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Based on observation, record review, and interview, the facility failed to provide documentation of five of twelve required fire drills for the 12 month period prior to the day of survey. Failure to train and exercise personnel in emergency procedures could result in panic and confusion in a true emergency. The deficient practice affected three of three smoke compartments, staff, visitors, and patients. The facility is licensed for 13 beds with a census of zero the day of survey.

Findings include:

During review of the facility's fire drill reports for the year prior to the survey on 08/08/13 at 10:19 a.m., the facility was unable to provide documented fire drills for the first and second shifts of the first quarter 2013, the first and second shift of the third quarter 2012 and the first shift of the fourth quarter of 2012. Interview with the Support Services Manager on 08/08/13 at 10:19 a.m., revealed that the facility thought they could count fire drills in off-site buildings as fire drills in the hospital..

This finding was acknowledged by the Chief Executive Officer and verified by the Support Services Manager at the exit interview on 08/08/13.

Actual NFPA Standard: NFPA 101, 19.7.1.2. Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions to simulate the unusual conditions occurring in case of fire.

Based on observation, interview, and record review, the facility failed to properly maintain the water based fire protection systems. Maintaining the sprinkler system helps to ensure system and system component reliability. The deficient practice affected three of three smoke compartments, staff, visitors, and all patients. The facility is licensed for 13 beds with a census of zero the day of survey. Findings include:

1.) During record review of the facility's automatic (wet) sprinkler system's inspection and testing reports for the 12 month period prior to the day of survey on 08/08/13 at 8:50 a.m., the facility was unable to provide a documented quarterly test report of the automatic (wet) sprinkler system's water flow, supervisory and pressure switch devices for the second quarter of 2013. Interview with the Support Services Manager on 08/08/13 at 8:50 a.m., revealed the facility was aware of the requirement for quarterly testing of the automatic (wet) sprinkler system's water flow alarm, supervisory, and pressure switch devices but was unaware of the missing second quarter test.

2.) During record review of the facility's sprinkler testing reports for the last 60 month period on 08/08/13 at 9:45 a.m., the facility was unable to provide any documented 5 year internal piping inspection reports of the automatic sprinkler system. Interview with the Support Services Manager on 08/08/13 at 8:45 a.m., revealed the facility was not aware of the 5 year internal piping inspection had not been performed.

3.) During the facility tour on 08/08/13 at 11:50 a.m., it was observed that data cables were attached to the sprinkler system piping in the IT room. Interview on 08/08/13 at 11:50 a.m., with the Support Services Manager revealed that the facility was not aware that the data cables were attached to the sprinkler system piping.

These findings were acknowledged by the Chief Executive Officer and verified by the Support Services Manager at the exit interview on 08/08/13.

Actual NFPA Standards:

Item 1.) Actual NFPA Standard: NFPA 25, 2-3.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water-flow devices and pressure switches that provide audible or visual signals shall be tested quarterly.

Item 2.) NFPA 25, 10-2.2 Obstruction Prevention. Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Item 3.) NFPA 13, NFPA 13, 6-1.1.5 Sprinkler piping or hangers shall not be used to support nonsystem components.

Based on observation, interview, and record review, the facility failed to provide a properly maintained and installed kitchen hood suppression system, failed to provide documented semiannual maintenance of the kitchen hood suppression and exhaust system at a minimum interval of at least every six months and failed to locate grease producing cooking appliances under the kitchen hood. Maintaining the hood helps to reduce the possibility of a hood fire occurring, and helps to ensure suppression system component reliability in the event of a fire.The deficient practice affected one of three smoke compartments, staff, visitors and patients. The facility is licensed for 13 beds with a census of zero the day of the survey.

Findings include:

1.) During record review for the 12 month period prior to the day of survey on 08/08/13 at 9:50 a.m., the facility was unable to provide documented inspection and test reports for semi-annual maintenance of the kitchen hood exhaust system. The reports reflect annual inspection and maintenance was performed on 04/02/13 and 04/17/12. Interview on 08/08/13 at 9:50 a.m., with the Support Services Manager disclosed the facility was unaware of the six month inspection and servicing interval.

