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Based on observation, the facility failed to ensure the automatic sprinkler system was maintained and inspected periodically as evidenced by sprinklers that had gaps and were not flushed with the ceiling. This failure could result in the sprinkler system not functioning as designed in the event of a fire. This affected patients in 1 of 2 smoke compartments.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water- Base Fire Protection Systems, 1998 Edition
Chapter 2 Sprinkler Systems 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g. upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with the Director of Plant Operations "DPO" on 11/19/13 and 11/20/13, the sprinkler system was observed.

At 11:21 a.m., the sprinkler escutcheon rings located in the ICU corridor outside of patient room 22 and 23, had a gaps and were not flush with the ceiling. This was acknowledged by the DPO during the survey.

Based on observation and interview, the facility failed to maintain electrical safety in accordance with NFPA 70. This was evidenced by an electrical cover plate that was not flush to the wall and by an extension cord that was running through a door way. This failure could result in an increased risk of an electrical fire causing potential harm to patients in 1 of 2 smoke compartments.

NFPA 70, National Electrical Code, 1999 Edition.
400-8. Uses not permitted.
Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with the Director of Plant Operations (DPO) on 11/19/13 and 11/20/13, the electrical wiring and equipment was observed.

1. At 11:27 a.m., the electrical cover plate in ICU room 24 was not flush. The cords were pulling on the cover plate. This was acknowledged by the DPO during the survey.

2. At 11:28 a.m., there was an orange extension cord running under the ICU utility room corridor door and into patient room 24. During an interview, the Director of Plant Operations stated the cord is used for Dialysis and further stated he did not know why the extension cord was running under the utility room door and into the patient room.