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Based on observation and staff interview during the survey, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 39.2.1.1 and Chapter 7. This was evidenced by the following:

Stair case from the second floor to the first floor had items stored in the stairwell.

7.1.10 Means of Egress Reliability.
7.1.10.1* General.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 Furnishings and Decorations in Means of Egress.
7.1.10.2.1No furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress there from, or visibility thereof.

The means of egress deficiency has the potential to affect occupants, who might include staff, residents and visitors within the affected smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation during the course of the survey, it was determined the facility failed to maintain the exit ramp used as a means of egress in accordance with NFPA 101, 7.1.6.2. The following evidenced this:

East exit ramp does not meet requirements, gap drop off more than 1/2 inch.

7.1.6.2 Changes in Elevation. Abupt changes in elevation of walking surfaces shall not exceed1/4 in. (6.3 mm).

The deficiency has the potential to affect occupants, who might include staff, residents and visitors within effected compartment. This item was discussed during the survey and again during the exit conference.

Based on observation during the course of the survey, it was determined the facility failed to maintain the horizontal exit used as a fire barrier separating building construction types in accordance with NFPA 101, 39.2.8 including 7.8 and 7.10.5.2.1. The following evidenced this:

1. No documentation of Illumination of means of egress being tested if battery backup and back up battery back up non functional in hte main corridor hallway.

Life Safety Code Section 39.2.8 Illumination of Means of Egress.Means of egress shallbe illuminated in accordance with Section 7.8.

7.8.2 Sources of Illumination.7.8.2.1*Illumination of means of egress shall be from a sourceconsidered reliable by the authority having jurisdiction.7.8.2.2Battery-operated electric lights and other types of por-table lamps or lanterns shall not be used for primary illumina-tion of means of egress. Battery-operated electric lights shallbe permitted to be used as an emergency source to the extent permitted under Section 7.9.

7.10.5.2.1Every sign required to be illuminated by 7.10.6.3,7.10.7, and 7.10.8.1 shall be continuously illuminated as requiredunder the provisions of Section 7.8, unless otherwise provided in7.10.5.2.2.

The deficiency has the potential to affect occupants, who might include staff, residents and visitors within affected smoke compartments. This item was discussed during the survey and again during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:

Exit signs were missing from exit doors.

7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within effected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Based on observation and record review during the course of the survey, it was determined the facility failed to maintain emergency lighting in accordance with NFPA 101, section 19.2.9 and section 7.9. This was evidenced by:

1) Documentation was unavailable to indicate if the facility was testing each individual battery back-up unit for the emergency egress lighting in accordance with 7.9.3.1.

Documentation of locations to include a 30 second monthly and a 90-minute annual test was not provided.

The deficiency has the potential to affect occupants, who might include staff, residents and visitors within all smoke compartments; items were discussed during the survey and again during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:

1) Exit signs are not configured correctly according to the exit discharges. Need reconfigured appropriately.
2) No documentation of emergency light function test.

Life Safety Code section 21.2.10 to comply with section 7.10. Section 7.10 Where required. Means of egress shall be marked in accordance with section 7.10 where required in Chapters 11-43.
7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2) *The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The deficiency has the potential to affect occupants, who might include staff, residents and visitors within all smoke compartments. This item was discussed during the survey and again during the exit conference.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain alchol based sanitizer dispensers in accordance with NFPA Life Safety 101 19.3.2.6. This was evidence by the following:

Alcohol based hand sanitizer was installed above either outlets/light switches throughout the facility.

