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Based on observation and staff confirmation the facility failed to continuously maintain the automatic sprinkler systems in reliable operating condition as required by NFPA 101 (2000), 19.7.6, 9.7.5, 4.6.12, NFPA 13 (1999), 5-5.4., 5-6.4, NFPA 25.

Findings include:

1. On 12/17/12, the first day of survey, observation during the interior tour conducted from 9:30 a.m., to 4:00 p.m., accompanied by a Facility Representative, revealed pendent styled sprinkler heads with less than 1 inch distance between the deflector and the ceiling surface above thereby distorting the sprinkler pattern in the event of fire. The sprinkler heads were located in the corridor at the the Endoscopy Nursing Station, the corridor at the Endoscopy Physicians Reading Room, the corridor at the entrance to the Pharmacy and the corridor at the entrance to the Laboratory. The Facility Representative confirmed the observation that the referenced deflectors were less than 1 inch from the deflector to the ceiling surface above at each of the locations identified.

NFPA 101 (2000), 19.7.6, 9.7.5, 4.6.12
NFPA 13 (1999), 5-5.4., 5-6.4
NFPA 25
Reference: NFPA 13 (1999), 5-5.4 Deflector Position. 5-5.4.1* Distance Below Ceilings. The distances between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. 5-6.4 Deflector Position (Standard Pendent and Upright Spray Sprinklers). 5-6.4.1 Distance Below Ceilings. 5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).

Based on observation and staff confirmation the facility failed to tether natural gas powered cooking equipment, on casters, as required by NFPA 101 (2000), 19.3.2.6, 9.2.3, NFPA 96 (1998), and NFPA 54 (1999), 9.6.1.1 and 9.6.1.2

1. On 12/17/12, observation during the interior tour conducted from 9:30 a.m., to 4:00 p.m., accompanied by a Facility Representative, revealed in the facility kitchen a natural gas powered grill mounted on casters with no tethering device to prevent movement of the grill to a point where the flexible gas lines separate and produce a fire or explosion. The Facility Representative and a Dietary Department Representative confirmed the grill was on casters and not tethered.

NFPA 101 (2000), 19.3.2.6, 9.2.3,
NFPA 96 (1998)
NFPA 54 (1999), 9.6.1.1
Reference: NFPA 54 (1999), 9.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer's installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connector installation shall be configured in accordance with the manufacturer's installation instructions. 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions.

Based on observation and staff interview the facility failed to insure paper shredding collection containers do not exceed 32 gal (121 L) in capacity in areas greater than 64 sq ft (5.9-sq m), and that shredding collection containers exceeding 32 gallons are stored in rooms protected as a hazardous area as required by NFPA 101 (2000), 19.7.5.5.

1. On 12/17/12, observation during the interior tour conducted from 9:30 a.m., to 4:00 p.m., accompanied by a Facility Representative, revealed 95 gallon dark gray shredding material containers parked in the following locations, Medical Records Department, (three 95 gallon containers), Emergency Room Registration area, (one 95 gallon container), and MDC Diagnostic Center, (one 95 gallon container). None of the three locations are protected as hazardous areas.

2. On 12/17/12, staff interview of Medical Records personnel during the interior tour conducted from 9:30 a.m., to 4:00 p.m., revealed the three 95 gallon paper shredding collection containers were kept in the Medical Records Department for one week and removed each Wednesday.

NFPA 101 (2000), 19.7.5.5.
Reference: NFPA 101 (2000), 19.7.5.5 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended. Exception: Container size and density shall not be limited in hazardous areas.

Based on observation and staff confirmation the facility failed to prevent the substitution of facility structural wiring with flexible cords and cables as required by NFPA 101 (2000), 19.5.1, 9.1.2, NFPA 99 (1999), 3-3.2.1.2, 10-2.3.6, and NFPA 70 (1999), 400.8.

1. On 12/17/12, observation during the interior tour conducted from 9:30 a.m., to 4:00 p.m., accompanied by a Facility Representative, revealed a power strip connected and in use supplying power to patient care equipment in Operating Room 5, (power strip to Datex, Aestiva 5, 7900, anesthesia machine). The Facility Representative confirmed the observations.

