Mosaic Medical Center Albany

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 39354 Based on observation, interview, and nationally recognized standards, the facility failed to store hazardous materials in a hazardous area (areas that pose a degree of hazard greater than normal to the general occupancy of the building such as areas used for storage or use of combustibles or flammables, toxic, noxious, or corrosive materials, or heat producing appliances). Failure to store hazardous materials in a hazardous area, puts all patients, staff and visitors at risk of injury or death from a fire by not containing the fire and smoke within the hazardous area and eliminating the two required means of egress. The facility census was two. Observation on 05/11/26 between 1:05 PM and 4:30 PM, during the Life Safety Code tour of the hospital, showed the administration conference room area had a cardboard box that contained a bag of charcoal, a bottle of lighter fluid, two lighters and a jug of liquid oil. During an interview on 05/13/26 at 9:05 AM, Staff E, the Maintenance Director, stated that they had no idea why or that the charcoal, lighter fluid, lighters and oil were in a cardboard box in the hospital conference room. During an interview on 05/13/26 at 9:05 AM, Staff G, Facilities Director, stated that they expected the charcoal, lighter fluid, lighters and oil not to be stored inside the hospital. NFPA 101, 2012 edition, Section 19.3.2.1.5 states: “19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following: (1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2) (3) Paint shops (4) Repair shops (5) Rooms with soiled linen in volume exceeding 64 gal (242 L) (6) Rooms with collected trash in volume exceeding 64 gal (242 L) (7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.” Review of NFPA 101, 2012 Edition, Section 19.3.2 showed hazardous areas, protected by an automatic extinguishing system, shall be separated from other spaces by smoke partitions and self-closing or automatic-closing doors.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 39354 Based on observation, interview, and nationally recognized standards, the facility failed to ensure space heaters met the requirements of NFPA 101. The census was two. Observation on 05/11/26 between 1:05 PM and 4:30 PM, during the Life Safety Code tour of the hospital, showed the following: - In the nurse’s work room, a portable space heater; - In the Radiology area, a portable space heater; - In the Director of Nursing (DON) office, a portable space heater; - In the Chief Operating Officers (COO) office, a portable space heater; - In the Outpatient office, a portable space heater; - In the Human Resources (HR) area, a portable space heater; - In the front receptionist area, a portable space heater; - In the Case Managers area, a portable space heater; - In the Information Technology (IT) office, a portable space heater. During an interview on 05/13/26 at 9:05 AM, Staff E, the Maintenance Director, stated that they were aware space heaters were not to be used, and they had no idea they were in the hospital. During an interview on 05/13/26 at 9:05 AM, Staff G, Facilities Director, stated that they expected no space heaters to be used in the hospital. Review of NFPA 101 section 3.19.7.8 Portable Space-Heating Devices. Portable space heating devices shall be prohibited in all health care occupancies”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 39354 Based on observation, interview, and nationally recognized standards, the facility failed to ensure electrical wiring was maintained so as to not be a fire hazard in accordance with NFPA 70, National Electric Code. The census was two. Observation on 05/11/26 between 1:05 PM and 4:30 PM, during the Life Safety Code tour of the hospital, showed the following: - In Patient Room 204, a three-plug adapter behind the television (TV); - In Patient Room 207, a three-plug adapter behind the TV; - In Patient Room 210, a three-plug adapter behind the TV; - In Patient Room 110, a three-plug adapter behind the TV; - In Patient Room 109, a three-plug adapter behind the TV; - In Patient Room 108, a six-plug adapter behind the TV; - In Patient Room 107, a three-plug adapter behind the TV; - In Patient Room 105, a three-plug adapter behind the TV; - In Patient Room 104, a three-plug adapter behind the TV; - In Patient Room 103, a three-plug adapter behind the TV; - In Patient Room 301, a three-plug adapter behind the TV; - In the nurse’s breakroom, a three-plug adapter behind the TV; - In the Director of Nursing (DON) office, a three-plug adapter plugged into a power strip; - In the Outpatient office, a power strip plugged into another power strip; - In the Social Services office, a power strip plugged into another power strip; - In the Case Managers office, a space heater plugged into a power strip; - In the Cardiac Rehabilitation area, a three-plug adapter. During an interview on 05/13/26 at 9:05 AM, Staff E, the Maintenance Director, stated that they were aware that adapters were not to be used. They were aware adapters were not to be plugged into power strips. They were aware that power strips were not to be plugged into other power strips. They were not aware of the adapters and power strips that were found during the tour of the hospital. During an interview on 05/13/26 at 9:05 AM, Staff G, Facilities Director, stated that they expected no adapters to be used. They expected no adapters to be plugged into power strips. They expected that no power strips were to be plugged into other power strips. Review of NFPA 70 section 400.8 Uses Not Permitted showed 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 this Code (7) Where subject to physical damage. 10.2.4 Adapters and Extension Cords. 10.2.4.1 Three-prong to two-prong adapters shall not be permitted. 10.2.4.2 Adapters and extension cords meeting the requirements of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted. 10.2.4.2.1 All adapters shall be listed for the purpose. 10.2.4.2.2 Attachment plugs and fittings shall be listed for the purpose. 10.2.4.2.3 The cabling shall comply with 10.2.3.”