Life Safety Code 101 19.3.2.6 Alcohol-Based Hand-Rub Dispensers. Alcohol-based
hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all
of the following conditions are met:
(1) Where dispensers are installed in a corridor, the corridor shall have a
minimum width of 6 ft.
(2) The maximum individual dispenser fluid capacity shall be as follows:
(a) 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to
corridors
(b) 0.53 gal (2.0 L) for dispensers in suites of rooms
(3) Where aerosol containers are used, the maximum capacity of the aerosol
dispenser shall be 18 oz and shall be limited to Level 1 aerosols as defined in
NFPA30B, Code for the Manufacture and Storage of Aerosol Products.
(4) Dispensers shall be separated from each other by horizontal spacing of not
less than 48 in.
(5) Not more than an aggregate 10 gal (37.8 L) of alcohol based hand-rub
solution or 1135 oz of Level 1 aerosols, or a combination of liquids and Level
1 aerosols not to exceed, in total, the equivalent of 10 gal (37.8 L) or 1135
oz, shall be in use outside of a storage cabinet in a single smoke
compartment, except as otherwise provided in 19.3.2.6(6).
(6) One dispenser complying with 19.3.2.6 (2) or (3) per room and located in
that room shall not be included in the aggregated quantity addressed in
19.3.2.6(5).
(7) Storage of quantities greater than 5 gal (18.9 L) in a single smoke
compartment shall meet the requirements of NFPA 30, Flammable and
Combustible Liquids Code.
(8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. horizontal distance from each side
of the ignition source
(b) To the side of an ignition source within a 1 in. horizontal distance from
the ignition source
(c) Beneath an ignition source within a 1 in. vertical distance from the
ignition source
(9) Dispensers installed directly over carpeted floors shall be permitted only
in sprinklered smoke compartments.
(10) The alcohol-based hand-rub solution shall not exceed 95 percent alcohol
content by volume.
(11) Operation of the dispenser shall comply with the following criteria:
(a) The dispenser shall not release its contents except when the dispenser is
activated, either manually or automatically by touch-free activation.
(b) Any activation of the dispenser shall occur only when an object is placed
within 4 in. of the sensing device.
(c) An object placed within the activation zone and left in place shall not
cause more than one activation.
(d) The dispenser shall not dispense more solution than the amount required
for hand hygiene consistent with label instructions.
(e) The dispenser shall be designed, constructed, and operated in a manner
that ensures that accidental or malicious activation of the dispensing device
is minimized.
(f) The dispenser shall be tested in accordance with the manufacturer ' s care
and use instructions each time a new refill is installed.

Based on observation during the survey it was determined the facility failed to install alcohol based hand rub dispensers in accordance with NFPA 101, 19.3.2.6. The following evidenced this:

AHSU installed above light switch in treatment room.

A. Alcohol based hand rub dispensers located in most of the rooms were not installed with adequate separation from an ignition source, as required by 21.3.2.6(8). Dispensers were installed directly above electrical outlets and switches

The deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within the effected smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation during the survey it was determined the facility failed to install alcohol based hand rub dispensers in accordance with NFPA 101, 21.3.2.6. The following evidenced this:
During the walk through with the Administrator and Maintenance Director;
A. Alcohol based hand rub dispensers located in most of the rooms were not installed with adequate separation from an ignition source, as required by 21.3.2.6(8).
Dispensers were installed directly above electrical outlets and switches

The deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within effected smoke compartments; items were discussed during the survey and again during the exit conference.

Based on observation during the survey, conducted on January 30&31, 2018, it was determined the facility failed to install and maintain the fire alarm system in accordance with NFPA 101, section 19.3.4, 19.3.4.5, and 9.6, including NFPA 72 National Fire Alarm Code. The following evidenced this:

Smoke detector in the lab processing area closer than 3 feet of a return or supply diffuser which could prevent the operation of the detector.
Fire alarm devices are not labeled throughout building.

Detectors are not installed in accordance with NFPA 72, 17.7.4.

The fire alarm deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within the affected smoke compartment; items were discussed during the survey and again during the exit conference.

Based on the observation during the survey, it was determined the facility failed to install a fire alarm sytem in accordance with NFPA 101 21.3.4 and 9.6, including NFPA 72 National Fire Alarm Code. The following is evidence by:

No manual fire alarm system is installed as this is considered an ambulatory healthcare occupancy.

NFPA 101 21.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

NFPA 72 10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 72. This was evidenced by:

Lead acid batteries in fire alarm panel were past the 5 year life span.

NFPA 72 14.4.3.2 states, replace batteries in accordance with the recommendations of the alarm equipment manufacturer or when the recharged battery voltage or current falls below the manufacturer recommendation.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance director during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 72. This was evidenced by:

No documentation of semi-annual fire alarm inspection reports was available during time of inspection.

NFPA 72 section 14.4.5 requires, in part, testing shall be performed in accordance with the schedules in Table 14.4.5.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 72. This was evidenced by:

Smoke detector was missing from the nurses station. The base was there but no detector.
Missing CO 2 detector in furnace room.

