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Based on observations and confirmed by staff, the facility failed to assure that the 2-hour fire walls / horizontal exit, between the healthcare occupancy (Rehab Hospital) and the non healthcare occupancy (Community Center) is properly maintained. NFPA section 18.1.2.1 states that sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours. Section 18.1.1.4.2 states communicating openings in dividing fire barriers required by Section 18.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing doors. Section 18.2.2.2.6 states any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with Section 7.2.1.8.2. Section 7.2.1.8.2 includes the following:
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.

THE FINDINGS INCLUDE:

During a facility tour of the Rehab Hospital on the afternoon of 7/22/14 it was observed that the pair of ninety (90) minute fire rated horizontal exit doors, which are included in the required two hour fire rated separation between the healthcare and business occupancies, do not conform to Section 18.1.1.4.2. Observations at time of survey revealed that one of the doors automatic self-closing devices had been disconnected. As a result the door is incapable of automatically closing or self-closing and is non-compliant with Section 18.1.1.4.2 and Section 7.2.1.8.2 of NFPA #101 Life Safety Code 2000 Edition.

The findings were confirmed by the Director of Plant Services during the exit conference.

A. Based on observation, the facility failed to ensure compliance with Section 18.3.6.1 which requires corridors to be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5.
However, kitchens can be open to an exit corridor under certain circumstances in accordance with NFPA 101, 2012 edition, Sections 18/19.3.2.5 based upon the CMS issued S&C letter, S&C 12-21.
NFPA 101, 2012 edition states the following:
18.3.2.5 Cooking Facilities.
18.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 18.3.2.5.2, 18.3.2.5.3,or 18.3.2.5.4.
18.3.2.5.2* Where residential cooking equipment is used for food warming or limited cooking, the equipment shall not be required to be protected in accordance with 9.2.3, and the presence of the equipment shall not require the area to be protected as a hazardous area.
18.3.2.5.3* Within a smoke compartment, where residential or commercial cooking equipment is used to prepare meals for 30 or fewer persons, one cooking facility shall be permitted to be open to the corridor, provided that all of the following conditions are met:
(1) The portion of the health care facility served by the cooking facility is limited to 30 beds and is separated from other portions of the health care facility by a smoke barrier constructed in accordance with 18.3.7.3,
18.3.7.6, and 18.3.7.8.
(2) The cooktop or range is equipped with a range hood of a width at least equal to the width of the cooking surface, with grease baffles or other grease-collecting and clean-out capability.
(3)*The hood systems have a minimum airflow of 500 cfm (14,000 L/min).
(4) The hood systems that are not ducted to the exterior additionally have a charcoal filter to remove smoke and odor.
(5) The cooktop or range complies with all of the following:
(a) The cooktop or range is protected with a fire suppression system listed in accordance with UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Commercial Cooking Equipment, or is tested and meets all requirements of UL 300A, Extinguishing System Units for Residential Range Top Cooking Surfaces, in accordance with the applicable testing document ' s scope.
(b) A manual release of the extinguishing system is provided in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 10.5.
(c) An interlock is provided to turn off all sources of fuel and electrical power to the cooktop or range when the suppression system is activated.
(6)*The use of solid fuel for cooking is prohibited.
(7)*Deep-fat frying is prohibited
(8) Portable fire extinguishers in accordance with NFPA 96 are located in all kitchen areas.
(9)*A switch meeting all of the following is provided:
(a) A locked switch, or a switch located in a restricted location, is provided within the cooking facility that deactivates the cooktop or range.
(b) The switch is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision.
(c) The switch is on a timer, not exceeding a 120-minute capacity that automatically deactivates the cooktop or range, independent of staff action.
(10) Procedures for the use, inspection, testing, and maintenance of the cooking equipment are in accordance with Chapter 11 of NFPA 96 and the manufacturer ' s instructions and are followed.
(11)*Not less than two AC-powered photoelectric smoke alarms, interconnected in accordance with 9.6.2.10.3, equipped with a silence feature, and in accordance with NFPA 72,National Fire Alarm and Signaling Code, are located not closer than 20 ft (6.1 m) from the cooktop or range.
(12) No smoke detector is located less than 20 ft (6.1m) from the cooktop or range.
18.3.2.5.4* Within a smoke compartment, residential or commercial cooking equipment that is used to prepare meals for 30 or fewer persons shall be permitted, provided that the cooking facility complies with all of the following conditions:
(1) The space containing the cooking equipment is not a sleeping room.
(2) The space containing the cooking equipment is separated from the corridor by partitions complying with 18.3.6.2 through 18.3.6.5.
(3) The requirements of 18.3.2.5.3(1) through (10) are met.
18.3.2.5.5* Where cooking facilities are protected in accordance with 9.2.3, the presence of the cooking equipment shall not cause the room or space housing the equipment to be classified as a hazardous area with respect to the requirements of 18.3.2.1, and the room or space shall not be permitted to be open to the corridor.


