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15 AIKEN AVENUE

FRANKLIN, NH 03235

No Description Available

Tag No.: K0017

19.3.6.2.1, NFPA 101, LIFE SAFETY CODE
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

19.3.6.2.2, NFPA 101, LIFE SAFETY CODE
Corridor walls shall form a barrier to limit the transfer of smoke.

Based on observation and interview the facility failed to ensure that corridor walls are properly constructed and maintained to limit the transfer of smoke.

Findings include:

Observation during tour on 1/12/10 with Staff A (Manager, FRH Building and Grounds) and Staff B (Project Coordinator) and during tour on 1/13/10 with Staff A revealed the following:

1. The corridor wall separating the Physicians Lounge from the corridor on the first floor has an assembly which contains multiple mailboxes constructed of wood which measures approximately 4 feet in length and 4 feet in height. The mailbox assembly has open slots on the corridor side and flip-up doors for each individual mailbox in the assembly which does not have any self-closing devices to ensure that the doors to the individual mailboxes remains closed. Interview with Staff A and Staff B during tour on 1/12/10 at the time of discovery confirmed the findings.

2. The wall separating the IT Closet on the first floor revealed that the wall is open above the suspended ceiling for the width of the closet and is approximately 4 to 6 inches in width between the ceiling deck and the top of the wall in this area. Interview with Staff A during tour on 1/13/10 at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0018

19.3.6.3.1, NFPA 101, LIFE SAFETY CODE
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.

19.3.6.3.2, NFPA 101, LIFE SAFETY CODE
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

S&C-07-18, CMS MEMORANDUM (April 20, 2007)
In smoke compartment not sprinklered, ? in. gap is permitted. In smoke compartment, sprinklered, ? in. gap is permitted.

Based on observation and interview corridor doors are not capable of resisting the passage of smoke and/or do not latch when closed.

Findings include:

Observation during tour on 1/12/10 with Staff A (Manager, FRH Building and Grounds) and Staff B (Project Coordinator) and during tour on 1/13/10 with Staff A revealed that the following doors do not resist the passage of smoke and/or do not latch when closed:

1. First floor, Rehab Services, Technician Office: The Technician Office that opens to a corridor used as a means of egress has a gap between the door leaf and the door frame when the door is closed of approximately 43/64 inch, which is greater than the maximum 1/2 (32/64) inch gap allowed. Interview with Staff A and Staff B at the time of discovery during tour on 1/12/10 confirmed the findings.

2. First floor, Rehab Services, Exam Room: The exam room that opens to a corridor used as a means of egress has a gap between the door leaf and the door frame when the door is closed of approximately 23/32 inch, which is greater than the maximum 1/2 (16/32) inch gap allowed. Interview with Staff A and Staff B at the time of discovery during tour on 1/12/10 confirmed the findings.

3. First floor, Radiology Section, Room 1: Room 1 entry door installed with a self-closing device that opens to a corridor used as a means of egress does not have a latching mechanism installed in the door preventing the door from latching when closed. Interview with Staff A at the time of discovery during tour on 1/13/10 confirmed the findings.

4. First Floor, IT Closet near the Radiology section: The IT Closet entry door is a louvered door that does not resist the passage of smoke. Interview with Staff A at the time of discovery during tour on 1/13/10 confirmed the findings.

No Description Available

Tag No.: K0029

19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Based on observation and interview the facility failed to ensure that areas considered to be hazardous locations have the appropriate protective devices installed.

Findings include:

Observation during tour on 1/13/10 with Staff A (Manager, FRH Building and Grounds) between 2:37 PM and 2:55 PM revealed that entry doors serving hazardous areas do not have self-closing devices installed at two soiled utility rooms located on the second floor. Interview with Staff A at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0034

19.2.2.3, NFPA 101, LIFE SAFETY CODE
Stairs: Stairs complying with 7.2.2 shall be permitted.

7.2.2.5.3, NFPA 101, LIFE SAFETY CODE
Usable Space: There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

Based on observation and interview the facility failed to ensure that stairwells are kept free of storage.

