HospitalInspections.org

19.3.6.3.1, NFPA 101, LIFE SAFETY CODE
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.

19.3.6.3.2, NFPA 101, LIFE SAFETY CODE
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Based on observation and interview the facility failed to ensure that corridor doors close to a latched position.

Findings include:

Observation during tour on 8/31/11 between 2:10 p.m. and 2:20 p.m. with Staff C (Director Plant Operations) and Staff D (Facility Manager) revealed that rooms 314 and 309 which are equipped with self-closing devices on Med Surge West do not close to a latched position.

Interview during tour on 8/31/11 with Staff C and Staff D confirmed the findings at the time of discovery.

19.3.7.6, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.3.4.1, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

A.8.3.4.1, NFPA 101, LIFE SAFETY CODE
The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

1-3.1, NFPA 105, Installation of Smoke-Control Door Assemblies
NFPA 101, Life Safety Code, and building codes include specific requirements for smoke-control door assemblies and should be consulted in every instance. NFPA 80, Standard for Fire Doors and Fire Windows, should be followed when fire door assemblies are used as smoke-control door assemblies.
2-1.1, NFPA 105, Installation of Smoke-Control Door Assemblies
The installation of fire door assemblies is covered by NFPA 80, Standard for Fire Doors and Fire Windows.
2-3.1.7, NFPA 80, FIRE DOORS AND FIRE WINDOWS
The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. !O 1/16 in. (3.18 mm !O 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.

3-1.4, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Operation of Doors: The doors shall swing easily and freely on their hinges. The latches shall operate freely.

8.3.4.3, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that smoke barrier doors operate properly.

Findings include:

Interview during tour on 8/31/11 and 9/2/11 with Staff C (Director Plant Operations) and Staff D (Facility Manager) confirmed the locations of smoke barriers and smoke barrier doors.

Observation during tour on 8/31/11 between 1:00 p.m. and 4:00 p.m. with Staff C and Staff D and during tour on 9/2/11 with Staff D revealed the following:

1. One leaf of the smoke barrier door equipped with fire door hardware on Med Surge West located near the Rehab room failed to latch when closed.

2. The smoke barrier door to Rehab Room 1 located on Med Surge West has the self-closing arm disconnected from the door.

3. The Lobby smoke barrier double doors do not close completely.

4. The smoke barrier double doors in the area of Northwing Radiology have a gap between the meeting edges between 1/4 inch and 3/8 inch.

19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that all entry doors serving hazardous areas close to a latched position.

Findings include:

Observation during tour on 8/31/11 with Staff C (Director Plant Operations) and Staff D (Facility Manager) and during tour on 9/2/11 with Staff D revealed that the ER and the Med Surge East soiled utility rooms equipped with latching devices do not close to a latched position.

Interview during tour on 8/31/11 and 9/2/11 with Staff C and Staff D confirmed the findings.

19.2.1, NFPA 101, LIFE SAFETY CODE
General: Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

19.2.7, NFPA 101, LIFE SAFETY CODE
Discharge from Exits: Discharge from exits shall be arranged in accordance with Section 7.7.

7.1.10.1, NFPA 101, LIFE SAFETY CODE
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.

7.2.1.4.5, NFPA 101, LIFE SAFETY CODE
The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.
Exception No. 1: The opening force for existing doors in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.

7.7.3, NFPA 101, LIFE SAFETY CODE
The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Based on observation and interview the facility failed to ensure that all exit doors operate properly.

Findings include:

Observation during tour on 9/2/11 at approximately 2:15 p.m. with Staff D (Facility Manager) revealed that the exterior door at the lower level does not open when body weight is applied to the door releasing mechanism in the stairwell connecting Med Surge West to the lower level near the Rehabilitation area.

Interview during tour on 9/2/11 with Staff D confirmed the findings at the time of discovery.

19.2.2.5, NFPA 101, LIFE SAFETY CODE
Horizontal Exits: Horizontal exits complying with 7.2.4 and the modifications of 19.2.2.5.1 through 19.2.2.5.4 shall be permitted.

7.2.4.1.1, NFPA 101, LIFE SAFETY CODE
Where horizontal exits are used in the means of egress, they shall conform to the general requirements of Section 7.1 and the requirements of 7.2.4.

