HospitalInspections.org

Based on observation and interview, the facility failed to ensure materials used as an interior finish in the corridor had a flame spread rating of Class A or Class B in order to protect all occupants. LSC 101 10.2.3.2 states products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale. This deficient practice could affect any occupant on the main floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the Therapist office on the main floor had two corridor walls constructed with a wood lattice material. Interview with the Plant Operations Manager at the time of observation revealed no documentation was immediately available to demonstrate the wood lattice material exhibited a flame spread classification of Class A or B.

Based on observation and interview, the facility failed to ensure materials used as an interior finish in rooms and spaces not in the corridor had a flame spread rating of Class A or Class B in order to protect all occupants. LSC 101 10.2.3.2 states products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale. This deficient practice could affect any occupant on the main floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the following was noted:
a. The Registration office on the main floor had a wall covered by corkboard which was being used as an interior finish.
b. The walls of the copy room on the main floor were covered by a fiber wall covering material being used a an interior finish.
Interview with the Plant Operations Manager after the observation revealed no documentation was immediately available to demonstrate the materials used as an interior finish exhibited a flame spread classification of Class A or B.

1. Based on observation and interview, the facility failed to ensure 4 of 60 corridor doors closed and latched automatically into the door frame to protect all occupants. This deficient practice could affect any occupant on the main floor or inpatient floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the following was noted:
a. The clean linen room on the inpatient floor had a set of double corridor doors. The inactive leaf was equipped with a manual flush bolt latch which required a manual operation to allow the active leaf to latch into the inactive leaf.
b. The Medical Clinic room on the main floor had a dutch door. The upper half of the door was equipped with a slide bolt that required a manual operation to latch the upper half of the door.
c. The main office on the main floor had a dutch door and a 4 foot by 3 foot opening that was provided with doors or shutters that could be closed. The upper half of the dutch door was equipped with a slide bolt that required a manual operation to latch the upper half of the door. The doors or shutters in the opening were also equipped with slide bolts that required a manual operation for latching. Based on interview at the time of observation, the Plant Operations Manager acknowledged the aforementioned conditions.

2. Based on observation and interview, the facility failed to ensure 2 of 60 corridor doors were capable of resisting smoke to protect all occupants. This deficient practice could affect any occupant on the inpatient floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the set of double doors to the clean linen room on the inpatient floor had a 3/8 inch gap between the doors. Based on interview at the time of observation, the Plant Operations Manager acknowledged the gap exceeded 1/8 of an inch and would not resist the passage of smoke.

Based on observation and interview, the facility failed to ensure 2 of 2 pharmacy pass-through windows did not exceed 20 square inches in the aggregate area of the room. LSC 19.3.6.5 allows miscellaneous openings to be installed in vision panels or doors without special protection, provided the aggregate area of the openings per room does not exceed 20 square inches and the openings are installed at or below half the distance from the floor to the room ceiling. This deficient practice could affect any occupant on the main floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the pharmacy had two 12 inch by 12 inch windows with fixed-wire, sliding glass panels that exceeded 20 square inches in total aggregate area. Based on interview at the time of observation, the Plant Operations Manager acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 2 of 5 doors serving hazardous areas such as an area exceeding 50 square feet and storing quantities of combustible materials automatically closed and latched to prevent the passage of smoke. This deficient practice could affect any occupant on the lower level.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the following was noted:
a. The door serving the Records room on the lower level lacked a door closer. This room exceeded 50 square feet in size and was being used for storage of a large quantity of paper files.
b. The door serving room 30 on the lower level lacked a door closer. This room exceeded 50 square feet in size and was being used for the storage of at least 80 cardboard boxes of patient files
Based on interview at the time of observation, the Plant Operations Manager acknowledged the aforementioned conditions.

1. Based on interview and record review, the facility failed to conduct quarterly fire drills on each shift for 1 of 4 quarters. This deficient practice affects all occupants in the facility.

Findings include:

Based on review of "Risk Management Reports" with the Plant Operations Manager from 1:45 p.m. to 3:45 p.m. on 06/25/14, documentation of fire drills was not available to review for the first and second shifts of the third quarter of 2013. Based on interview at the time of record review, the Plant Operations Manager acknowledged the fire drill reports were in the process of being transferred and the documentation was not available for review to verify drills during these time periods were conducted.

2. Based on record review and interview, the facility failed to conduct fire drills under varied conditions in 10 of 10 fire drills. This deficient practice affects all occupants in the facility.

