HospitalInspections.org

Based on observation and interview, it was determined the facility failed to ensure corridors are separated from use areas in accordance with the National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and the census was eight (8) on the day of the survey.

The findings include:

Observation, on 03/03/15 at 3:10 PM, with the Plant Operations Manager revealed a roll down type service door located in the corridor wall separating the Specialty Center Registration Office from the egress path. The roll down type door was not self-closing or connected to the fire alarm to close in the event of an emergency.

Interview, on 03/03/15 at 3:11 PM, with the Plant Operations Manager revealed he was not aware of the requirements for corridor walls protecting the egress path.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Reference: NFPA 101 (2000 edition)

19.3.6.3 Corridor Doors.
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.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.
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.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.
19.3.6.3.3*
Hold-open devices that release when the door is pushed or pulled shall be permitted.
19.3.6.3.4
Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.
Reference: NFPA 80, Standard for Fire Doors and Windows (1999 Edition)
Chapter 10 Fire Shutters
10-1 Shutters.
10-1.1 Construction.
Fire doors without glass lights shall be used as fire shutters.
10-1.2 Types.
Shutters shall be of the following three general types:
(a) Swinging door
(b) Horizontally or vertically sliding door
(c) Rolling steel door
10-2 Installation.
The installation of shutters shall be in accordance with the requirements for installation of swinging, sliding, and rolling steel doors.
10-3 Operation.
10-3.1 Automatic Closing.
All shutters shall be equipped to close automatically in the event of fire.
10-3.2* Weather Protection.
Where shutters are installed on the outside of an opening, they shall be protected against the weather to ensure proper operation.
10-3.3 Other Requirements.
The operation of shutters shall be in accordance with the requirements for operation of swinging, sliding, and rolling steel doors.
Chapter 11 Access Doors
11-1 Doors.
11-1.1 General.
This chapter shall cover the installation of both horizontal and vertical access doors in fire-rated walls, floors, and floor-ceiling or roof-ceiling assemblies.
11-1.2 Components.
An access door shall be an integral unit including the door, frame, hinges, latch, and closing device (where required) bearing a label that reads " Frame and Fire Door Assembly. "
Exception: A vertical access door shall be permitted to have hinges that are not part of the labeled assembly, provided the hinges conform to Table 2-4.3.1.
11-1.2.1
Access doors shall be self-closing.
11-1.2.2
Access doors shall be self-latching.
Exception: A horizontal access door that does not open downward and that remains in place when an upward force of 1 psf (48 N/m2) is applied over the entire exposed surface of the door shall not be required to be self-latching.
11-1.2.3
Self-closing access doors that are intended to be used to allow a person to enter the concealed space behind the door completely shall be operable from the inside without the use of a key or tool.
11-1.2.4
Access doors shall be installed in accordance with their listing.
11-2 Types of Doors.
11-2.1 Horizontal Access Doors.
11-2.1.1
Door assemblies used in fire-rated floors or floor-ceiling or roof-ceiling assemblies shall be tested in the horizontal position in accordance with the procedures described in NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials, and shall be labeled as horizontal access doors.
11-2.1.2
A horizontal access door shall bear a label that includes the additional wording " For Horizontal Installation. "
11-2.1.3
A horizontal access door shall be used in a fire-rated floor or floor-ceiling or roof-ceiling assembly only where it has been tested and listed for use as a component of the assembly.
11-2.1.4
Horizontal access doors shall not be required to be subject to the hose stream test.
11-2.2 Vertical Access Doors.
11-2.2.1
Vertical access doors shall have a fire protection rating of 3/4 hour, 1 hour, or 11/2 hours. (See Appendix F.)
11-2.2.2
Vertical access doors shall be used only in walls.
11-2.2.3
Where the authority having jurisdiction determines that a vertical access door is located in proximity to combustibles so that, in a fire condition, the door is likely to transmit sufficient heat to ignite the combustibles, the temperature rise on the unexposed face of the door shall not exceed 250°F (139°C) at the end of a 30-minute exposure to the standard fire test as described in NFPA 252, Standard Methods of Fire Tests of Door Assemblies. Such an access door shall bear a label indicating a maximum temperature rise of 250°F (139°C).
11-2.2.4
Closing by means of gravity using top-hinging vertical access doors shall be permitted to meet the requirements for self-closing doors.
11-2.2.5
A vertical access door shall bear a label that includes the additional wording " For Vertical Installation. "
Chapter 12 Service Counter Doors

Based on observation and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect five (5) of five (5) smoke compartments, twenty-five (25) patients, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1) Observation, on 03/03/15 at 9:45 AM, with the Plant Operations Manager revealed unsealed penetrations around pipes in the smoke barrier extending above the ceiling located at the cross corridor doors in the Cafeteria Hall.

Interview, on 03/03/15 at 9:46 AM, with the Plant Operations Manager revealed he was not aware the unsealed penetrations around the pipes.

2) Observation, on 03/03/15 at 9:50 AM, with the Plant Operations Manager revealed a penetration of missing concrete blocks around duct work in the smoke barrier extending above the ceiling located above the Health Information Management Office.

Interview, on 03/03/15 at 9:51 AM, with the Plant Operations Manager revealed he was not aware of the missing concrete blocks around the duct work.

3) Observation, on 03/03/15 at 10:05 AM, with the Plant Operations Manager revealed the use of unrated expandable foam to seal penetrations in the smoke barrier extending above the ceiling located at the cross corridor doors in the Administrative Hall by the Gift Shop.

Interview, on 03/03/15 at 10:06 AM, with the Plant Operations Manager revealed he was not aware of the unrated expandable foam being used to seal penetrations.

4) Observation, on 03/03/15 at 10:20 AM, with the Plant Operations Manager revealed the use of drywall joint compound being used to seal the concrete block wall to the roof deck above in the smoke barrier extending above the ceiling located in Eye Room #3.

Interview, on 03/03/15 at 10:21 AM, with the Plant Operations Manager revealed he was not aware of the joint compound being used on the concrete block wall to seal penetrations.

5) Observation, on 03/03/15 at 10:28 AM, with the Plant Operations Manager revealed the use of unrated expandable foam to seal penetrations in the smoke barrier extending above the ceiling located at the cross corridor doors in Hall 2 Medical Surgery.

Interview, on 03/03/15 at 10:29 AM, with the Plant Operations Manager revealed he was not aware of the use of expandable foam to seal penetrations.

6) Observation, on 03/03/15 at 10:30 AM, with the Plant Operations Manager revealed unsealed penetrations in the smoke barrier extending above the ceiling located in the Chief Financial Officers Office.

Interview, on 03/03/15 at 10:31 AM, with the Plant Operations Manager revealed he was not aware the unsealed penetrations.

7) Observation, on 03/03/15 at 10:55 AM, with the Plant Operations Manager revealed unsealed penetrations inside pipe sleeves in the smoke barrier extending above the ceiling located in the Emergency Room Hall.

Interview, on 03/03/15 at 10:56 AM, with the Plant Operations Manager revealed he was not aware of the unsealed pipe sleeves.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition).19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: 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 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.
Reference: NFPA 101 (2000 Edition)19.3.7.5
Openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than 20 minutes. Nonrated factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted.
Exception: Doors shall be permitted to have fixed fire window assemblies in accordance with 8.2.3.2.2.
Reference: NFPA 101 (2000 Edition) 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure the doors in smoke barriers were maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect three (3) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1) Observation, on 03/03/15 at 9:50 AM, with the Plant Operations Manager revealed the smoke barrier door located inside the Health Information Management Office did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 9:51 AM, with the Plant Operations Manager revealed he was not aware the door was part of the smoke barrier.

2) Observation, on 03/03/15 at 10:10 AM, with the Plant Operations Manager revealed the smoke barrier door located between the Laboratory and the Laboratory Break Room had been removed.

Interview, on 03/03/15 at 10:11 AM, with the Plant Operations Manager revealed he was not aware the door was part of the smoke barrier.

3) Observation, on 03/03/15 at 10:12 AM, with the Plant Operations Manager revealed the smoke barrier door located on the Laboratory Storage Room did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 10:13 AM, with the Plant Operations Manager revealed he was not aware the door was part of the smoke barrier.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition) 19.3.7.5
Openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than 20 minutes. Nonrated factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted.
Exception: Doors shall be permitted to have fixed fire window assemblies in accordance with 8.2.3.2.2.
19.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.
19.3.7.7
Door openings in smoke barriers shall be protected by a swinging door providing a clear width of not less than 32 in. (81 cm) or by a horizontal sliding door complying with 7.2.1.14 and providing a clear width of not less than 32 in. (81 cm).
Exception: Existing 34-in. (86-cm) doors.

