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Classification of interior finish materials shall be in accordance with tests made under conditions simulating actual installations, provided that the authority having jurisdiction shall be permitted to establish the classification of any material on which a rating by standard test is not available, unless otherwise provided in 10.2.1.2. 10.2.1.1

A review of documentation, during the facility survey during the afternoon of 03/06/2013, with the director of operations revealed that no information on flame spread ratings for facility finishes/surfaces (other than concrete, plaster, or gypsum board) had or was being kept in facility records/logs - including the new vinyl wood-look flooring being installed in a majority of corridors and patient care areas.

This STANDARD is not being met, as evidenced by: Based on observation during the Survey on the afternoon of 03/13/2013, with the director of operations, mattresses and upholstered furniture found in patient care areas did not have flame retardant properties on attached tags.


A review of documentation, during the facility survey during the afternoon of 03/06/2013, with the director of operations revealed that no information on flame retardant properties of mattresses or upholstered furniture had or was being kept in facility records/logs on file.

Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. NFPA 70: 517-19

This STANDARD is not being met, as evidenced by: Based on observation during the Survey on the morning of 03/13/2013, with the director of operations, numerous emergency system electrical receptacles in patient care areas did not have non-removable labels identifying the electrical panelboard and circuit number supplying them.