7.2.4.3.1, NFPA 101, LIFE SAFETY CODE
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. (See also 8.2.3.)

7.2.4.3.4, NFPA 101, LIFE SAFETY CODE
Any opening in such fire barriers shall be protected as provided in 8.2.3.2.3.

8.2.3.2.3.1, NFPA 101, LIFE SAFETY CODE
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42

8.2.3.2.1, NFPA 101, LIFE SAFETY CODE
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.

2-3.1.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled door frames shall be used.

2-4.4.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled locks and latches or labeled fire exit hardware (panic devices) meeting both life safety requirements and fire protection requirements shall be used.

2-4.4.2, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Fire exit hardware shall be installed only on fire doors bearing the marking, " Fire Door To Be Equipped with Fire Exit Hardware. " Fire exit hardware shall be labeled for both fire and panic. Fire exit hardware shall have a permanently attached label that bears the serial number and shows the manufacturer ' s name and type of approval. The label shall differentiate between panic hardware, which is not acceptable for use on fire doors and fire exit hardware.

2-4.4.3, NFPA 80, FIRE DOORS AND FIRE WINDOWS
All single doors and active leaves of pairs of doors shall be provided with an active latch bolt that cannot be held in a retracted position...

Based on interview and observation the facility failed to ensure that horizontal exits are properly maintained.

Findings include:

Interview during tour on 8/31/11 and 9/2/11 with Staff C (Director Plant Operations) and Staff D (Facility Manager) confirmed the locations of two hour fire barriers and fire doors used as horizontal exits.

Observation during tour on 8/31/11 between 1:00 p.m. and 4:00 p.m. with Staff C and Staff D and during tour on 9/2/11 at approximately 1:30 p.m. with Staff D revealed the following:

1. One of the two leafs of the fire door assembly in the two hour fire barrier separating Med Surge West from other portions of the facility does not close to a latched position.

2. The fire door assembly in the two hour fire barrier separating Med Surge East from the Birthing Center has painted fire rating labels, penetrations in the face of the door leaf from where a portion of the door handle assembly is missing, and a door handle assembly without any indication of the fire rating.

Interview during tour on 8/31/11 and 9/2/11 with Staff C and Staff D confirmed the findings.

19.3.4.1, NFPA 101, LIFE SAFETY CODE
General: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4, NFPA 101, LIFE SAFETY CODE
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

2-3.5.1, NFPA 72, NATIONAL FIRE ALARM CODE
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1, NFPA 72, NATIONAL FIRE ALARM CODE
Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

Based on observation and interview the facility failed to ensure that fire alarm systems are properly maintained.

Findings include:

Observation during tour on 8/31/11 between 1:00 p.m. and 2:30 p.m. with Staff C (Plant Operations Director) and Staff D (Facilities Manager) revealed the following:

1. Two smoke detectors in Med Surge West corridor are located between 1 and 2 feet from HVAC (Heating, Ventilation, and Air Conditioning) ducts.

2. One smoke detectors in the Lobby Coffee Shop is located approximately 1 foot, 6 inches from an HVAC (Heating, Ventilation, and Air Conditioning) duct.

Interview during tour on 8/31/11 with Staff C and Staff D confirmed the findings.

19.3.2.6, NFPA 101, LIFE SAFETY CODE
Cooking Facilities: Cooking facilities shall be protected in accordance with 9.2.3.

9.2.3, NFPA 101, LIFE SAFETY CODE
Commercial Cooking Equipment: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

9-1.2.2, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
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.

7-2.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.

7-2.1.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

7-2.2.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer ' s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

9-2.1, NFPA 17, Standard for Dry Chemical Extinguishing Systems
On a monthly basis, inspection shall be conducted in accordance with the manufacturer ' s listed installation and maintenance manual or owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

9-2.2, NFPA 17, Standard for Dry Chemical Extinguishing Systems
If any deficiencies are found, appropriate corrective action shall be taken immediately.

9-2.3, NFPA 17, Standard for Dry Chemical Extinguishing Systems
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.

9-2.4, NFPA 17, Standard for Dry Chemical Extinguishing Systems
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.

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

5-2.2, NFPA 17A, Standard for Wet Chemical Extinguishing Systems
If any deficiencies are found, appropriate corrective action shall be taken immediately.