8.3.4 Doors.
8.3.4.1*
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.
8.3.4.2*
Where a fire resistance rating for smoke barriers is specified elsewhere in the Code, openings shall be protected as follows:
(1) Door opening protectives shall have a fire protection rating of not less than 20 minutes where tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test, unless otherwise specified by Chapters 12 through 42.
(2) Fire windows shall comply with 8.2.3.2.2.
Exception: Latching hardware shall not be required on doors in smoke barriers where so indicated by Chapters 12 through 42.
8.3.4.3*
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Based on observation and interview, it was determined the facility failed to meet the requirements for Protection of Hazards, in accordance with the National Fire Protection Agency (NFPA) standards. The deficiency had the potential to affect five (5) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1. Observation, on 03/03/15 at 1:42 PM, with the Plant Operations Manager revealed the Medical Records Overflow Storage Room had hazardous amounts of combustible paper and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 1:43 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

2. Observation, on 03/03/15 at 1:50 PM, with the Plant Operations Manager revealed the Medical Records Storage Room door to the corridor was equipped with a self-closing device; however, a chain and hook held the door open preventing the door from self-closing.

Interview, on 03/03/15 at 1:51 PM, with the Plant Operations Manager revealed he was not aware the door was being held open with an unapproved hold open device.

3. Observation, on 03/03/15 at 2:08 PM, with the Plant Operations Manager revealed the Medical Records Overflow Storage Room had hazardous amounts of combustible paper and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 2:09 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

4. Observation, on 03/03/15 at 2:10 PM, with the Plant Operations Manager revealed the Kitchen Dry Storage Room had hazardous amounts of combustible boxes and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 2:11 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

5. Observation, on 03/03/15 at 2:14 PM, with the Plant Operations Manager revealed the Kitchen Garbage Room had hazardous amounts of combustible trash and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 2:15 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

6. Observation, on 03/03/15 at 2:39 PM, with the Plant Operations Manager revealed the Surgery Storage Room had hazardous amounts of combustible paper and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 2:40 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

7. Observation, on 03/03/15 at 3:25 PM, with the Plant Operations Manager revealed the Cashiers Office and the Senior Accountant Office had hazardous amounts of combustible paper and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 3:26 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

8. Observation, on 03/04/15 at 9:45 AM, with the Plant Operations Manager revealed hazardous amounts of combustible paper medical records being stored in the Carrollton Internal Medicine Referrals Office. The room did not have a one (1) hour rating or have a self-closing device installed on the door.

Interview, on 03/04/15 at 9:46 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

9. Observation, on 03/04/15 at 10:16 AM, with the Plant Operations Manager revealed hazardous amounts of combustible paper/medical records were being stored in the Carrollton Internal Medicine Nurses Office and did not have a self-closing device installed on the door.

Interview, on 03/04/15 at 10:17 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

10. Observation, on 03/04/15 at 10:18 AM, with the Plant Operations Manager revealed the Carrollton Internal Medicine Chart Room had hazardous amounts of combustible paper and the self-closing device had been removed from the door.

Interview, on 03/04/15 at 10:19 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

11. Observation, on 03/04/15 at 10:22 AM, with the Plant Operations Manager revealed hazardous amounts of combustible paper/medical records being stored in the Physician's Office and did not have a self-closing device installed on the door.

Interview, on 03/04/15 at 10:23 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

12. Observation, on 03/04/15 at 10:35 AM, with the Plant Operations Manager revealed the Occupational Medicine Office had hazardous amounts of combustible paper/medical records stored in the room and did not have a self-closing device installed on the door.

Interview, on 03/04/15 at 10:36 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

13. Observation, on 03/04/15 at 10:40 AM, with the Plant Operations Manager revealed hazardous amounts of combustible paper/medical records were stored in the Central Scheduling Room and did not have a self-closing device installed on the door.

Interview, on 03/04/15 at 10:41 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition) 19.3.2 Protection from Hazards.

Reference: NFPA 101 (2000 Edition) 19.3.2.1 Hazardous Areas. 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. 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) Soiled linen rooms
(6) Trash collection rooms
(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.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Reference: NFPA 101 (2000 Edition) 7.2.1.8 Self-Closing Devices.

Reference: NFPA 101 (2000 Edition) 7.2.1.8.1* A door 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.

Reference: NFPA 101 (2000 Edition) 7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Based on observation and interview, it was determined the facility failed to ensure egress lighting was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect three (3) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1. Observation, on 03/03/15 at 2:00 PM, with the Plant Operations Manager revealed the facility failed to provide egress lighting outside of the Cafeteria Exit.

Interview, on 03/03/15 at 2:01 PM, with the Plant Operations Manager revealed he was not aware the exit discharge did not have proper egress lighting.

2. Observation, on 03/03/15 at 2:42 PM, with the Plant Operations Manager revealed a single lighting unit located outside the Kitchen Exit.

Interview, on 03/03/15 at 2:43 PM, with the Plant Operations Manager revealed he was not aware the exit discharge did not have proper egress lighting.

3. Observation, on 03/04/15 at 10:42 AM, with the Plant Operations Manager revealed the facility failed to provide egress lighting outside of the Cardiac Services Entrance.

Interview, on 03/04/15 at 10:43 AM, with the Plant Operations Manager revealed he was not aware the exit discharge did not have proper egress lighting.

4. Observation, on 03/04/15 at 11:00 AM, with the Plant Operations Manager revealed a single lighting unit located outside both exits in the Medical Surgery South Hall.

Interview, on 03/04/15 at 11:01 AM, with the Plant Operations Manager revealed he was not aware the exit discharge did not have proper egress lighting.

5. Observation, on 03/04/15 at 11:17 AM, with the Plant Operations Manager revealed a single lighting unit located outside the Basement Exit.

Interview, on 03/04/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the exit discharge did not have proper egress lighting.

The census of eight (8) was verified by the Administrator on 03/04/15. The survey findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition) 7.8 ILLUMINATION OF MEANS OF EGRESS
7.8.1 General.
7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3*
The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.
7.8.1.4*
Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.
7.8.1.5
The equipment or units installed to meet the requirements of Section 7.10 also shall be permitted to serve the function of illumination of means of egress, provided that all requirements of Section 7.8 for such illumination are met.
7.8.2 Sources of Illumination.
7.8.2.1*
Illumination of means of egress shall be from a source considered reliable by the authority having jurisdiction.
7.8.2.2
Battery-operated electric lights and other types of portable lamps or lanterns shall not be used for primary illumination of means of egress. Battery-operated electric lights shall be permitted to be used as an emergency source to the extent permitted under Section 7.9.

Based on observation and interview, it was determined the facility failed to maintain emergency lighting in accordance with the National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect five (5) of five (5) smoke compartments, twenty-five (25) residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and the census was eight (8) on the day of the survey.

The findings include:

Observation, on 03/03/15 at 10:55 AM, with the Plant Operations Manager revealed the facility failed to document the monthly thirty (30) second test and the annual ninety (90) minute test for battery powered emergency lighting.

Interview, on 03/03/15 at 10:56 AM, with the Plant Operations Manager revealed he was not aware documentation was to be provided for the thirty (30) second monthly and ninety (90) minute test for battery powered emergency lighting.

The census of eight (8) was verified by the Administrator on 03/04/15. The survey findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Reference: NFPA 101 (2000 edition)

7.9.2.1* Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6
lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than
11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at random times, in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect five (5) of five (5) smoke compartments, all residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

Review of the facility's Fire Drill documentation, on 03/03/15 at 11:45 AM, with the Plant Operations Manager revealed the facility failed to conduct fire drills at unexpected times on second (2nd) shift. Six (6) out of the last eight (8) fire drills conducted on second (2nd) shift within the last four (4) quarters were conducted in the hour of 4:00 PM. Further review revealed the facility did not conduct a fire drill on first (1st) shift, in the second (2nd) quarter of 2014. Further review revealed the facility did not conduct a fire drill on third (3rd) shift, in the fourth (4th) quarter of 2014.

Interview, on 03/03/15 at 11:46 AM, with the Plant Operations Manager revealed he was unaware the fire drills were not being conducted as required.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 edition) 19.7.1.2. Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Based on observation, interview, Fire Alarm Testing, and Fire Alarm Inspection review, it was determined the facility failed to ensure the fire alarm system was inspected and tested in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice has the potential to affect five (5) of five (5) smoke compartments, twenty-five residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

Review of the fire alarm inspection, on 03/03/15 at 11:30 AM, with the Plant Operations Manager revealed the charger test was not documented on the fire alarm inspection paperwork.

Interview, on 03/03/15 at 11:31 AM, with the Plant Operations Manager revealed he was unaware the inspection company was to perform a charger test for the fire alarm batteries on an annual basis.

Review of the fire alarm inspection, on 03/03/15 at 11:30 AM, with the Plant Operations Manager revealed the discharge test was not documented on the fire alarm inspection paperwork.

Interview, on 03/03/15 at 11:31 AM, with the Plant Operations Manager revealed he was unaware the inspection company was to perform a discharge test for the fire alarm batteries on an annual basis.

Review of the fire alarm inspection, on 03/03/15 at 11:30 AM, with the Plant Operations Manager revealed the load voltage test was not documented on the fire alarm inspection paperwork.

Interview, on 03/03/15 at 11:31 AM, with the Plant Operations Manager revealed he was unaware the inspection company was to perform a load voltage test for the fire alarm batteries on a semi-annual basis.

Observation, on 03/04/15 at 10:52 AM, with the Plant Operations Manager revealed the Fire Alarm Control Panel (FACP) indicated active trouble.

