HospitalInspections.org

NFPA 101
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

This REQUIREMENT is not met as evidenced by:
Based on surveyor observation and staff interview, it was determined that the hospital door to room B137 was not being maintained in accordance with NFPA 99 2012 Edition, NFPA 101 2012 Edition.

Findings are as follows:

A tour of the Eleanor Slater Hospital-Roosevelt Benton Center building #07 was conducted on 9/17/2021 starting at approximately 8:45 AM and ending at approximately 12:15 PM. The tour was conducted with the Administrator of Safety and Security, the Associate Director of BHDDH, and the Chief Property Manager-Special Projects Division of Capital Asset Management & Maintenance (DCAMM).

Observations made during the tour revealed that the hospital staff were keeping the door to room B137 (nursing office) in the open position, which is equipped with an automatic closing device, utilizing a wooden door chock (wedge) which will not automatically release allowing the door to close.

An interview was conducted with the Administrator of Safety and Security and the Associate Director of the Department of BHDDH on 9/17/2021 at approximately 12:15 AM. They both acknowledged that the door did have an automatic closer installed on it and that it was being held open with a wooden chock.

NFPA 101
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.
19.2.10.2 Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons.
19.2.10.3 Where the path of egress travel is obvious, signs shall not be required at gates in outside secured areas.
19.2.10.4 Access to exits within rooms or sleeping suites shall not be required to be marked where staff is responsible for relocating or evacuating occupants.

7.10 Marking of Means of Egress.
7.10.1 General.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 43.
7.10.1.2 Exits.
7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.
7.10.1.2.2* Horizontal components of the egress path within an exit enclosure shall be marked by approved exit or directional exit signs where the continuation of the egress path is not obvious.
7.10.2 Directional Signs.
7.10.2.1* A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.


This REQUIREMENT is not met as evidenced by:

Based on surveyor observation and staff interviews, it has been determined that the facility lacked adequate exit signage in the kitchen to make the direction of egress from the area readily visible from any direction of exit access.

Findings are as follows:

A life safety code tour of the Eleanor Slater Hospital-Regan building #01 was conducted on 9/13/2021 starting at approximately 9:00 AM and ending at approximately 2:15 PM. The tour was conducted with the Administrator of Safety and Security, the Associate Director of the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH), and the Chief Property Manager-Special Projects Division of Capital Asset Management & Maintenance (DCAMM).

Observations made of the kitchen at approximately 1:30 PM revealed that the exits for the kitchen were not obvious due to a lack of adequate exit signage.

An interview was conducted with the Administrator of Safety and Security, the Associate Director of the Department of BHDDH, and the Chief Property Manager-Special Projects DCAMM on 9/13/2021 while in the kitchen at approximately 1:35 PM. They all acknowledged that exiting from the kitchen would be challenging due to a lack of direction to the exits. The Chief Property Manager-Special Projects also acknowledged that adding any kind of a smoke condition to an emergency in the kitchen could have negative effects.

Without adequate exit signage and proper maintenance of the exit and all its components, kitchen staff are at risk should an emergency occur that may include smoke obscuring a person's vision. This smoke condition could have a negative effect should the hospital need to use the egress for evacuation or relocation efforts.

NFPA 101
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

4.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

7.1.3 Separation of Means of Egress. See also Section 8.2.
7.2.1.8 Self-Closing Devices.
7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to
be automatic closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released, and the door leaf becomes self-closing.


This REQUIREMENT is not met as evidenced by:

Based on surveyor observation and staff interview, it was determined that the hospital failed to maintain corridor doors by the security office, which are required to be self-closing or automatic closing, so that they close and latch properly when released by the magnetic hold open device in accordance with NFPA 99 2012 edition, NFPA 101 2012 edition.


Findings are as follows:

A life safety code tour was completed of the Eleanor Slater Hospital Zambarano/Beazley building #04 on 9/14/2021 starting at approximately 8:45 AM and ending at approximately 1:30 PM. The tour was conducted with the Administrator of Safety and Security, the Associate Director of Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH), and the Acting State Buildings and Grounds Officer of the facility.