5-2.3, NFPA 17A, Standard for Wet Chemical Extinguishing Systems
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.

5-2.4, NFPA 17A, Standard for Wet Chemical Extinguishing Systems
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections.

Based on record review, observation, and interview the facility failed to ensure that cooking facility protection systems are properly maintained.

Findings include:

Record review of inspection documentation during tour on 9/2/11 at approximately 12:00 p.m. with Staff D (Facility Manager) in the Kitchen revealed that monthly inspections of the hood suppression system have not been recorded.

Observation during tour on 9/2/11 with Staff D revealed that there is no signage present in the area of at least one of the Class K extinguishers which advises staff to use the hood suppression system prior to using the Class K extinguisher to control a fire.

Interview during tour on 9/2/11 with Staff D at the time of discovery revealed that the hood suppression system has not been inspected on a monthly basis and confirmed the findings.

4-3.1.1.1, NFPA 99, HEALTH CARE FACILITIES
Cylinder and Container Management: Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2(a)4, NFPA 99, HEALTH CARE FACILITIES
Storage Requirements (Location, Construction, Arrangement): 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.

Based on record review, observation, and interview the facility failed to properly maintain the medical gas system.

Findings include:

Record review of the 2011 annual inspection vendor report for the medical gas system dated 4/4/11 and the 2011 vendor repair report for the medical gas system dated 4/13/11 stated that the following issues are in need of correcting:

Manifold Room:
a. There are electrical devices located below 5 ft. from the floor.

Observation during tour on 9/2/11 between 10:00 a.m. and 3:00 p.m. with Staff D (Facilities Manager) confirmed that there are electrical devices (two outlets and one light switch) located below 5 feet from the floor in the manifold room. Observation during tour also revealed the following in the manifold room:

1. Approximately 24 cylinders, each containing between 300 to 500 cubic feet of compressed gas (carbon dioxide, nitrogen, nitrous oxide, and oxygen) are grouped together and secured with a single chain which will cause the cylinders to be free standing once the chain is released.

2. Approximately 12 cylinders, each containing between 20 to 60 cubic feet of compressed gas (nitrogen, nitrous oxide, and oxygen) and approximately 8 cylinders containing approximately 9 cubic feet of compressed oxygen are grouped together and secured with a single chain which will cause the cylinders to be free standing once the chain is released.

Interview during tour on 9/2/11 with Staff D confirmed the findings.

4-3.1.1.8, NFPA 99, HEALTH CARE FACILITIES
General Requirements for Gas Central Supply Systems: Piped oxygen and medical air shall not be piped to, or used for, any purpose except for use in patient care applications.
(f) Check Valves. Supply systems... shall have a check valve in the primary supply main, upstream of the point of intersection with the secondary or reserve supply main.

4-3.1.2.2(b)2, NFPA 99, HEALTH CARE FACILITIES
Gas Warning Systems: The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location).

4-3.1.2.2(a)6, NFPA 99, HEALTH CARE FACILITIES
Gas Warning Systems: All pressure switches, pressure gauges, and pressure sensing devices downstream of the source valve shall be provided with a gas specific demand check fitting to facilitate servicing, testing, or replacement.

4-3.1.2.2(b)3.e, , NFPA 99, HEALTH CARE FACILITIES
Gas Warning Systems: It shall be indicated separately for each medical gas piping system when the pressure in the main line increases 20 percent or decreases 20 percent from the normal operating pressure. The actuating switch for these signals shall be installed in the main line immediately downstream (on the piping distributing side) of the main line shutoff valve or the source valve if the main line shutoff valve is not required.

Based on record review, observation, and interview the facility failed to properly maintain the medical gas system.

Findings include:

Record review of the 2011 annual inspection vendor report for the medical gas system dated 4/4/11 and the 2011 vendor repair report for the medical gas system dated 4/13/11 stated that the following issues are in need of correcting:

1. Master Alarm:

a. The oxygen pressure switch connected to the master alarm has no gas specific demand check.

b. The master alarm panel is a black Ohio that is under recall.

c. There is only one master alarm panel.

2. Vacuum Pump:

a. The pressure switch and final line gauge for the master alarm system is not located immediately after the source valve.