Interview, on 03/04/15 at 10:53 AM, with the Plant Operations Manager revealed he was not aware the FACP was in trouble mode. The Plant Operations Manager called the FACP monitoring company and was informed the FACP had been in trouble since 02/14/15 at 4:07 PM.

A Fire Alarm Test, on 03/04/15 at 11:50 AM, with the Plant Operations Manager revealed the FACP worked properly, performing all functions as designed.

Interview, on 03/04/15 at 1:12 PM, with the Plant Operations Manager revealed the cause of the trouble mode was a failure in the secondary phone line. The problem with the FACP had been corrected and no longer in trouble mode.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 ed.), 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.

Based on observation, interview, and sprinkler testing review, it was determined the facility failed to maintain the sprinkler system in accordance with National Fire Protection (NFPA) standards. The deficient practice has the potential to affect five (5) of five (5) smoke compartments, all residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1. Review of the Sprinkler testing records, on 03/03/15 at 11:17 AM, with the Plant Operations Manager revealed the facility could not provide documentation that the gauges on the sprinkler system had been calibrated or replaced within the last five (5) years.

Interview, on 03/03/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the sprinkler system testing was not up to date.

2. Review of the Sprinkler testing records, on 03/03/15 at 11:17 AM, with the Plant Operations Manager revealed the facility could not provide documentation that the interior pipe inspection had been performed within the last five (5) years.

Interview, on 03/03/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the sprinkler system testing was not up to date.

3. Review of the Sprinkler testing records, on 03/03/15 at 11:17 AM, with the Plant Operations Manager revealed the facility could not provide documentation that the check valves had been inspected within the last five (5) years.

Interview, on 03/03/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the sprinkler system testing was not up to date.

4. Review of the Sprinkler testing records, on 03/03/15 at 11:17 AM, with the Plant Operations Manager revealed the facility could not provide documentation that the interior of the alarm valve had been inspected within the last five (5) years.

Interview, on 03/03/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the sprinkler system testing was not up to date.

5. Review of the Sprinkler testing records, on 03/03/15 at 11:17 AM, with the Plant Operations Manager revealed the facility could not provide documentation that the Fire Department check valves had been inspected within the last five (5) years.

Interview, on 03/03/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the sprinkler system testing was not up to date.

6. Observation, on 03/03/15 at 1:30 PM, with the Plant Operations Manager revealed storage within eighteen (18) inches of a sprinkler head located in the Environmental Services Storage Room.

Interview, on 03/03/15 at 1:31 PM, with the Plant Operations Manager revealed he was not aware the items had been stored within eighteen (18) inches of the sprinkler head.

7. Observation, on 03/03/15 at 1:40 PM, with the Plant Operations Manager revealed data phone lines were strapped to the sprinkler piping located in the Receiving Office.

Interview, on 03/03/15 at 1:41 PM, with the Plant Operations Manager revealed he was not aware the wires could not be strapped to the sprinkler piping.

8. Observation, on 03/03/15 at 1:40 PM, with the Plant Operations Manager revealed the sprinkler heads in the Receiving Office were dust loaded.

Interview, on 03/03/15 at 1:41 PM, with the Plant Operations Manager revealed he was not aware the sprinkler heads were dust loaded.

9. Observation, on 03/04/15 at 10:16 AM, with the Plant Operations Manager revealed the sprinkler heads located in the Carrolton Internal Medicine Reception area were dust loaded.

Interview, on 03/04/15 at 10:17 AM, with the Plant Operations Manager revealed he was not aware the sprinkler heads were dust loaded.

10. Observation, on 03/04/15 at 11:22 AM, with the Plant Operations Manager revealed a sprinkler valve located on the sprinkler riser was not electronically supervised.

Interview, on 03/03/15 at 11:23 AM, with the Plant Operations Manager revealed he was not aware the sprinkler valve had to be electronically supervised.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition) 19.3.5 Extinguishment Requirements.
19.3.5.1
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.
19.3.5.2*
Where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

Reference: NFPA 25 (1998 Edition).
2-1 General. This chapter provides the minimum requirements
for the routine inspection, testing, and maintenance of
sprinkler systems. Table 2-1 shall be used to determine the
minimum required frequencies for inspection, testing, and
maintenance.
Exception: Valves and fire department connections shall be inspected,
tested, and maintained in accordance with Chapter 9.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing
weather)
2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years
thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years
thereafter
2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

Table 9-1 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance
Component Activity Frequency Reference
Control Valves
Sealed Inspection Weekly 9-3.3.1
Locked Inspection Monthly 9-3.3.1 Exception No. 1
Tamper switches Inspection Monthly 9-3.3.1 Exception No. 1
Alarm Valves
Exterior Inspection Monthly 9-4.1.1
Interior Inspection 5 years 9-4.1.2
Strainers, filters, orifices Inspection 5 years 9-4.1.2
Check Valves
Interior Inspection 5 years 9-4.2.1
Preaction/Deluge Valves
Enclosure (during cold weather) Inspection Daily/weekly 9-4.3.1
Exterior Inspection Monthly 9-4.3.1.2
Interior Inspection Annually/5 years 9-4.3.1.3
Strainers, filters, orifices Inspection 5 years 9-4.3.1.4
Dry Pipe Valves/Quick-Opening
Devices
Enclosure (during cold weather) Inspection Daily/weekly 9-4.4.1.1
Exterior Inspection Monthly 9-4.4.1.3
Interior Inspection Annually 9-4.4.1.4
Strainers, filters, orifices Inspection 5 years 9-4.4.1.5
Pressure Reducing and Relief Valves
Sprinkler systems Inspection Quarterly 9-5.1.1
Hose connections Inspection Quarterly 9-5.2.1
Hose racks Inspection Quarterly 9-5.3.1
Fire pumps
Casing relief valves Inspection Weekly 9-5.5.1, 9-5.5.1.1
Pressure relief valves Inspection Weekly 9-5.5.2, 9-5.5.2.1
Backflow Prevention Assemblies
Reduced pressure Inspection Weekly/monthly 9-6.1
Reduced pressure detectors Inspection Weekly/monthly 9-6.1
Fire Department Connections Inspection Quarterly 9-7.1
Main Drains Test Annually 9-2.6, 9-3.4.2
Waterflow Alarms Test Quarterly 9-2.7
Control Valves
Position Test Annually 9-3.4.1
Operation Test Annually 9-3.4.1
Supervisory Test Semiannually 9-3.4.3
Preaction/Deluge Valves
Priming water Test Quarterly 9-4.3.2.1
Low air pressure alarms Test Quarterly 9-4.3.2.10
Full flow Test Annually 9-4.3.2.2
Dry Pipe Valves/Quick-Opening
Devices
Priming water Test Quarterly 9-4.4.2.1
Low air pressure alarm Test Quarterly 9-4.4.2.6
Quick-opening devices Test Quarterly 9-4.4.2.4
Trip test Test Annually 9-4.4.2.2
Full flow trip test Test 3 years 9-4.4.2.2.1
Pressure Reducing and Relief Valves
Sprinkler systems Test 5 years 9-5.1.2
Circulation relief Test Annually 9-5.5.1.2
Pressure relief valves Test Annually 9-5.5.2.2
Hose connections Test 5 years 9-5.2.2
Hose racks Test 5 years 9-5.3.2
Backflow Prevention Assemblies Test Annually 9-6.2
Control Valves Maintenance Annually 9-3.5
Preaction/Deluge Valves Maintenance Annually 9-4.3.3.2
Dry Pipe Valves/Quick-Opening
Devices
Maintenance Annually 9-4.4.3.2

Based on observation and interview, it was determined the facility failed to ensure the manual hood suppression pull was readily available, in accordance with the National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of five (5) smoke compartments, residents, staff, and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

Observation, on 03/03/15 at 2:05 PM, with the Plant Operations Manager revealed the manual pull for the Kitchen Hood Suppression System was not located in the egress path. The manual pull was located beside a door leading to a dining room; however, the exit was located on the other side of the Kitchen.

Interview, on 03/03/15 at 2:06 PM, with the Plant Operations Manager revealed he was not aware of the requirements for the location of the manual hood suppression pull.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

NFPA 96 (1998 edition)7-6.2 Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation shall activate the fire alarm signaling system.

Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on observations and interview, it was determined the facility failed to ensure portable space heaters used in the facility were in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect two (2) of five (5) smoke compartments, residents, staff, and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1. Observation, on 03/03/15 at 1:26 PM, with the Plant Operations Manager revealed a portable space heater located in the Conference Room. The portable heater had a heating element that exceeded 212 degrees.

Interviews, on 03/03/15 at 1:26 PM, with the Plant Operations Manager revealed he was not aware of the portable space heater being in use in the Conference Room.

2. Observation, on 03/04/15 at 10:26 AM, with the Plant Operations Manager revealed a portable space heater located in the Carrollton Internal Medicine Office. The portable heater had a heating element that exceeded 212 degrees.

Interviews, on 03/04/15 at 10:27 AM, with the Plant Operations Manager revealed he was not aware of the portable space heater being in use in the Carrollton Internal Medicine Office.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator verified by the Plant Operations Manager at the exit interview on 03/04/15.

Reference: NFPA 101 (2000 edition)

19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212°F (100°C).