Findings include:

Observation during tour on 1/13/10 at approximately 11:25 am with Staff A (Manager, FRH Building and Grounds) revealed that the ground floor level of stairwell 6 has stored items consisting of multiple metal bed-frames in it.

Interview with Staff A during tour on 1/13/10 at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0045

19.2.8, NFPA 101, LIFE SAFETY CODE
Illumination of Means of Egress: Means of egress shall be illuminated in accordance with Section 7.8.

7.8.1.2, NFPA 101, LIFE SAFETY CODE
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.

7.8.1.4, NFPA 101, LIFE SAFETY CODE
Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

Based on observation and interview the facility failed to ensure that illumination in means of egress is continuous and functions in the event of a power loss.

Findings include:

Observation during tour on 1/13/10 at approximately 9:50 am with Staff A (Manager, FRH Building and Grounds) revealed that all of the lights serving a portion of a corridor leading to the Employees Gym and separated by doors from other portions of the corridor are able to be turned off with a light switch leaving the area in darkness (as measured at 0.024 ft-candles with a light meter). Interview during tour on 1/13/10 with Staff A at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0046

19.2.9.1, NFPA 101, LIFE SAFETY CODE
Emergency lighting shall be provided in accordance with Section 7.9.

7.8.2.1, NFPA 101, LIFE SAFETY CODE
Illumination of means of egress shall be from a source considered reliable by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that illumination in means of egress is continuous and functions in the event of a power loss.

Findings include:

Observation during tour on 1/13/10 at approximately 9:50 am with Staff A (Manager, FRH Building and Grounds) revealed that all of the lights serving a portion of a corridor leading to the Employees Gym and separated by doors from other portions of the corridor are able to be turned off with a light switch leaving the area in darkness (as measured at approximately 0.024 ft-candles with a light meter) which will prevent the lights from operating through an emergency power source. Interview with Staff A at the time of discovery during tour on 1/13/10 revealed that there are no emergency lights other than the overhead lights which can be shut-off with the light switch and confirmed the findings.

No Description Available

Tag No.: K0047

19.2.10.1, NFPA 101, LIFE SAFETY CODE
Means of egress shall have signs in accordance with Section 7.10.

7.10.6.3, NFPA 101, LIFE SAFETY CODE
Level of Illumination: Externally illuminated signs shall be illuminated by not less than 5 ft-candles (54 lux) at the illuminated surface and shall have a contrast ratio of not less than 0.5.

Based on observation and interview the facility failed to ensure that exit signs are properly illuminated.

Findings include:

Observation during tour on 1/13/10 at approximately 9:50 am with Staff A (Manager, FRH Building and Grounds) revealed that two externally illuminated exit signs serving a portion of a corridor leading to the Employees Gym and separated by doors from other portions of the corridor are not illuminated when the lights are turned off with a light switch which leaves the area in darkness (as measured at approximately 0.024 ft-candles with a light meter). Interview during tour on 1/13/10 with Staff A at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0051

19.3.4.1, NFPA 101, LIFE SAFETY CODE
General: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4, NFPA 101, LIFE SAFETY CODE
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

1-5.2.5.2, NFPA 72, NATIONAL FIRE ALARM CODE
Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on observation and interview the facility failed to ensure that the fire alarm circuit is adequately protected.

Findings include:

Observation during tour on 1/13/10 at approximately 1:40 PM with Staff A (Manager, FRH Building and Grounds) revealed that the fire alarm circuit located in the Electrical/Fire Alarm Panel Room on the ground floor does not have an anti-tamper lock installed on the circuit breaker, which will prevent manually shutting off the circuit while allowing the circuit to trip due to electrical issues. Interview during tour with Staff A at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0056

19.3.5.1, NFPA 101, LIFE SAFETY CODE
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

5-13.6.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.

A-5-13.6.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The sprinklers in the pit are intended to protect against fires cause by debris, which can accumulate over time. Ideally, the sprinklers should be located near the side of the pit below the elevator doors, where most debris accumulates. However, care should be taken that the sprinkler location does not interfere with the elevator toe guard, which extends below the face of the door opening. ASME A17.1, Safety Code for Elevators and Escalators, allows the sprinklers within 2 ft (0.65 m) of the bottom of the pit to be exempted from the special arrangements of inhibiting waterflow until elevator recall has occurred.

