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Based on observation and staff interview, the facility failed to preserve the integrity of a fire or smoke compartments, all openings and penetrations for doors, ducts, floors, walls and building services (e.g., electric power, telephone, water supply, waste lines, and etc.) must also be effectively closed or fitted with automatic closures requirements as stated in NFPA 101 (2000) LSC, 19.3.7.3, 18.3.7.3, 19.1.6.3, 18.1.6.3 19.1.6.3, 18.1.6.3 and 8.3

Findings include:

1. On 02/05/2013 observation during the interior tour from 9:10 a.m. to 12:00 p.m. accompanied by facility representatives revealed ceiling penetrations in all Mechanical/Electrical Rooms throughout the facility. The penetration locations are:
Addiction Center Wing-All Mechanical/Electrical Rooms-ceiling and wall penetrations around electrical conduits, dusts and other piping.
Crisis Center Wing-All Mechanical/Electrical Rooms-ceiling and wall penetrations around electrical conduits, dusts and other piping.
Children's Program Wing-All Mechanical/Electrical Rooms-ceiling and wall penetrations around electrical conduits, dusts and other piping.
Hospital Wing-All Mechanical/Electrical Rooms-ceiling and wall penetrations around electrical conduits, dusts and other piping.

The facility representatives confirmed the observations.

2. On 02/05/2013 an interview conducted with the Facility Director revealed the facility was unaware of all penetrations in the mechanical and electrical Rooms. The Facility Director stated the maintenance personnel were working to correct the penetrations in the Fire Alarm Panel Room and Server Room as they were installing new computer lines to upgrade the system in the facility. He also stated the installation of the new computer lines was not complete at the time of the survey. The Facility Director stated he was unaware of the penetrations in the other mechanical and electrical rooms.
Reference:
NFPA 101 (2000) LSC, 19.3.7.3, 18.3.7.3, 19.1.6.3, 18.1.6.3 19.1.6.3, 18.1.6.3 and 8.3
NFPA 99
NFPA 101 CHAPTER 8 Features of Fire Protection (+)
8.2 Construction and Compartmentation fire or smoke compartment, all openings and penetrations for doors, ducts, and building services (e.g., electric power, telephone, water supply, and waste lines) must also be effectively closed or fitted
8.2 Construction and Compartmentation
The general requirements in Section 8.2 aid in limiting the spread of smoke and fire and protect exit access corridors, exits, and other areas of the building from fire in adjoining areas and on other floors. Construction and Compartmentation requirements vary by occupancy and are specified in Chapters 12 through 42 of the Code.
To preserve the integrity of a fire or smoke compartment, all openings and penetrations for doors, ducts, and building services (e.g., electric power, telephone, water supply, and waste lines) must also be effectively closed or fitted with automatic closures. Equally important, and sometimes overlooked, are concealed spaces, particularly those above suspended ceilings, that frequently have been the means of spreading fire into otherwise protected areas. 1 In some instances, these interstitial spaces might be 8 ft. (2440 mm) or more in height; in others, they might serve as supply- or return-air plenums for heating, ventilating, and air-conditioning systems. Proper protection of concealed spaces can include fire stopping, draft stopping, installation of automatic sprinklers, area limitations, and other limitations on the combustibility of contents, interior finishes, and construction materials. For specific concealed space protection details, see 8.6.10.

Based on observation and staff interview, the facility failed to tether a natural gas powered cooking equipment with casters as required by NFPA 101 (2000), 19.3.2.6, 9.2.3, NFPA 96, and NFPA 54, 9.6.1.2.

Findings include:

1. On 02/05/2013 observation during the interior tour from 9:15 a.m. to 12:00 p.m. accompanied by facility representatives revealed in the Kitchen, a gas powered cooking appliance (oven/stove top) with casters, without a tether to prevent moving the appliance to the point where the gas lines shear and potentially cause fire or explosion.
The facility representative confirmed the observation.

2. On 02/05/2013 during the Facility Director's interview it was revealed the facility failed to secure a gas powered cooking appliance. The Facilities Director stated he did not realize the oven with casters had to be secured or tethered to the wall.

NFPA 101(2000), 19.3.2.6, 9.2.3
NFPA 54 (1999), 9.6.1.1
Reference:
NFPA 101 (2000), 19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3. 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.
NFPA 54 (1999), 9.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer's installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connector installation shall be configured in accordance with the manufacturer's installation instructions. 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions.