Findings include:

Based on review of "Risk Management Reports" with the Plant Operations Manager from 1:45 p.m. to 3:45 p.m. on 06/25/14, fire drills conducted over the past four quarters were not held at random times on each shift. Three of three first shift drills conducted over the past 4 quarters were between 10:00 a.m. and 10:35 a.m.; three of three second shift drills conducted over the past 4 quarters were between 5:00 p.m. and 5:15 p.m. and four of four third shift drills conducted over the past 4 quarters were between 6:00 a.m. and 6:30 a.m.
Based on interview at the time of record review, the Plant Operations Manger acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 6 smoke detectors located on the main floor and connected to the fire alarm system was properly separated from an air supply or return vent. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect any occupant on the main floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the smoke detector located near the pharmacy was one foot from an air supply vent. Based on interview at the time of observation, the Plant Operations Manager acknowledged the distance between the vent and agreed the air flow could interfere with smoke detector function.

Based on observation and interview, the facility failed to inspect 2 of 15 portable fire extinguishers each month. NFPA 10, Standard for Portable Fire Extinguishers, Section 4-3.4.2 requires fire extinguisher inspections at least monthly with the date of inspection and the initials of the person performing being recorded. In addition, NFPA 10, Section 4-2.1 defines inspection as a "quick check" to ensure the fire extinguisher is available and will operate. It is intended to give reasonable assurance the fire extinguisher is fully charged and operable, verifying it is in its designated place, it has not been actuated or tampered with and there is no obvious or physical damage or condition to prevent its operation. This deficient practice could affect any occupant on the main floor or lower level.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the following was noted:
a. The monthly inspection tag on the fire extinguisher located in the cabinet next to the main floor north exit stairwell lacked documentation of a monthly inspection for the month of May of 2014.
b. The monthly inspection tag on the fire extinguisher located in the lower level telephone equipment room lacked documentation of a monthly inspection for the months of April and May of 2014.
Based on interview during the times of observation, the Plant Operations Manager acknowledged the monthly inspections had been missed.

Based on observation and interview, the facility failed to ensure curtains throughout the facility were flame retardant. This deficient practice could affect any occupant in the facility.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., curtains in rooms 211, 214, 215, 216, 217, 227, 228, 229, 230, 231, 232 and in the inpatient exam room and dining room lacked attached documentation indicating they were inherently flame retardant. Based on interview at the time of observation with the Plant Operations Manager, there was no documentation regarding flame retardancy for the aforementioned curtains available for review.

Based on observation and interview, the facility failed to ensure 2 of 3 cylinders of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart. NFPA 99, Health Care Facilities, 8-3.1.11.2(h) requires cylinder or container restraint shall meet NFPA 99, 4-3.5.2.1(b)27 which requires freestanding cylinders be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect any occupant on the inpatient floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., there were three oxygen E-cylinders in the inpatient exam room. Two of the three cylinders were standing in the corner of the room without support. Based on interview at the time of observation, the Plant Operations Manager acknowledged the cylinders should have been in stands or chained to the wall.

1. Based on record review and interview, the facility failed to exercise the generator for 12 of 12 months to meet the requirements of NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. NFPA 99, the Standard for Health Care Facilities, Nursing Home requirements requires essential electrical distribution systems to conform to Type 2 systems as described in Chapter 3 of NFPA 99. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Chapter 6-4.2.2 of NFPA 110, requires diesel-powered EPS installations that do not meet the requirements of Chapter 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
This deficient practice could affect all occupants of the facility.

Findings include:

Based on review of generator load testing documentation with the Plant Operations Manager from 1:45 p.m. to 3:45 p.m. on 06/25/14, the load information to show the actual load percentage for the diesel powered generator was not documented. Based on interview at the time of record review, the Plant Operations Manager acknowledged the generator ran under load on a weekly basis but does not achieve 30 % of the name plate rating. Additionally, the Plant Operations Manager acknowledged a load bank test for the generator had not occurred within the past year.

2. Based on observation and interview, the facility failed to provide emergency task lighting in and around the generator set in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 7.9.2.3 requires that emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery powered emergency lighting. This deficient practice could affect all occupants of the facility.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the generator set was inside an enclosure within a fenced in area and was not provided with a battery powered emergency light for task lighting. Based on interview at the time of observation, Plant Operations Manager acknowledged battery powered emergency task lighting was not provided.

3. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was provided with a functioning remote alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires 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. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
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:
1. Low lubricating oil pressure.
2. Low water temperature.
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. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., a remote alarm annunciator for the generator was provided at the inpatient nurses station but was not functional. Based on interview at the time of observation, the Plant Operations Manager acknowledged the generator remote annunciator was not functional and indicated the generator is slated to be replaced and will have a compliant annunciator.

4. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators with over 100 horsepower was equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the generator in the exterior enclosure was not equipped with a remote manual stop switch. Based on an interview at the time of observation, the Plant Operations Manager acknowledged the generator engine provides more than 100 horsepower and lacks a remote manual stop station.

