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Based on observation, interview and national standards, the facility staff failed to ensure corridor doors did not have kickdowns. The facility census was six.

Findings included:

1.Observations on 6/24/24, during the facility tour, showed the following corridor doors had kickdowns attached to them:

- Information Technology Storage room
- Patients Accounts Leader room
- Patients Benefit Advisor room
- Extra Office
- Tel Co Room

2.During an interview 6/24/24 the Facility Operations Manager confirmed the observations.
NFPA 101, 2012 edition, section 19.2.2.2.7 states:

3."19.2.2.2.7* 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."

Based on observation, interview, record review and national standards, the facility staff failed to provide continuously maintained exit ways free of all obstructions or impediments continuous to a public way such as a parking lot. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Failure to ensure exterior exit ways comply with LSC requirements could delay evacuation out of the building in the event of a fire or other emergency. This facility had a census of six.

Findings included:

1. Observation on 6/24/25 and 6/25/24, during the facility tour, showed the following exit discharge areas required residents, staff, and visitors to traverse grass to reach a parking lot or sidewalk:
- Exit by training room
- Patient exit stairwell
- Administrative Hallway exit
- Stairwell B exit
- Stairwell A exit

2.During interviews on 6/24/24 and 6/25/24 the Facility Operations Manager confirmed the observations.

3.Record review of the facility layout showed the exit discharge area designated for patient, staff and visitors use.

4. National Fire Protection Association 101, Life Safety Code 2012 Edition, section 7.7 state:
7.7 Discharge from Exits.
7.7.1* Exit Termination. Exits shall terminate directly, at a
public way or at an exterior exit discharge, unless otherwiseprovided in 7.7.1.2 through 7.7.1.4.

Based on observation, interview and national standards, the facility failed to provide and maintain one of one kitchen range hood in accordance with NFPA 96, Standard for Ventilation Control and Fire Prevention of Commercial Cooking Operations, 2011 edition. The facility census was six.

Findings included:

1. Observation on 6/25/24, during the facility tour, showed the range hood did not have an enclosed metal container to collect grease from the drip tray.

2. During an interview on 6/25/24 at 10:05 P.M., the Facility Operations Manager confirmed the observation.

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

Based on observation, interview and national standards, the facility failed to ensure an interior partition had a class A or B rating. The facility had a census of six.

Findings included:

1.Observation on 6/24/24, during the facility tour showed an interior partition in the training room. Further observation showed the interior partition did not have a tag identify it as fire rated.

2.During an interview on 6/24/24 at 2:50 P.M., the Facility Operations Manager said that he did not know if the interior partition had a fire rating.

3.See NFPA 101, 2012 edition, section 10.2, 19.3.3.1, and 19.3.3.2

Based on observation, interview and national standards, 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 six.

Findings included:

1. Observation on 6/25/24, during the facility tour, showed the following areas did not have smoke detector coverage:
- 2nd Floor Medication Room
- 2nd Floor Dictation Room
- 2nd Floor Coffee room

2.During an interview on 6/25/24 the Facility Operations Manager confirmed the observations.

3.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 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, interview and national standards, the facility failed to ensure the building sprinkler system met NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. This deficient practice could delay prompt fire extinguishment and evacuation in the event of a fire. The facility census was six.

Findings included:

1. Observations on 6/24/24, during the facility tour, showed elevators 1 & 2, did not have sprinklers installed in the pit. Observation showed the elevators used combustible hydraulic fluid.

2.During an interview on 6/24/24 at 10:45 A.M., the Facility Operations Manager said the elevator pits did not have sprinkler coverage.

3. NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS, 2010 Edition section 8.15.5 states:

"8.15.5 Elevator Hoistways and Machine Rooms.

8.15.5.1* Sidewall spray sprinklers shall be installed at the bottom
of each elevator hoistway not more than 2 ft (0.61 m)
above the floor of the pit.

8.15.5.2 The sprinkler required at the bottom of the elevator
hoistway by 8.15.5.1 shall not be required for enclosed, noncombustible
elevator shafts that do not contain combustible
hydraulic fluids.

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

Findings included:

1.Record review on 6/25/24 showed the following inspections:
- One quarterly waterflow alarm test in the last 12 months dated 6/13/23.
- The last five year internal pipe inspection dated 5/19.

2.During an interview on 6/25/24 at 2:13 P.M., the Facility Operations Manager said that the last quarterly waterflow alarm test was conducted on 6/13/23. The Facility Operations Manager said that he did not have any other waterflow alarm tests.