Based on observation and staff interview, the facility failed to maintain electrical safety requirements as stated in NFPA 101 (2000), 19.5.1, 9.1 NFPA 70 (2005) National Electrical Code, and NFPA 99 (2005) Health Care Facilities, .

Findings include:

1. Observations during the interior tour on 02/05/2013 from 9:15 a.m. to 12:00 p.m. accompanied by facility representatives revealed flexible cords, (extension cords, power taps, power strips, surge protectors and surge/UPS, (uninterruptible power supply) and battery back-up units being used as a substitute for the fixed wiring of the facility, prohibited by NFPA 70. The observations were made in the following locations:
Staff Lounge Room 134-Power Strip plugged into refrigerator, APS battery back-up plugged into coffee maker.
Staff Development Liaison Office Room 131-two Power Strips plugged into APS battery back-up(daisy chaining).
PI-Nurse Manager Office Room 118-Power Strip plugged into refrigerator.
Utilization Review Specialist Office Room 128-Extension Cord plugged into Power Strip.
Medical Record Office Room 108-Power strip plugged into three small fans, coffee maker, refrigerator and microwave.
Children's Program Wing-Room 105-Power Strip plugged into Power Strip (daisy chaining) and Power Strip plugged into a Large Xerox Work Center 5735 Copier.
Pharmacy Room 136-Power Strip plugged into Power Strip into APS battery back-up (daisy chaining). Office Room 87-Extension Cord. Addiction Center Wing-Office Room 304-Power Strip plugged into APS battery back-up (daisy chaining), Room 204-Power Strip plugged into refrigerator, Power Strip plugged into Large Image Runner Copier.
Hospital Wing-Room 205-Power Strip plugged into Power Strip (daisy chaining), Room 191-Power Strip plugged into refrigerator and Room 203-Power Strip plugged into Power Strip (daisy chaining).

The observations were confirmed by the facility representatives.

2. On 02/05/2013 during the Facility Director's interview at 10:10 a.m., the director stated he had all power strip removed after the last inspection and did not realize that staff had placed the devices back into the facility offices and rooms. He also stated he did not know that power strips or such cannot be plugged or place into refrigerators, large copiers and heating elements.

NFPA 70 (2005), Chapter 4 Equipment for General Use, ARTICLE 400, 4.7
NFPA 99 (2005), 4.3.2.2
NFPA 101 Life Safety Code (2000), 19.5.1, 9.1.
References:
NFPA 101, (2000), 19.5 Building Services. 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.
Merriam-Webster as referenced in NFPA 101, Power strip - "an electrical device consisting of a cord with a plug on one end and several sockets on the other; Extension cord - "an electric cord fitted with a plug at one end and a receptacle at the other"; Surge protector - " an electrical device that moderates power-line surges to prevent damage to attached electronic devices (as a television or computer)"; UPS - "uninterruptable power supply".
NFPA 70 (2008), Chapter 4 Equipment for General Use, ARTICLE 400 Flexible Cords and Cables, 400.7 Uses Permitted. (A) Uses. Flexible cords and cables shall be used only for the following: (1) Pendants (2) Wiring of luminaries (3) Connection of portable luminaries, portable and mobile signs, or appliances (4) Elevator cables (5) Wiring of cranes and hoists (6) Connection of utilization equipment to facilitate frequent Interchange (7) Prevention of the transmission of noise or vibration (8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection (9) Connection of moving parts(10) Where specifically permitted elsewhere in this Code (B) Attachment Plugs. Where used as permitted in 400.7(A) (3), (A) (6), and (A) (8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet. 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.
NFPA 99 (2005), 10.2.3.6* Over current Protection. 10.2.3.6.1 An over current protective device shall be permitted to be placed in any of the following locations: (1) In the attachment plug (2) In the power cord (3) In the main body of the appliance 10.2.3.6.2 the over current protective device shall precede any other components within the appliance, including the primary power-control switch. 10.2.3.6.3 Listed insulated terminal blocks or strips, listed connecting devices, and RFI filters for use on power systems shall be permitted to precede the over current device (see 10.2.3.5). 10.2.3.6.4 The use of over current protective devices within the appliance shall be permitted. 10.2.3.6.5 The power-control switch and over current protective device shall be permitted to be combined into one component provided it is identified to indicate the combined function.

