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. Based on observation and staff interviews, the facility failed to assure that all of the required areas are sprinklered or sealed, failing to meet the building construction requirements for 1 of the 5 smoke zones. The facility has a capacity of 36 with a census of 19.

FINDINGS INCLUDE:

During the tour and record reviews on 8-8-2012 from 9:00 A.M. to 3:30 P.M., the following is noted:

--1. The maintenance closet by radiology has no sprinkler coverage provided.

Maintenance staff A was present and acknowledges the finding.

NFPA Standard: All concealed spaces enclosed wholly or partly by exposed combustible construction shall be protected by sprinklers. Exceptions: 1) Spaces formed by studs/joists with less than 6 inches between the inside edges of the studs/joists, or 2) Spaces formed by bar joists with less than 6 in. between the roof or floor deck and ceiling, or 3) Spaces formed by ceilings attached directly or within 6 in. of wood joist construction, or 4) Spaces formed by ceilings attached to the underside of composite wood joist s, provided the channels are fire stopped into volumes each not exceeding 160 ft 3 using materials equivalent to the web construction, or 5) Spaces filled with noncombustible insulation, or 6) Spaces in wood joist construction and composite wood joist construction having noncombustible insulation filling the space from the ceiling up to the bottom edge of the joist of the roof or floor deck, provided that the joist channels are fire-stopped with material equivalent to the web construction, or 7) Spaces over isolated small rooms not exceeding 55 ft 2 in area, or 8) Where rigid materials are used and exposed surfaces have a flame spread rating of 25 or less and have demonstrated not to propagate fire in the form in which they are installed, or 9) Spaces in which the exposed materials are constructed entirely of fire-retardant treated wood as defined by NFPA 703, or 10) Noncombustible spaces having exposed combustible insulation where the heat content of the facing and substrate of the insulation material does not exceed 1000 BTU/ft 2, or 11) Spaces below insulation that is laid directly on top of or within the ceiling joists in an otherwise sprinklered attic, or 12) Pipe chases under 10 ft 2 formed by studs or wood joists; and multifloor chases are firestopped at each floor using materials equal to the floor construction; and they contain no source of ignition, piping is noncombustible, and penetrations at each floor are properly sealed. 1999 NFPA 13, 5-13.1.1

. Based on observation and staff interview, the facility failed to ensure that portable fire extinguishers are in place. This deficient practice may prevent the portable fire extinguisher from being readily accessible, affecting 1 of 5 smoke zones. The facility has a capacity of 36 and a census of 19.

FINDINGS INCLUDE:

During the tour and record reviews on 8-8-2012 from 9:00 A.M. to 3:30 P.M., the following is noted:

--1. The fire extinguisher cabinet across from mammography has no fire extinguisher in it.

Maintenance staff A was present and acknowledges the finding.

NFPA Standard: Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

. Based on observation and staff interview, the facility fails to assure that all electrical wiring and equipment is installed and maintained in accordance with the requirements NFPA 70. This deficient practice increases the risk of an electrical fire. The deficient practice could affect all occupants in 1 of 5 smoke zones. The facility has a capacity of 36 with a census of 19.

FINDINGS INCLUDE:

During the tour and record reviews on 8-8-2012 from 9:00 A.M. to 3:30 P.M., the following is noted:

--1. In the business office at the coding office desk, a power strip is plugged into another power strip.

Maintenance staff A was present and acknowledges the finding.

NFPA Standard: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in Section 210-24. A 15- or 20-ampere branch circuit shall be permitted to supply lighting units or other utilization equipment, or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied. 1999 NFPA 70, 210-23