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National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 Edition

19.3.2.1.3 The doors shall be self-closing or automatic closing.

19.3.2.1.5 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) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(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

Based on observation, interview, and measurement, the facility failed to ensure that all hazardous areas were properly fire barrier protected.

Findings include:

On 12/08/21, the dry storage room door, in the kitchen, was not equipped with a self-closing device. This room contained cardboard boxes, plastics, and various paper products. The room measured 209.4 square feet, less than the 50 square foot exception.

On 12/08/21, the Director of Facility Operations confirmed the finding upon discovery.

NFPA 96
National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
10.2.2 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire-extinguishing system shall be conspicuously placed near each portable fire extinguisher in the cooking area.
11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction in accordance with Table 11.4.

In Table 11.4, Schedule of Inspection for Grease Buildup, the facility shall inspect and clean their hood system semiannually. Type or Volume of Cooking: Systems serving high-volume cooking operations (utilization of deep fryer) -- Quarterly.

Based on observation and documentation review, the facility failed to provide evidence that the cooking facilities exhaust hood system had been appropriately serviced and cleaned as required and ensure one, required, sign was posted near the portable "K" extinguisher in the cooking area.

Findings include:

On 12/08/21, the following concerns were identified:

1) The facility had range hood cleaning performed on 12/07/20. No other documentation of additional cleanings was provided for the period between 12/07/20 and 12/08/21. The time after the most recent cleaning was more than six months.

2) There was no sign located near the portable "K" extinguisher which would instruct kitchen staff to first activate the fire suppression system before using the "K" extinguisher to put out a grease fire

On 12/08/21, the Director of Facility Operations confirmed each deficiency as they were identified. The Director of Facility Operations was not aware of the K-extinguisher signage requirement.

NFPA 13
National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition
6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.
6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly.
6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Findings include:

On 11/15/21 and 11/16/21, the following sprinkler concerns were identified:

1) Physician Sleep Room Bathroom - a sprinkler had a gap in its escutcheon, exposing the interstitial space.
2) Vestibule - a sprinkler had a dropped escutcheon, exposing the interstitial space.
3) Kitchen - a sprinkler had a dropped escutcheon, exposing the interstitial space.
4) Dexa Room - a sprinkler had a gap in its escutcheon, exposing the interstitial space.
e) Janitor's Closet - a sprinkler was missing its escutcheon, exposing the interstitial space.

On 11/15/21 and 11/16/21, the Plant Facility and Safety Director confirmed the findings at the time of discovery.

Based on observation and interview, the facility failed to protect corridor openings, because doors would not close properly.

Findings include:

On 12/08/21, the following concerns with doors were found:

1) The corridor door to the Treatment Room was impeded from closing completely by a bed parked against the wall, and was unable to resist the passage of smoke.

2) The self-closing door to the Ultrasound Room was held open with a sandbag.

On 12/08/21, the Director of Facility Operations acknowledged the deficiencies at the time of each discovery.

Based on observation and interview, the facility failed to ensure smoke barrier construction was properly sealed at points of penetration.

Findings include:

On 12/08/21, the LAN room had a penetration through a smoke barrier wall with data wires running through the penetration.

On 12/08/21, the Maintenance Director confirmed the penetration was not sealed to properly to prevent the passage of smoke.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operations and maintenance of such equipment.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26 (A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.

(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26 (A)(1) unless the requirements of 110.26 (A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed. (Nominal Voltage to Ground of 0 -150 = 3 feet).

(a) Dead-Front Assemblies. Working space shall not be required in the back or sides of assemblies, such as dead-front switch boards or motor control centers, where all connections and all renewable or adjustable parts, such as fuses or switches, are accessible from locations other than the back or sides. Where rear access is required to work on non-electrical parts on the back of enclosed equipment, a minimum horizontal working space of 762 mm (30 in.) shall be provided.
(b) Low Voltage. By special permission, smaller working spaces shall be permitted where all exposed live parts operate at not greater than 30 volts rms, 42 volts peak, or 60 volt dc.
(c) Existing Buildings. In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switch boards, panel boards, or monitor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.

Article 408.4 Field Identification Required
(A) Circuit Directory of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy.

Based on observation and interview, the facility failed to ensure electrical wiring and equipment complied with the National Electric Code, National Fire Protection Association (NFPA) 70.

Findings include:

On 12/06/21 and 12/07/21, the following electrical concerns were identified:

a) Panelboard EJ - a cart of patient gowns was parked against the wall below the panelboard.
b) Panelboard KK - circuit breakers 20, and 23 were identified on the schedule directory as "Spare"; however, were in the "On" position.

On 11/15/21 and 11/16/21, the Plant Facility and Safety Director was present at each discovery.

NFPA 80, Standard for Fire Doors and Other Opening Protectives.
6.3.1.7* Clearances.
6.3.1.7.1 The clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1/8 in. ± 1/16 in. (3.18 mm ± 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.

Based on observation and interview, the facility failed to ensure that fire door assemblies were maintained in accordance with NFPA 80.

Findings include:

On 12/08/21, the cross-corridor doors outside the CT Room contained a ½ inch gap between the two leaves at the bottom of the doors.

On 12/08/21, the Plant Facility and Safety Director confirmed deficiency.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

210.8 Ground-Fault Circuit-Interrupter Protection for Personnel. Ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.
(A)(7) Sinks - located in areas other than kitchens where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink.

Based on observation and interview, the facility failed to install ground fault circuit interrupters (GFCI) in areas less than six feet from a sink edge.

Findings include:

On 12/06/21 and 12/07/21, the following areas did not contain the required GFCI receptacles:

1) Room behind nurse's station - a duplex receptacle was 35 ½ inches from a sink edge; however, the receptacle was not the required GFCI and was not on a GFCI circuit breaker.
2) Patient rooms (except Room 4) - a duplex receptacle was 13 inches from a sink edge; however, the receptacle was not the required GFCI and was not on a GFCI circuit breaker.
3) Treatment Room- a duplex receptacle was 13 inches from a sink edge; however, the receptacle was not the required GFCI and was not on a GFCI circuit breaker.
4) X-ray Bathroom- a duplex receptacle was 16 inches from a sink edge; however, the receptacle was not the required GFCI and was not on a GFCI circuit breaker.
5) Bathroom for Clinic - a duplex receptacle was 13 ½ inches from a sink edge; however, the receptacle was not the required GFCI and was not on a GFCI circuit breaker.

On 12/06/21 and 12/07/21, the Maintenance Manager confirmed the measurements and verbalized GCFI receptacles should be installed.