HospitalInspections.org

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The facility failed to maintain the interior finish per code. Findings include:

During the survey, the following is an example of what was observed:
Procedure Clean up Room/Proposed Scope Room - had wood paneling on the upper part of the walls in this room.
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2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
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The facility failed to maintain the corridor doors per code. Findings include:

During the survey, the following are examples of what was observed:
1. The following room corridor doors were observed with three unsealed holes:
a. 124
b. 101
2. Corridor door for room 116 was not positive latching
3. The Procedure Suite/Old OR Suite cross corridor doors did not have positive latching hardware
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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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The facility failed to maintain the smoke barrier per code. Findings include:

During the survey, the following are examples of what was observed:
The smoke barrier in the bathroom in the Nurse Manager's Office/Proposed Pixis Room was observed with the following:
1. Unsealed penetration of a sprinkler pipe
2. Unsealed conduit end

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2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partition b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
1. Central Supply/Receiving Room - over 50 sq. ft. with combustibles, the door had a self-closing device, but was being held open
2. Clean Linen Room - over 50 sq. ft. with combustibles, the corridor door was not positive latching
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2000 NFPA 101, 19.3.2.1 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 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following is an example of what was observed:
The Cooler/Freezer had a hasp lock, which would prevent exiting from this space.
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2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
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The facility failed to maintain the two hour fire barrier per code. Findings include:

During the survey, the following is an example of what was observed:
The two hour fire barrier for the E.R. Addition at Radiologist Reading Room had nonrated foam sealing a penetration of a sprinkler pipe and grey wires.

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2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
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The facility failed to maintain the phone lines for the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:
After testing the fire alarm system, the monitoring company was called - the phone line troubles were not received at the monitoring company

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2000 NFPA 101, 9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
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The facility failed to maintain the smoke detectors per code. Findings include:

During the survey, the following is an example of what was observed:
Per sensitivity documentation dated 05/03/2012 provided by the facility, contained the following: "Smoke detector in emergency rm area device #41 out of sensitivity range, needs replaced."
Per maintenance staff this had not been corrected at the time of the survey.

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2000 NFPA 101, 9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
1999 NFPA 72, 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods: (1) Calibrated test method (2) Manufacturer ' s calibrated sensitivity test instrument (3) Listed control equipment arranged for the purpose (4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range (5) Other calibrated sensitivity test methods approved by the authority having jurisdiction Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
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The facility failed to maintain the combustible overhang per code. Findings include:

During the survey, the following is an example of what was observed:
East Exit - had an eight ft. wide combustible canopy that was not sprinklered protected
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1999 NFPA 13, 5-13.8.1 Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following are examples of what was observed:
The following fire extinguishers were observed mounted over five feet above the finished floor:
1. In Outside Boiler Room
2. In Outside Emergency Generator Room
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1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of monthly inspections of the kitchen hood

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1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
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The facility failed to maintain the location of transferring of oxygen per code. Findings include:

