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Based on observation, the facility failed to ensure an alcohol based handrub dispenser (ABHR) was installed a safe distance from an ignition source as outlined in the Life Safety Code.

Findings include:

On 11/15/2023, observation within the fluoroscopy room revealed an alcohol based handrub dispenser (ABHR) was installed directly above the light switch.

This observation was made in the presence of the Director of Plant Operations.

National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 Edition
10.5.5.2 Circuit Identification and Accessibility.
10.5.5.2.1 The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit.
10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."
10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.
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Based on observation, the facility failed to appropriately identify the fire alarm circuit in/on the electrical panelboard in accordance with NFPA 72, National Fire Alarm and Signaling Code.

Findings include:

On 11/14/2023 and 11/15/2023, observation of the facility's electrical panelboards was conducted. The panelboard "ELSLB" revealed the fire alarm circuit was not appropriately identified with the wording, "FIRE ALARM CIRCUIT" and the circuit was not marked in red. In addition, circuit breaker #7 was labeled as "F/A Penthouse". An interview with the Director of Plant Operations revealed the facility did not have a Penthouse and it was unknown if the circuit breaker actually sent power to a fire system component.

On 11/15/2023, the panelboard "ELSL1" revealed the fire alarm circuits were marked in red but the labeling was not consistent with the required identification of "FIRE ALARM CIRCUIT".

The Director of Plant Operations acknowledged the findings as they were discovered.

NOTE: The location of the dedicated branch circuit disconnecting means (on electrical panelboards) shall be permanently identified at the control unit using the words, "FIRE ALARM CIRCUIT" and shall be marked in red.

National Fire Protection Association (NFPA) 13, Standard For The Installation of Sprinkler Systems, 2010 Edition.

Section 6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.
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Based on observation, the facility failed to ensure sprinkler guards were installed to protect fire sprinkler heads from mechanical injury within the kitchen walk-in refrigerator.

Findings include:

On 11/14/2023, the facility's kitchen's walk-in refrigerator and freezer were observed. The facility's walk-in freezer was accessed by walking through the refrigerator and both had low-ceilings. The walk-in refrigerator was noted to contain one sprinkler head and the freezer did not have a sprinkler head. The refrigerator sprinkler head was observed to be located near the top shelves of the walk-ins and was not protected by a sprinkler guard, which subjected the head to possible mechanical injury.

This observation was made in the presence of the Director of Plant Operations.

National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

24.4 Instructions. The installing contractor shall provide the property owner or the property owner's authorized representative with the following: (...)
(2) NFPA 25, Standard for the inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)* Loading
5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.
5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.
5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

13.6.2 Testing (Back Flow)
13.6.2.1* All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
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Based on observation, interview and document review, the facility failed to test and maintain the automatic fire sprinkler system as required.

Findings include:

On 11/14/2023 and 11/15/2023, document review and observations during a tour of the facility revealed the following:

1) The facility did not have a copy of the NFPA 25. (Copy required by NFPA 13)

2) During a tour of the facility fire sprinklers were observed to be loaded or were covered in an unidentifiable substance in the following areas:
a. Kitchen: six of nine sprinkler heads in the main food preparation area
b. CAT Scan Control Room: four sprinkler heads

3) The interstitial space above the smoke barrier cross corridor doors located adjacent to the maintenance room was observed with the following:
a. Low voltage electrical wiring was hung over the sprinkler pipes and;
b. Insulated duct work was observed touching or leaning on the sprinkler piping.

4) The vendor report dated 02/06/2023 indicated the backflow devices were last tested on 09/08/2022. There was no supportive documentation to show an annual backflow test had been completed as required.

The facility's vendor was present during the discovery and the Director of Plant Operations was informed of the findings as they were discovered.

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

Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhole Enclosures
314.28 Pull and Junction Boxes and Conduit Bodies.
(...)(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Article 406 - Receptacles, Cord Connectors, and Attachment Plugs (Caps)
Article 406.9 Receptacles in Damp of Wet Locations
(...)(B) Wet Locations.
(1) 15- and 20-Ampere Receptacles in a Wet Location.
15- and 20-ampere, 125- and 250-volt receptacles install in a wet location shall have an enclosure that is weatherproof whether or not the attachment plug cap is inserted. For other than one- or two-family dwellings, an outlet box hood installed for this purpose shall be listed, and where installed on an enclosure supported from grade as described in 314.23(B) or as described in 314.23(F) shall be identified as "extra-duty." All 15- and 20-ampere, 125- and 250-volt nonlocking-type receptacles shall be listed weather-resistant type.
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Based on observation, interview and document review, the facility failed to ensure the facility had installed and/or maintained the electrical system within the building per NFPA 70, National Electrical Code.

