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National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 Edition

19.3.2.1.3 The doors shall be self-closing or automatic closing.

19.3.2.1.5 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) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(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 all hazardous areas were properly fire barrier protected.

Findings include:

On 11/08/21 and 11/09/21, the following hazardous areas were not protected properly:
a) Room RT04 contained five empty e-style cylinders. The door was required to be one hour fire rated; however, lacked documented evidence of a rating label. The absence of the rating label deemed this door unrated. The door was also required to be equipped with a self-closer; however, the door was not self-closing.
b) the dry storage room in the kitchen was not equipped with a self-closer. This room contained cardboard boxes, plastics, and various paper products. The room was larger than 50 square feet; therefore, did not meet the "less than 50 square feet" exception.

On 11/08/21 and 11/09/21, the Plant Facility and Safety Director and Food Service Supervisor confirmed the findings upon discovery.

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

6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.
6.2.7.3 Cover plates used with concealed sprinklers shall be part of the listed sprinkler assembly.
6.2.8 Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.

8.6.4.1.1.1 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) throughout the area of coverage of the sprinkler.

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.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Findings include:

On 11/08/21 and 11/09/21, the following sprinkler concerns were identified:

1) Staff bathroom - the sprinkler and its escutcheon were loaded with dust.
2) Room RD139 - a sprinkler was ½ inch from the ceiling, less than the required one inch.
3) Room 25 bathroom - the sprinkler's escutcheon was dropped, exposing the annular space.
4) Equipment Storage room across from Room 20/21 - the sprinkler was missing its escutcheon.
5) Dining Room - a sprinkler was loaded with lint.
6) Kitchen locker room - a sprinkler was corroded, and its escutcheon had a gap, exposing the annular space.
7) Dictation office - the sprinkler had a gap in its escutcheon, exposing the annular space.
8) Laboratory - two sprinklers had gaps in their escutcheons, exposing the annular space.

On 11/08/21 and 11/09/21, the Plant Facility and Safety Director confirmed the findings at the time of discovery.

National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3 Placement.
6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.
6.1.3.2 Fire extinguishers shall be located along normal paths of travel, including exits from areas.
6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.
6.1.3.3.2* In large rooms and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.
6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses
6.1.3.5 Wheeled fire extinguishers shall be located in designated locations.
6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem.
6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.
6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).
6.1.3.10 Cabinets.
6.1.3.10.2 The location of fire extinguishers as described in
6.1.3.3.2 shall be marked conspicuously.

Based on observation and interview, the facility failed to maintain portable fire extinguishers (PFE) as required.

Findings include:

On 11/08/21 through 11/09/21, the following PFE issues were observed:
- PFEs throughout the facility lacked the required signage.
- a PFE in the Shipping and Receiving room was blocked by a cart loaded with boxes.

On 11/08/21 through 11/09/21, the Plant Facility and Safety Director confirmed the facility's PFEs lacked the required signage and was unaware of this requirement. The Plant Facility and Safety Director confirmed the PFE was blocked.

Based on observation and interview, the facility failed to ensure smoke barrier construction was properly sealed at points of penetration.

Findings include:

On 11/08/21, the IT room ceiling contained four pipes penetrating the ceiling without protection.

On 11/08/21, the Plant Facility and Safety Director confirmed the unprotected penetrations at the time of discovery.

NFPA 70; 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.

Article 400 - Flexible Cords and Cables

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
2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
3) Where run through doorways, windows, or similar openings
4) Where attached to building surfaces
Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6) Where installed in raceways, except as otherwise permitted in the Code
7) Where subject to physical damage

Based on observation and interview, the facility failed to ensure electrical wiring and equipment complied with the National Electric Code, National Fire Protection Association (NFPA) 70.

Findings include:

On 11/08/21 and 11/09/21, the following electrical concerns were identified:

a) Panelboard PH - circuit breaker 12 was identified on the schedule directory as "Spare"; however, was in the "On" position.
b) Panelboard SL - circuit breakers 10, 11, and 12 were identified on the schedule directory as "Spare"; however, were in the "On" position.
c) Panelboard NS - circuit breaker 7 was identified on the schedule directory as "Panel C"; however, was a Space.
d) Panelboard NS - circuit breaker 10 was identified on the schedule directory as "Plug #20"; however, was a Space.
e) Panelboard NS - circuit breaker 38 was not identified on the schedule directory; however, was in the "On" position.
f) Panelboard P3 - circuit breaker 4 was identified on the schedule directory as "Treadmill"; however, was a Space.
g) Panelboard P3 - circuit breaker 6 was identified on the schedule directory as "Spare"; however, was in the "On" position.
h) Panelboard P3 - circuit breaker 24 was not identified on the schedule directory; however, was in the "On" position.
i) Panelboard P3 - circuit breaker 28 was not identified on the schedule directory; however, was in the "On" position.
j) Panelboard P3 - circuit breakers 30 and 32 were identified on the schedule directory as "Spare"; however, was in the "On" position.
k) Panelboard AP - circuit breaker 13 was identified on the schedule directory as "Spare"; however, was in the "On" position.
l) Electrical Room - a water cooler was plugged into a relocatable power tap (RPT).
m) Radiology - a mammography bed was plugged into a nine-receptacle RPT.
n) Triage Room - A vital signs machine was plugged into a nine-receptacle RPT.
o) Doctors' Sleeping Room - A microwave was plugged into a RPT.
p) Break Room - a water dispenser and a small refrigerator were plugged into a five-receptacle residential style RPT.
q) Panelboard ON1 - a ladder was leaning against the panel.
r) Panelboard KPI - circuit breaker 15 was identified on the schedule directory as "Disposer"; however, was a "Spare".
s) Dietary Manager office - a seven-plug RPT was plugged into an orange extension cord, creating a daisy-chain.
t) Coffee Cart - two commercial-size coffee bean grinders were plugged into a residential-style RPT.

On 11/08/21 and 11/09/21, the Plant Facility and Safety Director Maintenance Director was present at each discovery.

Based on observation and interview, the facility failed to limit combustible decorations within a smoke compartment.

Findings include:

On 11/08/21, the Respiratory Therapy door was decorated with more than the allowed 30 percent combustible decorations. The door measured 83 inches by 34 ½ inches. The decorations measured 83 inches by 30 ¾ inches.

On 11/08/21, the Plant Facility and Safety Director confirmed the finding and measurements.

NFPA 99, Health Care Facilities Code, 2015 Edition

The requirements of Chapter 6 shall apply to the essential electrical system for the emergency power supply installation.

NFPA 110, Standard for Emergency and Standby Power System, 2013 Edition
5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.
5.6.5.6.1 The remote manual stop station shall be labeled.
5.6.6 Remote Controls and Alarms. A remote, common audible alarm shall be provided as specified in 5.6.5.2(4) that is powered by the storage battery and located outside of the EPS
service room at a work site observable by personnel.

Based on observation and interview, the facility failed to install remote manual stop station and remote annunciator for one of two essential electrical systems (generator).

Findings include:

On 11/08/21, the generator in the parking garage area lacked a remote manual stop. This generator also lacked a remote annunciator.

On 11/08/21, the Plant Facility and Safety Director confirmed each finding at the time of discovery.