2.) During record review of the annual test report for semi-annual maintenance of the kitchen hood suppression and exhaust system on 08/08/13 at 9:55 a.m., the facility was unable to provide evidence that the deficiency noted on the 04/02/13 inspection report was corrected. The inspection report noted the following deficiency: "Fan is hard wired to the top of the ductwork and cannot be tilted. Top of the ductwork is not grease tight". Interview with the y Support Services Manager on 08/08/13 at 9:55 a.m., revealed the facility was not aware of the documented deficiency on the inspection report.

3.) Observation on 08/08/13 at 10:55 a.m., revealed that the facility failed locate the portable table top deep fat fryer under the kitchen hood where the grease laden vapors can be collected and the appliance can be protected by the kitchen hood fire suppression system. Interview with the Support Services Manager on 08/08/13 at 10:55 a.m., revealed the facility was not aware the fryer was required to be under the kitchen hood.

These findings were acknowledged by the Chief Executive Officer and verified by the Support Services Manager at the exit interview on 08/08/13.

Actual NFPA Standard(s):

Item 1.) NFPA 96 8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1. 8-3.1.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

Item 2.) NFPA 96 2-1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood ' s lower outermost perimeter. Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made greasetight. 5-1.1 Approved upblast fans with motors surrounded by the airstream shall be hinged, supplied with flexible weatherproof electrical cable and service hold-open retainers, and listed for this use

Item 3.) NFPA 96 7-1.2 Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment. 9-1.2.2 Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior reevaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire-extinguishing system.

Based on observation and interview, the facility failed to provide the required protective features for storage of oxygen. The deficient practice affected three of three smoke compartments, staff, visitors, and patients. The facility is licensed for 13 beds with a census of zero the day of survey.

Findings include:

1.) On 08/08/13 at 11:30 a.m., it was observed that the storage of 4 "K" type oxygen cylinders in the compressed gas storage room, were not individually secured and located to prevent falling or being knocked over. Cylinders that are not properly secured could fall over and possibly rupture. Interview with the Support Services Manager on 08/08/13 at 11:30 a.m., revealed that the facility was not aware of the requirement that oxygen gas cylinders were to be individually secured and located to prevent falling or being knocked over.

2.) On 08/08/13 at 11:35 a.m., it was observed that combustible fabric was stored on top of two 160-liter Dewars oxygen storage vessels attached to the compressed gas manifold. Fabric saturated in oxygen could create an environment that can increase the possibility for ignition of a fire. Interview with the Support Services Manager on 08/08/13 at 11:35 a.m., revealed that the facility was not aware of the requirement that combustible materials shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide.

3.) On 08/08/13 at 11:40 a.m., it was observed that the storage of four 160-liter Dewars oxygen storage vessels, were stored outside of the building against the exterior wall of the compressed gas storage room, in an area that was not secure from unauthorized entry. Unauthorized tampering with these vessels could result in a catastrophic event. Interview with the Support Services Manager on 08/08/13 at 11:40 a.m., revealed that the facility was not aware of the requirement that oxygen gas cylinders are to be stored in an enclosure secure from unauthorized entry.

The finding was acknowledged by the Chief Executive Officer and verified by the Support Services Manager at the exit interview on 04/25/12.

Item 1.) Actual NFPA Standard: NFPA 99, 4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Item 2.) Actual NFPA Standard: NFPA 99, 4-3.1.1.2 (a)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.

Item 2.) Actual NFPA Standard: NFPA 99, 8-3.1.11.2 (a). Storage for nonflammable gases less than 3000 ft3 (85 m3) shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

Based on record review and interview, the facility failed to inspect and load test the Emergency Power Supply System (EPSS). Failure to load test the generator monthly could result in the generator not starting or functioning properly in the event of a power outage. The deficient practice affected three of three smoke compartments, staff, visitors, and patients. The facility is licensed for 13 beds and at the time of the survey, the census was zero.