4.6.12.2. No existing life safety feature shall be removed or reduced where such feature is a requirement for new construction.

The fire alarm deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within all smoke compartments. These items were discussed during the survey and again during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 25. This was evidenced by:

1. Sprinkler Head in Recovery room 2 was loaded.
2. No documentation of one quarterly fire sprinkler system inspection reports was available during time of inspection.

Life Safety Code Section 9.7.5 maintenance and testing of automatic sprinkler systems to comply with NFPA 25.
NFPA 25 section 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
(6) Painting unless painted by the sprinkler manufacturer

Life Safety Code Section 19.3.5.1 to comply with section 9.7. Section 9.7.5 maintenance and testing to comply with NFPA 25. NFPA 25 section 5.1.1.2 requires, in part, testing and maintenance frequencies shall be determined by Table 5.1.1.2.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4. This was evidence by the following:

1.Fire extinguishers in the main entrance, dental area, and second floor storage area currently past due for 1 year maintenance.
2. Fire extinguishers in the dental area not being signed off monthly.

7.2.1.2 Fire extinguishers shall be inspected either manuallyor by means of an electronic monitoring device/system at aminimum of 30-day intervals.
7.3.1.1.1Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.

The deficiency has the potential to affect all occupants, who might include staff, residents and visitors.

This item was discussed during the survey and again during the exit conference.

Based on observation during the survey it was determined the facility failed to install and maintain portable fire extinguishers in accordance with NFPA 101, section 21.3.5.3, 9.7.4.1. and NFPA 10 The following evidenced this:

Fire extinguisher near Bio hazard closet is mounted higher than 5 feet.

NFPA 10 section 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.

The fire extinguisher deficiency has the potential to affect all room and building occupants, who might include staff, residents and visitors within effected smoke compartment; items were discussed during the survey and again during the exit conference.

Through record review and observation during the tour of the facility, it was determined the facility failed to maintain doors to the corridor per NFPA Life Safety Code 101-19.3.3 (2012 Edition) and NFPA 80-2010-Standard for Fire Doors and other Openings Protectives. This was evidenced by the following:

1. Fire door going from the hospital to clinic which is a two hour fire wall and door has holes in it that negates the rating on the door.
2. Fire door going from the ER to the patient hallway would not release with 15 lbs of pressure. This is the path of an exit and the door was locked against egress into the exit path.

5.2.4.2As a minimum, the following items shall be verified:(1) No open holes or breaks exist in surfaces of either thedoor or frame.
(2) Glazing, vision light frames, and glazing beads are intactand securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and non combustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4and 6.3.1.7.
(6) The self-closing device is operational; that is, the activedoor completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes be-fore the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

This door deficiency could affect all residents, visitors, and staff through-out the smoke compartment by allowing the spread of smoke to the adjoining compartments.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 19.3.2.1 This deficient practice could affect all residents in all smoke compartment by allowing the spread of fire and smoke to the adjoining compartments. This was evidenced by the following:

1. Boiler room has penetrations through 2 hour fire wall.
2. Fire wall going from the ER to Patient area has penetrations.
3. Hallway by entry has penetrations through fire wall.
4. Oxygen room fire wall has penetrations.
5. ER hallway fire wall has penetrations.
6. Unsealed penetration in the ceiling tile in conference room two.
Both sides of fire walls need to be checked for penetrations. Numerous penetrations through all walls insepcted.

Life Safety Code Section 19.3.2.1 requires that the fire barrier walls be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than ½ hour. 8.3.1.2*The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier. 8.3.2.1.1*Fire resistance-rated glazing tested in accordance with ASTM E119, Standard Test Methods for Fire Tests of Building Construction and Materials, or ANSI/UL 263, Standard for Fire Tests of Building Construction and Materials, shall be permitted.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain the building services for gas equipment in accordance with NFPA 101, 19.5.2.2*. NFPA 54 National Fuel Gas Code 9.3.1.1. This is evidenced by the following:

Combustible material in the boiler room.
Blanket covering the fresh air intake vent to boiler room.