Based on observation and interview, it was determined the facility failed to ensure oxygen storage areas were protected in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

Observation, on 03/04/15 at 10:44 AM, with the Plant Operations Manager revealed the piped in medical gas shut off valve located at the Nurses' Station in the Medical Surgery Hall was obstructed by a Blood/Gas Machine being installed in front of the shut off valve.

Interview, on 03/04/15 at 10:45 AM, with the Plant Operations Manager revealed he was not aware of the requirements for piped in medical gas.

The census of eight (8) was verified by the Administrator, on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Reference: NFPA 101 (2000 edition)

19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Based on interview and fire/smoke damper testing review, it was determined the facility failed to ensure fire/smoke dampers were maintained in accordance with NFPA standards. The deficient practice has the potential to affect five (5) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

Review of the fire/smoke damper testing, on 03/03/15 at 12:04 PM, with the Plant Operations Manager revealed the facility did not have documentation that fire/smoke dampers had been tested within the last four (4) years.

Interview, on 03/03/15 at 12:05 PM, with the Plant Operations Manager revealed he was not aware of the testing requirements for the fire/smoke dampers.

The census of twenty-five (25) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard: Reference: NFPA 90A (1999 edition)

3-4.7 Maintenance. At least every 4 years, fusible links (where
applicable) shall be removed; all dampers shall be operated to
verify that they fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.

Based on an interview and record review, it was determined the facility failed to maintain the generator set by National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect five (5) of five (5) smoke compartments, twenty-five (25) residents, staff and visitors. The facility has the capacity for twenty-five (25) beds with a census of eight (8) on the day of the survey.

The findings include:

Review of the generator documentation, on 03/03/15 at 11:55 AM, with the Plant Operations Manager revealed the facility did not have an annual load bank test performed on the generator. Further record review revealed the facility did not have documentation of the percentage of load the generator was under or the exhaust temperature during monthly tests to determine if an annual load bank test was required.

Interview, on 03/03/15 at 11:56 AM, with the Plant Operations Manager revealed he was not aware of the requirements for generator testing

Review of the generator documentation, on 03/03/15 at 11:55 AM, with the Plant Operations Manager revealed the facility did not have documentation of the transfer time for the monthly transfer of power while testing the generator. Further record review revealed the facility did not have documentation that an annual Preventative Maintenance had been performed on the generator.

Interview, on 03/03/15 at 11:56 AM, with the Plant Operations Manager revealed he was not aware of the requirements for generator testing

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 99 (1999 Edition) 3-4.1.1.15 + Alarm Annunciator. A remote annunciator, 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 NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
a. Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
b. Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

Reference: NFPA 110 (1999 Edition) 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.

Reference: NFPA 99 (1999 Edition) 3-5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-5.3.1.
(b) Inspection and Testing. Generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b).
Actual Standard: NFPA 110, 6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. 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.
Actual Standard: NFPA 99, 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1. Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.
Actual Standard: NFPA 99, 3- 3-4.4.2. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Reference: NFPA 99 (1999 Edition) 6-1.1* The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction

Reference: NFPA 99 (1999 Edition) 6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established

Reference: NFPA 99 (1999 Edition) 6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Reference: NFPA 99 (1999 Edition) 6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. 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.

Reference: NFPA 101 ( 2000 edition) 7.9.1.2 Where maintenance of illumination depends on
changing from one energy source to another, a delay of not
more than 10 seconds shall be permitted.
Reference: NFPA 110 (1999 ed.)
5-7 Heating, Cooling, and Ventilating.
5-7.1* Consideration shall be given to properly sizing the ventilation
or air-conditioning systems to remove all the heat
rejected to the EPS equipment room by the energy converter,
uninsulated or insulated exhaust pipes, and other heat-producing
equipment.
5-7.2 Adequate ventilation shall be provided to prevent temperatures
or temperature rises in the EPS and related accessory
equipment that exceed the recommendations of the
manufacturer.
5-7.3 For the EPS equipment room, the ventilation or cooling
equipment, or both, shall be sized so that the ambient temperature
shall not exceed the EPS equipment manufacturer ' s criteria
or allowable maximum temperatures.

Reference: NFPA 110 (1999 Edition) 5-2.1 The EPS shall be installed in a separate room for Level
1 installations. EPSS equipment shall be permitted to be
installed in this room. The room shall have a minimum 2-hour
fire rating or shall be located in an adequate enclosure located
outside the building capable of resisting the entrance of snow
or rain at a maximum wind velocity required by local building
codes. No other equipment, including architectural appurtenances,
except those that serve this space, shall be permitted
in this room.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect five (5) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1. Observation, on 03/03/15 at 10:18 AM, with the Plant Operations Manager revealed Romex cable was run above the drop ceiling located in Eye Room #3.

Interview, on 03/03/15 at 10:19 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper wiring over suspended ceilings; however, he was not aware of the Romex cable over the ceiling.

2. Observation, on 03/03/15 at 10:30 AM, with the Plant Operations Manager revealed Romex cable was run above the drop ceiling located in the Chief Financial Officer's Office. Further observation above the ceiling in the Chief Financial Officer's Office revealed open electrical junction boxes.

Interview, on 03/03/15 at 10:31 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper wiring over suspended ceilings; however he was not aware of the Romex cable or the open electrical junction boxes over the ceiling.

3. Observation, on 03/03/15 at 1:28 PM, with the Plant Operations Manager revealed a washing machine was plugged into a power strip located in the Environmental Services Storage Room.

Interview, on 03/03/15 at 1:29 PM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the washing machine was plugged into a power strip.

4. Observation, on 03/03/15 at 1:40 PM, with the Plant Operations Manager revealed a heater was plugged into a multi-plug adaptor located in the Receiving Office.

Interview, on 03/03/15 at 1:41 PM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of multi-plug adaptors; however, he was not aware the multi-plug adaptor was in use.

5. Observation, on 03/03/15 at 1:44 PM, with the Plant Operations Manager revealed an electrical panel located in the Medical Records File Room was blocked by a file cabinet.

Interview, on 03/03/15 at 1:45 PM, with the Plant Operations Manager revealed he was not aware the file cabinet was in front of the electrical panel making it not accessible.

6. Observation, on 03/03/15 at 2:31 PM, with the Plant Operations Manager revealed a microwave and a refrigerator were plugged into a power strip located in the X-Ray Computer Room.

Interview, on 03/03/15 at 2:32 PM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware power strip was being misused.

7. Observation, on 03/04/15 at 9:45 AM, with the Plant Operations Manager revealed a refrigerator was plugged into a power strip located in the Testing Room of the Rural Health Clinic.

Interview, on 03/04/15 at 9:46 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the power strip was being misused.

8. Observation, on 03/04/15 at 9:50 AM, with the Plant Operations Manager revealed a coffee maker was plugged into a power strip located in the Break Area of the Rural Health Clinic.

Interview, on 03/04/15 at 9:51 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the power strip was being misused.

9. Observation, on 03/04/15 at 9:58 AM, with the Plant Operations Manager revealed a refrigerator was plugged into a power strip located in the Rural Health Clinic Office.

Interview, on 03/04/15 at 9:59 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the power strip was being misused.

10. Observation, on 03/04/15 at 10:24 AM, with the Plant Operations Manager revealed a refrigerator, toaster, and coffee maker was plugged into a power strip that was plugged into another power strip which also had a microwave and toaster oven plugged in it.

Interview, on 03/04/15 at 10:25 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the power strips were being misused.

11. Observation, on 03/04/15 at 11:07 AM, with the Plant Operations Manager revealed a refrigerator was plugged into a power strip located in the Utilization Review Office.

Interview, on 03/04/15 at 11:08 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the power strip was being misused.

12. Observation, on 03/04/15 at 11:15 AM, with the Plant Operations Manager revealed open electrical junction boxes located in the Basement Mechanical Room.

Interview, on 03/04/15 at 11:16 AM, with the Plant Operations Manager revealed he was aware of the requirements for the junction boxes; however, he was not aware of the open electrical junction boxes.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 70 (1999 Edition) 400-8 ( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Reference: NFPA 99 (1999 edition) 3-3.2.1.2 (D) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Based on observation and interview, it was determined the facility failed to ensure corridors are separated from use areas in accordance with the National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and the census was eight (8) on the day of the survey.

The findings include:

Observation, on 03/03/15 at 3:10 PM, with the Plant Operations Manager revealed a roll down type service door located in the corridor wall separating the Specialty Center Registration Office from the egress path. The roll down type door was not self-closing or connected to the fire alarm to close in the event of an emergency.