THE FINDINGS INCLUDE:

During the afternoon hours of 7/21/14 while touring the facility it was found that the fifteen open residential kitchens are not in compliance with NFPA 101, 2012 edition, Sections 18/19.3.2.5. The kitchens are located as follows:
Level 1- three open residential kitchens
Level 2- six open residential kitchens
Level 3 - six open residential kitchens
The fifteen open kitchens are not in compliance specifically with Section 18.3.2.5 (4), Section 18.3.2.5 (5), and Section 18.3.2.5 (11).

B. Based on observations and confirmed by staff, the facility failed to ensure compliance with NFPA #101 Life Safety Code 2000 Edition. Chapter 18, Section 18.3.6.2. states corridor walls shall form a barrier to limit the transfer of smoke. Such walls shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

THE FINDINGS INCLUDE:

During the afternoon hours of 7/21/14 while touring the facility a two (2) inch x three (3) inch void was discovered, above the layed-in ceiling tiles, in the corridor wall on the 3rd floor North East House near room 7303. Observations further revealed that the corridor ceilings, which are of the suspended type, are not constructed to limit the transfer of smoke. As such the corridor walls are required to be continuous and without penetrations to the deck above.
As a result of the findings the facility is found to be non-compliant with NFPA #101 Chapter 18. Section 18.3.6.2.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations, the facility failed to ensure that doors protecting corridor openings are in compliance with section 19.3.6.3.

THE FINDINGS INCLUDE:

The following was observed on 7/22/14 and 7/23/14:

1) The corridor doors to patient rooms #520 and #531 are not constructed as required. Each room has a modified 48" wide Dutch door. The top leaf has been secured to the bottom leaf on both the corridor and room side by a 2" x 46" strip of metal. A 3/4" X 1/2" gap remains on both latch and hinge side of the doors.

2) The corridor door to the B1 level Pharmacy has a 1/4" gap between the vision panel and the steel frame.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observation and confirmed by staff, corridor walls are not constructed as required. Section 19.3.6.2.3 states fixed fire window assemblies in accordance with 8.2.3.2.2 shall be permitted in corridor walls. Section 8.2.3.2.2 states fire window assemblies shall be permitted in fire barriers having a required fire resistance rating of 1 hour or less and shall be of an approved type with the appropriate fire protection rating for the location in which they are installed. The Exception to 19.3.6.2.3 does not restrict in area or fire resistance of the glass used in corridor walls and doors in smoke compartments protected throughout by automatic sprinklers.

THE FINDINGS INCLUDE:

On 7/23/14 it was observed that plain glass vision panels are installed in corridor walls in the Fiscal Office. The plain glass vision panels do not meet Exception to 19.3.6.2.3 because the following areas of Berenson B1 were not provided with sprinkler protection.

- The upper level of the ceiling in the Fiscal Office where two new offices were installed,
- The approximate 18" x 18" closet located within the Fiscal Office, and
- The old walk-in refrigerator area of the kitchen.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations, the facility failed to assure that vertical shafts are enclosed as required.

THE FINDINGS INCLUDE:

THE FINDING INCLUDES:

On 7/22/14 and 7/23/14 it was observed that:

1) The two electrical closets, located on the north and south sides of the service corridor are stacked on top of each other from floor level 1 through floor level 5. Each of these closets is equipped with 2 bus ducts that penetrate the floor at each level. The area around the ducts are not properly fire sealed/stopped in many locations as light is visible from floor to floor. As a result, the electrical room floor openings are creating a non-sealed vertical shaft.
Note: The electrical rooms are not constructed to meet the requirements of a shaft.

2) The trash chute discharge room located on the B1 level is not constructed as required. The masonry block corridor wall to the discharge room has unsealed voids above the in-lay ceiling tiles around BX electrical tubing and around HVAC duct.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations, plan review, and confirmed by staff, the facility failed to provide smoke barrier walls with a 1-hour fire rating assembly.

THE FINDINGS INCLUDE:

During the afternoon hours of 7/21/14 while touring the facility, it was observed that the smoke barrier wall located on the 3rd floor North East House had a 3" x 3" void in the corridor wall above the suspended ceiling.

