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Ref: NFPA 13
National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

6.2.9.7 A list of the sprinklers installed in the property shall be posted in the sprinkler cabinet.
6.2.9.7.1* The list shall include the following:
(1) Sprinkler Identification Number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating
(2) General description
(3) Quantity of each type to be contained in the cabinet
(4) Issue or revision date of the list

Ref: NFPA 25
National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)* Loading
5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.

Based on observation, interview and document review, the facility failed to maintain the water-based fire protection systems as required.

Findings include:

On 09/06/18, during a tour of the facility the following water-based fire protection systems concerns were observed:

1) The fire sprinkler riser room revealed that the fire sprinkler spare box did not have a list of sprinklers installed on the property, along with a listing of the quantity of each type of sprinkler to be contained in the spare cabinet.

An interview with the Plant Operations Manager revealed no knowledge that the sprinkler spare cabinet was required to contain a list of sprinklers installed on the property along with a listing of the quantity of each type of sprinkler to be contained in the spare cabinet.

2) The sprinkler located in the walk-in freezer was loaded with foreign material and had a loss of fluid in the glass bulb (heat responsive element).

An interview with the Plant Operations Manager revealed no knowledge that the sprinkler was damaged.

Based on observation and interview, the facility failed to ensure smoke barrier construction was properly sealed at points of penetration.

Findings include:

On 09/06/18, observation of the following areas revealed penetrations in the smoke barrier construction:

1) In the Riser Room, there were open penetrations around two sets of four flexible conduit runs that ran through the wall that were not sealed.

2) In the Electrical Room located in the 100 Hall Unit, the following concerns were observed:
a) there was an open penetration around two rigid conduit runs that ran through the wall and was not sealed.
b) there were two rigid conduit runs that ran through the wall that was not sealed.

3) In the Electrical Room located in the 300 Hall Unit, there was an open conduit run that ran through the wall and was not sealed.

4) In the High Voltage Room located in the 300 Hall Unit, there were two open conduit runs that ran through the wall and were not sealed.

5) In the interstitial space above the cross-corridor doors located on the first floor near the passenger elevators, there were open penetrations around two flexible conduit runs that ran through the wall that were not sealed.

An interview with the Plant Operations Manager, revealed that he was unaware of the identified open penetrations.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

Article 400 - Flexible Cords and Cables
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
Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6) Where installed in raceways, except as otherwise permitted in the Code
7) Where subject to physical damage

Based on observation, the facility failed to maintain electrical wiring, equipment, and installations as required by NFPA 70.

Findings include:

On 09/06/18, observation of the following Administrative offices/areas revealed the following concerns:

a) Copy Area: a microwave and a refrigerator plugged into a relocatable power tap (RPT)
b) Director of Nursing's Office: a refrigerator plugged into an RPT.
c) Nurse Supervisor's Office (300E): a refrigerator plugged into an RPT.
d) Medical Staff Coordinator's Office: 1) a refrigerator plugged into an RPT and 2) one RPT device plugged into another RPT device (daisy chained).
e) Business Services Office: one RPT device plugged into another RPT device (daisy chained).

An interview with the Director of Plant Operations revealed that he was unaware of the electrical issues stated above.

Based on document review and interview, the facility failed to conduct fire drills as required and at least quarterly on each shift.

Findings include:

On 09/05/18, documentation review revealed that fire drills were not conducted on a quarterly basis on the following shifts:

1) The second shift did not have a fire drill during the first quarter of 2018.
2) The first shift did not have a fire drill during the second quarter of 2018.
3) The second shift did not have a fire drill during the fourth quarter of 2017.

An interview with the Plant Operations Manager revealed that the shifts indicated above were missed by the facility.

Based on document review and interview, the facility failed to provide evidence that means of egress in any area undergoing construction, repair, or improvements were inspected daily.

Findings include:

On 09/05/18, document review revealed no evidence that the means of egress within the areas undergoing construction were inspected daily as required.

The Plant Operations Manager indicated that inspections were being conducted by maintenance daily; however, it was not documented.

Ref: NFPA 99
National Fire Protection Association (NFPA) 99, Health Care Facilities Code - Including all Gas & Vacuum System Requirements, 2012 Edition

9.3 General
9.3.1 Heating, Cooling, Ventilating, and Process Systems.
9.3.1.1 Heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities, shall be provided in accordance with ASHRAE 170.

Ref: ASHRAE/ASHE Standard
American Society of Heating, Refrigerating and Air-Conditioning Engineers/American Society for Healthcare Engineering Standard, Ventilation of Heath Care Facilities, 2008 Edition

6.3.2 Exhaust Discharges. Exhaust discharge outlets that discharge air from AII rooms, bronchoscopy rooms, emergency department waiting rooms, nuclear medicine laboratories, radiology waiting, and laboratory chemical fume hoods shall

a) be designed so that all ductwork in occupied spaces is under negative pressure;
b) discharge in a vertical direction at least 10 ft (3m) above roof level and shall be located not less than 10 ft horizontally from air intakes, openable windows/doors, or areas that are normally accessible to the public or maintenance personnel and that are higher in elevation than the exhaust discharge; and
c) be located such that they minimize the recirculation of exhausted air back into the building.

Based on observation and interview, the facility failed to comply with the American Society of Heating, Refrigerating and Air-Conditioning Engineers/American Society for Healthcare Engineering, Ventilation of Heath Care Facilities Standard.

Findings include:

On 09/06/18, during a tour of the facility, two exhaust discharge outlets located on the roof were discovered at 31 inches above roof level.

An interview with the Plant Operations Manager revealed that there have been no changes to the exhaust discharge outlets. POM was unaware that the exhaust discharge outlets were required to be at least 10 feet above roof level.

Based on observation and interview, the facility failed to locate the remote generator audible alarm at a work site observable by personnel.

Findings include:

On 09/05/18 - 09/06/18, during a tour of the facility, the remote audible alarm for the emergency generator was discovered to be on the wall in the 100 Hall Nurse's Station.

An interview with the Plant Operations Manager (POM) revealed that the 100's Hall Unit had been temporarily vacant and closed since June 2018. The POM explained the only remote audible alarm for the emergency generator was located at the 100 Hall Nurse's Station. When asked, the POM explained that since the 100's Hall Unit was temporarily closed, it was not staffed 24 hours a day.

The 100 Hall's remote generator audible alarm was not located in an area that was work site observable by personnel.

Based on observation and interview, the facility failed to check and test the essential electric system (generator) weekly as required.

Findings include:

Document review revealed that the required weekly generator checks were not conducted during the following weeks:

a) 12/10/17 - 12/16/17
b) 12/31/17 - 01/06/18

An interview with the Plant Operations Manager revealed that he was off during the weeks listed above.