Findings include:

Record review on 08/08/13 at 10:00 a.m., of the facility's generator inspection logs for the calendar year prior to the survey indicated that the generator was being tested under load on a monthly basis for 20 minutes. Interview with the Support Services Manager on 08/08/13 at 10:00 a.m.,disclosed the facility was not aware testing under load was required for a minimum of 30 minutes each month.

This finding was acknowledged by the Chief Executive Office and verified by the Support Services Manager at the exit interview on 08/08/13.

Actual NFPA Standards:
NFPA 110, 6-3.4
A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer

NFPA 110, 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.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

NFPA 110, 6-4.2
Generator sets in Level 1 and Level 2 service shall 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.

Actual NFPA 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.

Based on observation and interview, the facility failed to ensure electrical wiring was in accordance with the National Electrical Code. The deficient practice affected three of three smoke compartments, staff, visitors, and patients. The facility is licensed for 13 beds with a census of zero the day of survey.

Findings include:

1.) Observation on 08/08/13 at 10:30 a.m., revealed electric circuit breakers were not labeled in breaker panels labeled N2, N4, and N5 as to what they control. Unlabeled circuits could lead to a fire or shock injury when the need to de-energize a circuit in an expedient manner arises. Interview with the Support Services Manager on 08/08/13 revealed that the facility was not aware the circuits were not properly labeled.

2. On 08/08/13 at 11:10 a.m., a relocatable power tap (power strip) was observed not be used in accordance with the listing and labeling of said equipment (computer, AV equipment, and peripherals) on battery chargers in the sterile processing room. Utilizing relocatable power taps can lead to overloaded wiring and start a fire. Interview with the Support Services Manager on 08/08/13 at 11:10 a.m. indicated the facility was not aware the power tap was being utilized.

These findings were acknowledged by the Chief Executive Officer and verified by the Support Services Manager at the exit interview on 08/08/13.

Actual NFPA Standard(s):

Item 1.) NFPA 70, 110-22 Identification of Disconnecting Means
Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

Item 2.) NFPA 70,110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Based on observation, record review, and interview, the facility failed to provide documentation of five of twelve required fire drills for the 12 month period prior to the day of survey. Failure to train and exercise personnel in emergency procedures could result in panic and confusion in a true emergency. The deficient practice affected three of three smoke compartments, staff, visitors, and patients. The facility is licensed for 13 beds with a census of zero the day of survey.

Findings include:

During review of the facility's fire drill reports for the year prior to the survey on 08/08/13 at 10:19 a.m., the facility was unable to provide documented fire drills for the first and second shifts of the first quarter 2013, the first and second shift of the third quarter 2012 and the first shift of the fourth quarter of 2012. Interview with the Support Services Manager on 08/08/13 at 10:19 a.m., revealed that the facility thought they could count fire drills in off-site buildings as fire drills in the hospital..

This finding was acknowledged by the Chief Executive Officer and verified by the Support Services Manager at the exit interview on 08/08/13.

Actual NFPA Standard: NFPA 101, 19.7.1.2. Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions to simulate the unusual conditions occurring in case of fire.

Based on observation, interview, and record review, the facility failed to properly maintain the water based fire protection systems. Maintaining the sprinkler system helps to ensure system and system component reliability. The deficient practice affected three of three smoke compartments, staff, visitors, and all patients. The facility is licensed for 13 beds with a census of zero the day of survey. Findings include:

1.) During record review of the facility's automatic (wet) sprinkler system's inspection and testing reports for the 12 month period prior to the day of survey on 08/08/13 at 8:50 a.m., the facility was unable to provide a documented quarterly test report of the automatic (wet) sprinkler system's water flow, supervisory and pressure switch devices for the second quarter of 2013. Interview with the Support Services Manager on 08/08/13 at 8:50 a.m., revealed the facility was aware of the requirement for quarterly testing of the automatic (wet) sprinkler system's water flow alarm, supervisory, and pressure switch devices but was unaware of the missing second quarter test.

