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Based on observations, the facility failed to maintain the sprinkler system in accordance with NFPA 25, which could result in the failure of the system to activate, endangering the patients, staff, and other building occupants.


The Findings Include:


1.On April 9, 2014 at 4:04 PM while on tour with facility staff on the 5th floor in the egress corridor outside Room 5-IC547, it was observed that the concealed plate cover for the automatic fire sprinkler system had become stuck to the ceiling assembly, due to application of drywall mud. This can lead to the failure of the cover to dislodge upon heat activation, to allow proper activation of the automatic fire sprinkler head. Concealed head cover plates shall not be coated, painted, or damaged in accordance with NFPA 13 (1999) 3-2.6, 3-2.6.3, 3-2.6.4, 5-3.1.1.1, 12-1, NFPA 25 (1998) 2-2.1.1, 2-4.1.8, NFPA 101 (2000) 4.5.1, 4.5.2, 4.5.7, 4.6.12.1, 9.7.1, 9.7.1.1, 9.7.5, 19.3.5.1, 19.7.6.

2. On April 10, 2014 at 9:57 AM while on tour with facility staff in the Endoscopy corridor outside Rooms 5 & 6, it was observed that the automatic fire sprinkler heads protecting the spaces were intermixed with early suppression fast response and quick response heads. Areas protected by fringible bulb automatic sprinkler heads shall be of the same temperature and time activation in accordance with NFPA 13 (1999) 5-1.1(1-3), 5-3.1.4, 5-3.1.4.2(1-7), 5-3.1.5.1, 5-3.1.5.2, 12-1, NFPA 25 (1998) 1-4, 1-4.1, 1-4.2, 1-4.4, 1-4.5, 1-4.6, 1-11, NFPA 101 (2000) 1.2.1, 1.2.3, 1.4.1, 4.5.2(1-6), 4.5.6, 4.5.7, 4.6.12, 9.7.1.1, 9.7.5, 19.1.1.1.1, 19.1.1.1.2, 19.1.1.2, 19.1.1.3(1-3), 19.3.5.1, 19.7.6.

3. On April 10, 2014 at 10:32 AM while on tour with facility staff in the OR corridor outside Room 5, it was observed that the automatic fire sprinkler heads protecting the space were intermixed with early suppression fast response and quick response heads. Areas protected by fringible bulb automatic sprinkler heads shall be of the same temperature and time activation in accordance with NFPA 13 (1999) 5-1.1(1-3), 5-3.1.4, 5-3.1.4.2(1-7), 5-3.1.5.1, 5-3.1.5.2, 12-1, NFPA 25 (1998) 1-4, 1-4.1, 1-4.2, 1-4.4, 1-4.5, 1-4.6, 1-11, NFPA 101 (2000) 1.2.1, 1.2.3, 1.4.1, 4.5.2(1-6), 4.5.6, 4.5.7, 4.6.12, 9.7.1.1, 9.7.5, 19.1.1.1.1, 19.1.1.1.2, 19.1.1.2, 19.1.1.3(1-3), 19.3.5.1, 19.7.6.

These findings were confirmed with the Chief Executive Officer, Director of Plant Operations, Assitant Facilities Director, and Administrative staff during the exit conference April 10, 2014 at 4:30 PM.

Based on observations, facility failed to maintain proper storage practices of medical gas cylinders. Failure to maintain proper storage practices can result in endangerment to patients, staff, and other building occupants.


The Findings Include:


1. On April 9, 2014 at 3:59 PM while on tour with facility staff on the 5th floor in Room 5-IC536, it was observed that the storage of oxygen cylinders, both full and empty, were improperly stored with the labeled 'full cylinders only' rack, which is not in accordance with NFPA 99 (1999) 8-2.3.2.4, NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.3.2.4, 19.7.6.

2. On April 10, 2014 at 1:14 PM while on tour with facility staff in the Storage room for the Gift Shop, it was observed an H-sized cylinder had no protection from tipping or falling. Failure to properly secure compressed gases from tipping or falling can result in a dangerous and explosive discharge of the cylinder. Cylinders shall be properly protected, in accordance with NFPA 99 (1999) 4-3.1.1.2(a)(3), 4-3.1.1.8(a), 4-3.5.2.1(b)(27), 4-3.5.2.2(b)(2), 4-4.5.2, 4-5.1.1.1, 8-3.1.11.2, NFPA 101 (2000) 4.6.12.1, 19.3.2.4, 19.7.6.

3. On April 10, 2014 at 4:15 PM while on tour with facility staff in the Plant Chiller room, it was observed three compressed gas cylinders, free standing, were not provided with protection from tipping or falling. Failure to properly secure compressed gases from tipping or falling can result in a dangerous and explosive discharge of the cylinder. Cylinders shall be properly protected, in accordance with NFPA 99 (1999) 4-3.1.1.2(a)(3), 4-3.1.1.8(a), 4-3.5.2.1(b)(27), 4-3.5.2.2(b)(2), 4-4.5.2, 4-5.1.1.1, 8-3.1.11.2, NFPA 101 (2000) 4.6.12.1, 19.3.2.4, 19.7.6.