Findings include:

On 11/14/2023 and 11/15/2023, a tour of the facility revealed the following electrical code deficiencies:

1. Observation of the interstitial space located at the smoke barrier cross corridor doors adjacent to the Maintenance shop room revealed an uncovered red junction box. (Junction box covers shall be provided.)

2. The Janitors closet located in the kitchen was observed. There was a Ground Fault Circuit Interrupter (GFCI) protected duplex receptacle installed approximately 18 inches from the floor, adjacent to the mop sink. The outlet did not have an enclosure that was weatherproof (designed for wet locations).

3. The GFCI protected duplex receptacle located in the Janitors closet had been tripped (activated). The Director of Plant Operations was not aware the receptacle had been tripped and was unaware as to the reason for its activation at the time of discovery.

The Director of Plant Operations acknowledged the above noted findings as they were discovered.

National Fire Protection Association (NFPA) 99, Health Care Facilities Code. 2012 Edition.

6.5.2.2.2 Life Safety Branch.
6..5.2.2.2.1 The life safety and critical branches shall supply power for lighting, receptacles, and equipment as follows:

(1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code
(3) Alarm and alerting systems, including the following:
(a) Fire alarms
(b) Alarms required for systems used for the piping of non-flammable medical gases as specified in Chapter 5
(4)* Communications systems, where used for issuing instructions during emergency conditions
(5) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of a minimum of 5 ft-candles
(6) Task illumination and select receptacles at the generator set location
(7) Elevator cab lighting, control, communications, and signal systems

6.5.2.2.2.2 No functions other than those listed in 6.5.2.2.2.1 (1) through (7), shall be connected to the life safety.


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

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.
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Based on observation and interview, the facility failed to ensure the Life Safety Branch of the Essential Electrical System did not include prohibited functions.

Findings include:

Based on observation and interview, the facility failed to ensure the Life Safety Branch(es) of the Essential Electrical System supplied power to the required lighting, receptacles, equipment and did not include prohibited functions.

Findings include:

On 11/14/2023 and 11/15/2023, while touring the facility's electrical room(s), the life safety branches (LSB) as identified by the maintenance staff were inspected. The following observations were made for panels ELSLB, ELSL1 SEC 1 and SEC 2, EQLB, CBL1 SEC 1 and SEC2. The electrical panel schedules lacked circuit breaker details as noted below.

1) Circuit breaker labels had minimal description for what was being powered and did not indicate specific locations for the following:
a. corridor lighting,
b. receptacles for emergency power and,
c. fire system components to include the Fire Alarm Annunciator or the Fire Alarm Control Panel.

2) Other schedules associated with the life safety branches had circuit breakers labeled as:
a. "UPS BATT BACKUP 151" but it was unclear as to what device would be supplied power if on generator power,
b. "FIRE DAMPER" the location for the fire damper was not specified,
c. "PATIENT AREA S/D" it was unknown which patient area the smoke damper was located and,
d. "EMERGENCY S/D" it was unknown where in the emergency room or area the smoke damper was located.

3) Additional observations, interviews and a review of the on-site electrical system(s) as-built line drawings could not determine which circuit breaker supplied power to each individual fire/smoke damper nor matched what was denoted on the line drawings for the facilities electrical panels.

The Director of Environmental Services acknowledged the findings as they were discovered.

Based on observation and interview, the facility failed to properly identify and segregate medical gas (oxygen) cylinders as required.

Findings include:

On 11/14/23 and 11/15/2023, while touring the facility all patient care areas or rooms had full E-size oxygen cylinders. The areas or rooms where the cylinders were observed included but were not limited to the PACU bays, the ER rooms, the nuclear medicine rooms and in addition to the rooms, tanks were also attached to the patient gurneys. The facility failed to have the appropriate markings or signage to identify the empty, partially full or partially empty and full E-size oxygen cylinders in order to prevent commingling or confusion.

On 11/16/2023, document review of the facility's policy entitled "Oxygen Review" revealed a section subtitled "Storage". This section read as follows:

1. "Storing oxygen cylinders is about managing empty cylinders. Those cylinders defined as PSI of 500 or less. Any oxygen tank with PSI of 500 or less will be segregated from all other cylinders that are intended for patient care use. Empty cylinders shall be marked as such by either individual tagging, as indicated by the integral gauge, or group signage. (Example) Empty E tanks will be placed in a tank rack with a sign "EMPTY" on it."
2. "All full oxygen tanks will be stored in a rack with a sign "FULL" attached to it."
3. "All oxygen tanks with less than 2000 psi but more than 500 psi will be considered partially full and will be stored in a rack with a sign "PARTIALLY FULL" attached to it."

The facility was not following their own policy for the storage, proper signage as detailed in the policy document.

The Director of Plant Operations and the Director of Nursing were present each time E-size cylinders were found in patient care areas.