Observations made at approximately 12:15 PM revealed that the first floor hallway double doors by the security office did not close and latch upon release of the magnetic hold open device.

During an interview with the Acting State Buildings and Grounds Officer of the hospital on 9/14/2021 at approximately 1:00 PM, he acknowledged the doors were not closing and latching properly.

An interview was conducted with the Administrator of Safety and Security and the Associate Director of the Department of BHDDH on 9/17/2021 at approximately 12:25 AM. They both acknowledged that the doors were not closing and latching properly.

NFPA 101
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
19.3.6.2 Construction of Corridor Walls.
19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8.
19.3.6.2.2* Corridor walls shall have a minimum 1/2-hour fire resistance rating.
19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke.

7.2.4.3 Fire Barriers.
7.2.4.3.1 Fire barriers separating buildings or areas between which there are horizontal exits shall have a minimum 2-hour fire resistance rating, unless otherwise provided in 7.2.4.4.1, and shall provide a separation that is continuous to the finished
ground level. (See also Section 8.3.)

8.3.5 Penetrations. The provisions of 8.3.5 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations in fire walls, fire barrier walls, and fire resistance-rated horizontal
assemblies. The provisions of 8.3.5 shall not apply to approved existing materials and methods of construction used to protect existing through-penetrations and existing membrane penetrations in fire walls, fire barrier walls, or fire resistance-rated horizontal assemblies, unless otherwise required by Chapters 11 through 43.


This REQUIREMENT is not met as evidenced by:

Based on surveyor observation, record review, and staff interviews, it was determined that the facility had smoke and fire barriers in the corridors throughout building that are not properly firestopped.

Findings are as follows:

A life safety code tour of the Eleanor Slater Hospital-Reagan building #01 was conducted on 9/13/2021 starting at approximately 9:00 AM and ending at approximately 2:15 PM. The tour was conducted with the Administrator of Safety and Security, the Associate Director of the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH), and the Chief Property Manager-Special Projects Division of Capital Asset Management & Maintenance (DCAMM).

Observations made during the tour on 9/13/2021 revealed plumbing pipes and electrical tubing penetrating the corridor walls not properly firestopped on all patient units.

Document review of 154 open work orders for the Reagan building was conducted on 9/16/2021 through 9/17/2021 with the Administrator of Safety and Security. The records revealed multiple work orders due to plumbing pipes and electrical tubing penetrating the corridor walls not properly firestopped on all patient units. Penetrations throughout the building that were not properly firestopped. The records also revealed that many of these repairs were originally discovered and even had an open work order request dating back to 2015.

The open work orders consist of, but are not limited to, the following:
1) "RPA 1C.1-3 Penetrations of fire rated barrier not properly sealed." This work order indicates a location of "all rooms with ductwork next to S stairwell".
2) "RPA-2A.13-1 Fire barrier penetration is sealed with non-listed material." This work order indicates a location as "Shaft enclosure in room 353."
3) " RPA-2A.2-1 Duct enclosures across from North & South stairwells in Regan." This work order indicates a location as "All floors duct enclosures".

During an interview on 9/17/2021 at approximately 1:15 PM, with the Administrator of Safety and Security, the Associate Director of the Department of BHDDH, and the Chief Property Manager-Special Projects DCAMM, they all acknowledged that there were uncompleted open work orders to repair penetrations throughout the building that were not properly firestopped.

NFPA 101
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
19.3.6.2 Construction of Corridor Walls.
19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8.
19.3.6.2.2* Corridor walls shall have a minimum 1/2-hour fire resistance rating.
19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke.

7.2.4.3 Fire Barriers.
7.2.4.3.1 Fire barriers separating buildings or areas between which there are horizontal exits shall have a minimum 2-hour fire resistance rating, unless otherwise provided in 7.2.4.4.1, and shall provide a separation that is continuous to the finished
ground level. (See also Section 8.3.)

