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Based on observation and facility staff interview, facility staff failed to provide emergency lighting at exit discharge areas. The facility census was 10.


1. Observation on 9/10/19, during the facility tour showed no emergency lighting at any of the exit discharge areas.

During an interview on 9/10/19 at 11:42 A.M., the Maintenance Supervisor 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".

Based on observation and facility staff interview, facility staff failed to provide emergency lighting not controlled by light switches inside one medication rooms and one pharmacy. The facility census was 10.

1. Observations on 9/10/19, during the facility tour, showed the following light fixtures in the building controlled by a light switch:

- Pharmacy;

- Emergency department medication room.


During an interview on 9/10/19 at 11:57 A.M., the Maintenance Supervisor 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 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 deficient practice has the potential to effect all facility patients, staff and visitors. The deficient practice could delay fire and emergency personnel response in the event of a fire. The census was 10.

1. Observation on 9/10/19, during the facility tour, showed the following area did not have adequate smoke detector coverage:

During an interview on 9/10/19 at 12:01 P.M., the Maintenance Supervisor confirmed the observation.

- The gift shop corridor. Observation showed the corridor measured approximately 70 feet long. Observation showed the corridor contained one smoke detector.

National Fire Protection Association 101, 2012 edition, section 19.3.4.1 states:

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

Refer to NAPA 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.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, section:

10.5.5.2 Circuit Identification and Accessibility.

10.5.5.2.1 The location of the dedicated branch circuit disconnecting
means shall be permanently identified at the control
unit.

10.5.5.2.2 For fire alarm systems the circuit disconnecting
means shall be identified as "FIRE ALARM CIRCUIT."

10.5.5.2.3 For fire alarm systems the circuit disconnecting
means shall have a red marking.

10.5.5.2.4 The circuit disconnecting means shall be accessible
only to authorized personnel.

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 10.

Observations on 9/10/19, 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:

- Patient registration office;

- Gift Shop

During an interview on 9/10/19 at 11:47 A.M., the Maintenance Supervisor 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 observation and interview, the facility failed to install a sprinkler system in accordance with the National Fire Protection Association 13, Standards for the Installation of Sprinkler Systems. These deficient practices affects all patients in the facility. The facility census was 10.

1. Observation on 9/10/19, during the facility tour, showed standard sprinkler heads and quick response sprinkler heads mounted in the same compartment in the therapy /cardio pulmonary room.

During an interview on 9/10/19, at 12:07 P.M., the Maintenance Supervisor confirmed the observation.

Section 8.3.3.2 of the National Fire Protection Association (NFPA) 13 states: "Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3

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 10.

Record review on 9/10/19 did not show the following inspections:


-5 year internal pipe inspection.

During an interview on 9/10/19 at 1:45 A.M., the Maintenance Supervisor said the sprinkler system was installed in 2012. The Maintenance Supervisor 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 facility staff failed to provide an emergency stop switch away from the generator set location. The facility census was 10.

1. Observation on 9/10/19, during the facility tour, showed the emergency generator's emergency stop switch located on the generator set.

During an interview on 9/10/19 at 1:04 P.M., the Maintenance Supervisor 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