3. Nitrous Oxide Manifold:
a. The pressure switch is not located on the patient side of the source valve.

4. Nitrogen Manifold:
a. The pressure switch is not located on the patient side of the source valve.

5. Oxygen Supply System:
a. The pressure switch and final line gauge for oxygen needs to have gas specific demand checks to facilitate repairs and testing.

6. Surgical Suite:
a. The area alarm panel located at the Nurses' Station has its "Normal" indicator light not functioning.

Interview during tour on 9/2/11 with Staff D (Facilities Manager) was unaware of which items have been corrected.

Observation during tour on 9/2/11 between 10:00 a.m. and 3:00 p.m. with Staff D confirmed that the "Normal" indicator light in the area alarm panel located at the Nurses' Station in the surgical suite is not functioning.

19.5.1, NFPA 101, LIFE SAFETY CODE
Utilities: Utilities shall comply with the provisions of Section 9.1.

9.1.2, NFPA 101, LIFE SAFETY CODE
Electric: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

210-8, NFPA 70, NATIONAL ELECTRICAL CODE
All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified below shall have ground-fault circuit-interrupter protection for personnel.
(7) Where the receptacles are installed to serve the countertop surfaces and are located within 6 ft (1.83 m) of the outside edge of the... sink.

400-8, NFPA 70, NATIONAL ELECTRICAL CODE
Uses Not Permitted: Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Based on observation and interview the facility failed to ensure that electrical wiring and equipment are properly installed.

Findings include:

Observation during tour on 8/31/11 at approximately 1:25 p.m. with Staff C (Plant Operations Director) and Staff D (Facilities Manager) and tour on 9/2/11 at approximately 1:25 p.m. with Staff D revealed the following:

1. Med Surge West Pantry: One extension cord in use connecting a coffee maker to an outlet.

2. Med Surge East Dirty Utility Room: Two electrical duplex receptacle outlets without Ground Fault Circuit Interrupter protection installed within 4 feet of the outside edge of the sink.

Interview during tour on 8/31/11 with Staff C and 9/2/11 with Staff D confirmed the findings.

19.3.6.3.1, NFPA 101, LIFE SAFETY CODE
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.

19.3.6.3.2, NFPA 101, LIFE SAFETY CODE
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Based on observation and interview the facility failed to ensure that corridor doors close to a latched position.

Findings include:

Observation during tour on 8/31/11 between 2:10 p.m. and 2:20 p.m. with Staff C (Director Plant Operations) and Staff D (Facility Manager) revealed that rooms 314 and 309 which are equipped with self-closing devices on Med Surge West do not close to a latched position.

Interview during tour on 8/31/11 with Staff C and Staff D confirmed the findings at the time of discovery.

19.3.7.6, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.3.4.1, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

A.8.3.4.1, NFPA 101, LIFE SAFETY CODE
The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

1-3.1, NFPA 105, Installation of Smoke-Control Door Assemblies
NFPA 101, Life Safety Code, and building codes include specific requirements for smoke-control door assemblies and should be consulted in every instance. NFPA 80, Standard for Fire Doors and Fire Windows, should be followed when fire door assemblies are used as smoke-control door assemblies.
2-1.1, NFPA 105, Installation of Smoke-Control Door Assemblies
The installation of fire door assemblies is covered by NFPA 80, Standard for Fire Doors and Fire Windows.
2-3.1.7, NFPA 80, FIRE DOORS AND FIRE WINDOWS
The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. !O 1/16 in. (3.18 mm !O 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.

3-1.4, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Operation of Doors: The doors shall swing easily and freely on their hinges. The latches shall operate freely.

8.3.4.3, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that smoke barrier doors operate properly.

Findings include:

Interview during tour on 8/31/11 and 9/2/11 with Staff C (Director Plant Operations) and Staff D (Facility Manager) confirmed the locations of smoke barriers and smoke barrier doors.

Observation during tour on 8/31/11 between 1:00 p.m. and 4:00 p.m. with Staff C and Staff D and during tour on 9/2/11 with Staff D revealed the following:

1. One leaf of the smoke barrier door equipped with fire door hardware on Med Surge West located near the Rehab room failed to latch when closed.