8.3.5 Penetrations. The provisions of 8.3.5 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations in fire walls, fire barrier walls, and fire resistance-rated horizontal
assemblies. The provisions of 8.3.5 shall not apply to approved existing materials and methods of construction used to protect existing through-penetrations and existing membrane penetrations in fire walls, fire barrier walls, or fire resistance-rated horizontal assemblies, unless otherwise required by Chapters 11 through 43.


This REQUIREMENT is not met as evidenced by:

Based on surveyor observation, record review, and staff interviews, it was determined that the facility had smoke barriers in the corridor walls throughout building that are not properly firestopped.

Findings are as follows:

A life safety code tour of the Eleanor Slater Hospital-Adolph Meyer building #02 was conducted on 9/15/2021 starting at approximately 8:30 AM and ending at approximately 2:00 PM. The tour was conducted with the Administrator of Safety and Security, the Associate Director of the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH), and the Chief Property Manager-Special Projects Division of Capital Asset Management & Maintenance (DCAMM).

Observations made during the tour on 9/15/2021 revealed plumbing pipes and electrical tubing penetrating the corridor walls not properly firestopped on all patient units.

Document review of 94 open work orders for the Adolph Meyer building was conducted on 9/16/2021 through 9/17/2021 with the Administrator of Safety and Security. The records revealed multiple work orders due to plumbing pipes, electrical tubing and data cables penetrating the corridor walls not properly firestopped on all patient units. Penetrations throughout the building that were not properly firestopped. The records also revealed that many of these repairs were originally discovered and had open work order requests dating as far back as 2019.

The open work orders consist of, but are not limited to, the following:
1) "RPA 1A.2-8 Please re-apply a listed material/system such as foreproofing...." This work order indicates a location of "Throughout the Adolph Meyer building".
2) "RPA-2A.13-2 Fire barrier penetration is sealed with non-listed material." This work order indicates a location as "2-hr. at door to Main stairwell."
3) " RPA-2A.13-3 Fire barrier penetration is sealed with non-listed material." This work order indicates a location as "2-hr. at door to North 1 stairwell."

During an interview on 9/17/2021 at approximately 12:45 PM, with the Administrator of Safety and Security, the Associate Director of the Department of BHDDH, and the Chief Property Manager-Special Projects DCAMM, they all acknowledged that there were uncompleted open work orders to repair penetrations throughout the building that were not properly firestopped.

NFPA 101
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
19.3.6.2 Construction of Corridor Walls.
19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8.
19.3.6.2.2* Corridor walls shall have a minimum 1?2-hour fire resistance rating.
19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke.

7.2.4.3 Fire Barriers.
7.2.4.3.1 Fire barriers separating buildings or areas between which there are horizontal exits shall have a minimum 2-hour fire resistance rating, unless otherwise provided in 7.2.4.4.1, and shall provide a separation that is continuous to the finished
ground level. (See also Section 8.3.)

8.3.5 Penetrations. The provisions of 8.3.5 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations in fire walls, fire barrier walls, and fire resistance-rated horizontal
assemblies. The provisions of 8.3.5 shall not apply to approved existing materials and methods of construction used to protect existing through-penetrations and existing membrane penetrations in fire walls, fire barrier walls, or fire resistance-rated horizontal assemblies, unless otherwise required by Chapters 11 through 43.


This REQUIREMENT is not met as evidenced by:
Based on surveyor observation, record review, and staff interviews, it was determined that the facility had smoke barriers in the corridors throughout building that are not properly firestopped.

Findings are as follows:

A life safety code tour of the Eleanor Slater Hospital-Zambarano Hospital Beazly building #04 was conducted on 9/14/2021 starting at approximately 8:45 AM and ending at approximately 1:30 PM. The tour was conducted with the Administrator of Safety and Security, the Associate Director of the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH), and the Acting State Buildings and Grounds Officer.

