HospitalInspections.org

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Based on the observation on 02/24/2015 of this facility's construction type, the facility failed to provide a building construction type for a one story building of Type II (000) with a complete automatic sprinkler system or a Type II (111) for a building with a partial automatic sprinkler system. Findings include:

1. The following areas were observed without the one hour fire rated protection for the structural roof members (these areas did not have an automatic sprinkler system):
a. The little hallway across from room 109
b. The radiology addition except for the X-ray Room and the File Storage Room

2. The following areas were observed with unsealed penetrations in the one hour fire rated continuous membrane ceiling protection for the structural roof members:
a. Lab. above the lay-in ceiling, several
b. Purchasing's vestibule above the lay-in ceiling, one large
c. X-ray Room above the lay-in ceiling, several

This deficiency impacted 3 of 3 smoke compartments.
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Review of 2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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Based on the observation on 02/24/2015 of this facility's corridor doors, the facility failed to maintain the corridor door's positive latching. Findings include:

1. The Kitchen's back door at the old bathrooms was not positive latching.


33932


2. The door latch at Microwave/Break room failed to keep the door closed in the frame.

The deficiency impacted 1 of 3 smoke compartments.
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Review of 2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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Based on the observation of all smoke barriers on 2/24/2015, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

The smoke barrier at D.O.N. office had an unsealed penetration of 2 blue wires.

The deficiency impacted 2 of 3 smoke compartments.
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Review of 2000 NFPA 101, 8.3.6.1
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Based on the observation on 2/24/2015, the facility failed to maintain the smoke barrier doors to restrict the passage of smoke. Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation.

Observation revealed the smoke barrier doors by the D.O.N. office failed to close tight in the door frame during testing of the fire alarm system.

The deficiency impacted 2 of 3 smoke compartments.
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Review of 2000 NFPA 101, 8.3.4.1*
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Based on the observation on 02/24/2015 of this facility's hazardous areas, the facility failed to maintain the hazardous areas per code. Findings include:

Per observation of the hazardous areas:
1. The bath across from room 109 was being used as a storage room, the door had a self-closing device on it with a toe-stop on the same door.
2. The Insurance Office/Storage Room was over 50 sq. ft. with combustibles the doors self-closing device failed to close the door's positive latching device.
3. The Medical Records Storage Room was over 50 sq. ft. with combustibles, the door had a self-closing device, but was being held open by a wedge.


33932

4. The door latch on Janitor Closet near Room 108 failed to keep the door tight in the frame, therefore it is not capable of resisting fire/smoke.
5. The door latch on Bathroom used for storage near Room 109 failed to keep the door tight in the frame, therefore it is not capable of resisting fire/smoke.
6. The door latch on Storage Room at the end of the hall near Basement Entrance failed to keep the door tight in the frame, therefore it is not capable of resisting fire/smoke.
7. The Closet door by Medical Records had a dime size hole above the door knob.

The deficiency impacted 2 of 3 smoke compartments.
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Review of 2000 NFPA 101, 19.3.2.1

Review of HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."
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Based on the observation of all exit doors on 2/24/2015, the facility failed to maintain door in means of egress. Findings include:

The access-controlled magnetic locking device on the exit door near Trauma/ER Room failed to disengage when the fire alarm was activated and it did not have a "Push to Exit" button.

The deficiency impacted 1 of 3 smoke compartments. Building is licensed for 32 residents.
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Review of 2000 NFPA 101 7.2.1.6.2 Access-Controlled Egress Doors.
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
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Based on the observation of the emergency lights on 2/24/2015, the facility failed to maintain the emergency lighting per code. Findings include:

The 2 emergency lights in the CT Trailer did not operate when tested.

The deficiency impacted 1 of 3 smoke compartments.
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Review of 2000 NFPA 101, 7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.
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Based on the observation on 02/24/2015 of this facility's exit lights, the facility failed to maintain the exit lights per code. Findings include:

1. The C.T. Trailer had an exit light over a door that was not an exit.
2. The C.T. Trailer had 2 exit lights that were not illuminated.

This deficiency impacted 1 of 3 smoke compartments.
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Review of 2000 NFPA 101, 7.10.5.2
Review of 2000 NFPA 101, 7.10.1.1
Review of 2000 NFPA 101, 7.10.8.1
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Based on the review of documentation on 02/24/2015 of the facility's fire drill reports, the facility failed to conduct fire drills per code. Findings include:

First Shift (7 am - 7 pm)
01/26/2015 - 10:00 am
10/29/2014 - 7:20 am
07/29/2014 - 7:05 am
04/29/2014 - 7:00 am

Three of four drills were within 20 minutes of each other.