Interview, on 03/03/15 at 3:11 PM, with the Plant Operations Manager revealed he was not aware of the requirements for corridor walls protecting the egress path.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Reference: NFPA 101 (2000 edition)

19.3.6.3 Corridor Doors.
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.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.
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.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.
19.3.6.3.3*
Hold-open devices that release when the door is pushed or pulled shall be permitted.
19.3.6.3.4
Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.
Reference: NFPA 80, Standard for Fire Doors and Windows (1999 Edition)
Chapter 10 Fire Shutters
10-1 Shutters.
10-1.1 Construction.
Fire doors without glass lights shall be used as fire shutters.
10-1.2 Types.
Shutters shall be of the following three general types:
(a) Swinging door
(b) Horizontally or vertically sliding door
(c) Rolling steel door
10-2 Installation.
The installation of shutters shall be in accordance with the requirements for installation of swinging, sliding, and rolling steel doors.
10-3 Operation.
10-3.1 Automatic Closing.
All shutters shall be equipped to close automatically in the event of fire.
10-3.2* Weather Protection.
Where shutters are installed on the outside of an opening, they shall be protected against the weather to ensure proper operation.
10-3.3 Other Requirements.
The operation of shutters shall be in accordance with the requirements for operation of swinging, sliding, and rolling steel doors.
Chapter 11 Access Doors
11-1 Doors.
11-1.1 General.
This chapter shall cover the installation of both horizontal and vertical access doors in fire-rated walls, floors, and floor-ceiling or roof-ceiling assemblies.
11-1.2 Components.
An access door shall be an integral unit including the door, frame, hinges, latch, and closing device (where required) bearing a label that reads " Frame and Fire Door Assembly. "
Exception: A vertical access door shall be permitted to have hinges that are not part of the labeled assembly, provided the hinges conform to Table 2-4.3.1.
11-1.2.1
Access doors shall be self-closing.
11-1.2.2
Access doors shall be self-latching.
Exception: A horizontal access door that does not open downward and that remains in place when an upward force of 1 psf (48 N/m2) is applied over the entire exposed surface of the door shall not be required to be self-latching.
11-1.2.3
Self-closing access doors that are intended to be used to allow a person to enter the concealed space behind the door completely shall be operable from the inside without the use of a key or tool.
11-1.2.4
Access doors shall be installed in accordance with their listing.
11-2 Types of Doors.
11-2.1 Horizontal Access Doors.
11-2.1.1
Door assemblies used in fire-rated floors or floor-ceiling or roof-ceiling assemblies shall be tested in the horizontal position in accordance with the procedures described in NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials, and shall be labeled as horizontal access doors.
11-2.1.2
A horizontal access door shall bear a label that includes the additional wording " For Horizontal Installation. "
11-2.1.3
A horizontal access door shall be used in a fire-rated floor or floor-ceiling or roof-ceiling assembly only where it has been tested and listed for use as a component of the assembly.
11-2.1.4
Horizontal access doors shall not be required to be subject to the hose stream test.
11-2.2 Vertical Access Doors.
11-2.2.1
Vertical access doors shall have a fire protection rating of 3/4 hour, 1 hour, or 11/2 hours. (See Appendix F.)
11-2.2.2
Vertical access doors shall be used only in walls.
11-2.2.3
Where the authority having jurisdiction determines that a vertical access door is located in proximity to combustibles so that, in a fire condition, the door is likely to transmit sufficient heat to ignite the combustibles, the temperature rise on the unexposed face of the door shall not exceed 250°F (139°C) at the end of a 30-minute exposure to the standard fire test as described in NFPA 252, Standard Methods of Fire Tests of Door Assemblies. Such an access door shall bear a label indicating a maximum temperature rise of 250°F (139°C).
11-2.2.4
Closing by means of gravity using top-hinging vertical access doors shall be permitted to meet the requirements for self-closing doors.
11-2.2.5
A vertical access door shall bear a label that includes the additional wording " For Vertical Installation. "
Chapter 12 Service Counter Doors

Based on observation and interview, it was determined the facility failed to maintain smoke barriers that would resist the passage of smoke between smoke compartments in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect five (5) of five (5) smoke compartments, twenty-five (25) patients, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1) Observation, on 03/03/15 at 9:45 AM, with the Plant Operations Manager revealed unsealed penetrations around pipes in the smoke barrier extending above the ceiling located at the cross corridor doors in the Cafeteria Hall.

Interview, on 03/03/15 at 9:46 AM, with the Plant Operations Manager revealed he was not aware the unsealed penetrations around the pipes.

2) Observation, on 03/03/15 at 9:50 AM, with the Plant Operations Manager revealed a penetration of missing concrete blocks around duct work in the smoke barrier extending above the ceiling located above the Health Information Management Office.

Interview, on 03/03/15 at 9:51 AM, with the Plant Operations Manager revealed he was not aware of the missing concrete blocks around the duct work.

3) Observation, on 03/03/15 at 10:05 AM, with the Plant Operations Manager revealed the use of unrated expandable foam to seal penetrations in the smoke barrier extending above the ceiling located at the cross corridor doors in the Administrative Hall by the Gift Shop.

Interview, on 03/03/15 at 10:06 AM, with the Plant Operations Manager revealed he was not aware of the unrated expandable foam being used to seal penetrations.

4) Observation, on 03/03/15 at 10:20 AM, with the Plant Operations Manager revealed the use of drywall joint compound being used to seal the concrete block wall to the roof deck above in the smoke barrier extending above the ceiling located in Eye Room #3.

Interview, on 03/03/15 at 10:21 AM, with the Plant Operations Manager revealed he was not aware of the joint compound being used on the concrete block wall to seal penetrations.

5) Observation, on 03/03/15 at 10:28 AM, with the Plant Operations Manager revealed the use of unrated expandable foam to seal penetrations in the smoke barrier extending above the ceiling located at the cross corridor doors in Hall 2 Medical Surgery.

Interview, on 03/03/15 at 10:29 AM, with the Plant Operations Manager revealed he was not aware of the use of expandable foam to seal penetrations.

6) Observation, on 03/03/15 at 10:30 AM, with the Plant Operations Manager revealed unsealed penetrations in the smoke barrier extending above the ceiling located in the Chief Financial Officers Office.

Interview, on 03/03/15 at 10:31 AM, with the Plant Operations Manager revealed he was not aware the unsealed penetrations.

7) Observation, on 03/03/15 at 10:55 AM, with the Plant Operations Manager revealed unsealed penetrations inside pipe sleeves in the smoke barrier extending above the ceiling located in the Emergency Room Hall.

Interview, on 03/03/15 at 10:56 AM, with the Plant Operations Manager revealed he was not aware of the unsealed pipe sleeves.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition).19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: 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 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.
Reference: NFPA 101 (2000 Edition)19.3.7.5
Openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than 20 minutes. Nonrated factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted.
Exception: Doors shall be permitted to have fixed fire window assemblies in accordance with 8.2.3.2.2.
Reference: NFPA 101 (2000 Edition) 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(a) The space between the penetrating item and the smoke barrier shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(b) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall
1. Be filled with a material capable of maintaining the smoke resistance of the smoke barrier, or
2. Be protected by an approved device designed for the specific purpose.
(c) Where designs take transmission of vibration into consideration, any vibration isolation shall
1. Be made on either side of the smoke barrier, or
2. Be made by an approved device designed for the specific purpose.

Based on observation and interview, it was determined the facility failed to ensure the doors in smoke barriers were maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect three (3) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1) Observation, on 03/03/15 at 9:50 AM, with the Plant Operations Manager revealed the smoke barrier door located inside the Health Information Management Office did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 9:51 AM, with the Plant Operations Manager revealed he was not aware the door was part of the smoke barrier.

2) Observation, on 03/03/15 at 10:10 AM, with the Plant Operations Manager revealed the smoke barrier door located between the Laboratory and the Laboratory Break Room had been removed.

Interview, on 03/03/15 at 10:11 AM, with the Plant Operations Manager revealed he was not aware the door was part of the smoke barrier.

3) Observation, on 03/03/15 at 10:12 AM, with the Plant Operations Manager revealed the smoke barrier door located on the Laboratory Storage Room did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 10:13 AM, with the Plant Operations Manager revealed he was not aware the door was part of the smoke barrier.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition) 19.3.7.5
Openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as 13/4-in. (4.4-cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than 20 minutes. Nonrated factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted.
Exception: Doors shall be permitted to have fixed fire window assemblies in accordance with 8.2.3.2.2.
19.3.7.6*
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.
19.3.7.7
Door openings in smoke barriers shall be protected by a swinging door providing a clear width of not less than 32 in. (81 cm) or by a horizontal sliding door complying with 7.2.1.14 and providing a clear width of not less than 32 in. (81 cm).
Exception: Existing 34-in. (86-cm) doors.

8.3.4 Doors.
8.3.4.1*
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.
8.3.4.2*
Where a fire resistance rating for smoke barriers is specified elsewhere in the Code, openings shall be protected as follows:
(1) Door opening protectives shall have a fire protection rating of not less than 20 minutes where tested in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, without the hose stream test, unless otherwise specified by Chapters 12 through 42.
(2) Fire windows shall comply with 8.2.3.2.2.
Exception: Latching hardware shall not be required on doors in smoke barriers where so indicated by Chapters 12 through 42.
8.3.4.3*
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Based on observation and interview, it was determined the facility failed to meet the requirements for Protection of Hazards, in accordance with the National Fire Protection Agency (NFPA) standards. The deficiency had the potential to affect five (5) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1. Observation, on 03/03/15 at 1:42 PM, with the Plant Operations Manager revealed the Medical Records Overflow Storage Room had hazardous amounts of combustible paper and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 1:43 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

2. Observation, on 03/03/15 at 1:50 PM, with the Plant Operations Manager revealed the Medical Records Storage Room door to the corridor was equipped with a self-closing device; however, a chain and hook held the door open preventing the door from self-closing.