3.During an interview on 6/24/24 the Facility Operations Manager said that the last five year internal pipe inspection was in May of 2019. The Facility Operations Manager said that a five year internal pipe inspection is not scheduled.

4.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 interview, the facility failed to ensure corridor doors were positive latching. This deficient practice had the potential to affect all patients, staff and visitors. Failure to ensure corridor doors positive latch had the potential to prevent or delay evacuation out of the building in the event of a fire or other emergency by allowing smoke, fumes and the products of fire from entering the exit corridors in the event of a fire. The facility census was six.

Findings included:

1.Observation on 6/24/24, during the building tour, showed the double doors to the training room did not latch.

2.During an interview on 6/24/24 at 2:46 P.M., the Director of Plant Operations confirmed the observation

Based on observation and interview, the facility failed to ensure a hazardous waste room was adequately vented and kept under a relative negative pressure. This deficient practice has the potential to effect all residents, staff and visitors. Failure to provide adequate ventilation could increase the concentration of smoke, products of combustion and noxious fumes. The facility census was six.

Findings included:

1.Observation on 6/25/24, during the facility tour, showed the hazardous area room did not have functioning exhaust ventilation.

2.During an interview on 6/25/24 at 9:50 A.M., the Facility Operations Manager said that the hazardous waste room did not have ventilation.

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

Findings included:

1. Observations on 6/24/24 and 6/25/24, during the Life Safety Code tour, showed window blinds and curtains throughout the facility that did not have identification that showed them as being flame retardant.

2.During an interview on 6/24/24 at 2:50 P.M., the Facility Operations Manager said he did not know if the window covering had a rating.

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

Based on observation, interview and national standards, the facility failed to ensure space heaters met the requirements of NFPA 101, 2012 edition. The facility census was six.

Findings included:

1.Observations on 6/24/24 and 6/25/24, during the facility tour, showed the following areas contained space heaters built into the wall:
- IT storage room
- Patient Access stairwell exit
- Elevator room (basement)

2.During an interview on 6/24/24 at 3:30 P.M., the Facility Operations Manager the space heaters have been in the walls since the building was constructed.

3.19.7.8 Portable Space-Heating Devices. Portable spaceheating
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

Based on observation, interview and national standards, the facility failed to provide a constantly attended remote annunciator panel (a panel providing information on the condition and problems with the emergency generator) for two of two emergency generators. The census was six.

Findings included:

1. Observation on 6/24/24, during the facility tour, did not show a remote annunciator panel for the emergency generator in a constantly attended location.

2.During an interview on 6/24/24 at 4:00 P.M., the Facility Operations Manager said the remote annunciator panel is located in the basement area of the facility and not constantly attended.

3.NFPA 99, 2012 edition, section 6.4.1.1.17 states:

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

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

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

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

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

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

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


Table 6.4.1.1.16.2 Safety Indications and Shutdowns
Level 1
Indicator Function (at Battery Voltage) CV S RA
(a) Overcrank
(b) Low water temperature
(c) High engine temperature pre-alarm
(d) High engine temperature
(e) Low lube oil pressure pre-alarm
(f) Low lube oil pressure
(g) Overspeed
(h) Low fuel main tank
(i) Low coolant level
(j) EPS supplying load

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

Based on observation, interview and national standards, the facility failed to provide an emergency stop switch away from the generator set location. This facility had a census of six.

Findings Included:

1. Observation 6/24/24, during the facility tour, showed the twos emergency generator's emergency stop switches located on the generator.

2. During an interview on 6/24/24 at 4:02 P.M.,, the Facility Operations Manager confirmed the observation. The Facility Operations Manager said there are no emergency stop switches located away rom the generator set.


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

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

5.6.5.6.1 The remote manual stop station shall be labeled.

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

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

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

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

8.3 Maintenance and Operational Testing.

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

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

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

8.3.3 A written schedule for routine maintenance and operational
testing of the EPSS shall be established.

8.3.4 A permanent record of the EPSS inspections, tests, exercising,
operation, and repairs shall be maintained and readily
available.

8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective
action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the
manufacturer

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

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

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

8.3.7.1 Maintenance of lead-acid batteries shall include the
monthly testing and recording of electrolyte specific gravity. Battery
conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.

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

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

8.4 Operational Inspection and Testing.

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

8.4.6 Transfer switches shall be operated monthly.

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

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

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

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