Second Shift (7 pm - 7 am)
01/12/2015 - 6:30 am
10/10/2014 - 6:20 am
07/23/2014 - 6:15 am
04/18/2014 - 5:45 am

All four drills were within 45 minutes of each other.

This deficiency impacted 3 of 3 smoke compartments
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Review of 2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

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Based on the observation on 02/24/2015 of this facility's fire alarm system, the facility failed to maintain the fire alarm system. Findings include:

1. The Fire alarm panel and remote annunciator panel shows zones 1-9 on the read out, but there were no instructions on where or what these zones represent.
2. The two backflow valves in the pit in front of the facility each had a tamper switch, but these devices were not wired to the fire alarm panel.

This deficiency impacted 3 of 3 smoke compartments.
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Review of 2000 NFPA 101, 9.7.2.1* Supervisory Signals.
Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
Review of 2000 NFPA 101, 9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
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Based on observation of automatic sprinkler system and sprinkler system documentation on 2/24/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.
2. Documentation provided during the survey indicated on the backflow test report that check valve #1 failed testing and control valve #2 needs to be replace with new packing bolts.

The deficiency impacted 3 of 3 smoke compartments. Building is licensed for 32 residents.
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Review of 2000 NFPA 13, 3-2.9.2 A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.
Regview of 1998 NFPA 25, 9-6.2.1* All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
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Based on the observation on 02/24/2015 of this facility's cooking facilities, the facility failed to maintain the cooking facilities per code. Findings include:

1. The facility failed to conduct and document monthly inspections on the automatic suppression system.
2. The only documented exhaust hood cleaning service was conducted on 09/13/2014 (nothing before or after this date).
This deficiency impacted 1 of 3 smoke compartments.
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Review of 1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b)The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.

Review of 1998 NFPA 96, Table 8-3.1
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Based on observation of the electrical wiring and equipment on 2/24/2015, the facility failed to prohibit an appliance from being plugged into a surge protector (extension cord). Findings include:

Room 119 had a microwave plugged into a surge protector.

The deficiency impacted 1 of 3 smoke compartments. Building is licensed for 32 residents.
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Review of 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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Based on the observation on 02/24/2015 of this facility's construction type, the facility failed to provide a building construction type for a one story building of Type II (000) with a complete automatic sprinkler system or a Type II (111) for a building with a partial automatic sprinkler system. Findings include:

1. The following areas were observed without the one hour fire rated protection for the structural roof members (these areas did not have an automatic sprinkler system):
a. The little hallway across from room 109
b. The radiology addition except for the X-ray Room and the File Storage Room

2. The following areas were observed with unsealed penetrations in the one hour fire rated continuous membrane ceiling protection for the structural roof members:
a. Lab. above the lay-in ceiling, several
b. Purchasing's vestibule above the lay-in ceiling, one large
c. X-ray Room above the lay-in ceiling, several

This deficiency impacted 3 of 3 smoke compartments.
_______________

Review of 2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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Based on the observation on 02/24/2015 of this facility's corridor doors, the facility failed to maintain the corridor door's positive latching. Findings include:

1. The Kitchen's back door at the old bathrooms was not positive latching.


33932


2. The door latch at Microwave/Break room failed to keep the door closed in the frame.

The deficiency impacted 1 of 3 smoke compartments.
_______________

Review of 2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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Based on the observation of all smoke barriers on 2/24/2015, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

The smoke barrier at D.O.N. office had an unsealed penetration of 2 blue wires.

The deficiency impacted 2 of 3 smoke compartments.
_______________

Review of 2000 NFPA 101, 8.3.6.1
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Based on the observation on 2/24/2015, the facility failed to maintain the smoke barrier doors to restrict the passage of smoke. Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation.

Observation revealed the smoke barrier doors by the D.O.N. office failed to close tight in the door frame during testing of the fire alarm system.

The deficiency impacted 2 of 3 smoke compartments.
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Review of 2000 NFPA 101, 8.3.4.1*
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Based on the observation on 02/24/2015 of this facility's hazardous areas, the facility failed to maintain the hazardous areas per code. Findings include:

Per observation of the hazardous areas:
1. The bath across from room 109 was being used as a storage room, the door had a self-closing device on it with a toe-stop on the same door.
2. The Insurance Office/Storage Room was over 50 sq. ft. with combustibles the doors self-closing device failed to close the door's positive latching device.
3. The Medical Records Storage Room was over 50 sq. ft. with combustibles, the door had a self-closing device, but was being held open by a wedge.


33932

4. The door latch on Janitor Closet near Room 108 failed to keep the door tight in the frame, therefore it is not capable of resisting fire/smoke.
5. The door latch on Bathroom used for storage near Room 109 failed to keep the door tight in the frame, therefore it is not capable of resisting fire/smoke.
6. The door latch on Storage Room at the end of the hall near Basement Entrance failed to keep the door tight in the frame, therefore it is not capable of resisting fire/smoke.
7. The Closet door by Medical Records had a dime size hole above the door knob.