This was acknowledged by facility personnel during the tour and by Administration and the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

NFPA 80, 2009 Standard for Fire Doors and Fire Windows, 2009 edition, Section 1-11.4 states clearances under the bottoms of doors shall be in accordance with Table 1-11.4. Table 1-11.4 allows swinging doors with fire door hardware to have a clearance of 1/2 inch.

THE FINDINGS INCLUDE:

1) On 7/22/14 at 2:45 P.M., the soiled utility room door by room #243 was tested for proper operation. It was observed that the striker plate was filled with paper towels preventing the door from achieving positive latching as required.
Note: This was removed when brought to the staff's attention.

2) On 7/23/14, it was noted that two sets of corridor doors to the kitchen do not self-close and latch as required due to an air pressure differential between the kitchen and the corridor.

3) On 7/23/14 it was noted that the set of corridor doors to the dishwashing room, which is part of the kitchen, has a 1 3/4" minimum under cut which is greater that the allowed 1/2 inch.

4) On 7/23/14 it was observed that the double doors and the single door which lead from the Main Dining Room to the kitchen are not equipped with the required latching hardware.

5) On 7/23/14, it was noted that the electrical room located on the B1 level in the Fiscal Office is not smoke tight to due to two approximate 1 1/2" voids located around the conduit which penetrates the ceiling.

6) On 7/23/14 it was noted that the two electrical closets locate on the B1 level in the Resident Dining Room are not smoke tight due to voids in the walls and ceiling.

7) On 7/23/14 it was observed that the double doors from the corridor to Central Storage are not smoke resisting due to the gap at the meeting edges which is greater than 1/4 inch.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.


16934

Based on observations, the facility failed to ensure that exit stairways are enclosed as required.

Section 7.7.2 states that not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall be permitted to discharge through areas on the level of exit discharge, provided that the criteria of 7.7.2(1) through (3) are met:
(1) Such discharge shall lead to a free and unobstructed way to the exterior of the building, and such way is readily visible and identifiable from the point of discharge from the exit.
(2) The level of discharge shall be protected throughout by an approved, automatic sprinkler system in accordance with Section 9.7, or the portion of the level of discharge used for this purpose shall be protected by an approved, automatic sprinkler system in accordance with Section 9.7 and shall be separated from the nonsprinklered portion of the floor by a fire resistance rating meeting the requirements for the enclosure of exits (see 7.1.3.2.1).
Exception: The requirement of 7.7.2(2) shall not apply where the discharge area is a vestibule or foyer meeting all of the following:
(a) The depth from the exterior of the building shall not be more than 10 ft (3 m) and the length shall not be more than 30 ft (9.1 m).
(b) The foyer shall be separated from the remainder of the level of discharge by construction providing protection not less than the equivalent of wired glass in steel frames.
(c) The foyer shall serve only as means of egress and shall include an exit directly to the outside.
(3) The entire area on the level of discharge shall be separated from areas below by construction having a fire resistance rating not less than that required for the exit enclosure.
Exception: Levels below the level of discharge shall be permitted to be open to the level of discharge in an atrium in accordance with 8.2.5.6.
Exception No. 1: One hundred percent of the exits shall be permitted to discharge through areas on the level of exit discharge as provided in Chapters 22 and 23.
Exception No. 2: In existing buildings, the 50 percent limit on egress capacity shall not apply if the 50 percent limit on the required number of exits is met.


THE FINDINGS INCLUDE:

Observations while touring the facility on 7/22/14 and 7/23/14 revealed that:

1) Each of the building's - north east, north west, south east, south west, and center - stair towers have unsealed voids on the stair side and above the in-lay ceiling tiles on the corridor side. These voids were noted on the B1, first, second, third, fourth and fifth floor levels around sprinkler pipe, hot/cold chiller pipe, and electric metal tubing penetrations.

2) The B1 level center stair discharge corridor, noted as a two hour fire rated enclosure on the facility's floor plans dated 9/28/09, has unsealed voids above the in-lay ceiling tiles. These voids were noted around sprinkler pipe, hot/cold chiller pipe, electric metal tubing and security wire penetrations. Larger voids, where 12" x 12" pieces of gypsum wallboard were removed and not replaced, were also noted.

3) The HIS/QA office, located along the B1 level center stair discharge corridor, has a 45 minute rated door.

