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Provide a placard placed conspicously near the Class "K" fire extinguisher after June 30, 1998. Placard to read: "fire protection system shall be activated prior of using fire extinguisher." NFPA 10: 4.3.2.2

This STANDARD is not being met as evidenced by: Based on observation during the Survey on the afternoon of 03/07/2013, with the Director of Plant Services (St. Elizabeth campus), the required placard was not found present near, or anywhere around, the location of the Class "K" fire extinguisher found near the kitchen ventilation hood.

Where the total volume of medical gases connected and in storage is less than 84,950 L (3,000 cu.ft.) at STP or the only compressed gas in the room is medical air, natural ventilation shall be permitted to be employed. NFPA 99 (2002): 5.1.3.3.3.1 (D)

Where natural ventilation is permitted, it shall consist of two louvered openings, each having a minimum free area of 46,500 mm.sq. (72 cu.in.), with one located within 300 mm (1 ft.) of the floor and one located within 300 mm (1 ft.) of the ceiling. NFPA 99(2002): 5.1.3.3.3.1 (E)

This STANDARD is not being met as evidenced by: Based on observation during the Survey on the afternoon of 03/07/2013, with the Director of Plant Services (St. Mary campus), the newly constructed Medical Gas Room serving the Operating Rooms was not naturally ventilated.

Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. NFPA 70: 517-19

This STANDARD is not being met, as evidenced by: Based on observation during the Survey on the afternoon of 03/07/2013, with the Director of Plant Services (St. Mary campus), numerous emergency system electrical receptacles did not have non-removable labels identifying the electrical panelboard and circuit number supplying them.

Provide a placard placed conspicously near the Class "K" fire extinguisher after June 30, 1998. Placard to read: "fire protection system shall be activated prior of using fire extinguisher." NFPA 10: 4.3.2.2

This STANDARD is not being met as evidenced by: Based on observation during the Survey on the afternoon of 03/07/2013, with the Director of Plant Services (St. Elizabeth campus), the required placard was not found present near, or anywhere around, the location of the Class "K" fire extinguisher found near the kitchen ventilation hood.

Where the total volume of medical gases connected and in storage is less than 84,950 L (3,000 cu.ft.) at STP or the only compressed gas in the room is medical air, natural ventilation shall be permitted to be employed. NFPA 99 (2002): 5.1.3.3.3.1 (D)

Where natural ventilation is permitted, it shall consist of two louvered openings, each having a minimum free area of 46,500 mm.sq. (72 cu.in.), with one located within 300 mm (1 ft.) of the floor and one located within 300 mm (1 ft.) of the ceiling. NFPA 99(2002): 5.1.3.3.3.1 (E)

This STANDARD is not being met as evidenced by: Based on observation during the Survey on the afternoon of 03/07/2013, with the Director of Plant Services (St. Mary campus), the newly constructed Medical Gas Room serving the Operating Rooms was not naturally ventilated.

Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. NFPA 70: 517-19

This STANDARD is not being met, as evidenced by: Based on observation during the Survey on the afternoon of 03/07/2013, with the Director of Plant Services (St. Mary campus), numerous emergency system electrical receptacles did not have non-removable labels identifying the electrical panelboard and circuit number supplying them.