NFPA 101 (2000), 19.5.1, 9.1.2
NFPA 99 (1999), 3-3.2.1.2, 10-2.3.6
NFPA 1 (2000), 6-1.5
NFPA 70 (1999), 400.8.
References: NFPA 99 (1999) 3-3.2.1.2 All Patient Care Areas, (d) Receptacles 2. Minimum number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Merriam-Webster as referenced in NFPA 101, Power strip - " an electrical device consisting of a cord with a plug on one end and several sockets on the other; Extension cord -" an electric cord fitted with a plug at one end and a receptacle at the other " ; Surge protector -" an electrical device that moderates power-line surges to prevent damage to attached electronic devices (as a television or computer) " .

NFPA 70, (1999) Chapter 4 Equipment for General Use, ARTICLE 400 Flexible Cords and Cables. 400.7 Uses Permitted. (A) Uses. Flexible cords and cables shall be used only for the following: (1) Pendants (2) Wiring of luminaires (fixtures) (3) Connection of portable lamps, portable and mobile signs, or appliances (4) Elevator cables (5) Wiring of cranes and hoists (6) Connection of utilization equipment to facilitate frequent interchange (7) Prevention of the transmission of noise or vibration (8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection (9) Connection of moving parts (10) Where specifically permitted elsewhere in this Code. (B) Attachment Plugs. Where used as permitted in 400.7(A)(3), (A)(6), and (A)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet. Exception: As permitted in 368.56. 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.

NFPA 99, (1999), 10.2.3.6* an exception permitting overcurrent devices. 10.2.3.6* Overcurrent Protection. 10.2.3.6.1 An overcurrent protective device shall be permitted to be placed in any of the following locations: (1) In the attachment plug (2) In the power cord (3) In the main body of the appliance 10.2.3.6.2 The overcurrent protective device shall precede any other components within the appliance, including the primary power-control switch.

Based on observation and staff confirmation the facility failed to continuously maintain the automatic sprinkler systems in reliable operating condition as required by NFPA 101 (2000), 19.7.6, 9.7.5, 4.6.12, NFPA 13 (1999), 5-5.4., 5-6.4, NFPA 25.

Findings include:

1. On 12/17/12, the first day of survey, observation during the interior tour conducted from 9:30 a.m., to 4:00 p.m., accompanied by a Facility Representative, revealed pendent styled sprinkler heads with less than 1 inch distance between the deflector and the ceiling surface above thereby distorting the sprinkler pattern in the event of fire. The sprinkler heads were located in the corridor at the the Endoscopy Nursing Station, the corridor at the Endoscopy Physicians Reading Room, the corridor at the entrance to the Pharmacy and the corridor at the entrance to the Laboratory. The Facility Representative confirmed the observation that the referenced deflectors were less than 1 inch from the deflector to the ceiling surface above at each of the locations identified.

NFPA 101 (2000), 19.7.6, 9.7.5, 4.6.12
NFPA 13 (1999), 5-5.4., 5-6.4
NFPA 25
Reference: NFPA 13 (1999), 5-5.4 Deflector Position. 5-5.4.1* Distance Below Ceilings. The distances between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. 5-6.4 Deflector Position (Standard Pendent and Upright Spray Sprinklers). 5-6.4.1 Distance Below Ceilings. 5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).

Based on observation and staff confirmation the facility failed to tether natural gas powered cooking equipment, on casters, as required by NFPA 101 (2000), 19.3.2.6, 9.2.3, NFPA 96 (1998), and NFPA 54 (1999), 9.6.1.1 and 9.6.1.2

1. On 12/17/12, observation during the interior tour conducted from 9:30 a.m., to 4:00 p.m., accompanied by a Facility Representative, revealed in the facility kitchen a natural gas powered grill mounted on casters with no tethering device to prevent movement of the grill to a point where the flexible gas lines separate and produce a fire or explosion. The Facility Representative and a Dietary Department Representative confirmed the grill was on casters and not tethered.