2. The smoke barrier door to Rehab Room 1 located on Med Surge West has the self-closing arm disconnected from the door.

3. The Lobby smoke barrier double doors do not close completely.

4. The smoke barrier double doors in the area of Northwing Radiology have a gap between the meeting edges between 1/4 inch and 3/8 inch.

19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that all entry doors serving hazardous areas close to a latched position.

Findings include:

Observation during tour on 8/31/11 with Staff C (Director Plant Operations) and Staff D (Facility Manager) and during tour on 9/2/11 with Staff D revealed that the ER and the Med Surge East soiled utility rooms equipped with latching devices do not close to a latched position.

Interview during tour on 8/31/11 and 9/2/11 with Staff C and Staff D confirmed the findings.

19.2.1, NFPA 101, LIFE SAFETY CODE
General: Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

19.2.7, NFPA 101, LIFE SAFETY CODE
Discharge from Exits: Discharge from exits shall be arranged in accordance with Section 7.7.

7.1.10.1, NFPA 101, LIFE SAFETY CODE
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.

7.2.1.4.5, NFPA 101, LIFE SAFETY CODE
The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.
Exception No. 1: The opening force for existing doors in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.

7.7.3, NFPA 101, LIFE SAFETY CODE
The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Based on observation and interview the facility failed to ensure that all exit doors operate properly.

Findings include:

Observation during tour on 9/2/11 at approximately 2:15 p.m. with Staff D (Facility Manager) revealed that the exterior door at the lower level does not open when body weight is applied to the door releasing mechanism in the stairwell connecting Med Surge West to the lower level near the Rehabilitation area.

Interview during tour on 9/2/11 with Staff D confirmed the findings at the time of discovery.

19.2.2.5, NFPA 101, LIFE SAFETY CODE
Horizontal Exits: Horizontal exits complying with 7.2.4 and the modifications of 19.2.2.5.1 through 19.2.2.5.4 shall be permitted.

7.2.4.1.1, NFPA 101, LIFE SAFETY CODE
Where horizontal exits are used in the means of egress, they shall conform to the general requirements of Section 7.1 and the requirements of 7.2.4.

7.2.4.3.1, NFPA 101, LIFE SAFETY CODE
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. (See also 8.2.3.)

7.2.4.3.4, NFPA 101, LIFE SAFETY CODE
Any opening in such fire barriers shall be protected as provided in 8.2.3.2.3.

8.2.3.2.3.1, NFPA 101, LIFE SAFETY CODE
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42

8.2.3.2.1, NFPA 101, LIFE SAFETY CODE
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.

2-3.1.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled door frames shall be used.

2-4.4.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled locks and latches or labeled fire exit hardware (panic devices) meeting both life safety requirements and fire protection requirements shall be used.

2-4.4.2, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Fire exit hardware shall be installed only on fire doors bearing the marking, " Fire Door To Be Equipped with Fire Exit Hardware. " Fire exit hardware shall be labeled for both fire and panic. Fire exit hardware shall have a permanently attached label that bears the serial number and shows the manufacturer ' s name and type of approval. The label shall differentiate between panic hardware, which is not acceptable for use on fire doors and fire exit hardware.

2-4.4.3, NFPA 80, FIRE DOORS AND FIRE WINDOWS
All single doors and active leaves of pairs of doors shall be provided with an active latch bolt that cannot be held in a retracted position...

Based on interview and observation the facility failed to ensure that horizontal exits are properly maintained.

Findings include:

Interview during tour on 8/31/11 and 9/2/11 with Staff C (Director Plant Operations) and Staff D (Facility Manager) confirmed the locations of two hour fire barriers and fire doors used as horizontal exits.

Observation during tour on 8/31/11 between 1:00 p.m. and 4:00 p.m. with Staff C and Staff D and during tour on 9/2/11 at approximately 1:30 p.m. with Staff D revealed the following:

1. One of the two leafs of the fire door assembly in the two hour fire barrier separating Med Surge West from other portions of the facility does not close to a latched position.

2. The fire door assembly in the two hour fire barrier separating Med Surge East from the Birthing Center has painted fire rating labels, penetrations in the face of the door leaf from where a portion of the door handle assembly is missing, and a door handle assembly without any indication of the fire rating.