4) On 7/22/14 at the fifth floor level and first floor level of the south west stair tower, it was noted that the respective stair door did not close and latch in the door frame. When released from the open position, each door's latch mechanism failed to overcome the resistance at the strike plate. Note: This item was noted as repaired on 7/23/14 prior to the exit interview.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations, the facility failed to keep stair landings clear in accordance with the requirements. Section 7.2.2.5.3 requires that there be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure.

THE FINDINGS INCLUDE:

Observations while touring the facility on 7/23/14 revealed that the B1 center stair discharge corridor, across from the HIS/QA office, is utilized to store four (4) approximate gallon shred/recycle bins and a wheeled wooden ramp.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that egress routes are constructed as required. Section 7.7.1 states exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
7.1.10.1 states means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

THE FINDINGS INCLUDE:

During the morning hours of 7/23/14 at approximately 10:30 A.M., it was observed that the required stairwell egress from the cafeteria leads to an exterior grass lawn. There is no walkway provided to ensure the means of egress is always free of obstructions that would prevent its use, such as ice, sleet, snow and the need for its removal in climates such as the Northeast region. In addition, the lawn has an approximate grade of 20 degrees which slopes upwards towards the driveway.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility was not in compliance with Section 18.2.3.3.

THE FINDINGS INCLUDE:

Observations while touring the building on 7/21/14 revealed that the exit access from each of the six nursing units located on the 1st, 2nd, and 3rd floors does not comply to section 18.2.3.3. . The exit access corridors from each of these nursing units leading to the stairwell is 6 feet in width for a length of 9'6" just prior to the exit door into the stairwell. This does not meet the 8 foot requirement per Section 18.2.3.3.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2000 edition; however it would meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition where such equivalency is requested and approved.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground.

THE FINDINGS INCLUDE:

On 7/23/14 it was observed that the B1 horizontal exit wall is not constructed as shown on the facility floor plans dated 9/28/09.

1. The 2-hour wall separating the Physical Therapy (P.T.) from the P.T. office area has an approximate 24" diameter unsealed void where a 10" x 10" H.V.A.C. duct penetrates the opening. Facility staff indicated that the office area had been utilized as a laundry area and the 24" diameter penetration was more than likely utilized for laundry exhaust purposes.

2. The 2-hour wall separating the Berger Building's B1 corridor from the Berenson Building's corridor has several unsealed voids in the wall above the in-lay ceiling tiles at the cross corridor doors along the north and south sides of the Information Technologies (I.T.) offices. These voids were noted around sprinkler pipe, hot/cold chiller pipe, electric metal tubing, and security wire penetrations.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that egress lighting is properly provided. Section 7.8.1.2 requires all illumination in the means of egress be continuous during the time that the conditions of occupancy require that the means of egress be available for use.

THE FINDINGS INCLUDE:

Observations while touring the facility on 7/23/14 at 10:15 A.M. revealed that the lighting in the stairwell leading from the cafeteria is not maintained as required. The stairwell was found in complete darkness as none of the fluorescent light fixtures were illuminated.
Note: The facility was in the process of changing the ballasts & bulbs in all of the fixtures of this stairwell.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler heads are installed as required. NFPA 13 section 5-6.4.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).

THE FINDINGS INCLUDE:

During the morning hours of 7/21/14 between the hours of 10:50 A.M. and 12:15 P.M, the following items were observed regarding the sprinkler system:
Note: The space above the lay-in ceiling tiles to the actual roof deck above on the 6th floor level is approximately 4' in height.

1) The 6th floor house keeping closet by room #649 is missing two ceiling tiles. As a result, the sprinkler heads are located a distance of approximately 4' below the decking above compromising the reliability of the sprinkler system.

2) The 6th floor Data room is missing three ceiling tiles. As a result, the sprinkler heads are located a distance of approximately 4' below the decking above compromising the reliability of the sprinkler system.

3) The two sprinklered closets located on level B1 in the Adult Day Health are missing ceiling tiles. As a result, the sprinkler heads are located a distance greater than 12 inches below the decking above compromising the reliability of the sprinkler system.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff interview, the facility failed to ensure that the heating, ventilating, and air conditioning systems (HVAC) are maintained in accordance with NFPA #90A. NFPA #90A, Section 3.4.7 requires fusible links (where applicable) on fire dampers to be removed; all dampers to be operated to verify that they fully close; the latch, if provided, to be checked; and moving parts to be lubricated as necessary, at least every 4 years.

THE FINDINGS INCLUDE:

Although the required maintenance outlined above is performed on fire dampers that are installed in the HVAC systems throughout floors B1 through the 5th floor, the required maintenance is not being performed for the fire dampers on floor B2.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure compliance with the restrictions of portable space heating devices. Section 9.7.8 states portable space-heating devices shall be prohibited in all health care occupancies.

