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Based on observation and interview the facility failed to provide a smoke (or heat) detector above a remote fire alarm control panel on the third floor. This deficient practice affected all smoke compartments, all residents, visitors and staff of the facility. The facility is licensed for 283 beds with a census of 150 on the day of the survey.

Findings include:

Observation of the fire alarm control panel in the third floor telephone equipment room on September 27, 2010 at approximately 11:30 A.M. revealed the facility failed to provide automatic detection at the fire alarm control panel. Lack of detection may cause the fire alarm control panel to be incapacitated by fire before a detection device responded. Interview with the Director of Plant Operations during the observation, indicated the facility was not aware that detection was required at this location.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on September 28, 2010.

Actual NFPA standard: NFPA 72 ? 1-5.6 Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

Based upon observation and interview the facility failed to ensure exit access corridors where maintained free of obstructions or impediments to egress. The facility is licensed for 76 beds and had a census of 31 on the day of the survey.

Findings include:

1) During the facility tour at the Behavioral Health Center on 9/28/10 at approximately 1:35 PM observation revealed boxes, coal lockers and other furnishings partially blocking the exit access corridor next to the dining and kitchen area. Observation of the exit plan posted indicated this corridor was a part of the facility emergency evacuation route, which was confirmed by the Director of Plant Operations.

2) During the facility tour at the Behavioral Health Center on 9/28/10 at approximately 2:00 PM observation revealed two folding tables with beverage service materials partially blocking the exit access corridor on the administration wing near the classroom. Observation of the exit plan posted indicated this was a part of the facility emergency evacuation route, which was confirmed by the Director of Plant Operations.

Actual NFPA reference:

NFPA 101, 7.1.10.1
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.
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1
No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Based upon observation and interview, the facility failed to ensure electrical safety by not prohibiting the use of extension cords and relocatable power taps throughout the facility. The facility is licensed for 283 beds and had a census of 150 on the first day of the survey.

Findings include:

1) During the facility tour on September 27 & 28, 2010, extension cords were identified in the following locations; CT room 1, Cardiac Rehab Classroom and Pharmacy (powering a refrigerator). This finding was witnessed and acknowledged by the Director of Plant operations who confiscated the majority of these cords and stated that he was unaware that these devices were in use.

2) During the facility tour on September 27 & 28, 2010, Relocatable Power Taps (power strips) were observed to not be used in accordance with the listing and labeling of said equipment (computer, AV equipment and peripherals) in the following locations; ICU-A storage, PACU, Cardiac Rehab Gym, Echo office, and on anesthesia carts in operating rooms 5 and 14 on 9/27/10 and 9/28/10. This finding was witnessed and acknowledged by the Director of Plant Operations who confiscated the majority of these devices and stated that he was unaware that these devices were in use.

Actual NFPA reference:

Extension cords;
NFPA 70, 400.8 Uses Not Permitted.
Unless specifically permitted in 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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.8.
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code

Relocatable Power Taps:
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.

Also refer to UL 1363