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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. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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.
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.
Based on observation and interview the facility failed to ensure that the following entry doors are capable of resisting the passage of smoke.
Findings include:
Observation during tour on 11/4/10 between 9:00 a.m. and 12:00 p.m. with Staff B (Plant Operations/Maintenance) and Staff C (Maintenance) revealed that the following doors are not resistant to the passage of smoke and/or do not latch when closed:
1. Housekeeping area near the time clock on first floor: Door fails to latch when closed.
2. Room 218: Door gap of approximately 11/16 inch.
3. Room 213: Door gap of approximately 9/16 inch.
4. Room 205: Door gap of approximately 41/64 inch.
Interview during tour on 11/4/10 with Staff B and Staff C confirmed the findings.
Tag No.: K0020
19.3.1.1, NFPA 101, LIFE SAFETY CODE
Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
8.2.3.2.1, NFPA 101, LIFE SAFETY CODEDoor assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.
1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.
Based on observation and interview the facility failed to ensure that stairwell entry doors have labels and that labels are legible.
Findings include:
Observation during tour on 11/4/10 between 11:55 a.m. and 1:35 p.m. with Staff B (Plant Operations/Manager) and Staff C (Maintenance) revealed that the following doors are without labels and/or the existing labels are painted:
1. Stair 2, level 2: Door leaf without a label.
2. Stair 3, level 2: Door leaf without a label.
3. Stair 5, level 3: Door leaf with a painted (illegible) label.
Interview during tour on 11/4/10 at the time of discovery with Staff B confirmed the findings.
8.2.5.1, NFPA 101, LIFE SAFETY CODE
Every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation.
8.2.5.3, NFPA 101, LIFE SAFETY CODE
Vertical openings (shafts) that do not extend to the bottom or the top of the building or structure shall be enclosed at the lowest or highest level of the shaft, respectively, with construction in accordance with 8.2.5.4.
8.2.5.4, NFPA 101, LIFE SAFETY CODE
The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four stories or more in new construction ? 2-hour fire barriers
(2) Other enclosures in new construction ? 1-hour fire barriers
(3) Existing enclosures in existing buildings ? 1/2-hour fire barriers
Based on observation and interview the facility failed to ensure that access panels which provide access to tunnels underneath the floor are capable of resisting the passage of smoke.
Findings include:
Observation during tour on 11/4/10 with Staff B and Staff C revealed that the following locations have horizontally mounted access panels to permit access to tunnel(s) beneath the first floor which have unsealed openings to allow for removal of the panels.
Interview during tour on 11/4/10 with Staff B and Staff C confirmed the findings.
Tag No.: K0029
19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safe-guarded 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.
8.2.4.2, NFPA 101, LIFE SAFETY CODE
Smoke partitions shall extend 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.
Exception: Smoke partitions shall be permitted to terminate at the underside of a monolithic or suspended ceiling system where the following conditions are met:
(a) The ceiling system forms a continuous membrane.
(b) A smoketight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling.
(c) The space above the ceiling is not used as a plenum.
8.2.4.4.1, 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 smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
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 smoke partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
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 hazardous areas are separated from other areas with smoke-resisting partitions and/or self-closing doors.
Findings include:
Observation during tour on 11/3/10 and 11/4/10 with Staff B (Plant Operations/Manager) and Staff C (Maintenance) revealed that the sprinkler system protected hazardous areas are not properly protected to prevent the migration of smoke in the following locations:
1. The separating wall of the Kitchen on level one has at least one unsealed penetration.
2. The separating wall of the housekeeping/electrical room located on level one has at least one unsealed penetration.
3. The entry door for the soiled utility room located in the "short stay" area of level 3 does not have a self-closing device installed.
Interview during tour between 11/3/10 and 11/4/10 with Staff B at the times of discovery confirmed the findings.
Tag No.: K0034
19.2.2.3, NFPA 101, LIFE SAFETY CODEStairs: 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.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)
7.1.3.2.3, NFPA 101, LIFE SAFETY CODE
An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
Based on observation and interview the facility failed to ensure that either storage is not placed in stairwells or that storage under stairs is enclosed and is not accessible from within the stair enclosure.
Findings include:
Observation during tour on 11/4/10 at approximately 10:30 a.m. with Staff B (Plant Operations/Manager) and Staff C (Maintenance) revealed that in the enclosure for stairwell 5 at the base of the stairwell, underneath the stairs, is an enclosure with storage in it that has a door that opens into the stairwell.
Interview during tour on 11/4/10 with Staff B and Staff C at the time of discovery confirmed the findings.
Tag No.: K0047
19.2.10.1, NFPA 101, LIFE SAFETY CODE
Means of egress shall have signs in accordance with Section 7.10.
7.10.1.2, NFPA 101, LIFE SAFETY CODE
Exits: Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.2, NFPA 101, LIFE SAFETY CODE
Directional Signs: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
Based on observation and interview the facility failed to ensure that exits are appropriately marked with an exit sign and, where not readily visible, additional readily visible signs with directional indicators are in use.