THE FINDING INCLUDE:

Observations while touring the facility on 7/23/14 at 10:15 A.M. revealed that non-approved portable space heating devices are used in the facility. A total of three (3) electric coil type heaters were observed in the Department of Medicine office area. This type of electric heater exceeds the allowable 212 degrees F.
Note: The devices were not in use when observed, but two of the three were currently plugged in.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that all draperies/curtains are in compliance with section 10.3.1 and the required testing of NFPA 701.

THE FINDINGS INCLUDE:

During the morning hours of 7/21/14 at approximately 11:35 A.M., it was observed that the 6th floor nursing stations (East & West) have been converted into office space areas. Each of these areas has been equipped with an approximate 9' x 4' hanging drape to create some privacy from the corridor. The drapes are not provided with any fabric tags signifying that they meet the requirements of the referenced code.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that paper recycle containers are stored in properly enclosed rated rooms.

THE FINDINGS INCLUDE:

During the morning hours of 7/21/14 at approximately 11:15 A.M. while performing the facility tour, it was observed that two paper recycle containers (64 gallons each in size) are stored in the 6th floor corridor by room #640.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on observations the facility failed to properly store oxygen. NFPA 99, Sections 16.3.8.1, 8.3.1.11.2(h), and 4.3.5.2.1(b) 27 requires freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart. CMS "S&C-07-10" allows up to 300 cubic feet (i.e. 12 E sized cylinders) of nonflammable medical gas to be accessible as an operational supply at locations open to the corridor (located outside of a properly enclosed storage room) when properly secured.

THE FINDINGS INCLUDE:

During a facility tour of the Rehab Hospital on morning of 7/22/14 an unsecured "E" type oxygen cylinder was observed being stored in a closet located in the first floor outpatient rehab gym. As a result, the facility is found to be non-compliant with above listed sections of NFPA 99.

The findings were confirmed by the Director of Plant Services during the exit conference.

Based on observations, the facility failed to ensure the bulk oxygen tank is maintained in accordance with NFPA 50. Sections 2.2.1 and 2.2.1.12 require the minimum distance between any bulk oxygen storage container and any sidewalk or parked vehicle to be at least 10 feet.

THE FINDINGS INCLUDE:

Observations while touring the facility on the morning of 7/22/14 at 9:30 A.M. revealed that a car was parked within four feet of the bulk oxygen tank.

This was confirmed by the Director of Engineering and the facility Administration staff during a summary of survey findings.

Based on observations and confirmed by staff, the facility failed to ensure that liquid oxygen is properly stored/transfilled in accordance with NFPA 99.
Section 4-3.1.1.2 states the following for storage requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130°F (54°C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2. Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].
6. Cylinders containing compressed gases and containers for volatile liquids shall be kept away from radiators, steam piping, and like sources of heat.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.
8. When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
9. Containers shall not be stored in a tightly closed space such as a closet [see 8-2.1.2.3(c)].

THE FINDINGS INCLUDE:

During the afternoon hours of 7/22/14, while touring each of the building floor levels, it was liquid oxygen Dewars are store in the shower rooms opposite patient room # 310 and #110. Both of these rooms were observed to have storage of other items not pertaining to the administering of oxygen.

This was acknowledged by the Vice President of Post Acute Care & the Director of Engineering during the exit interview process.

Based on record review and confirmed by staff interview, the facility failed to ensure that the "Emergency Power Supply System" (EPSS) is maintained and tested in accordance with NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition.
1) NFPA 110 Section 6.4.2 requires generators 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, or (b) loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
2) NFPA 110 Section 6.4.2.2 requires diesel-powered EPS installations that do not meet the requirements of 6.4.2 to 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.

THE FINDINGS INCLUDE:

During the afternoon hours of 7/21/14, at approximately 3:00 P.M., while conducting the record review process it was noted that the monthly load tests of the facility's emergency generator do not exceed thirty (30) percent of the emergency generator's name plate rating. Of the twelve (12) monthly load test reports reviewed all indicated that the facility's generator was being exercised at less than thirty percent of the name plate requirement. When asked if an annual two hour load bank test as described in NFPA 110 Section 6.4.2.2 was conducted, the Director of Plant Services stated no.

Note: Both voltage readings and amperage readings are documented line items on the facility's load test report form.

As a result of the finding the facility is found to be non-compliant with above listed sections of NFPA 110.

The findings were confirmed by the Director of Plant Services during the exit conference.