Based on observation and interview, the facility failed to ensure materials used as an interior finish in the corridor had a flame spread rating of Class A or Class B in order to protect all occupants. LSC 101 10.2.3.2 states products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale. This deficient practice could affect any occupant on the main floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the Therapist office on the main floor had two corridor walls constructed with a wood lattice material. Interview with the Plant Operations Manager at the time of observation revealed no documentation was immediately available to demonstrate the wood lattice material exhibited a flame spread classification of Class A or B.

Based on observation and interview, the facility failed to ensure materials used as an interior finish in rooms and spaces not in the corridor had a flame spread rating of Class A or Class B in order to protect all occupants. LSC 101 10.2.3.2 states products required to be tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale. This deficient practice could affect any occupant on the main floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the following was noted:
a. The Registration office on the main floor had a wall covered by corkboard which was being used as an interior finish.
b. The walls of the copy room on the main floor were covered by a fiber wall covering material being used a an interior finish.
Interview with the Plant Operations Manager after the observation revealed no documentation was immediately available to demonstrate the materials used as an interior finish exhibited a flame spread classification of Class A or B.

1. Based on observation and interview, the facility failed to ensure 4 of 60 corridor doors closed and latched automatically into the door frame to protect all occupants. This deficient practice could affect any occupant on the main floor or inpatient floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the following was noted:
a. The clean linen room on the inpatient floor had a set of double corridor doors. The inactive leaf was equipped with a manual flush bolt latch which required a manual operation to allow the active leaf to latch into the inactive leaf.
b. The Medical Clinic room on the main floor had a dutch door. The upper half of the door was equipped with a slide bolt that required a manual operation to latch the upper half of the door.
c. The main office on the main floor had a dutch door and a 4 foot by 3 foot opening that was provided with doors or shutters that could be closed. The upper half of the dutch door was equipped with a slide bolt that required a manual operation to latch the upper half of the door. The doors or shutters in the opening were also equipped with slide bolts that required a manual operation for latching. Based on interview at the time of observation, the Plant Operations Manager acknowledged the aforementioned conditions.

2. Based on observation and interview, the facility failed to ensure 2 of 60 corridor doors were capable of resisting smoke to protect all occupants. This deficient practice could affect any occupant on the inpatient floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the set of double doors to the clean linen room on the inpatient floor had a 3/8 inch gap between the doors. Based on interview at the time of observation, the Plant Operations Manager acknowledged the gap exceeded 1/8 of an inch and would not resist the passage of smoke.

Based on observation and interview, the facility failed to ensure 2 of 2 pharmacy pass-through windows did not exceed 20 square inches in the aggregate area of the room. LSC 19.3.6.5 allows miscellaneous openings to be installed in vision panels or doors without special protection, provided the aggregate area of the openings per room does not exceed 20 square inches and the openings are installed at or below half the distance from the floor to the room ceiling. This deficient practice could affect any occupant on the main floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the pharmacy had two 12 inch by 12 inch windows with fixed-wire, sliding glass panels that exceeded 20 square inches in total aggregate area. Based on interview at the time of observation, the Plant Operations Manager acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 2 of 5 doors serving hazardous areas such as an area exceeding 50 square feet and storing quantities of combustible materials automatically closed and latched to prevent the passage of smoke. This deficient practice could affect any occupant on the lower level.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the following was noted:
a. The door serving the Records room on the lower level lacked a door closer. This room exceeded 50 square feet in size and was being used for storage of a large quantity of paper files.
b. The door serving room 30 on the lower level lacked a door closer. This room exceeded 50 square feet in size and was being used for the storage of at least 80 cardboard boxes of patient files
Based on interview at the time of observation, the Plant Operations Manager acknowledged the aforementioned conditions.

1. Based on interview and record review, the facility failed to conduct quarterly fire drills on each shift for 1 of 4 quarters. This deficient practice affects all occupants in the facility.

Findings include:

Based on review of "Risk Management Reports" with the Plant Operations Manager from 1:45 p.m. to 3:45 p.m. on 06/25/14, documentation of fire drills was not available to review for the first and second shifts of the third quarter of 2013. Based on interview at the time of record review, the Plant Operations Manager acknowledged the fire drill reports were in the process of being transferred and the documentation was not available for review to verify drills during these time periods were conducted.

2. Based on record review and interview, the facility failed to conduct fire drills under varied conditions in 10 of 10 fire drills. This deficient practice affects all occupants in the facility.