Findings include:
Observation during tour on 11/4/10 between 10:00 a.m. and 10:15 a.m. with Staff B (Plant Operations/Manager) and Staff C (Maintenance) revealed that exits are not readily visible and/or are not immediately discernable as exits in the Cardiac Rehabilitation and Rehabilitation Work Area in the Physical Therapy area on level one.
Record review of the egress map mounted on the walls of the Physical Therapy area during tour on 11/4/10 at the time of discovery provides a diagram of the path of egress occupants are to use.
Interview during tour on 11/4/10 with Staff B and Staff C confirmed the findings.
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 11/4/10 at approximately 10:40 a.m. with Staff B (Plant Operations/Manager) and Staff C (Maintenance) revealed that the fire alarm circuit breaker (number 18) in panel LSDP located in the Main Electrical Room does not have an anti-tamper lock in place which will prevent the fire alarm circuit from being tripped by accidental or purposeful means and will allow the breaker to trip due to electrical issues.
Interview during tour on 11/4/10 at the time of discovery with Staff B and Staff C confirmed the findings.
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
5-13.3.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.
Based on observation and interview the facility failed to ensure that sprinklers are installed under the first landing above the bottom of the stair shaft.
Findings include:
Observation during tour on 11/3/10 at approximately 2:45 p.m. with Staff B (Plant Operations/Manager) and Staff C (Maintenance) revealed that stair shaft 1 at level 1 does not have any sprinkler heads installed under the first landing above the stair shaft.
Interview during tour on 11/3/10 at the time of discovery with Staff B and Staff C confirmed the findings.
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.
9.7.5, NFPA 101, LIFE SAFETY CODE
Maintenance and Testing: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection 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 Temperature Classification
Glass Bulb Colors: Orange or red
Maximum Ceiling Temperature: 100
Temperature Rating: 135-170
Intermediate Temperature Classification
Glass Bulb Colors: Yellow or green
Maximum Ceiling Temperature: 150
Temperature Rating: 175-225
High Temperature Classification
Glass Bulb Colors: Blue
Maximum Ceiling Temperature: 225
Temperature Rating: 250-300
Extra High Temperature Classification
Glass Bulb Colors: Purple
Maximum Ceiling Temperature: 300
Temperature Rating: 325-375
5-3.1.4.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Ordinary-temperature-rated sprinklers shall be used throughout buildings.
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 high-powered 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. (See 4-9.6.)
2-2.1.1, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Based on observation and interview the facility failed to ensure that the sprinkler system is properly maintained.
Findings include:
Observation during tour between 11/3/10 and 11/5/10 with Staff B (Plant Operations/Manager) and Staff C (Maintenance) revealed the following:
1. Loaded/Corroded sprinkler heads: At least one loaded and/or corroded sprinkler heads were found in the following locations:
a. Laundry in the area of the dryers.
b. Clean linen
c. Kitchen
d. Corridor near rest room in the area of Radiology and Fluoroscopy
e. Radiology Technician Area
f. Room 2-249
Interview during tour between 11/3/10 and 11/5/10 with Staff B and Staff C confirmed the findings.
2. Inappropriate temperature classification of sprinkler heads installed:
a. At least one intermediate temperature sprinkler head in the janitors closet in the Kitchen. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
b. At least one high temperature sprinkler head in the electrical closet in the Emergency Room. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
c. At least one intermediate temperature sprinkler head in Med. Storage (#2-195). Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
d. At least one intermediate temperature sprinkler head in the rest room in the Nurses Locker Room (#2-214). Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
e. At least one intermediate temperature sprinkler head in restroom of room 215. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
f. At least one intermediate temperature sprinkler head in the electrical closet (#2-217A). Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
g. At least one intermediate temperature sprinkler head in restroom of room 218. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
h. At least one intermediate temperature sprinkler head in restroom of room 219. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
i. At least one intermediate temperature sprinkler head in restroom of room 220. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
j. At least one intermediate temperature sprinkler head in restroom of room 215. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
k. At least one intermediate temperature sprinkler head in the second level corridor near room 2-190. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
l. At least one intermediate temperature sprinkler head in the electrical closet (#2-142A). Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
m. At least one intermediate temperature sprinkler head in restroom of room 203. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
n. At least one intermediate temperature sprinkler head in the chapel. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
o. At least one intermediate temperature sprinkler head in the area of level 3 of stairwell 4. Interview at the time of discovery with Staff B and Staff C confirmed that no heat sources are present which would indicate the need for an intermediate temperature sprinkler head.
Tag No.: K0069
19.3.2.6, NFPA 101, LIFE SAFETY CODE
Cooking Facilities: Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3, NFPA 101, LIFE SAFETY CODE
Commercial Cooking Equipment: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
2-1.2, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
All seams, joints, and penetrations of the hood enclosure that direct and capture grease-laden vapors and exhaust gases shall have a liquidtight continuous external weld to the hood ' s lower outermost perimeter. Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made greasetight.
