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Based on observation, the facility failed to maintain the fire sprinkler system.

Findings include:

Observation on 6/16/10, the below listed fire sprinkler head (FSH) locations had the following problems:

1)The Radiology Department, a storage room located next to X-ray Room #7, the FSH only had 11" clearance between it and the supply boxes beneath.

2) The Engineering Department, a storage area in the HVAC Shop, the FSH only had 10" clearance between it and the materials stored beneath.

Based on observation, the facility failed to have an annual inspection on a portable fire extinguisher.

Findings include:

On the third floor of the Northeast Tower, in an Electrical Room near the Plastics/Medical Surgery area, a portable Halotron fire extinguisher was not renewed during the past two years. The last documented annual inspection was on 6/1/08.

Based on observation, the facility failed to ensure that all smoke barrier penetrations were protected.

Findings include:

Observation on 6/15/10, in the Mechanical Room on the 4th floor, several conduits (with cable lines) had unprotected openings to allow for the transfer of smoke between smoke compartments.

NFPA 101
Chapter 12-5.1.1 Utilities shall comply with the provisions of Section 7-1
Chapter 7-1.2 Electrical wiring and equipment installed shall be in accordance with NFPA 70, National Electric Code.
Exception: Existing installations may be continued in service subject to approval by the authority having jurisdiction.

NFPA 70

COVERS:
NFPA 70, Section 370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixed canopy.

EXTENSION CORDS:
NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(a) As a substitute for fixed wiring of a structure
NFPA 70, Section 305-4(h) Protection from Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protections shall be provided to avoid damage.

BRANCH CIRCUIT, FEEDER, AND SERVICE CALCULATIONS
NFPA 70, Section 220-3 Computation of Branch Circuit Loads. Branch circuit loads shall be computed as shown in (a) through (c).
(a) Lighting Loads for Specified Occupancies.
(b) Other Loads - All Occupancies.
(c) Loads for Additions to Existing Installations.


Based on observation, the facility failed to ensure that the electrical installations within the building conformed to NFPA 70, National Electrical Code.

Findings include:

In the Administrative Assistant's Office, across the hall from the Director's Office, the facility was using a power strip as permanent wiring to supply power to a portable fan, microwave oven, radio and stapler as permanent wiring.