19.5.2.2*Any heating device, other than a central heating plant, shall be designed and installed so that combustible material cannot be ignited by the device or its appurtenances, and the following requirements also shall apply:
9.3.1.1Air for combustion, ventilation, and dilution of fluegases for appliances installed in buildings shall be obtained byapplication of one of the methods covered in 9.3.2 through9.3.6. Where the requirements of 9.3.2 are not met, outdoorair shall be introduced in accordance with methods covered in9.3.3 through 9.3.6.
9.3.7.1 Louvers and Grilles.The required size of openings forcombustion, ventilation, and dilution air shall be based on thenet free area of each opening. Where the free area through adesign of louver, grille, or screen is known, it shall be used incalculating the size opening required to provide the free areaspecified. Where the louver and grille design and free area arenot known, it shall be assumed that wood louvers have 25 percent free area, and metal louvers and grilles have 75 percentfree area. Nonmotorized louvers and grilles shall be fixed inthe open position.

The building service deficiencies has the potential to affect all room occupants, who might include staff, residents and visitors within this smoke compartment; items were discussed during the survey and again during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the building services requirements in accordance with NFPA 101, 80, 90A, and 105. This was evidenced by:

Four-year fire/smoke damper testing and inspection report was unavailable at time of survey.

Life Safety Code section 21.5.2.1 to comply with section 9.2. Section 9.2 to comply with NFPA 90A

NFPA 90A section 5.4.8 to comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

NFPA 80 section 19.4 Periodic Inspection and Testing

NFPA 105 section 6.5 Periodic Inspection and Testing

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the operating features requirements in accordance with NFPA 101. This was evidenced by:

1) Fire drill documentation missing from 4th quarter of 2020 and all 3 quarters of 2021.

21.7.1.6 Drills shall be conducted quarterly on each shift tofamiliarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emer-gency action required under varied conditions.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the operating features requirements in accordance with NFPA 101. This was evidenced by:

1) Fire drill documentation missing from first quarter (Oct -Dec 2020) from second shift.

Life Safety Code, section 19.7.1.2 requires, in part, fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the operating features requirements in accordance with NFPA 101. This was evidenced by:

1) Fire drill documentation not provided.

Life Safety Code, section 21.7.1.6 requires, in part, fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the operating procedures requirements in accordance with NFPA 101. This was evidenced by:

No smoking signs were not posted at all major entrances.

19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the affected areas. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 99 and NFPA 110. This was evidenced by:

1) No documentation of monthly testing/recording of electrolyte specific gravity or battery conductance test on generator lead-acid type batteries.
2) No monthly voltage testing being completedc per manufacturers recommendation.

Health care facilities code requires generator maintenance and testing to be in accordance with NFPA 110. NFPA 110, Section 8.3.7
8.3.7* Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected
weekly and maintained in full compliance with manufacturer's specifications.
8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery
conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by:

1. Power-strip not plugged directly into an electrical outlet, "daisy-chain."
2. Refrigerator plugged into a power-strip. Locations:Lab refrigerators
3. Hole in drywall from nurses station into med room, exposed wiring.

NFPA 70, Section 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 floor
(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 this Code
(7) Where subject to physical damage. Furthermore, Health Care Facilities Code section 10.2.3.6 (2), "The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets."
This deficiency has the potential to affect the occupants, who might include the resident, staff, and visitors within affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by:

Refrigerator plugged into a power-strip. Locations: Two large appliances supplied power through multiplex. Large freezer being supplied power through multi-plex.
Electric power cords daisy cahin in dental office.

NFPA 70, Section 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 floor
(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 this Code
(7) Where subject to physical damage. Furthermore, Health Care Facilities Code section 10.2.3.6 (2), "The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets."
NFPA 70 2011 section 110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

This deficiency has the potential to affect the occupants, who might include the resident, staff, and visitors within affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference

Based on observation during the course of the survey , it was determined the facility failed to maintain the oxygen storage/transferring room accordance with NFPA 99 - Health Care Facilities 5.1.3.3.1.6. This was evidence by the following:

Flammable materials were stored in the oxygen room.

5.1.3.3.1.6 Indoor locations for oxygen, nitrous oxide, and mixtures of these gases shall not communicate with the following:
(1) Areas involved in critical patient care
(2) Anesthetizing locations
(3) Locations storing flammables
(4) Rooms containing open electrical contacts or transformers
(5) Storage tanks for flammable or combustible liquids
(6) Engines
(7) Kitchens
(8) Areas with open flames