4-3.4.4, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Access panels shall be of the same material and thickness as the duct. Access panels shall have a gasket or sealant that is rated for 1500 F and shall be greasetight. Fasteners, such as bolts, weld studs, latches, or wing nuts, used to secure the access panels shall be carbon steel or stainless steel and shall not penetrate duct walls.
4-5.2.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
All seams, joints, penetrations, and duct-to-hood collar connections shall have a liquidtight continuous external weld.
Based on record review and interview the facility failed to ensure that the hood is properly maintained to be greasetight and liquidtight.
Findings include:
Record review of hood vendor reports during tour on 11/3/10 between 10:45 a.m. and 2:00 p.m. revealed the following:
1. Cleaning report dated 11/3/10 states: "The first port leaks... the right side of duct work to the hood. The middle box leaks on top of tile. Both... need fire proof seal and needs to be welded same with other port. Recommend new... work from fan to hood. Didn't continue to spray after first port because leak and damage to ceiling tiles."
2. Deficiency Notification Report dated 5/12/10 states: "Holes or breaks in duct work" followed by "all ducts need to be sealed". According to the report, the duct was sealed on 5/15/10.
3. Cleaning report dated 3/2/10 states: "Can't spray down duct work leaks on the other... of the wall of the hood duct work needs to be replaced is... old and has old grease on it..."
4. Inspection report dated 10/15/09 states: "Hood/duct penetrations sealed" then "yes" is handwritten in.
5. Cleaning report dated 9/10/09 states: "the other side of the wall behind hood leaks in... from duct work"
6. Cleaning report dated 3/30/09 states: "duct work leaks under fan on back side of hood"
Interview during tour on 11/3/10 with Staff B (Plant Operations/Manager) during record review confirmed the findings.
Tag No.: K0076
4-3.1.1.1, NFPA 99, HEALTH CARE FACILITIES
Cylinder and Container Management: Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.5.2.1(b), NFPA 99, HEALTH CARE FACILITIES
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
Based on observation and interview the facility failed to ensure that medical gas cylinders are properly secured.
Findings include:
Observation during tour on 11/3/10 at approximately 2:20 p.m. with Staff B (Plant Operations/Manager) and Staff C (Maintenance) revealed that approximately 16 medical gas cylinders located at an exterior storage area containing Oxygen, Nitrogen, Argon, or N.O.S. are not individually secured. At the time of discovery, the two ends of the single chain used to secure the group of cylinders is not connected causing the cylinders to be freestanding.
Interview during tour on 11/3/10 with Staff B at the time of discovery confirmed the findings.
Tag No.: K0104
19.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
8.3.6.1, 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 floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke 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 smoke barrier, the sleeve shall be solidly set in the smoke 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 smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) 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 smoke 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 openings in smoke barrier walls are adequately protected.
Findings include:
Interview during tour on 11/4/10 with Staff B (Plant Operations/Maintenance) and Staff C (Maintenance) identified the locations of smoke barriers.
Observation during tour on 11/4/10 between 11:15 a.m. and 3:15 p.m. with Staff B and Staff C revealed that the following smoke barriers have unprotected penetrations:
1. The corridor portion of smoke barrier near room 214.
2. The smoke barrier separation between the Medical Records room and the Board Room on level 2.
Interview during tour on 11/4/10 with Staff B and Staff C at the times of discovery confirmed the findings.
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.
110-14(b), NFPA 70, NATIONAL ELECTRICAL CODE
Splices: Conductors shall be spliced or joined with splicing devices identified for the use... All splices and joints and the free ends of conductors shall be covered with an insulation equivalent to that of the conductors or with an insulating device identified for the purpose.
110-26, NFPA 70, NATIONAL ELECTRICAL CODE
Spaces About Electrical Equipment: Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) Working Space: Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space: The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a).
Table 110-26(a). Working Spaces
Nominal Voltage to Ground: 0-150
Minimum Clear Distance (ft) (Condition 1): 3
Condition 1 - Exposed live parts on one side and no live or grounded
parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
(2) Width of Working Space: The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(3) Height of Working Space: The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.
(b) Clear Spaces: Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
(e) Headroom: The minimum headroom of working spaces about service equipment, switchboards, panelboards, or motor control centers shall be 61/2 ft (1.98 m). Where the electrical equipment exceeds 61/2 ft (1.98 m) in height, the minimum headroom shall not be less than the height of the equipment.
370-28, NFPA 70, NATIONAL ELECTRICAL CODE
Pull and Junction Boxes: Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(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.
Based on observation and interview the facility failed to ensure that electrical devices and wiring are properly installed and that required clearances are maintained.
Findings include:
Observation during tour between 11/3/10 and 11/5/10 with Staff B (Plant Operations/Maintenance) and Staff C (Maintenance) revealed the following:
1. Material Handling Area, Level 1: At least one electrical junction box without a cover installed.
2. Case Management, Level 2: At least one electrical junction box without a cover installed with a unprotected splice for a grounding conductor protruding from the unenclosed junction box.
3. Medical Records, Level 2: A photocopier is located less than 36 inches of the wall housing electrical distribution panel(s).