During the survey, the following are examples of what was observed:
1. The facility failed to provide "OXYGEN - NO SMOKING - NO OPEN FLAME" signs for the location where oxygen is transferred
2. The liquid oxygen container was observed not completely on a firm foundation - part on a concrete pad and part on steel sheets (just laying on the ground) not meeting the 3'-0" in diameter distance per 2001 NFPA 50, 2.1.4
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2001 NFPA 50, 3.5.8 The bulk oxygen storage location shall be permanently placarded to indicate " OXYGEN - NO SMOKING - NO OPEN FLAMES. "
1999 NFPA 99, 8-6.2.5.2 Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and (b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and (c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.
Transferring shall be accomplished utilizing equipment designed to comply with the performance requirements and producers of CGA Pamphlet P-2.6, Transfilling of Low-Pressure Liquid Oxygen to be Used for Respiration, and adhering to those procedures.
The use and operation of small portable liquid oxygen systems shall comply with the requirements of CGA Pamphlet P-2.7, Guide for the Safe Storage, Handling and Use of Portable Liquid Oxygen Systems in Health Care Facilities.
CGA Pamphlet P-2.6, Transfilling of Low-Pressure Liquid Oxygen, 5.3.3 The tank pad and spill pad for liquid transfer including expansion joints in concrete pads shall be constructed of noncombustible material and kept free of oil, grease, or other combustible material.
2001 NFPA 50, 3.1.1 Permanently installed containers shall be provided with substantial supports of noncombustible material on firm foundations of noncombustible material.
2001 NFPA 50, 2.1.4 Where oxygen is stored as a liquid, surfacing of noncombustible material shall be provided at ground level under liquid delivery connections for the storage container and mobile supply equipment. This area of noncombustible surfacing shall be at least 3 ft (1 m) in diameter from points at ground level where leakage of liquid oxygen might fall during unloading and normal operation of the system. The area under the mobile supply equipment shall be at least the full width of the vehicle and at least 8 ft (2.5 m) in the direction of the vehicle axis. For purposes of this standard, asphaltic or bitumastic paving is considered to be combustible. The slope, if any, of such areas shall take into consideration the possible flow of spilled liquid oxygen to adjacent combustible material. If expansion joints are used, fillers shall also be of noncombustible materials.
2001 NFPA 50, 2.1.1 Bulk oxygen storage systems shall be located aboveground out of doors or shall be installed in a building of fire-resistive or noncombustible/limited-combustible construction, adequately vented, and used for that purpose exclusively. The location selected shall be such that containers and associated equipment shall not be beneath or exposed by the failure of electric power lines, piping containing all classes of flammable or combustible liquids (see 1.3.4 and 1.3.7), or piping containing flammable gases.
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The facility failed to maintain the emergency battery lighting for the emergency generator per code. Findings include:

During the survey, the emergency battery light in the Emergency Generator Room, when tested did not illuminate
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1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

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The facility failed to maintain the interior finish per code. Findings include:

During the survey, the following is an example of what was observed:
Procedure Clean up Room/Proposed Scope Room - had wood paneling on the upper part of the walls in this room.
_________________

2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
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The facility failed to maintain the corridor doors per code. Findings include:

During the survey, the following are examples of what was observed:
1. The following room corridor doors were observed with three unsealed holes:
a. 124
b. 101
2. Corridor door for room 116 was not positive latching
3. The Procedure Suite/Old OR Suite cross corridor doors did not have positive latching hardware
____________________

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 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. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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The facility failed to maintain the smoke barrier per code. Findings include:

During the survey, the following are examples of what was observed:
The smoke barrier in the bathroom in the Nurse Manager's Office/Proposed Pixis Room was observed with the following:
1. Unsealed penetration of a sprinkler pipe
2. Unsealed conduit end

__________________

2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows: (1) The space between the penetrating item and the smoke partition shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of limiting the transfer of smoke. b. It shall be protected by an approved device that is designed for the specific purpose. (3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions: a. It shall be made on either side of the smoke partition b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
1. Central Supply/Receiving Room - over 50 sq. ft. with combustibles, the door had a self-closing device, but was being held open
2. Clean Linen Room - over 50 sq. ft. with combustibles, the corridor door was not positive latching
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2000 NFPA 101, 19.3.2.1 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 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following is an example of what was observed:
The Cooler/Freezer had a hasp lock, which would prevent exiting from this space.
________________

2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
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The facility failed to maintain the two hour fire barrier per code. Findings include:

During the survey, the following is an example of what was observed:
The two hour fire barrier for the E.R. Addition at Radiologist Reading Room had nonrated foam sealing a penetration of a sprinkler pipe and grey wires.

___________________

2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows: (1) The space between the penetrating item and the fire barrier shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose. (2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions: a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier. b. It shall be protected by an approved device that is designed for the specific purpose.
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The facility failed to maintain the phone lines for the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:
After testing the fire alarm system, the monitoring company was called - the phone line troubles were not received at the monitoring company

___________________

2000 NFPA 101, 9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
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The facility failed to maintain the smoke detectors per code. Findings include:

During the survey, the following is an example of what was observed:
Per sensitivity documentation dated 05/03/2012 provided by the facility, contained the following: "Smoke detector in emergency rm area device #41 out of sensitivity range, needs replaced."
Per maintenance staff this had not been corrected at the time of the survey.