Observations made during the tour revealed penetrations in smoke barriers by electrical piping, plumbing pipes and data cables throughout building that were not properly firestopped. Further observations made during the tour revealed several missing ceiling tiles in the third floor Center nursing station.

Document review of 142 open work orders for the Beazley building was conducted on 9/16/2021 through 9/17/2021 with the Administrator of Safety and Security. The records revealed that there are penetrations in the corridor smoke barriers throughout the building that are not properly firestopped. The records also revealed that many of these repairs were originally discovered and had incomplete work order requests dating as far back as 2019.

The open work orders consist of, but are not limited to, the following:
1) "RPA 2A.5-28 Please re-apply a listed material/system such as foreproofing...." This work order indicates a location of "Basement B-182-hr. barrier in elevator machine Ro".
2) "RPA-2C.4-1 Smoke barrier penetration is not sealed." This work order indicates a location as "2N/ASoutheast at Room 2."
3) " RPA-2C.4-2 Smoke barrier penetration is sealed with non-listed material." This work order indicates a location as "2N/At Smoke Door to Northeast."

An interview was conducted with the Administrator of Safety and Security and the Associate Director of the Department of BHDDH on 9/17/2021 at approximately 12:25 AM. They both acknowledged that there were penetrations in the corridor smoke barriers throughout the building that are not properly firestopped. They also acknowledged that there were several incomplete open work orders to repair unsealed penetrations throughout the building.

NFPA 101
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.4 Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (1220 mm) above the bottom of the door.
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.

8.7 Special Hazard Protection.
8.7.1 General.
8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3
(2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7
(3) Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43

7.1.3 Separation of Means of Egress. See also Section 8.2.
7.2.1.8 Self-Closing Devices.
7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or were approved by the authority having jurisdiction, door leaves shall be permitted to
be automatic closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released, and the door leaf becomes self-closing.

This REQUIREMENT is not met as evidenced by:

Based on surveyor observation and staff interview, it was determined that the hospital failed to maintain doors which are required to be self-closing or automatic closing in accordance with NFPA 99 2012 edition, NFPA 101 2012 Edition.

Findings are as follows:

A life safety code tour was completed of the Eleanor Slater Hospital Zambarano/Beazley building #04 on 9/14/2021 starting at approximately 8:45 AM and ending at approximately 1:30 PM. The tour was conducted with the Administrator of Safety and Security, the Associate Director of Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH), and the Acting State Buildings and Grounds Officer of the facility.

Observations made during the tour revealed that the third-floor oxygen storage room door and third floor rooms S3-1, S3-4, S3-6, S3-7, S3-9 and S3-26 doors did not close fully.

An interview was conducted with the Acting State Buildings and Grounds Officer of the facility was conducted on 9/14/2021 at approximately 1:15 PM. He acknowledged that the aforementioned doors did have automatic closers installed on them and that the doors did not fully close.

An interview was conducted with the Administrator of Safety and Security and the Associate Director of the Department of BHDDH on 9/17/2021 at approximately 12:25 AM. They both acknowledged that the aforementioned doors did not fully close.

NFPA 101
19.5.4 Rubbish Chutes, Incinerators, and Laundry Chutes.
19.5.4.1 Existing rubbish chutes or linen chutes, including pneumatic rubbish and linen systems, that open directly onto any corridor shall be sealed by fire-resistive construction to prevent further use or shall be provided with a fire door assembly having a minimum 1-hour fire protection rating. All new chutes shall comply with Section 9.5.
4.5 Fundamental Requirements.
4.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.


This REQUIREMENT is not met as evidenced by:

Based on surveyor observation and staff interview, it was determined that the hospital failed to maintain the laundry chute in proper condition as evidenced by the lack of an automatic closing device in accordance with NFPA 99 2012 edition, NFPA 101 2012 Edition.