Interview, on 03/03/15 at 1:51 PM, with the Plant Operations Manager revealed he was not aware the door was being held open with an unapproved hold open device.

3. Observation, on 03/03/15 at 2:08 PM, with the Plant Operations Manager revealed the Medical Records Overflow Storage Room had hazardous amounts of combustible paper and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 2:09 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

4. Observation, on 03/03/15 at 2:10 PM, with the Plant Operations Manager revealed the Kitchen Dry Storage Room had hazardous amounts of combustible boxes and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 2:11 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

5. Observation, on 03/03/15 at 2:14 PM, with the Plant Operations Manager revealed the Kitchen Garbage Room had hazardous amounts of combustible trash and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 2:15 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

6. Observation, on 03/03/15 at 2:39 PM, with the Plant Operations Manager revealed the Surgery Storage Room had hazardous amounts of combustible paper and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 2:40 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

7. Observation, on 03/03/15 at 3:25 PM, with the Plant Operations Manager revealed the Cashiers Office and the Senior Accountant Office had hazardous amounts of combustible paper and did not have a self-closing device installed on the door.

Interview, on 03/03/15 at 3:26 PM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

8. Observation, on 03/04/15 at 9:45 AM, with the Plant Operations Manager revealed hazardous amounts of combustible paper medical records being stored in the Carrollton Internal Medicine Referrals Office. The room did not have a one (1) hour rating or have a self-closing device installed on the door.

Interview, on 03/04/15 at 9:46 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

9. Observation, on 03/04/15 at 10:16 AM, with the Plant Operations Manager revealed hazardous amounts of combustible paper/medical records were being stored in the Carrollton Internal Medicine Nurses Office and did not have a self-closing device installed on the door.

Interview, on 03/04/15 at 10:17 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

10. Observation, on 03/04/15 at 10:18 AM, with the Plant Operations Manager revealed the Carrollton Internal Medicine Chart Room had hazardous amounts of combustible paper and the self-closing device had been removed from the door.

Interview, on 03/04/15 at 10:19 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

11. Observation, on 03/04/15 at 10:22 AM, with the Plant Operations Manager revealed hazardous amounts of combustible paper/medical records being stored in the Physician's Office and did not have a self-closing device installed on the door.

Interview, on 03/04/15 at 10:23 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

12. Observation, on 03/04/15 at 10:35 AM, with the Plant Operations Manager revealed the Occupational Medicine Office had hazardous amounts of combustible paper/medical records stored in the room and did not have a self-closing device installed on the door.

Interview, on 03/04/15 at 10:36 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

13. Observation, on 03/04/15 at 10:40 AM, with the Plant Operations Manager revealed hazardous amounts of combustible paper/medical records were stored in the Central Scheduling Room and did not have a self-closing device installed on the door.

Interview, on 03/04/15 at 10:41 AM, with the Plant Operations Manager revealed he was not aware the room did not meet the requirements of protection from hazards.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition) 19.3.2 Protection from Hazards.

Reference: NFPA 101 (2000 Edition) 19.3.2.1 Hazardous Areas. 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. 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) Soiled linen rooms
(6) Trash collection rooms
(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.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Reference: NFPA 101 (2000 Edition) 7.2.1.8 Self-Closing Devices.

Reference: NFPA 101 (2000 Edition) 7.2.1.8.1* A door 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.

Reference: NFPA 101 (2000 Edition) 7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Based on observation and interview, it was determined the facility failed to ensure egress lighting was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect three (3) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1. Observation, on 03/03/15 at 2:00 PM, with the Plant Operations Manager revealed the facility failed to provide egress lighting outside of the Cafeteria Exit.

Interview, on 03/03/15 at 2:01 PM, with the Plant Operations Manager revealed he was not aware the exit discharge did not have proper egress lighting.

2. Observation, on 03/03/15 at 2:42 PM, with the Plant Operations Manager revealed a single lighting unit located outside the Kitchen Exit.

Interview, on 03/03/15 at 2:43 PM, with the Plant Operations Manager revealed he was not aware the exit discharge did not have proper egress lighting.

3. Observation, on 03/04/15 at 10:42 AM, with the Plant Operations Manager revealed the facility failed to provide egress lighting outside of the Cardiac Services Entrance.

Interview, on 03/04/15 at 10:43 AM, with the Plant Operations Manager revealed he was not aware the exit discharge did not have proper egress lighting.

4. Observation, on 03/04/15 at 11:00 AM, with the Plant Operations Manager revealed a single lighting unit located outside both exits in the Medical Surgery South Hall.

Interview, on 03/04/15 at 11:01 AM, with the Plant Operations Manager revealed he was not aware the exit discharge did not have proper egress lighting.

5. Observation, on 03/04/15 at 11:17 AM, with the Plant Operations Manager revealed a single lighting unit located outside the Basement Exit.

Interview, on 03/04/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the exit discharge did not have proper egress lighting.

The census of eight (8) was verified by the Administrator on 03/04/15. The survey findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition) 7.8 ILLUMINATION OF MEANS OF EGRESS
7.8.1 General.
7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3*
The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.
7.8.1.4*
Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.
7.8.1.5
The equipment or units installed to meet the requirements of Section 7.10 also shall be permitted to serve the function of illumination of means of egress, provided that all requirements of Section 7.8 for such illumination are met.
7.8.2 Sources of Illumination.
7.8.2.1*
Illumination of means of egress shall be from a source considered reliable by the authority having jurisdiction.
7.8.2.2
Battery-operated electric lights and other types of portable lamps or lanterns shall not be used for primary illumination of means of egress. Battery-operated electric lights shall be permitted to be used as an emergency source to the extent permitted under Section 7.9.

Based on observation and interview, it was determined the facility failed to maintain emergency lighting in accordance with the National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect five (5) of five (5) smoke compartments, twenty-five (25) residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and the census was eight (8) on the day of the survey.

The findings include:

Observation, on 03/03/15 at 10:55 AM, with the Plant Operations Manager revealed the facility failed to document the monthly thirty (30) second test and the annual ninety (90) minute test for battery powered emergency lighting.

Interview, on 03/03/15 at 10:56 AM, with the Plant Operations Manager revealed he was not aware documentation was to be provided for the thirty (30) second monthly and ninety (90) minute test for battery powered emergency lighting.

The census of eight (8) was verified by the Administrator on 03/04/15. The survey findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Reference: NFPA 101 (2000 edition)

7.9.2.1* Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6
lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than
11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at random times, in accordance with National Fire Protection Association (NFPA) standards. The deficient practice has the potential to affect five (5) of five (5) smoke compartments, all residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

Review of the facility's Fire Drill documentation, on 03/03/15 at 11:45 AM, with the Plant Operations Manager revealed the facility failed to conduct fire drills at unexpected times on second (2nd) shift. Six (6) out of the last eight (8) fire drills conducted on second (2nd) shift within the last four (4) quarters were conducted in the hour of 4:00 PM. Further review revealed the facility did not conduct a fire drill on first (1st) shift, in the second (2nd) quarter of 2014. Further review revealed the facility did not conduct a fire drill on third (3rd) shift, in the fourth (4th) quarter of 2014.

Interview, on 03/03/15 at 11:46 AM, with the Plant Operations Manager revealed he was unaware the fire drills were not being conducted as required.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 edition) 19.7.1.2. Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Based on observation, interview, Fire Alarm Testing, and Fire Alarm Inspection review, it was determined the facility failed to ensure the fire alarm system was inspected and tested in accordance with National Fire Protection Association (NFPA) Standards. The deficient practice has the potential to affect five (5) of five (5) smoke compartments, twenty-five residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

Review of the fire alarm inspection, on 03/03/15 at 11:30 AM, with the Plant Operations Manager revealed the charger test was not documented on the fire alarm inspection paperwork.

Interview, on 03/03/15 at 11:31 AM, with the Plant Operations Manager revealed he was unaware the inspection company was to perform a charger test for the fire alarm batteries on an annual basis.

Review of the fire alarm inspection, on 03/03/15 at 11:30 AM, with the Plant Operations Manager revealed the discharge test was not documented on the fire alarm inspection paperwork.

Interview, on 03/03/15 at 11:31 AM, with the Plant Operations Manager revealed he was unaware the inspection company was to perform a discharge test for the fire alarm batteries on an annual basis.

Review of the fire alarm inspection, on 03/03/15 at 11:30 AM, with the Plant Operations Manager revealed the load voltage test was not documented on the fire alarm inspection paperwork.

Interview, on 03/03/15 at 11:31 AM, with the Plant Operations Manager revealed he was unaware the inspection company was to perform a load voltage test for the fire alarm batteries on a semi-annual basis.

Observation, on 03/04/15 at 10:52 AM, with the Plant Operations Manager revealed the Fire Alarm Control Panel (FACP) indicated active trouble.

Interview, on 03/04/15 at 10:53 AM, with the Plant Operations Manager revealed he was not aware the FACP was in trouble mode. The Plant Operations Manager called the FACP monitoring company and was informed the FACP had been in trouble since 02/14/15 at 4:07 PM.

A Fire Alarm Test, on 03/04/15 at 11:50 AM, with the Plant Operations Manager revealed the FACP worked properly, performing all functions as designed.