Interview during tour on 8/31/11 and 9/2/11 with Staff C and Staff D confirmed the findings.

19.3.4.1, NFPA 101, LIFE SAFETY CODE
General: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4, NFPA 101, LIFE SAFETY CODE
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

2-3.5.1, NFPA 72, NATIONAL FIRE ALARM CODE
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1, NFPA 72, NATIONAL FIRE ALARM CODE
Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

Based on observation and interview the facility failed to ensure that fire alarm systems are properly maintained.

Findings include:

Observation during tour on 8/31/11 between 1:00 p.m. and 2:30 p.m. with Staff C (Plant Operations Director) and Staff D (Facilities Manager) revealed the following:

1. Two smoke detectors in Med Surge West corridor are located between 1 and 2 feet from HVAC (Heating, Ventilation, and Air Conditioning) ducts.

2. One smoke detectors in the Lobby Coffee Shop is located approximately 1 foot, 6 inches from an HVAC (Heating, Ventilation, and Air Conditioning) duct.

Interview during tour on 8/31/11 with Staff C and Staff D confirmed the findings.

19.3.2.6, NFPA 101, LIFE SAFETY CODE
Cooking Facilities: Cooking facilities shall be protected in accordance with 9.2.3.

9.2.3, NFPA 101, LIFE SAFETY CODE
Commercial Cooking Equipment: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

9-1.2.2, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
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.

7-2.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.

7-2.1.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

7-2.2.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer ' s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

9-2.1, NFPA 17, Standard for Dry Chemical Extinguishing Systems
On a monthly basis, inspection shall be conducted in accordance with the manufacturer ' s listed installation and maintenance manual or owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

9-2.2, NFPA 17, Standard for Dry Chemical Extinguishing Systems
If any deficiencies are found, appropriate corrective action shall be taken immediately.

9-2.3, NFPA 17, Standard for Dry Chemical Extinguishing Systems
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.

9-2.4, NFPA 17, Standard for Dry Chemical Extinguishing Systems
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.

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

5-2.2, NFPA 17A, Standard for Wet Chemical Extinguishing Systems
If any deficiencies are found, appropriate corrective action shall be taken immediately.

5-2.3, NFPA 17A, Standard for Wet Chemical Extinguishing Systems
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.

5-2.4, NFPA 17A, Standard for Wet Chemical Extinguishing Systems
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections.

Based on record review, observation, and interview the facility failed to ensure that cooking facility protection systems are properly maintained.

Findings include:

Record review of inspection documentation during tour on 9/2/11 at approximately 12:00 p.m. with Staff D (Facility Manager) in the Kitchen revealed that monthly inspections of the hood suppression system have not been recorded.

Observation during tour on 9/2/11 with Staff D revealed that there is no signage present in the area of at least one of the Class K extinguishers which advises staff to use the hood suppression system prior to using the Class K extinguisher to control a fire.

Interview during tour on 9/2/11 with Staff D at the time of discovery revealed that the hood suppression system has not been inspected on a monthly basis and confirmed the findings.

4-3.1.1.1, NFPA 99, HEALTH CARE FACILITIES
Cylinder and Container Management: Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2(a)4, NFPA 99, HEALTH CARE FACILITIES
Storage Requirements (Location, Construction, Arrangement): 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.

Based on record review, observation, and interview the facility failed to properly maintain the medical gas system.

Findings include:

Record review of the 2011 annual inspection vendor report for the medical gas system dated 4/4/11 and the 2011 vendor repair report for the medical gas system dated 4/13/11 stated that the following issues are in need of correcting:

Manifold Room:
a. There are electrical devices located below 5 ft. from the floor.

Observation during tour on 9/2/11 between 10:00 a.m. and 3:00 p.m. with Staff D (Facilities Manager) confirmed that there are electrical devices (two outlets and one light switch) located below 5 feet from the floor in the manifold room. Observation during tour also revealed the following in the manifold room:

1. Approximately 24 cylinders, each containing between 300 to 500 cubic feet of compressed gas (carbon dioxide, nitrogen, nitrous oxide, and oxygen) are grouped together and secured with a single chain which will cause the cylinders to be free standing once the chain is released.

