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NFPA 25 (1998 ed.)
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. ...

2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Hangers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.



Based on observation and interview, the facility failed to ensure sprinkler heads were properly maintained and that sprinkler pipe and fittings were free of external loads. These deficiencies affected 3 of 4 smoke compartments.

Findings include:

1) On 01/05/16 and 01/06/16, during a tour of the facility, the following sprinkler heads, escutcheons, and sprinkler covers were not in compliance:

a) Kitchen - three of six sprinkler heads (nearest to cooking exhaust hood) were loaded with foreign material.
b) Gym - four of 15 sprinkler heads were loaded with foreign material.
c) Day Room #2 East Wing - a sprinkler head cover plate was missing.
d) Men's Bathroom across from Dining Room - the sprinkler head was loaded with foreign material.
e) Intake Office near copier room - one sprinkler head had two broken pieces of ceiling tile material stuck to its deflector plate. One sprinkler was loaded with foreign material.
f) Laundry Room on North Wing - two sprinkler heads were loaded with foreign matter.

2) On 01/06/16, during a tour of the facility, metal conduit and wires were observed hanging from or resting on sprinkler pipe and fittings in the following areas:

a) Interstitial space immediately east of the smoke compartment doors separating smoke compartments two and three had five metal conduit runs and two wires resting or hanging from the sprinkler pipes. Two of the five metal conduit runs were held together with a zip tie and then attached to the sprinkler pipe with a single zip tie.

b) Interstitial space immediately west of the smoke compartment doors separating smoke compartments two and three had an undetermined number of metal conduit runs and wires resting on or hanging from the sprinkler pipes.

c) Interstitial space immediately south of the smoke compartment doors, separating smoke compartments three and one had a cluster of yellow cables resting on the sprinkler pipes.

The Director of Plant Operations was present during the tour and acknowledged all of the above mentioned findings at the time of discovery.

MARKING PANELBOARDS:
NFPA 70, 384-13 Panelboards General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboards circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel.

EXTENSION CORDS:
NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following: (a) As a substitute for fixed wiring of a structure

NFPA 70, Section 305-4 (h) Protection from Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protections shall be provided to avoid damage.


Based on observation, the following electrical wiring and equipment was not in accordance with the National Electric Code.

Findings include:

On 01/05/16 and 01/06/16, during a tour of the facility, the following electrical and wiring concerns were observed:

1) The interstitial space immediately east of the smoke compartment doors separating smoke compartments two and three had one standard voltage junction box uncovered exposing live wires.

2) The interstitial space immediately east of the smoke compartment doors separating smoke compartments two and three had two low voltage junction boxes without covers. The wires were running into and out of the junction boxes. With the observed configuration, had the covers been installed, the covers would have pinched the wires.

3) In the Kitchen, one outlet cover was loose exposing the wires of the junction box. This outlet was located to the left of the steamer on the lower portion of the wall.

4) In the Plant Operations Room, electrical panel "D" did not have a current circuit directory.

5) Located in the East Wing, electrical panels "CR2" and "H1 (Emergency)" did not have current circuit directories.

6) Located near the nurses station of the North Wing, in the laundry room, one dryer was plugged into an outlet that was hanging loose within its junction box exposing the internal wiring.

7) In the Medical Director's office, a power tap was observed plugged into a black extension cord powering office equipment (daisy chain).

8) In the Chief Financial Officer's office, one power tap was plugged into another power tap powering office equipment (daisy chain).

The Director of Plant Operations was present during the tour and acknowledged all of the above mentioned findings at the time of discovery.

Based on document review and interview, the facility failed to produce a complete fire watch policy for the fire sprinkler system.

Findings include:

On 01/05/16 at 1:35 PM, document review revealed the fire watch policy was incomplete. The policy did not specifically state that fire watch personnel have the "sole" function of conducting the fire watch. Individuals assigned to fire watch duty shall not conduct other duties during the fire watch shift.

On 01/05/16 at 3:05 PM, the Director of Plant Operations acknowledged the fire watch policy was incomplete by not including language that ensured the fire watch would be conducted by a dedicated staff member as their sole function.