Based on observation and staff interview, the facility failed to preserve the integrity of a fire or smoke compartments, all openings and penetrations for doors, ducts, floors, walls and building services (e.g., electric power, telephone, water supply, waste lines, and etc.) must also be effectively closed or fitted with automatic closures requirements as stated in NFPA 101 (2000) LSC, 19.3.7.3, 18.3.7.3, 19.1.6.3, 18.1.6.3 19.1.6.3, 18.1.6.3 and 8.3

Findings include:

1. On 02/05/2013 observation during the interior tour from 9:10 a.m. to 12:00 p.m. accompanied by facility representatives revealed ceiling penetrations in all Mechanical/Electrical Rooms throughout the facility. The penetration locations are:
Addiction Center Wing-All Mechanical/Electrical Rooms-ceiling and wall penetrations around electrical conduits, dusts and other piping.
Crisis Center Wing-All Mechanical/Electrical Rooms-ceiling and wall penetrations around electrical conduits, dusts and other piping.
Children's Program Wing-All Mechanical/Electrical Rooms-ceiling and wall penetrations around electrical conduits, dusts and other piping.
Hospital Wing-All Mechanical/Electrical Rooms-ceiling and wall penetrations around electrical conduits, dusts and other piping.

The facility representatives confirmed the observations.

2. On 02/05/2013 an interview conducted with the Facility Director revealed the facility was unaware of all penetrations in the mechanical and electrical Rooms. The Facility Director stated the maintenance personnel were working to correct the penetrations in the Fire Alarm Panel Room and Server Room as they were installing new computer lines to upgrade the system in the facility. He also stated the installation of the new computer lines was not complete at the time of the survey. The Facility Director stated he was unaware of the penetrations in the other mechanical and electrical rooms.
Reference:
NFPA 101 (2000) LSC, 19.3.7.3, 18.3.7.3, 19.1.6.3, 18.1.6.3 19.1.6.3, 18.1.6.3 and 8.3
NFPA 99
NFPA 101 CHAPTER 8 Features of Fire Protection (+)
8.2 Construction and Compartmentation fire or smoke compartment, all openings and penetrations for doors, ducts, and building services (e.g., electric power, telephone, water supply, and waste lines) must also be effectively closed or fitted
8.2 Construction and Compartmentation
The general requirements in Section 8.2 aid in limiting the spread of smoke and fire and protect exit access corridors, exits, and other areas of the building from fire in adjoining areas and on other floors. Construction and Compartmentation requirements vary by occupancy and are specified in Chapters 12 through 42 of the Code.
To preserve the integrity of a fire or smoke compartment, all openings and penetrations for doors, ducts, and building services (e.g., electric power, telephone, water supply, and waste lines) must also be effectively closed or fitted with automatic closures. Equally important, and sometimes overlooked, are concealed spaces, particularly those above suspended ceilings, that frequently have been the means of spreading fire into otherwise protected areas. 1 In some instances, these interstitial spaces might be 8 ft. (2440 mm) or more in height; in others, they might serve as supply- or return-air plenums for heating, ventilating, and air-conditioning systems. Proper protection of concealed spaces can include fire stopping, draft stopping, installation of automatic sprinklers, area limitations, and other limitations on the combustibility of contents, interior finishes, and construction materials. For specific concealed space protection details, see 8.6.10.

Based on observation and staff interview, the facility failed to tether a natural gas powered cooking equipment with casters as required by NFPA 101 (2000), 19.3.2.6, 9.2.3, NFPA 96, and NFPA 54, 9.6.1.2.

Findings include:

1. On 02/05/2013 observation during the interior tour from 9:15 a.m. to 12:00 p.m. accompanied by facility representatives revealed in the Kitchen, a gas powered cooking appliance (oven/stove top) with casters, without a tether to prevent moving the appliance to the point where the gas lines shear and potentially cause fire or explosion.
The facility representative confirmed the observation.

2. On 02/05/2013 during the Facility Director's interview it was revealed the facility failed to secure a gas powered cooking appliance. The Facilities Director stated he did not realize the oven with casters had to be secured or tethered to the wall.

NFPA 101(2000), 19.3.2.6, 9.2.3
NFPA 54 (1999), 9.6.1.1
Reference:
NFPA 101 (2000), 19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3. 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.
NFPA 54 (1999), 9.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer's installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connector installation shall be configured in accordance with the manufacturer's installation instructions. 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions.