2. Approximately 12 cylinders, each containing between 20 to 60 cubic feet of compressed gas (nitrogen, nitrous oxide, and oxygen) and approximately 8 cylinders containing approximately 9 cubic feet of compressed oxygen are grouped together and secured with a single chain which will cause the cylinders to be free standing once the chain is released.

Interview during tour on 9/2/11 with Staff D confirmed the findings.

4-3.1.1.8, NFPA 99, HEALTH CARE FACILITIES
General Requirements for Gas Central Supply Systems: Piped oxygen and medical air shall not be piped to, or used for, any purpose except for use in patient care applications.
(f) Check Valves. Supply systems... shall have a check valve in the primary supply main, upstream of the point of intersection with the secondary or reserve supply main.

4-3.1.2.2(b)2, NFPA 99, HEALTH CARE FACILITIES
Gas Warning Systems: The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location).

4-3.1.2.2(a)6, NFPA 99, HEALTH CARE FACILITIES
Gas Warning Systems: All pressure switches, pressure gauges, and pressure sensing devices downstream of the source valve shall be provided with a gas specific demand check fitting to facilitate servicing, testing, or replacement.

4-3.1.2.2(b)3.e, , NFPA 99, HEALTH CARE FACILITIES
Gas Warning Systems: It shall be indicated separately for each medical gas piping system when the pressure in the main line increases 20 percent or decreases 20 percent from the normal operating pressure. The actuating switch for these signals shall be installed in the main line immediately downstream (on the piping distributing side) of the main line shutoff valve or the source valve if the main line shutoff valve is not required.

Based on record review, observation, and interview the facility failed to properly maintain the medical gas system.

Findings include:

Record review of the 2011 annual inspection vendor report for the medical gas system dated 4/4/11 and the 2011 vendor repair report for the medical gas system dated 4/13/11 stated that the following issues are in need of correcting:

1. Master Alarm:

a. The oxygen pressure switch connected to the master alarm has no gas specific demand check.

b. The master alarm panel is a black Ohio that is under recall.

c. There is only one master alarm panel.

2. Vacuum Pump:

a. The pressure switch and final line gauge for the master alarm system is not located immediately after the source valve.

3. Nitrous Oxide Manifold:
a. The pressure switch is not located on the patient side of the source valve.

4. Nitrogen Manifold:
a. The pressure switch is not located on the patient side of the source valve.

5. Oxygen Supply System:
a. The pressure switch and final line gauge for oxygen needs to have gas specific demand checks to facilitate repairs and testing.

6. Surgical Suite:
a. The area alarm panel located at the Nurses' Station has its "Normal" indicator light not functioning.

Interview during tour on 9/2/11 with Staff D (Facilities Manager) was unaware of which items have been corrected.

Observation during tour on 9/2/11 between 10:00 a.m. and 3:00 p.m. with Staff D confirmed that the "Normal" indicator light in the area alarm panel located at the Nurses' Station in the surgical suite is not functioning.

19.5.1, NFPA 101, LIFE SAFETY CODE
Utilities: Utilities shall comply with the provisions of Section 9.1.

9.1.2, NFPA 101, LIFE SAFETY CODE
Electric: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

210-8, NFPA 70, NATIONAL ELECTRICAL CODE
All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified below shall have ground-fault circuit-interrupter protection for personnel.
(7) Where the receptacles are installed to serve the countertop surfaces and are located within 6 ft (1.83 m) of the outside edge of the... sink.

400-8, NFPA 70, NATIONAL ELECTRICAL CODE
Uses Not Permitted: Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Based on observation and interview the facility failed to ensure that electrical wiring and equipment are properly installed.

Findings include:

Observation during tour on 8/31/11 at approximately 1:25 p.m. with Staff C (Plant Operations Director) and Staff D (Facilities Manager) and tour on 9/2/11 at approximately 1:25 p.m. with Staff D revealed the following:

1. Med Surge West Pantry: One extension cord in use connecting a coffee maker to an outlet.

2. Med Surge East Dirty Utility Room: Two electrical duplex receptacle outlets without Ground Fault Circuit Interrupter protection installed within 4 feet of the outside edge of the sink.

Interview during tour on 8/31/11 with Staff C and 9/2/11 with Staff D confirmed the findings.