______________

2000 NFPA 101, 9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
1999 NFPA 72, 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods: (1) Calibrated test method (2) Manufacturer ' s calibrated sensitivity test instrument (3) Listed control equipment arranged for the purpose (4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range (5) Other calibrated sensitivity test methods approved by the authority having jurisdiction Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
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The facility failed to maintain the combustible overhang per code. Findings include:

During the survey, the following is an example of what was observed:
East Exit - had an eight ft. wide combustible canopy that was not sprinklered protected
_______________

1999 NFPA 13, 5-13.8.1 Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following are examples of what was observed:
The following fire extinguishers were observed mounted over five feet above the finished floor:
1. In Outside Boiler Room
2. In Outside Emergency Generator Room
_______________

1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
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The facility failed to maintain the cooking facilities per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of monthly inspections of the kitchen hood

________________

1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b) The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
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The facility failed to maintain the location of transferring of oxygen per code. Findings include:

During the survey, the following are examples of what was observed:
1. The facility failed to provide "OXYGEN - NO SMOKING - NO OPEN FLAME" signs for the location where oxygen is transferred
2. The liquid oxygen container was observed not completely on a firm foundation - part on a concrete pad and part on steel sheets (just laying on the ground) not meeting the 3'-0" in diameter distance per 2001 NFPA 50, 2.1.4
__________________

2001 NFPA 50, 3.5.8 The bulk oxygen storage location shall be permanently placarded to indicate " OXYGEN - NO SMOKING - NO OPEN FLAMES. "
1999 NFPA 99, 8-6.2.5.2 Transferring of liquid oxygen from one container to another shall be accomplished at a location specifically designated for the transferring that is as follows:
(a) Separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and (b) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring; and (c) The area is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted.
Transferring shall be accomplished utilizing equipment designed to comply with the performance requirements and producers of CGA Pamphlet P-2.6, Transfilling of Low-Pressure Liquid Oxygen to be Used for Respiration, and adhering to those procedures.
The use and operation of small portable liquid oxygen systems shall comply with the requirements of CGA Pamphlet P-2.7, Guide for the Safe Storage, Handling and Use of Portable Liquid Oxygen Systems in Health Care Facilities.
CGA Pamphlet P-2.6, Transfilling of Low-Pressure Liquid Oxygen, 5.3.3 The tank pad and spill pad for liquid transfer including expansion joints in concrete pads shall be constructed of noncombustible material and kept free of oil, grease, or other combustible material.
2001 NFPA 50, 3.1.1 Permanently installed containers shall be provided with substantial supports of noncombustible material on firm foundations of noncombustible material.
2001 NFPA 50, 2.1.4 Where oxygen is stored as a liquid, surfacing of noncombustible material shall be provided at ground level under liquid delivery connections for the storage container and mobile supply equipment. This area of noncombustible surfacing shall be at least 3 ft (1 m) in diameter from points at ground level where leakage of liquid oxygen might fall during unloading and normal operation of the system. The area under the mobile supply equipment shall be at least the full width of the vehicle and at least 8 ft (2.5 m) in the direction of the vehicle axis. For purposes of this standard, asphaltic or bitumastic paving is considered to be combustible. The slope, if any, of such areas shall take into consideration the possible flow of spilled liquid oxygen to adjacent combustible material. If expansion joints are used, fillers shall also be of noncombustible materials.
2001 NFPA 50, 2.1.1 Bulk oxygen storage systems shall be located aboveground out of doors or shall be installed in a building of fire-resistive or noncombustible/limited-combustible construction, adequately vented, and used for that purpose exclusively. The location selected shall be such that containers and associated equipment shall not be beneath or exposed by the failure of electric power lines, piping containing all classes of flammable or combustible liquids (see 1.3.4 and 1.3.7), or piping containing flammable gases.
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The facility failed to maintain the emergency battery lighting for the emergency generator per code. Findings include:

During the survey, the emergency battery light in the Emergency Generator Room, when tested did not illuminate
________________
1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.