2.) During record review of the facility's sprinkler testing reports for the last 60 month period on 08/08/13 at 9:45 a.m., the facility was unable to provide any documented 5 year internal piping inspection reports of the automatic sprinkler system. Interview with the Support Services Manager on 08/08/13 at 8:45 a.m., revealed the facility was not aware of the 5 year internal piping inspection had not been performed.

3.) During the facility tour on 08/08/13 at 11:50 a.m., it was observed that data cables were attached to the sprinkler system piping in the IT room. Interview on 08/08/13 at 11:50 a.m., with the Support Services Manager revealed that the facility was not aware that the data cables were attached to the sprinkler system piping.

These findings were acknowledged by the Chief Executive Officer and verified by the Support Services Manager at the exit interview on 08/08/13.

Actual NFPA Standards:

Item 1.) Actual NFPA Standard: NFPA 25, 2-3.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water-flow devices and pressure switches that provide audible or visual signals shall be tested quarterly.

Item 2.) NFPA 25, 10-2.2 Obstruction Prevention. Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Item 3.) NFPA 13, NFPA 13, 6-1.1.5 Sprinkler piping or hangers shall not be used to support nonsystem components.

Based on observation, interview, and record review, the facility failed to provide a properly maintained and installed kitchen hood suppression system, failed to provide documented semiannual maintenance of the kitchen hood suppression and exhaust system at a minimum interval of at least every six months and failed to locate grease producing cooking appliances under the kitchen hood. Maintaining the hood helps to reduce the possibility of a hood fire occurring, and helps to ensure suppression system component reliability in the event of a fire.The deficient practice affected one of three smoke compartments, staff, visitors and patients. The facility is licensed for 13 beds with a census of zero the day of the survey.

Findings include:

1.) During record review for the 12 month period prior to the day of survey on 08/08/13 at 9:50 a.m., the facility was unable to provide documented inspection and test reports for semi-annual maintenance of the kitchen hood exhaust system. The reports reflect annual inspection and maintenance was performed on 04/02/13 and 04/17/12. Interview on 08/08/13 at 9:50 a.m., with the Support Services Manager disclosed the facility was unaware of the six month inspection and servicing interval.

2.) During record review of the annual test report for semi-annual maintenance of the kitchen hood suppression and exhaust system on 08/08/13 at 9:55 a.m., the facility was unable to provide evidence that the deficiency noted on the 04/02/13 inspection report was corrected. The inspection report noted the following deficiency: "Fan is hard wired to the top of the ductwork and cannot be tilted. Top of the ductwork is not grease tight". Interview with the y Support Services Manager on 08/08/13 at 9:55 a.m., revealed the facility was not aware of the documented deficiency on the inspection report.

3.) Observation on 08/08/13 at 10:55 a.m., revealed that the facility failed locate the portable table top deep fat fryer under the kitchen hood where the grease laden vapors can be collected and the appliance can be protected by the kitchen hood fire suppression system. Interview with the Support Services Manager on 08/08/13 at 10:55 a.m., revealed the facility was not aware the fryer was required to be under the kitchen hood.

These findings were acknowledged by the Chief Executive Officer and verified by the Support Services Manager at the exit interview on 08/08/13.

Actual NFPA Standard(s):

Item 1.) NFPA 96 8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1. 8-3.1.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

Item 2.) NFPA 96 2-1.2 All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood ' s lower outermost perimeter. Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made greasetight. 5-1.1 Approved upblast fans with motors surrounded by the airstream shall be hinged, supplied with flexible weatherproof electrical cable and service hold-open retainers, and listed for this use

Item 3.) NFPA 96 7-1.2 Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment. 9-1.2.2 Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior reevaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire-extinguishing system.

Based on observation and interview, the facility failed to provide the required protective features for storage of oxygen. The deficient practice affected three of three smoke compartments, staff, visitors, and patients. The facility is licensed for 13 beds with a census of zero the day of survey.

