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

Section 7.1.10.1 means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergencies.


Based on observation, the facility failed to ensure all egress doors were unimpeded allowing for instant and full access.

Findings include:

On 06/26/2025, during a tour of the facilities laboratory, observation revealed an egress door marked with signage that read "EMERGENCY EXIT ONLY, ALARM WILL SOUND". The emergency egress door was obstructed by a black electrical pedestal fan and a hydraulic lab/specimen diagnostic machine.

Based on observation, the facility failed to properly install Alcohol-Based Hand Rub (ABHR) dispensers in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.3.2.6.

Findings include:

On June 26, 2025, during a tour of the facility's activities office, observation revealed an ABHR dispenser located directly above and in-line with a duplex electrical receptacle.

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.

National Fire Protection Association (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


Based on observation, the facility failed to maintain the water-based fire protection system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 Edition and NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.

Findings include:

1. On 06/25/2025, during a tour of the facility, observation revealed the following areas contained a sprinkler head escutcheon gap greater than 1/8 of inch revealing access into interstitial spacing:

a) The PPS-Geriatric Psychiatric Unit patient dining room contained an institutional style sprinkler head with annular escutcheon gapping.

b) Patient room # 102 contained a pendent sprinkler head located in the restroom with annular escutcheon gapping.

c) Patient room # 103 contained a pendent sprinkler head located in the restroom with annular escutcheon gapping.

d) Patient room # 112 contained a pendent sprinkler head located in the restroom with annular escutcheon gapping.

e) Patient room # 104 contained a pendent sprinkler head with annular escutcheon gapping.

f) Activities Office contained a pendent sprinkler head above the workspace with annular escutcheon gapping.

g) Laboratory "blood bank" room contained a pendent sprinkler head with annular escutcheon gapping.

h) Central Supply "breakdown" room contained a pendent sprinkler head with annular escutcheon gapping.

i) Emergency Department staff shower room contained a pendent sprinkler head with annular escutcheon gapping.

j) Facility Dining room contained 4 pendent sprinkler heads with annular escutcheon gapping due to cut/broken drop ceiling tiles.

k) X-Ray Room #1 contained two cosmetic pendent sprinkler heads with annular escutcheon gapping.

l) X-Ray Room #2 contained one cosmetic pendent sprinkler head with annular escutcheon gapping.

m) Radiology Technician supply room contained one pendent sprinkler head with annular escutcheon gapping.

n) Janitor Closet adjacent to the on-call physician room contained one pendent sprinkler head with annular escutcheon gapping.

2. On 06/26/2025, during a tour of the facility, observation revealed the following areas contained a sprinkler head that displayed obvious signs of corrosion and were loaded with foreign material:

a) Facility Dining room contained 4 pendent sprinkler heads loaded with foreign material.

b) Facility Kitchen contained 10 pendent sprinkler heads loaded with foreign material.

c) Facility Dish room contained 2 pendent sprinkler heads loaded with foreign material.

National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 2010 Edition.

6.1.3 Placement.

6.1.3.8 Installation Height.

6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) should 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).

7.2 Inspection.

7.2.1 Frequency.

7.2.1.1* Fire extinguishers shall be manually inspected when initially placed in service.

7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.

7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:

(1) Location in designated place

(2) No obstruction to access or visibility


Based on observation and measurement, the facility failed to provide evidence that portable fire extinguishers were 1) properly installed to the correct height from the finished floor and 2) their visibility and physical access were unobstructed.

Findings include:

1) On 06/25/2025, during a tour of the facility, observation and measurement of the fire extinguisher located on the 300-hallway near the cross-corridor doors revealed the height of the extinguisher handle was 5'2" from the floor.

2) On 06/26/2025, during a tour of the facility's kitchen, observation revealed a mounted portable fire extinguisher near the walk-in freezer had its visibility and accessibility physically obstructed by cardboard boxes of fruit juices.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition
COVERS

Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhold Enclosures

314.25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lamp holder, or luminaire canopy, except where the installation complies with 410.24(B).

314.28(c) Pull and Junction Boxes and Conduit Bodies.

(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. Where used, metal covers shall comply with the grounding requirements of 250.110.
Article 314 - Outlet, Device, Pull, and Junction Boxes; Conduit bodies; Fittings; and Handhold Enclosures

EXTENSION CORDS

Article 590.2 All Wiring Installations.

Article 590.2(A) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations.

Article 400.8 Uses Not Permitted. Unless specifically permitted in Article 400.7, flex 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 ceiling, dropped ceilings or floors.

(3) Where run through doorways, windows or similar openings.

(4) Where attached to building surfaces, exception to (4): Flex cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56.

(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings.

(6) Where installed in raceways, except as otherwise permitted by the Code.

(7) Where subject to physical damage.


Based on observation, the facility failed to maintain the electrical system within the building per NFPA 70, National Electrical Code.

Findings include:

On 06/25/2025 and 06/26/2025, during a tour of the facility, the following electrical system deficiencies were observed:

1) The plastic housing near the grounding slot of duplex receptacles was observed to be broken in the following locations:

a) (PPS)-Geriatric Psychiatric south corridor near exit door

b) Social Work office

c) MST Acute Care office

d) 100 Hallway Nurse's station

e) Mailroom

f) IT Manager's office

g) Patient room #120

h) Patient Room #121

i) IT work room #123

j) Dining Room vending machine

k) Janitor's closet in the facility kitchen

2) Use of extension cords, relocatable power taps, and cord adapters observed in the following locations:

a) (PPS)-Geriatric Psychiatric patient activity room contained a microwave and traditional coffee pot plugged into relocatable power tap (RPT).

b) On-Call Physician room contained a microwave, and a dorm-style refrigerator plugged into relocatable power tap (RPT).

Based on observation and interview, the facility failed to ensure all draperies within patient care areas were compliant with National Fire Protection Association (NFPA) 701.

Findings include:

On 06/26/2025, a tour of the Physical Therapy (PT) suite revealed six loose hanging panoramic synthetic draperies physically attached to the 2'x4' light fixtures located above within the drop ceiling tiles. The draperies did not contain a NFPA 701 label indicating flame retardant.

During an interview, the Director of Plant Operations indicated the facility could not produce flame spread or flame-retardant documentation for the draperies attached to the lighting fixtures.

Based on observation and interview, the facility failed to ensure combustible decorations were flame retardant or treated with an approved fire-retardant coating that was listed and labeled for the product and that such quantity was limited in that a hazard of fire development or spread were not present.

Findings include:

On 06/25/2026, during a tour of the Prospective Payment System (PPS)-Geriatric Psychiatric Unit, observation revealed a quantity of decorative stringed crate paper streamers, globes, and flags attached to the ceilings. The combustible decorations were attached to walls and ceilings throughout the resident dining room and administrative offices at the nurse's station in such a quantity as to pose a hazard of fire development aiding in subsequent spread. The facility failed to produce flame retardant documentation records.

During an interview, the Director of Plant Operations indicated the facility did not have documentation specific to flame retardant and/or flame spread levels for combustible decorations.