5-13.6.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Automatic sprinklers in elevator machine rooms or at the tops of hoistways shall be of ordinary- or intermediate-temperature rating.

A-5-13.6.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
ASME A17.1, Safety Code for Elevators and Escalators, requires the shutdown of power to the elevator upon or prior to the application of water in elevator machine rooms or hoistways. This shutdown can be accomplished by a detection system with sufficient sensitivity that operates prior to the activation of the sprinklers (see also NFPA 72, National Fire Alarm Code?). As an alternative, the system can be arranged using devices or sprinklers capable of effecting power shutdown immediately upon sprinkler activation, such as a waterflow switch without a time delay. This alternative arrangement is intended to interrupt power before significant sprinkler discharge.

5-13.6.3, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Upright or pendent spray sprinklers shall be installed at the top of elevator hoistways.
Exception: Sprinklers are not required at the tops of noncombustible hoistways of passenger elevators with car enclosure materials that meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators.

A-5-13.6.3, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Passenger elevator cars that have been constructed in accordance with ASME A17.1, Safety Code for Elevators and Escalators, Rule 204.2a (under A17.1a-1985 and later editions of the code) have limited combustibility. Materials exposed to the interior of the car and the hoistway, in their end-use composition, are limited to a flame spread rating of 0 to 75 and a smoke development rating of 0 to 450.

Based on observation and interview the facility failed to ensure that all required areas are protected by an automatic, supervised sprinkler system.

Findings include:

Observation during tour on 1/13/10 at approximately 1:55 PM with Staff A (Manager, FRH Building and Grounds) revealed that one of the elevator machine rooms on the ground floor does not have any sprinkler protection provided. Interview during tour on 1/13/10 with Staff A at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0062

19.3.5.1, NFPA 101, LIFE SAFETY CODE
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

3-2.5.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The liquid in bulb-type sprinklers shall be color coded in accordance with Table 3-2.5.1.
Table 3-2.5.1 Temperature Ratings, Classifications, and Color Codings
Ordinary Rated:
Glass Bulb Colors: Orange or red
Maximum Ceiling Temperature: 100
Temperature Rating: 135-170

Intermediate Rated:
Glass Bulb Colors: Yellow or green
Maximum Ceiling Temperature: 150
Temperature Rating: 175-225

High Rated:
Glass Bulb Colors: Blue
Maximum Ceiling Temperature: 225
Temperature Rating: 250-300

5-3.1.4.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Ordinary-temperature-rated sprinklers shall be used throughout buildings.
Exception No. 1: Where maximum ceiling temperatures exceed 100 F (38 C), sprinklers with temperature ratings in accordance with the maximum ceiling temperatures of Table 3-2.5.1 shall be used.
Exception No. 2: Intermediate- and high-temperature sprinklers shall be permitted to be used throughout ordinary and extra hazard occupancies.
Exception No. 3: Sprinklers of intermediate- and high-temperature classifications shall be installed in specific locations as required by 5-3.1.4.2.

5-3.1.4.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The following practices shall be observed to provide sprinklers of other than ordinary temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout.
(1) Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification.
(2) Sprinklers located within 12 in. (305 mm) to one side or 30 in. (762 mm) above an uncovered steam main, heating coil, or radiator shall be of the intermediate-temperature classification.
(3) Sprinklers within 7 ft (2.1 m) of a low-pressure blowoff valve that discharges free in a large room shall be of the high-temperature classification.
(4) Sprinklers under glass or plastic skylights exposed to the direct rays of the sun shall be of the intermediate-temperature classification.
(5) Sprinklers in an unventilated, concealed space, under an uninsulated roof, or in an unventilated attic shall be of the intermediate-temperature classification.
(6) Sprinklers in unventilated show windows having highpowered electric lights near the ceiling shall be of the intermediate-temperature classification.
(7) Sprinklers protecting commercial-type cooking equipment and ventilation systems shall be of the high- or extra-high-temperature classification as determined by use of a temperature-measuring device.

Based on observation and interview the facility failed to ensure that the appropriate classification of sprinkler heads are installed.