These findings were confirmed with the Chief Executive Officer, Director of Plant Operations, Assistant Facilities Director, and Administrative staff during the exit conference April 10, 2014 at 4:30 PM.

Based on observations and staff interviews, the facility failed to maintain proper storage and handling of flammable liquids. Improper storage and handling can result in a rapid fire spread, which can endanger the patients, staff, and other building occupants.

The Findings Include:

On April 9, 2014 at 5:00 PM while on tour with facility staff on the 3rd floor across from Room 370 in the Bio-Hazard disposal room, it was observed the storage of six one-gallon flammable liquid containers of Pen-Fix awaiting disposal not properly contained inside a flammable liquids storage locker. This room is located with the door directly accessing the egress corridor, and is in an area which could be utilized by a person undergoing medical gas therapy. When asked as to the reason for the chemicals being stored in the room during the tour, the Assistant Facilities Director acknowledged that the chemicals should not be stored in the room and called to have them removed immediately. Flammable liquids shall be properly stored in flammable liquids lockers and are not permitted for use in anesthetizing areas in accordance with NFPA 30 (1996) 4-2, 4-3, NFPA 99 (1999) 12-4.1, NFPA 101 (2000) 8.4.3, 19.3.2, 19.3.2.3, 19.3.2.4.


These findings were confirmed with the Chief Executive Officer, Director of Plant Operations, Assistant Facilities Director, and Administrative staff during the exit conference April 10, 2014 at 4:30 PM.

Based on observations, the facility failed to maintain electrical equipment and wiring in accordance with the National Electric Code (N.E.C.), NFPA 70, which could endanger the residents, staff, and other building occupants.


The Findings Include:


1. On April 10, 2014 at 9:00 AM to 4:00 PM while on tour with facility staff throughout the Operating Room spaces, it was observed multiple patient care equipment utilizing multiple outlet power tap cord devices, which were not part of an integral listed component from the manufacturer, in lieu of proper outlet power. Patient care machinery shall not utilize temporary-use cords or power tap cords in the patient care areas unless shown to be part of an integral manufacturer's rated assembly for the unit, and not in lieu of properly provided outlets, in accordance with NFPA 70 (1999) Articles 400-4, 400-7(a-b), 400-8, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.


These findings were confirmed with the Chief Executive Officer, Director of Plant Operations, Assistant Facilities Director, and Administrative staff during the exit conference April 10, 2014 at 4:30 PM.

Based on observations, the facility failed to maintain the sprinkler system in accordance with NFPA 25, which could result in the failure of the system to activate, endangering the patients, staff, and other building occupants.


The Findings Include:


1.On April 9, 2014 at 4:04 PM while on tour with facility staff on the 5th floor in the egress corridor outside Room 5-IC547, it was observed that the concealed plate cover for the automatic fire sprinkler system had become stuck to the ceiling assembly, due to application of drywall mud. This can lead to the failure of the cover to dislodge upon heat activation, to allow proper activation of the automatic fire sprinkler head. Concealed head cover plates shall not be coated, painted, or damaged in accordance with NFPA 13 (1999) 3-2.6, 3-2.6.3, 3-2.6.4, 5-3.1.1.1, 12-1, NFPA 25 (1998) 2-2.1.1, 2-4.1.8, NFPA 101 (2000) 4.5.1, 4.5.2, 4.5.7, 4.6.12.1, 9.7.1, 9.7.1.1, 9.7.5, 19.3.5.1, 19.7.6.

2. On April 10, 2014 at 9:57 AM while on tour with facility staff in the Endoscopy corridor outside Rooms 5 & 6, it was observed that the automatic fire sprinkler heads protecting the spaces were intermixed with early suppression fast response and quick response heads. Areas protected by fringible bulb automatic sprinkler heads shall be of the same temperature and time activation in accordance with NFPA 13 (1999) 5-1.1(1-3), 5-3.1.4, 5-3.1.4.2(1-7), 5-3.1.5.1, 5-3.1.5.2, 12-1, NFPA 25 (1998) 1-4, 1-4.1, 1-4.2, 1-4.4, 1-4.5, 1-4.6, 1-11, NFPA 101 (2000) 1.2.1, 1.2.3, 1.4.1, 4.5.2(1-6), 4.5.6, 4.5.7, 4.6.12, 9.7.1.1, 9.7.5, 19.1.1.1.1, 19.1.1.1.2, 19.1.1.2, 19.1.1.3(1-3), 19.3.5.1, 19.7.6.