Interview, on 03/04/15 at 1:12 PM, with the Plant Operations Manager revealed the cause of the trouble mode was a failure in the secondary phone line. The problem with the FACP had been corrected and no longer in trouble mode.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 ed.), 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.

Based on observation, interview, and sprinkler testing review, it was determined the facility failed to maintain the sprinkler system in accordance with National Fire Protection (NFPA) standards. The deficient practice has the potential to affect five (5) of five (5) smoke compartments, all residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1. Review of the Sprinkler testing records, on 03/03/15 at 11:17 AM, with the Plant Operations Manager revealed the facility could not provide documentation that the gauges on the sprinkler system had been calibrated or replaced within the last five (5) years.

Interview, on 03/03/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the sprinkler system testing was not up to date.

2. Review of the Sprinkler testing records, on 03/03/15 at 11:17 AM, with the Plant Operations Manager revealed the facility could not provide documentation that the interior pipe inspection had been performed within the last five (5) years.

Interview, on 03/03/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the sprinkler system testing was not up to date.

3. Review of the Sprinkler testing records, on 03/03/15 at 11:17 AM, with the Plant Operations Manager revealed the facility could not provide documentation that the check valves had been inspected within the last five (5) years.

Interview, on 03/03/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the sprinkler system testing was not up to date.

4. Review of the Sprinkler testing records, on 03/03/15 at 11:17 AM, with the Plant Operations Manager revealed the facility could not provide documentation that the interior of the alarm valve had been inspected within the last five (5) years.

Interview, on 03/03/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the sprinkler system testing was not up to date.

5. Review of the Sprinkler testing records, on 03/03/15 at 11:17 AM, with the Plant Operations Manager revealed the facility could not provide documentation that the Fire Department check valves had been inspected within the last five (5) years.

Interview, on 03/03/15 at 11:18 AM, with the Plant Operations Manager revealed he was not aware the sprinkler system testing was not up to date.

6. Observation, on 03/03/15 at 1:30 PM, with the Plant Operations Manager revealed storage within eighteen (18) inches of a sprinkler head located in the Environmental Services Storage Room.

Interview, on 03/03/15 at 1:31 PM, with the Plant Operations Manager revealed he was not aware the items had been stored within eighteen (18) inches of the sprinkler head.

7. Observation, on 03/03/15 at 1:40 PM, with the Plant Operations Manager revealed data phone lines were strapped to the sprinkler piping located in the Receiving Office.

Interview, on 03/03/15 at 1:41 PM, with the Plant Operations Manager revealed he was not aware the wires could not be strapped to the sprinkler piping.

8. Observation, on 03/03/15 at 1:40 PM, with the Plant Operations Manager revealed the sprinkler heads in the Receiving Office were dust loaded.

Interview, on 03/03/15 at 1:41 PM, with the Plant Operations Manager revealed he was not aware the sprinkler heads were dust loaded.

9. Observation, on 03/04/15 at 10:16 AM, with the Plant Operations Manager revealed the sprinkler heads located in the Carrolton Internal Medicine Reception area were dust loaded.

Interview, on 03/04/15 at 10:17 AM, with the Plant Operations Manager revealed he was not aware the sprinkler heads were dust loaded.

10. Observation, on 03/04/15 at 11:22 AM, with the Plant Operations Manager revealed a sprinkler valve located on the sprinkler riser was not electronically supervised.

Interview, on 03/03/15 at 11:23 AM, with the Plant Operations Manager revealed he was not aware the sprinkler valve had to be electronically supervised.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition) 19.3.5 Extinguishment Requirements.
19.3.5.1
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.
19.3.5.2*
Where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

Reference: NFPA 25 (1998 Edition).
2-1 General. This chapter provides the minimum requirements
for the routine inspection, testing, and maintenance of
sprinkler systems. Table 2-1 shall be used to determine the
minimum required frequencies for inspection, testing, and
maintenance.
Exception: Valves and fire department connections shall be inspected,
tested, and maintained in accordance with Chapter 9.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing
weather)
2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test At 20 years and every 10 years
thereafter
2-3.1.1 Exception No. 2
Sprinklers Test At 50 years and every 10 years
thereafter
2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

Table 9-1 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance
Component Activity Frequency Reference
Control Valves
Sealed Inspection Weekly 9-3.3.1
Locked Inspection Monthly 9-3.3.1 Exception No. 1
Tamper switches Inspection Monthly 9-3.3.1 Exception No. 1
Alarm Valves
Exterior Inspection Monthly 9-4.1.1
Interior Inspection 5 years 9-4.1.2
Strainers, filters, orifices Inspection 5 years 9-4.1.2
Check Valves
Interior Inspection 5 years 9-4.2.1
Preaction/Deluge Valves
Enclosure (during cold weather) Inspection Daily/weekly 9-4.3.1
Exterior Inspection Monthly 9-4.3.1.2
Interior Inspection Annually/5 years 9-4.3.1.3
Strainers, filters, orifices Inspection 5 years 9-4.3.1.4
Dry Pipe Valves/Quick-Opening
Devices
Enclosure (during cold weather) Inspection Daily/weekly 9-4.4.1.1
Exterior Inspection Monthly 9-4.4.1.3
Interior Inspection Annually 9-4.4.1.4
Strainers, filters, orifices Inspection 5 years 9-4.4.1.5
Pressure Reducing and Relief Valves
Sprinkler systems Inspection Quarterly 9-5.1.1
Hose connections Inspection Quarterly 9-5.2.1
Hose racks Inspection Quarterly 9-5.3.1
Fire pumps
Casing relief valves Inspection Weekly 9-5.5.1, 9-5.5.1.1
Pressure relief valves Inspection Weekly 9-5.5.2, 9-5.5.2.1
Backflow Prevention Assemblies
Reduced pressure Inspection Weekly/monthly 9-6.1
Reduced pressure detectors Inspection Weekly/monthly 9-6.1
Fire Department Connections Inspection Quarterly 9-7.1
Main Drains Test Annually 9-2.6, 9-3.4.2
Waterflow Alarms Test Quarterly 9-2.7
Control Valves
Position Test Annually 9-3.4.1
Operation Test Annually 9-3.4.1
Supervisory Test Semiannually 9-3.4.3
Preaction/Deluge Valves
Priming water Test Quarterly 9-4.3.2.1
Low air pressure alarms Test Quarterly 9-4.3.2.10
Full flow Test Annually 9-4.3.2.2
Dry Pipe Valves/Quick-Opening
Devices
Priming water Test Quarterly 9-4.4.2.1
Low air pressure alarm Test Quarterly 9-4.4.2.6
Quick-opening devices Test Quarterly 9-4.4.2.4
Trip test Test Annually 9-4.4.2.2
Full flow trip test Test 3 years 9-4.4.2.2.1
Pressure Reducing and Relief Valves
Sprinkler systems Test 5 years 9-5.1.2
Circulation relief Test Annually 9-5.5.1.2
Pressure relief valves Test Annually 9-5.5.2.2
Hose connections Test 5 years 9-5.2.2
Hose racks Test 5 years 9-5.3.2
Backflow Prevention Assemblies Test Annually 9-6.2
Control Valves Maintenance Annually 9-3.5
Preaction/Deluge Valves Maintenance Annually 9-4.3.3.2
Dry Pipe Valves/Quick-Opening
Devices
Maintenance Annually 9-4.4.3.2

Based on observation and interview, it was determined the facility failed to ensure the manual hood suppression pull was readily available, in accordance with the National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of five (5) smoke compartments, residents, staff, and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

Observation, on 03/03/15 at 2:05 PM, with the Plant Operations Manager revealed the manual pull for the Kitchen Hood Suppression System was not located in the egress path. The manual pull was located beside a door leading to a dining room; however, the exit was located on the other side of the Kitchen.

Interview, on 03/03/15 at 2:06 PM, with the Plant Operations Manager revealed he was not aware of the requirements for the location of the manual hood suppression pull.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

NFPA 96 (1998 edition)7-6.2 Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation shall activate the fire alarm signaling system.

Reference: NFPA 96 (1998 edition)
7-5.1 A readily accessible means for manual activation shall be located between 42 in. and 60 in. (1067 mm and 1524 mm) above the floor, located in a path of exit or egress, and clearly identify the hazard protected. The automatic and manual means of system activation external to the control head or releasing device shall be separate and independent of each other so that failure of one will not impair the operation of the other.
Exception No. 1: The manual means of system activation shall be permitted to be common with the automatic means if the manual activation device is located between the control head or releasing device and the first fusible link.
Exception No. 2: An automatic sprinkler system.

Based on observations and interview, it was determined the facility failed to ensure portable space heaters used in the facility were in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect two (2) of five (5) smoke compartments, residents, staff, and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1. Observation, on 03/03/15 at 1:26 PM, with the Plant Operations Manager revealed a portable space heater located in the Conference Room. The portable heater had a heating element that exceeded 212 degrees.

Interviews, on 03/03/15 at 1:26 PM, with the Plant Operations Manager revealed he was not aware of the portable space heater being in use in the Conference Room.