The deficiency impacted 2 of 3 smoke compartments.
_______________

Review of 2000 NFPA 101, 19.3.2.1

Review of HCFA Transmittal 40-93 It is the intent of the code that (smoke-resisting) separation be provided even in a sprinklered hazardous area. "Where the sprinkler option is used, the (hazardous) areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be equipped with self- or automatic closers and be positive latching."
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Based on the observation of all exit doors on 2/24/2015, the facility failed to maintain door in means of egress. Findings include:

The access-controlled magnetic locking device on the exit door near Trauma/ER Room failed to disengage when the fire alarm was activated and it did not have a "Push to Exit" button.

The deficiency impacted 1 of 3 smoke compartments. Building is licensed for 32 residents.
_______________

Review of 2000 NFPA 101 7.2.1.6.2 Access-Controlled Egress Doors.
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
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Based on the observation of the emergency lights on 2/24/2015, the facility failed to maintain the emergency lighting per code. Findings include:

The 2 emergency lights in the CT Trailer did not operate when tested.

The deficiency impacted 1 of 3 smoke compartments.
_______________

Review of 2000 NFPA 101, 7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.
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Based on the observation on 02/24/2015 of this facility's exit lights, the facility failed to maintain the exit lights per code. Findings include:

1. The C.T. Trailer had an exit light over a door that was not an exit.
2. The C.T. Trailer had 2 exit lights that were not illuminated.

This deficiency impacted 1 of 3 smoke compartments.
_______________

Review of 2000 NFPA 101, 7.10.5.2
Review of 2000 NFPA 101, 7.10.1.1
Review of 2000 NFPA 101, 7.10.8.1
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Based on the review of documentation on 02/24/2015 of the facility's fire drill reports, the facility failed to conduct fire drills per code. Findings include:

First Shift (7 am - 7 pm)
01/26/2015 - 10:00 am
10/29/2014 - 7:20 am
07/29/2014 - 7:05 am
04/29/2014 - 7:00 am

Three of four drills were within 20 minutes of each other.

Second Shift (7 pm - 7 am)
01/12/2015 - 6:30 am
10/10/2014 - 6:20 am
07/23/2014 - 6:15 am
04/18/2014 - 5:45 am

All four drills were within 45 minutes of each other.

This deficiency impacted 3 of 3 smoke compartments
_______________

Review of 2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

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Based on the observation on 02/24/2015 of this facility's fire alarm system, the facility failed to maintain the fire alarm system. Findings include:

1. The Fire alarm panel and remote annunciator panel shows zones 1-9 on the read out, but there were no instructions on where or what these zones represent.
2. The two backflow valves in the pit in front of the facility each had a tamper switch, but these devices were not wired to the fire alarm panel.

This deficiency impacted 3 of 3 smoke compartments.
_______________

Review of 2000 NFPA 101, 9.7.2.1* Supervisory Signals.
Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
Review of 2000 NFPA 101, 9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
.

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Based on observation of automatic sprinkler system and sprinkler system documentation on 2/24/2015, the facility failed to maintain the automatic sprinkler system. Findings include:

1. A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.
2. Documentation provided during the survey indicated on the backflow test report that check valve #1 failed testing and control valve #2 needs to be replace with new packing bolts.

The deficiency impacted 3 of 3 smoke compartments. Building is licensed for 32 residents.
_______________

Review of 2000 NFPA 13, 3-2.9.2 A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.
Regview of 1998 NFPA 25, 9-6.2.1* All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
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Based on the observation on 02/24/2015 of this facility's cooking facilities, the facility failed to maintain the cooking facilities per code. Findings include:

1. The facility failed to conduct and document monthly inspections on the automatic suppression system.
2. The only documented exhaust hood cleaning service was conducted on 09/13/2014 (nothing before or after this date).
This deficiency impacted 1 of 3 smoke compartments.
_______________

Review of 1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following: (a) The extinguishing system is in its proper location. (b)The manual actuators are unobstructed. (c) The tamper indicators and seals are intact. (d) The maintenance tag or certificate is in place. (e) No obvious physical damage or condition exists that might prevent operation. (f) The pressure gauge(s), if provided, is in operable range. (g) The nozzle blowoff caps are intact and undamaged. (h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.

Review of 1998 NFPA 96, Table 8-3.1
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Based on observation of the electrical wiring and equipment on 2/24/2015, the facility failed to prohibit an appliance from being plugged into a surge protector (extension cord). Findings include:

Room 119 had a microwave plugged into a surge protector.

The deficiency impacted 1 of 3 smoke compartments. Building is licensed for 32 residents.
_______________

Review of 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.
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