Based on observation and staff interview, the facility failed to maintain electrical safety requirements as stated in NFPA 101 (2000), 19.5.1, 9.1 NFPA 70 (2005) National Electrical Code, and NFPA 99 (2005) Health Care Facilities, .

Findings include:

1. Observations during the interior tour on 02/05/2013 from 9:15 a.m. to 12:00 p.m. accompanied by facility representatives revealed flexible cords, (extension cords, power taps, power strips, surge protectors and surge/UPS, (uninterruptible power supply) and battery back-up units being used as a substitute for the fixed wiring of the facility, prohibited by NFPA 70. The observations were made in the following locations:
Staff Lounge Room 134-Power Strip plugged into refrigerator, APS battery back-up plugged into coffee maker.
Staff Development Liaison Office Room 131-two Power Strips plugged into APS battery back-up(daisy chaining).
PI-Nurse Manager Office Room 118-Power Strip plugged into refrigerator.
Utilization Review Specialist Office Room 128-Extension Cord plugged into Power Strip.
Medical Record Office Room 108-Power strip plugged into three small fans, coffee maker, refrigerator and microwave.
Children's Program Wing-Room 105-Power Strip plugged into Power Strip (daisy chaining) and Power Strip plugged into a Large Xerox Work Center 5735 Copier.
Pharmacy Room 136-Power Strip plugged into Power Strip into APS battery back-up (daisy chaining). Office Room 87-Extension Cord. Addiction Center Wing-Office Room 304-Power Strip plugged into APS battery back-up (daisy chaining), Room 204-Power Strip plugged into refrigerator, Power Strip plugged into Large Image Runner Copier.
Hospital Wing-Room 205-Power Strip plugged into Power Strip (daisy chaining), Room 191-Power Strip plugged into refrigerator and Room 203-Power Strip plugged into Power Strip (daisy chaining).

The observations were confirmed by the facility representatives.

2. On 02/05/2013 during the Facility Director's interview at 10:10 a.m., the director stated he had all power strip removed after the last inspection and did not realize that staff had placed the devices back into the facility offices and rooms. He also stated he did not know that power strips or such cannot be plugged or place into refrigerators, large copiers and heating elements.

NFPA 70 (2005), Chapter 4 Equipment for General Use, ARTICLE 400, 4.7
NFPA 99 (2005), 4.3.2.2
NFPA 101 Life Safety Code (2000), 19.5.1, 9.1.
References:
NFPA 101, (2000), 19.5 Building Services. 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.
Merriam-Webster as referenced in NFPA 101, Power strip - "an electrical device consisting of a cord with a plug on one end and several sockets on the other; Extension cord - "an electric cord fitted with a plug at one end and a receptacle at the other"; Surge protector - " an electrical device that moderates power-line surges to prevent damage to attached electronic devices (as a television or computer)"; UPS - "uninterruptable power supply".
NFPA 70 (2008), Chapter 4 Equipment for General Use, ARTICLE 400 Flexible Cords and Cables, 400.7 Uses Permitted. (A) Uses. Flexible cords and cables shall be used only for the following: (1) Pendants (2) Wiring of luminaries (3) Connection of portable luminaries, portable and mobile signs, or appliances (4) Elevator cables (5) Wiring of cranes and hoists (6) Connection of utilization equipment to facilitate frequent Interchange (7) Prevention of the transmission of noise or vibration (8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection (9) Connection of moving parts(10) Where specifically permitted elsewhere in this Code (B) Attachment Plugs. Where used as permitted in 400.7(A) (3), (A) (6), and (A) (8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet. 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.
NFPA 99 (2005), 10.2.3.6* Over current Protection. 10.2.3.6.1 An over current protective device shall be permitted to be placed in any of the following locations: (1) In the attachment plug (2) In the power cord (3) In the main body of the appliance 10.2.3.6.2 the over current protective device shall precede any other components within the appliance, including the primary power-control switch. 10.2.3.6.3 Listed insulated terminal blocks or strips, listed connecting devices, and RFI filters for use on power systems shall be permitted to precede the over current device (see 10.2.3.5). 10.2.3.6.4 The use of over current protective devices within the appliance shall be permitted. 10.2.3.6.5 The power-control switch and over current protective device shall be permitted to be combined into one component provided it is identified to indicate the combined function.