Findings include:

Observation during tour on 1/12/10 at approximately 3:30 PM with Staff A (Manager, FRH Building and Grounds) and Staff B (Project Coordinator) revealed that an intermediate-rated sprinkler head is installed in the medical closet located in the Women's Health Section on the first floor. Interview during tour on 1/12/10 with Staff A and Staff B at the time of discovery confirmed the findings and that no heat sources are present in the closet which would necessitate the use of an intermediate-rated sprinkler head.





5-6.5.1.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Sprinklers shall be arranged to comply with Table 5-6.5.1.2...

Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)
Distance from Sprinklers to Side of Obstruction: Less than 1 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 0

Distance from Sprinklers to Side of Obstruction: 1 ft to less than 1 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 2-1/2

Distance from Sprinklers to Side of Obstruction: 1 ft 6 in. to less than 2 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 3-1/2

5-5.6, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Clearance to Storage: The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

12-1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
General: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

2-2.1.2, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
Unacceptable obstructions to spray patterns shall be corrected.

Based on observation and interview the facility failed to ensure that the spray pattern from sprinkler heads are not obstructed.

Findings include:

Observation during tour on 1/13/10 with Staff A (Manager, FRH Building and Grounds) revealed that the spray pattern of sprinkler heads in the following locations are obstructed:

1. Ground floor, Conference Room Storage: The spray pattern of one sprinkler head is obstructed by a storage rack with storage which is above the level of the deflector of the sprinkler head which is adjacent to (within 12 inches) of the sprinkler head.

2. Second floor, North Wing Shower Room: The spray pattern of one sprinkler head is obstructed by a wall section that projects from the ceiling approximately 13 inches and is approximately 20 inches from the sprinkler head which projects from the ceiling approximately 1 inch.

Interview during tour on 1/13/10 with Staff A confirmed the findings.

No Description Available

Tag No.: K0072

7.1.10.1, NFPA 101, LIFE SAFETY CODE
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.

7.1.10.2.1, NFPA 101, LIFE SAFETY CODE
No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Based on observation and interview the facility failed to ensure that items are not stored in corridors serving as a means of egress.

Findings include:

Observation during tour on 1/13/10 at between 11:00 am and 12:00 PM with Staff A (Manager, FRH Building and Grounds) revealed that the following corridors have storage placed in them:

1. Ground floor, corridor leading to stairwell 6: Furniture stored in the corridor. Interview during tour on 1/13/10 with Staff A at the time of discovery revealed that the items are waiting for storage and/or disposal.

2. Ground floor, corridor near Conference Room C: Furniture stored in corridor. Interview during tour on 1/13/10 with Staff A at the time of discovery confirmed the findings.

No Description Available

Tag No.: K0130

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and interview the facility failed to ensure that all penetrations in a fire barrier are properly protected.

Findings include:

Observation during tour on 1/12/10 at approximately 3:40 PM with Staff A (Manager, FRH Building and Grounds) and Staff B (Project Coordinator) revealed that the fire barrier at the Women's Health section of the first floor has at least one unsealed penetration. Interview during tour on 1/12/10 with Staff A and B at the time of discovery confirmed that the wall is a fire barrier and confirmed the findings.

No Description Available

Tag No.: K0147

19.5.1, NFPA 101, LIFE SAFETY CODE
Utilities: Utilities shall comply with the provisions of Section 9.1.

9.1.2, NFPA 101, LIFE SAFETY CODE
Electric: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

400-7, NFPA 70, NATIONAL ELECTRICAL CODE
(a) Uses: Flexible cords and cables shall be used only for the following:
(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their 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) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

Based on observation and interview the facility failed to ensure that extensions cords are not used.

Findings include:

Observation during tour on 1/12/10 at approximately 11:58 am with Staff A (Manager, FRH Building and Grounds) and Staff B (Project Coordinator) revealed that an extension cord is in use in the gift shop to connect a floor lamp to an outlet which is within the length of the flexible cord attached to the floor lamp. Interview during tour on 1/12/10 with Staff A at the time of discovery confirmed the findings.