Findings include:

1.) On 08/08/13 at 11:30 a.m., it was observed that the storage of 4 "K" type oxygen cylinders in the compressed gas storage room, were not individually secured and located to prevent falling or being knocked over. Cylinders that are not properly secured could fall over and possibly rupture. Interview with the Support Services Manager on 08/08/13 at 11:30 a.m., revealed that the facility was not aware of the requirement that oxygen gas cylinders were to be individually secured and located to prevent falling or being knocked over.

2.) On 08/08/13 at 11:35 a.m., it was observed that combustible fabric was stored on top of two 160-liter Dewars oxygen storage vessels attached to the compressed gas manifold. Fabric saturated in oxygen could create an environment that can increase the possibility for ignition of a fire. Interview with the Support Services Manager on 08/08/13 at 11:35 a.m., revealed that the facility was not aware of the requirement that combustible materials shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide.

3.) On 08/08/13 at 11:40 a.m., it was observed that the storage of four 160-liter Dewars oxygen storage vessels, were stored outside of the building against the exterior wall of the compressed gas storage room, in an area that was not secure from unauthorized entry. Unauthorized tampering with these vessels could result in a catastrophic event. Interview with the Support Services Manager on 08/08/13 at 11:40 a.m., revealed that the facility was not aware of the requirement that oxygen gas cylinders are to be stored in an enclosure secure from unauthorized entry.

The finding was acknowledged by the Chief Executive Officer and verified by the Support Services Manager at the exit interview on 04/25/12.

Item 1.) Actual NFPA Standard: NFPA 99, 4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Item 2.) Actual NFPA Standard: NFPA 99, 4-3.1.1.2 (a)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.

Item 2.) Actual NFPA Standard: NFPA 99, 8-3.1.11.2 (a). Storage for nonflammable gases less than 3000 ft3 (85 m3) shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

Based on record review and interview, the facility failed to inspect and load test the Emergency Power Supply System (EPSS). Failure to load test the generator monthly could result in the generator not starting or functioning properly in the event of a power outage. The deficient practice affected three of three smoke compartments, staff, visitors, and patients. The facility is licensed for 13 beds and at the time of the survey, the census was zero.

Findings include:

Record review on 08/08/13 at 10:00 a.m., of the facility's generator inspection logs for the calendar year prior to the survey indicated that the generator was being tested under load on a monthly basis for 20 minutes. Interview with the Support Services Manager on 08/08/13 at 10:00 a.m.,disclosed the facility was not aware testing under load was required for a minimum of 30 minutes each month.

This finding was acknowledged by the Chief Executive Office and verified by the Support Services Manager at the exit interview on 08/08/13.

Actual NFPA Standards:
NFPA 110, 6-3.4
A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer

NFPA 110, 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.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

NFPA 110, 6-4.2
Generator sets in Level 1 and Level 2 service shall 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.

Actual NFPA 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.

Based on observation and interview, the facility failed to ensure electrical wiring was in accordance with the National Electrical Code. The deficient practice affected three of three smoke compartments, staff, visitors, and patients. The facility is licensed for 13 beds with a census of zero the day of survey.

Findings include:

1.) Observation on 08/08/13 at 10:30 a.m., revealed electric circuit breakers were not labeled in breaker panels labeled N2, N4, and N5 as to what they control. Unlabeled circuits could lead to a fire or shock injury when the need to de-energize a circuit in an expedient manner arises. Interview with the Support Services Manager on 08/08/13 revealed that the facility was not aware the circuits were not properly labeled.

2. On 08/08/13 at 11:10 a.m., a relocatable power tap (power strip) was observed not be used in accordance with the listing and labeling of said equipment (computer, AV equipment, and peripherals) on battery chargers in the sterile processing room. Utilizing relocatable power taps can lead to overloaded wiring and start a fire. Interview with the Support Services Manager on 08/08/13 at 11:10 a.m. indicated the facility was not aware the power tap was being utilized.

These findings were acknowledged by the Chief Executive Officer and verified by the Support Services Manager at the exit interview on 08/08/13.

Actual NFPA Standard(s):

Item 1.) NFPA 70, 110-22 Identification of Disconnecting Means
Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

Item 2.) NFPA 70,110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.