Findings are as follows:

A life safety code tour was completed of the Eleanor Slater Hospital Zambarano/Beazley building #04 on 9/14/2021 starting at approximately 8:45 AM to approximately 1:30 PM. The tour was conducted with the Administrator of Safety and Security, the Associate Director of Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH), and the Acting State Buildings and Grounds Officer of the facility.

The tour revealed that the laundry chute door on the first floor South Unit in room #20 was missing the automatic closing device. The automatic door closer mechanism is a component of the laundry chute that is required to maintain the fire rating of the system.

An interview was conducted with the Administrator of Safety and Security and the Associate Director of the Department of BHDDH on 9/17/2021 at approximately 12:25 AM. They both acknowledged that the door for the laundry chute was missing the automatic closer.

NFPA 101 2012 edition
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.

NFPA 70
ARTICLE 410
Luminaires, Lampholders, and Lamps
410.5 Live Parts. Luminaires, portable luminaires, lampholders, and lamps shall have no live parts normally exposed to contact. Exposed accessible terminals in lampholders and switches shall not be installed in metal luminaire canopies or in open bases of portable table or floor luminaires.
Exception: Cleat-type lampholders located at least 2.5 m (8 ft) above the floor shall be permitted to have exposed terminals.
II. Luminaire Locations
410.10 Luminaires in Specific Locations.
(A) Wet and Damp Locations. Luminaires installed in wet or damp locations shall be installed such that water cannot enter or accumulate in wiring compartments, lampholders, or other electrical parts. All luminaires installed in wet locations shall be marked, "Suitable for Wet Locations." All luminaires installed in damp locations shall be marked "Suitable for Wet Locations" or "Suitable for Damp Locations."
(D) Bathtub and Shower Areas. No parts of cord-connected luminaires, chain-, cable-, or cord-suspended luminaires, lighting track, pendants, or ceiling-suspended (paddle) fans shall be located within a zone measured 900 mm (3 ft) horizontally and 2.5 m (8 ft) vertically from the top of the bathtub rim or shower stall threshold. This zone is all encompassing and includes the space directly over the tub or shower stall. Luminaires located within the actual outside dimension of the bathtub or shower to a height of 2.5 m (8 ft) vertically from the top of the bathtub rim or shower threshold shall be marked for damp locations, or marked for wet locations where subject to shower spray.

This REQUIREMENT is not met as evidenced by:

Based on surveyor observation, and staff interview, it was determined that the facility was not being maintained in accordance with NFPA 99 2012 Edition, NFPA 101 2012 Edition and NFPA 70 2011 edition regarding electrical fixtures that are installed in wet locations.

Findings are as follows:

A tour of the Eleanor Slater Hospital-Adolph Meyer (AM) building #02 was conducted on 9/15/2021 starting at approximately 8:30 AM and ending at approximately 12:30 PM. The tour was conducted with the Administrator of Safety and Security, the Associate Director of BHDDH, and the Chief Property Manager-Special Projects Division of Capital Asset Management & Maintenance (DCAMM).

The tour revealed two of the three shower stalls on the AM-9 unit had recessed lighting fixtures that were located in the shower stall and did not have trim ring leaving the light socket and wiring connections exposed. The trim ring is required to be suitable for wet locations.

An interview was conducted with the Administrator of Safety and Security, the Associate Director of the Department of BHDDH, and the Chief Property Manager-Special Projects DCAMM during the tour. They all acknowledged that the recessed lighting fixtures in the bathroom shower stalls were missing the trim ring that covers the light bulb and it's electrical connections.

During a second interview on 9/17/2021 at approximately 12:45 PM, with the Administrator of Safety and Security, the Associate Director of the Department of BHDDH, and the Chief Property Manager-Special Projects DCAMM, they all acknowledged that the recessed lighting fixtures in the bathroom shower stalls were not water resistant without the proper water resistant trim ring in place.

Without proper maintenance of the electrical fixtures in the shower stalls and the lack of water-resistant trim rings, patients and staff may access live electrical connections in a wet environment. This condition could have a negative effect that has the potential to cause serious harm to a patient or staff member.