370-23, NFPA 70, NATIONAL ELECTRICAL CODE
Supports. Enclosures within the scope of this article shall be supported in accordance with one or more of the provisions in (a) through (h).
(a) Surface Mounting: An enclosure mounted on a building or other surface shall be rigidly and securely fastened in place. If the surface does not provide rigid and secure support, additional support in accordance with other provisions of this section shall be provided.
(b) Structural Mounting: An enclosure supported from a structural member of a building or from grade shall be rigidly supported either directly, or by using a metal, polymeric, or wood brace.
(c) Mounting in Finished Surfaces: An enclosure mounted in a finished surface shall be rigidly secured thereto by clamps, anchors, or fittings identified for the application.
(d) Suspended Ceilings: An enclosure mounted to structural or supporting elements of a suspended ceiling shall be not more than 100 in.3 (1640 cm3) in size and shall be securely fastened in place in one of the following ways.
(1) Framing Members: An enclosure shall be fastened to the framing members by mechanical means such as bolts, screws, or rivets, or by the use of clips or other securing means identified for use with the type of ceiling framing member(s) and enclosure(s) employed. The framing members shall be adequately supported and securely fastened to each other and to the building structure.
(2) Support Wires: The installation shall comply with the provisions of Section 300-11(a). The enclosure shall be secured, using methods identified for the purpose, to ceiling support wires, including any additional support wires installed for that purpose. Support wires used for enclosure support shall be fastened at each end so as to be taut within the ceiling cavity.

Based on observation and interview the facility failed to ensure that installations involving electrical wiring are installed and/or maintained in an appropriate manner.

Findings include:

Observation during tour on 1/12/10 at approximately 2:55 PM with Staff A (Manager, FRH Building and Grounds) and Staff B (Project Coordinator) revealed that at least one junction box is unsupported at the area of the separating wall of the Kitchen and the corridor located above the suspended ceiling in the corridor. Interview during tour on 1/12/10 with Staff A confirmed the findings at the time of discovery.





210-8(a), NFPA 70, NATIONAL ELECTRICAL CODE
All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified below shall have ground-fault circuit-interrupter protection for personnel.
(7) Where the receptacles are installed to serve the countertop surfaces and are located within 6 ft (1.83 m) of the outside edge of the ... sink.

Based on observation and interview the facility failed to ensure that all electrical outlet within 6 feet of a water source are protected by a GFCI (Ground-fault Circuit-interrupter).

Findings include:

Observation during tour on 1/13/10 between 8:50 am and 2:35 PM with Staff A (Manager, FRH Building and Grounds) revealed that electrical outlets in the following locations are within 6 feet of the outside edge of a sink and are not GFCI protected:

1. First floor (portion of building corresponding to 1972 construction), Doctors Practice: Exam rooms 1, 2, 3, 4, and the bathroom have electrical outlets within 6 feet of the outside edge of sinks.

2. First floor, Echo Lab: At least one electrical outlet within 6 feet of the outside edge of a sink.

3. First floor, Triage: A quad outlet is within 6 feet of the outside edge of a sink.

4. First Floor, Emergency Department, Soiled Utility Room: At least one electrical outlet within 6 feet of the outside edge of a sink.

5. Ground floor (portion of building corresponding to 1991 construction), Oncology Department: At least four electrical outlets within the department are within 6 feet of the outside edge of sinks.

6. Second floor, Medication Room: At least one electrical outlet within 6 feet of the outside edge of a sink.

Interview during tour on 1/13/10 with Staff A confirmed the findings.





110-12, NFPA 70, NATIONAL ELECTRICAL CODE
Mechanical Execution of Work: Electrical equipment shall be installed in a neat and workmanlike manner.
(a) Unused Openings: Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.

Based on observation and interview the facility failed to ensure that all unused openings of installed electrical distribution devices are properly enclosed.

Findings include:
Observation during tour on 1/13/10 at approximately 2:45 PM with Staff A (Manager, FRH Building and Grounds) revealed that one of the electrical distribution panels, panel NP22-2, located on the second floor has at least one open slot where circuit breakers are installed. Interview during tour on 1/13/10 with Staff A confirmed the findings at the time of discovery.