined by the facility maintenance staff
(2) Based on flow of free air (Nl/min or SCFM) into a station inlet while simultaneously checking the vacuum level
2012 NFPA 99, 5.1.14.4.3 through 5.1.14.4.9

Based on record review and staff interview the facility fails to provide a documented maintenance and testing program for electrical receptacles. This deficient practice prevents the facility from ensuring that electrical receptacles are maintained and testing as required by NFPA 99 Health Care Facilities and could adversely affect all patients in all smoke zones. The facility has a capacity of 24 with a census of 13 at the time of the survey.

Findings include:

During the survey on December 30, 2019 it is revealed that there is no documented program for the annual inspection and testing of the physical integrity of electrical receptacles in resident care rooms at bed locations.

Staff B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: The physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). 2012 NFPA 99, 6.3.3.2.1 through 6.3.3.2.4

Review of the following NFPA Standard revealed: A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. 2012 NFPA 99, 6.3.4.2.1.1 and 6.3.4.2.1.2

Based on record review and staff interview the facility failed to assure the generator is inspected and tested in accordance with NFPA 110 and failed to ensure that the main and feeder circuits throughout the facility have a program established for their periodic exercising. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency and failed to ensure that main and feeder circuits are maintained as required, affecting all patients in all smoke zones. The facility has a capacity of 24 and census of 13 at the time of the survey.

Findings include:

During review of records on December 30, 2019 the following is revealed:

1. The documentation provided for the 36 month 4-hour load bank test dated 5-22-19 was only conducted for 3.7 hours.

2. There is no documentation available for review for the program established for the for periodically exercising the components and the annual testing on main and feeder circuits throughout the facility.

Staff B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1

Review of the following NFPA Standard revealed: A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
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. 2010 NFPA 110, 8.3.4, 8.3.4.1

Review of the following NFPA Standard revealed: 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. 2010 NFPA 110, 8.4.2

Review of the following NFPA Standard revealed: Level 1 EPSS shall be tested at least once within every
36 months. Level 1 EPSS shall be tested continuously for the duration of its assigned class (see Section 4.2). Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours. The test shall be initiated by operating at least one transfer switch test function and then by operating the test function of all remaining ATSs, or initiated by opening all switches or breakers supplying normal power to all ATSs that are part of the EPSS being tested. A power interruption to non-EPSS loads shall not be required. The minimum load for this test shall be as specified in 8.4.9.5.1, 8.4.9.5.2, or 8.4.9.5.3. 2010 NFPA 110, 8.4.9-8.4.9.4

Review of the following NFPA Standard revealed: 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 kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. 2010 NFPA 110, 8.4.2.3

Review of the following NFPA Standard revealed: For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS. A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. 8.4.9.5.2 For a diesel-powered EPS, loading shall be that which maintains the minimum exhaust gas temperatures as recommended by the manufacturer. 2010 NFPA 110, 8.4.9.5.1

Review of the following NFPA Standard revealed: Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations. 2012 NFPA 99, 6.4.4.1.2.1

Review of the following NFPA Standard revealed: A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. 2012 NFPA 99, 6.4.4.2

Based on observation and staff interview, the facility fails to assure that all relocatable power taps meet the requirements NFPA 70 National Electrical Code and NFPA 99 Health Care Facilities Code. This deficient practice increases the risk of an electrical fire and affects all residents in all smoke zones. The facility has a capacity of 24 with a census of 13 residents at the time of the survey.

Findings include:

During the survey on January 2, 2020 at 11:30 am it is observed that the relocatable power taps found in the Operating room on mobile carts that is no listed as UL 1363A compliant. (x4) They are listed as UL 1363.

Staff B was present during the survey and acknowledged the findings.


Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 9.1.2

Review of the following NFPA Standard revealed: Where used as permitted in 400.7(A)(3), (A)(6), and (A)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet or cord connector body.

Exception: As permitted in 368.56. 2011 NFPA 70, 400.7

Review of the following NFPA Standard revealed: Unless specifically permitted, flexible cords and cable shall not be used as a substitute for fixed wiring of a structure. NFPA 70, 400-8

Review of the following NFPA Standard revealed: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in 210.23(A) through (D) and as summarized in 210.24 and Table 210.24. 2011 NFPA 70, 210.23

Review of the following NFPA Standard revealed: All cord-connected electrically powered appliances
that are not double insulated and are used in the patient care vicinity shall be provided with a three-wire power cord and a three-pin grounding-type plug. Double-insulated appliances shall be permitted to have two conductor cords and shall be rated as Class II devices. 2012 NFPA 99, 10.2.2.1.1


Review of the following NFPA Standard revealed: The flexible cord, including the grounding conductor, shall be of a type suitable for the particular application; shall be listed for use at a voltage equal to or greater than the rated power line voltage of the appliance; and shall have an ampacity, as given in Table 400.5(A) of NFPA 70, National Electrical Code, equal to or greater than the current rating of the device. 2012 NFPA 99, 10.2.3.1.1

Review of the following NFPA Standard revealed: Multiple Outlet Connection. Two or more power receptacles
supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart mounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2) The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of
the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.
(4) The electrical and mechanical integrity of the assembly is regularly verified and documented.
(5) Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe. 2012 NFPA 99, 10.2.3.6

Review of the following NFPA Standard revealed: Nonpatient care-related electrical equipment, including facility- or patient-owned appliances that are used in the patient care vicinity and will, in normal use, contact patients, shall be visually inspected by the patient's care staff or other personnel. 2012 NFPA 99, 10.4.2.1