NFPA 25 (1998 ed.)
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. ...

2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Hangers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.



Based on observation and interview, the facility failed to ensure sprinkler heads were properly maintained and that sprinkler pipe and fittings were free of external loads. These deficiencies affected 3 of 4 smoke compartments.

Findings include:

1) On 01/05/16 and 01/06/16, during a tour of the facility, the following sprinkler heads, escutcheons, and sprinkler covers were not in compliance:

a) Kitchen - three of six sprinkler heads (nearest to cooking exhaust hood) were loaded with foreign material.
b) Gym - four of 15 sprinkler heads were loaded with foreign material.
c) Day Room #2 East Wing - a sprinkler head cover plate was missing.
d) Men's Bathroom across from Dining Room - the sprinkler head was loaded with foreign material.
e) Intake Office near copier room - one sprinkler head had two broken pieces of ceiling tile material stuck to its deflector plate. One sprinkler was loaded with foreign material.
f) Laundry Room on North Wing - two sprinkler heads were loaded with foreign matter.

2) On 01/06/16, during a tour of the facility, metal conduit and wires were observed hanging from or resting on sprinkler pipe and fittings in the following areas:

a) Interstitial space immediately east of the smoke compartment doors separating smoke compartments two and three had five metal conduit runs and two wires resting or hanging from the sprinkler pipes. Two of the five metal conduit runs were held together with a zip tie and then attached to the sprinkler pipe with a single zip tie.

b) Interstitial space immediately west of the smoke compartment doors separating smoke compartments two and three had an undetermined number of metal conduit runs and wires resting on or hanging from the sprinkler pipes.

c) Interstitial space immediately south of the smoke compartment doors, separating smoke compartments three and one had a cluster of yellow cables resting on the sprinkler pipes.

The Director of Plant Operations was present during the tour and acknowledged all of the above mentioned findings at the time of discovery.

MARKING PANELBOARDS:
NFPA 70, 384-13 Panelboards General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboards circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel.

EXTENSION CORDS:
NFPA 70, Section 400-8 Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following: (a) As a substitute for fixed wiring of a structure

NFPA 70, Section 305-4 (h) Protection from Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protections shall be provided to avoid damage.


Based on observation, the following electrical wiring and equipment was not in accordance with the National Electric Code.

Findings include:

On 01/05/16 and 01/06/16, during a tour of the facility, the following electrical and wiring concerns were observed:

1) The interstitial space immediately east of the smoke compartment doors separating smoke compartments two and three had one standard voltage junction box uncovered exposing live wires.

2) The interstitial space immediately east of the smoke compartment doors separating smoke compartments two and three had two low voltage junction boxes without covers. The wires were running into and out of the junction boxes. With the observed configuration, had the covers been installed, the covers would have pinched the wires.

3) In the Kitchen, one outlet cover was loose exposing the wires of the junction box. This outlet was located to the left of the steamer on the lower portion of the wall.

4) In the Plant Operations Room, electrical panel "D" did not have a current circuit directory.

5) Located in the East Wing, electrical panels "CR2" and "H1 (Emergency)" did not have current circuit directories.

6) Located near the nurses station of the North Wing, in the laundry room, one dryer was plugged into an outlet that was hanging loose within its junction box exposing the internal wiring.

7) In the Medical Director's office, a power tap was observed plugged into a black extension cord powering office equipment (daisy chain).

8) In the Chief Financial Officer's office, one power tap was plugged into another power tap powering office equipment (daisy chain).

The Director of Plant Operations was present during the tour and acknowledged all of the above mentioned findings at the time of discovery.

Based on document review and interview, the facility failed to produce a complete fire watch policy for the fire sprinkler system.

Findings include:

On 01/05/16 at 1:35 PM, document review revealed the fire watch policy was incomplete. The policy did not specifically state that fire watch personnel have the "sole" function of conducting the fire watch. Individuals assigned to fire watch duty shall not conduct other duties during the fire watch shift.

On 01/05/16 at 3:05 PM, the Director of Plant Operations acknowledged the fire watch policy was incomplete by not including language that ensured the fire watch would be conducted by a dedicated staff member as their sole function.