2. Observation, on 03/04/15 at 10:26 AM, with the Plant Operations Manager revealed a portable space heater located in the Carrollton Internal Medicine Office. The portable heater had a heating element that exceeded 212 degrees.

Interviews, on 03/04/15 at 10:27 AM, with the Plant Operations Manager revealed he was not aware of the portable space heater being in use in the Carrollton Internal Medicine Office.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator verified by the Plant Operations Manager at the exit interview on 03/04/15.

Reference: NFPA 101 (2000 edition)

19.7.8 Portable Space-Heating Devices. Portable space-heating
devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used
in non-sleeping staff and employee areas where the heating elements of
such devices do not exceed 212°F (100°C).

Based on observation and interview, it was determined the facility failed to ensure oxygen storage areas were protected in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

Observation, on 03/04/15 at 10:44 AM, with the Plant Operations Manager revealed the piped in medical gas shut off valve located at the Nurses' Station in the Medical Surgery Hall was obstructed by a Blood/Gas Machine being installed in front of the shut off valve.

Interview, on 03/04/15 at 10:45 AM, with the Plant Operations Manager revealed he was not aware of the requirements for piped in medical gas.

The census of eight (8) was verified by the Administrator, on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Reference: NFPA 101 (2000 edition)

19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Based on interview and fire/smoke damper testing review, it was determined the facility failed to ensure fire/smoke dampers were maintained in accordance with NFPA standards. The deficient practice has the potential to affect five (5) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

Review of the fire/smoke damper testing, on 03/03/15 at 12:04 PM, with the Plant Operations Manager revealed the facility did not have documentation that fire/smoke dampers had been tested within the last four (4) years.

Interview, on 03/03/15 at 12:05 PM, with the Plant Operations Manager revealed he was not aware of the testing requirements for the fire/smoke dampers.

The census of twenty-five (25) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard: Reference: NFPA 90A (1999 edition)

3-4.7 Maintenance. At least every 4 years, fusible links (where
applicable) shall be removed; all dampers shall be operated to
verify that they fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.

Based on an interview and record review, it was determined the facility failed to maintain the generator set by National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect five (5) of five (5) smoke compartments, twenty-five (25) residents, staff and visitors. The facility has the capacity for twenty-five (25) beds with a census of eight (8) on the day of the survey.

The findings include:

Review of the generator documentation, on 03/03/15 at 11:55 AM, with the Plant Operations Manager revealed the facility did not have an annual load bank test performed on the generator. Further record review revealed the facility did not have documentation of the percentage of load the generator was under or the exhaust temperature during monthly tests to determine if an annual load bank test was required.

Interview, on 03/03/15 at 11:56 AM, with the Plant Operations Manager revealed he was not aware of the requirements for generator testing

Review of the generator documentation, on 03/03/15 at 11:55 AM, with the Plant Operations Manager revealed the facility did not have documentation of the transfer time for the monthly transfer of power while testing the generator. Further record review revealed the facility did not have documentation that an annual Preventative Maintenance had been performed on the generator.

Interview, on 03/03/15 at 11:56 AM, with the Plant Operations Manager revealed he was not aware of the requirements for generator testing

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 99 (1999 Edition) 3-4.1.1.15 + Alarm Annunciator. A remote annunciator, 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 NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
a. Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
b. Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

Reference: NFPA 110 (1999 Edition) 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.

Reference: NFPA 99 (1999 Edition) 3-5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-5.3.1.
(b) Inspection and Testing. Generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b).
Actual Standard: NFPA 110, 6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. 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.
Actual Standard: NFPA 99, 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1. Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.
Actual Standard: NFPA 99, 3- 3-4.4.2. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Reference: NFPA 99 (1999 Edition) 6-1.1* The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction

Reference: NFPA 99 (1999 Edition) 6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established

Reference: NFPA 99 (1999 Edition) 6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Reference: NFPA 99 (1999 Edition) 6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. 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.

Reference: NFPA 101 ( 2000 edition) 7.9.1.2 Where maintenance of illumination depends on
changing from one energy source to another, a delay of not
more than 10 seconds shall be permitted.
Reference: NFPA 110 (1999 ed.)
5-7 Heating, Cooling, and Ventilating.
5-7.1* Consideration shall be given to properly sizing the ventilation
or air-conditioning systems to remove all the heat
rejected to the EPS equipment room by the energy converter,
uninsulated or insulated exhaust pipes, and other heat-producing
equipment.
5-7.2 Adequate ventilation shall be provided to prevent temperatures
or temperature rises in the EPS and related accessory
equipment that exceed the recommendations of the
manufacturer.
5-7.3 For the EPS equipment room, the ventilation or cooling
equipment, or both, shall be sized so that the ambient temperature
shall not exceed the EPS equipment manufacturer ' s criteria
or allowable maximum temperatures.

Reference: NFPA 110 (1999 Edition) 5-2.1 The EPS shall be installed in a separate room for Level
1 installations. EPSS equipment shall be permitted to be
installed in this room. The room shall have a minimum 2-hour
fire rating or shall be located in an adequate enclosure located
outside the building capable of resisting the entrance of snow
or rain at a maximum wind velocity required by local building
codes. No other equipment, including architectural appurtenances,
except those that serve this space, shall be permitted
in this room.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect five (5) of five (5) smoke compartments, residents, staff and visitors. The facility has the capacity for twenty-five (25) beds and at the time of the survey, the census was eight (8).

The findings include:

1. Observation, on 03/03/15 at 10:18 AM, with the Plant Operations Manager revealed Romex cable was run above the drop ceiling located in Eye Room #3.

Interview, on 03/03/15 at 10:19 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper wiring over suspended ceilings; however, he was not aware of the Romex cable over the ceiling.

2. Observation, on 03/03/15 at 10:30 AM, with the Plant Operations Manager revealed Romex cable was run above the drop ceiling located in the Chief Financial Officer's Office. Further observation above the ceiling in the Chief Financial Officer's Office revealed open electrical junction boxes.

Interview, on 03/03/15 at 10:31 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper wiring over suspended ceilings; however he was not aware of the Romex cable or the open electrical junction boxes over the ceiling.

3. Observation, on 03/03/15 at 1:28 PM, with the Plant Operations Manager revealed a washing machine was plugged into a power strip located in the Environmental Services Storage Room.

Interview, on 03/03/15 at 1:29 PM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the washing machine was plugged into a power strip.

4. Observation, on 03/03/15 at 1:40 PM, with the Plant Operations Manager revealed a heater was plugged into a multi-plug adaptor located in the Receiving Office.

Interview, on 03/03/15 at 1:41 PM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of multi-plug adaptors; however, he was not aware the multi-plug adaptor was in use.

5. Observation, on 03/03/15 at 1:44 PM, with the Plant Operations Manager revealed an electrical panel located in the Medical Records File Room was blocked by a file cabinet.

Interview, on 03/03/15 at 1:45 PM, with the Plant Operations Manager revealed he was not aware the file cabinet was in front of the electrical panel making it not accessible.

6. Observation, on 03/03/15 at 2:31 PM, with the Plant Operations Manager revealed a microwave and a refrigerator were plugged into a power strip located in the X-Ray Computer Room.

Interview, on 03/03/15 at 2:32 PM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware power strip was being misused.

7. Observation, on 03/04/15 at 9:45 AM, with the Plant Operations Manager revealed a refrigerator was plugged into a power strip located in the Testing Room of the Rural Health Clinic.

Interview, on 03/04/15 at 9:46 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the power strip was being misused.

8. Observation, on 03/04/15 at 9:50 AM, with the Plant Operations Manager revealed a coffee maker was plugged into a power strip located in the Break Area of the Rural Health Clinic.

Interview, on 03/04/15 at 9:51 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the power strip was being misused.

9. Observation, on 03/04/15 at 9:58 AM, with the Plant Operations Manager revealed a refrigerator was plugged into a power strip located in the Rural Health Clinic Office.

Interview, on 03/04/15 at 9:59 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the power strip was being misused.

10. Observation, on 03/04/15 at 10:24 AM, with the Plant Operations Manager revealed a refrigerator, toaster, and coffee maker was plugged into a power strip that was plugged into another power strip which also had a microwave and toaster oven plugged in it.

Interview, on 03/04/15 at 10:25 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the power strips were being misused.

11. Observation, on 03/04/15 at 11:07 AM, with the Plant Operations Manager revealed a refrigerator was plugged into a power strip located in the Utilization Review Office.

Interview, on 03/04/15 at 11:08 AM, with the Plant Operations Manager revealed he was aware of the requirements for the proper use of power strips; however, he was not aware the power strip was being misused.

12. Observation, on 03/04/15 at 11:15 AM, with the Plant Operations Manager revealed open electrical junction boxes located in the Basement Mechanical Room.

Interview, on 03/04/15 at 11:16 AM, with the Plant Operations Manager revealed he was aware of the requirements for the junction boxes; however, he was not aware of the open electrical junction boxes.

The census of eight (8) was verified by the Administrator on 03/04/15. The findings were acknowledged by the Administrator and verified by the Plant Operations Manager at the exit interview on 03/04/15.

Actual NFPA Standard:

Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 70 (1999 Edition) 400-8 ( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Reference: NFPA 99 (1999 edition) 3-3.2.1.2 (D) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.