NFPA 101 (2000), 19.3.2.6, 9.2.3,
NFPA 96 (1998)
NFPA 54 (1999), 9.6.1.1
Reference: NFPA 54 (1999), 9.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer's installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connector installation shall be configured in accordance with the manufacturer's installation instructions. 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions.

Based on observation and staff interview the facility failed to insure paper shredding collection containers do not exceed 32 gal (121 L) in capacity in areas greater than 64 sq ft (5.9-sq m), and that shredding collection containers exceeding 32 gallons are stored in rooms protected as a hazardous area as required by NFPA 101 (2000), 19.7.5.5.

1. On 12/17/12, observation during the interior tour conducted from 9:30 a.m., to 4:00 p.m., accompanied by a Facility Representative, revealed 95 gallon dark gray shredding material containers parked in the following locations, Medical Records Department, (three 95 gallon containers), Emergency Room Registration area, (one 95 gallon container), and MDC Diagnostic Center, (one 95 gallon container). None of the three locations are protected as hazardous areas.

2. On 12/17/12, staff interview of Medical Records personnel during the interior tour conducted from 9:30 a.m., to 4:00 p.m., revealed the three 95 gallon paper shredding collection containers were kept in the Medical Records Department for one week and removed each Wednesday.

NFPA 101 (2000), 19.7.5.5.
Reference: NFPA 101 (2000), 19.7.5.5 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended. Exception: Container size and density shall not be limited in hazardous areas.

Based on observation and staff confirmation the facility failed to prevent the substitution of facility structural wiring with flexible cords and cables as required by NFPA 101 (2000), 19.5.1, 9.1.2, NFPA 99 (1999), 3-3.2.1.2, 10-2.3.6, and NFPA 70 (1999), 400.8.

1. On 12/17/12, observation during the interior tour conducted from 9:30 a.m., to 4:00 p.m., accompanied by a Facility Representative, revealed a power strip connected and in use supplying power to patient care equipment in Operating Room 5, (power strip to Datex, Aestiva 5, 7900, anesthesia machine). The Facility Representative confirmed the observations.

NFPA 101 (2000), 19.5.1, 9.1.2
NFPA 99 (1999), 3-3.2.1.2, 10-2.3.6
NFPA 1 (2000), 6-1.5
NFPA 70 (1999), 400.8.
References: NFPA 99 (1999) 3-3.2.1.2 All Patient Care Areas, (d) Receptacles 2. Minimum number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Merriam-Webster as referenced in NFPA 101, Power strip - " an electrical device consisting of a cord with a plug on one end and several sockets on the other; Extension cord -" an electric cord fitted with a plug at one end and a receptacle at the other " ; Surge protector -" an electrical device that moderates power-line surges to prevent damage to attached electronic devices (as a television or computer) " .

NFPA 70, (1999) Chapter 4 Equipment for General Use, ARTICLE 400 Flexible Cords and Cables. 400.7 Uses Permitted. (A) Uses. Flexible cords and cables shall be used only for the following: (1) Pendants (2) Wiring of luminaires (fixtures) (3) Connection of portable lamps, portable and mobile signs, or appliances (4) Elevator cables (5) Wiring of cranes and hoists (6) Connection of utilization equipment to facilitate frequent interchange (7) Prevention of the transmission of noise or vibration (8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection (9) Connection of moving parts (10) Where specifically permitted elsewhere in this Code. (B) Attachment Plugs. Where used as permitted in 400.7(A)(3), (A)(6), and (A)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet. Exception: As permitted in 368.56. 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.

NFPA 99, (1999), 10.2.3.6* an exception permitting overcurrent devices. 10.2.3.6* Overcurrent Protection. 10.2.3.6.1 An overcurrent protective device shall be permitted to be placed in any of the following locations: (1) In the attachment plug (2) In the power cord (3) In the main body of the appliance 10.2.3.6.2 The overcurrent protective device shall precede any other components within the appliance, including the primary power-control switch.