Findings include:

Based on review of "Risk Management Reports" with the Plant Operations Manager from 1:45 p.m. to 3:45 p.m. on 06/25/14, fire drills conducted over the past four quarters were not held at random times on each shift. Three of three first shift drills conducted over the past 4 quarters were between 10:00 a.m. and 10:35 a.m.; three of three second shift drills conducted over the past 4 quarters were between 5:00 p.m. and 5:15 p.m. and four of four third shift drills conducted over the past 4 quarters were between 6:00 a.m. and 6:30 a.m.
Based on interview at the time of record review, the Plant Operations Manger acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 6 smoke detectors located on the main floor and connected to the fire alarm system was properly separated from an air supply or return vent. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect any occupant on the main floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the smoke detector located near the pharmacy was one foot from an air supply vent. Based on interview at the time of observation, the Plant Operations Manager acknowledged the distance between the vent and agreed the air flow could interfere with smoke detector function.

Based on observation and interview, the facility failed to inspect 2 of 15 portable fire extinguishers each month. NFPA 10, Standard for Portable Fire Extinguishers, Section 4-3.4.2 requires fire extinguisher inspections at least monthly with the date of inspection and the initials of the person performing being recorded. In addition, NFPA 10, Section 4-2.1 defines inspection as a "quick check" to ensure the fire extinguisher is available and will operate. It is intended to give reasonable assurance the fire extinguisher is fully charged and operable, verifying it is in its designated place, it has not been actuated or tampered with and there is no obvious or physical damage or condition to prevent its operation. This deficient practice could affect any occupant on the main floor or lower level.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the following was noted:
a. The monthly inspection tag on the fire extinguisher located in the cabinet next to the main floor north exit stairwell lacked documentation of a monthly inspection for the month of May of 2014.
b. The monthly inspection tag on the fire extinguisher located in the lower level telephone equipment room lacked documentation of a monthly inspection for the months of April and May of 2014.
Based on interview during the times of observation, the Plant Operations Manager acknowledged the monthly inspections had been missed.

Based on observation and interview, the facility failed to ensure curtains throughout the facility were flame retardant. This deficient practice could affect any occupant in the facility.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., curtains in rooms 211, 214, 215, 216, 217, 227, 228, 229, 230, 231, 232 and in the inpatient exam room and dining room lacked attached documentation indicating they were inherently flame retardant. Based on interview at the time of observation with the Plant Operations Manager, there was no documentation regarding flame retardancy for the aforementioned curtains available for review.

Based on observation and interview, the facility failed to ensure 2 of 3 cylinders of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart. NFPA 99, Health Care Facilities, 8-3.1.11.2(h) requires cylinder or container restraint shall meet NFPA 99, 4-3.5.2.1(b)27 which requires freestanding cylinders be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect any occupant on the inpatient floor.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., there were three oxygen E-cylinders in the inpatient exam room. Two of the three cylinders were standing in the corner of the room without support. Based on interview at the time of observation, the Plant Operations Manager acknowledged the cylinders should have been in stands or chained to the wall.

1. Based on record review and interview, the facility failed to exercise the generator for 12 of 12 months to meet the requirements of NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. NFPA 99, the Standard for Health Care Facilities, Nursing Home requirements requires essential electrical distribution systems to conform to Type 2 systems as described in Chapter 3 of NFPA 99. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.
Chapter 6-4.2.2 of NFPA 110, requires diesel-powered EPS installations that do not meet the requirements of Chapter 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
This deficient practice could affect all occupants of the facility.

Findings include:

Based on review of generator load testing documentation with the Plant Operations Manager from 1:45 p.m. to 3:45 p.m. on 06/25/14, the load information to show the actual load percentage for the diesel powered generator was not documented. Based on interview at the time of record review, the Plant Operations Manager acknowledged the generator ran under load on a weekly basis but does not achieve 30 % of the name plate rating. Additionally, the Plant Operations Manager acknowledged a load bank test for the generator had not occurred within the past year.

2. Based on observation and interview, the facility failed to provide emergency task lighting in and around the generator set in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 7.9.2.3 requires that emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery powered emergency lighting. This deficient practice could affect all occupants of the facility.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the generator set was inside an enclosure within a fenced in area and was not provided with a battery powered emergency light for task lighting. Based on interview at the time of observation, Plant Operations Manager acknowledged battery powered emergency task lighting was not provided.

3. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was provided with a functioning remote alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires 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. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
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:
1. Low lubricating oil pressure.
2. Low water temperature.
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. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., a remote alarm annunciator for the generator was provided at the inpatient nurses station but was not functional. Based on interview at the time of observation, the Plant Operations Manager acknowledged the generator remote annunciator was not functional and indicated the generator is slated to be replaced and will have a compliant annunciator.

4. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators with over 100 horsepower was equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Plant Operations Manager during a tour of the facility on 06/25/14 from 11:30 a.m. to 1:30 p.m., the generator in the exterior enclosure was not equipped with a remote manual stop switch. Based on an interview at the time of observation, the Plant Operations Manager acknowledged the generator engine provides more than 100 horsepower and lacks a remote manual stop station.