3. On April 10, 2014 at 10:32 AM while on tour with facility staff in the OR corridor outside Room 5, it was observed that the automatic fire sprinkler heads protecting the space were intermixed with early suppression fast response and quick response heads. Areas protected by fringible bulb automatic sprinkler heads shall be of the same temperature and time activation in accordance with NFPA 13 (1999) 5-1.1(1-3), 5-3.1.4, 5-3.1.4.2(1-7), 5-3.1.5.1, 5-3.1.5.2, 12-1, NFPA 25 (1998) 1-4, 1-4.1, 1-4.2, 1-4.4, 1-4.5, 1-4.6, 1-11, NFPA 101 (2000) 1.2.1, 1.2.3, 1.4.1, 4.5.2(1-6), 4.5.6, 4.5.7, 4.6.12, 9.7.1.1, 9.7.5, 19.1.1.1.1, 19.1.1.1.2, 19.1.1.2, 19.1.1.3(1-3), 19.3.5.1, 19.7.6.

These findings were confirmed with the Chief Executive Officer, Director of Plant Operations, Assitant Facilities Director, and Administrative staff during the exit conference April 10, 2014 at 4:30 PM.

Based on observations, facility failed to maintain proper storage practices of medical gas cylinders. Failure to maintain proper storage practices can result in endangerment to patients, staff, and other building occupants.


The Findings Include:


1. On April 9, 2014 at 3:59 PM while on tour with facility staff on the 5th floor in Room 5-IC536, it was observed that the storage of oxygen cylinders, both full and empty, were improperly stored with the labeled 'full cylinders only' rack, which is not in accordance with NFPA 99 (1999) 8-2.3.2.4, NFPA 101 (2000) 4.5.7, 4.6.12.1, 19.3.2.4, 19.7.6.

2. On April 10, 2014 at 1:14 PM while on tour with facility staff in the Storage room for the Gift Shop, it was observed an H-sized cylinder had no protection from tipping or falling. Failure to properly secure compressed gases from tipping or falling can result in a dangerous and explosive discharge of the cylinder. Cylinders shall be properly protected, in accordance with NFPA 99 (1999) 4-3.1.1.2(a)(3), 4-3.1.1.8(a), 4-3.5.2.1(b)(27), 4-3.5.2.2(b)(2), 4-4.5.2, 4-5.1.1.1, 8-3.1.11.2, NFPA 101 (2000) 4.6.12.1, 19.3.2.4, 19.7.6.

3. On April 10, 2014 at 4:15 PM while on tour with facility staff in the Plant Chiller room, it was observed three compressed gas cylinders, free standing, were not provided with protection from tipping or falling. Failure to properly secure compressed gases from tipping or falling can result in a dangerous and explosive discharge of the cylinder. Cylinders shall be properly protected, in accordance with NFPA 99 (1999) 4-3.1.1.2(a)(3), 4-3.1.1.8(a), 4-3.5.2.1(b)(27), 4-3.5.2.2(b)(2), 4-4.5.2, 4-5.1.1.1, 8-3.1.11.2, NFPA 101 (2000) 4.6.12.1, 19.3.2.4, 19.7.6.

These findings were confirmed with the Chief Executive Officer, Director of Plant Operations, Assistant Facilities Director, and Administrative staff during the exit conference April 10, 2014 at 4:30 PM.

Based on observations and staff interviews, the facility failed to maintain proper storage and handling of flammable liquids. Improper storage and handling can result in a rapid fire spread, which can endanger the patients, staff, and other building occupants.

The Findings Include:

On April 9, 2014 at 5:00 PM while on tour with facility staff on the 3rd floor across from Room 370 in the Bio-Hazard disposal room, it was observed the storage of six one-gallon flammable liquid containers of Pen-Fix awaiting disposal not properly contained inside a flammable liquids storage locker. This room is located with the door directly accessing the egress corridor, and is in an area which could be utilized by a person undergoing medical gas therapy. When asked as to the reason for the chemicals being stored in the room during the tour, the Assistant Facilities Director acknowledged that the chemicals should not be stored in the room and called to have them removed immediately. Flammable liquids shall be properly stored in flammable liquids lockers and are not permitted for use in anesthetizing areas in accordance with NFPA 30 (1996) 4-2, 4-3, NFPA 99 (1999) 12-4.1, NFPA 101 (2000) 8.4.3, 19.3.2, 19.3.2.3, 19.3.2.4.


These findings were confirmed with the Chief Executive Officer, Director of Plant Operations, Assistant Facilities Director, and Administrative staff during the exit conference April 10, 2014 at 4:30 PM.

Based on observations, the facility failed to maintain electrical equipment and wiring in accordance with the National Electric Code (N.E.C.), NFPA 70, which could endanger the residents, staff, and other building occupants.


The Findings Include:


1. On April 10, 2014 at 9:00 AM to 4:00 PM while on tour with facility staff throughout the Operating Room spaces, it was observed multiple patient care equipment utilizing multiple outlet power tap cord devices, which were not part of an integral listed component from the manufacturer, in lieu of proper outlet power. Patient care machinery shall not utilize temporary-use cords or power tap cords in the patient care areas unless shown to be part of an integral manufacturer's rated assembly for the unit, and not in lieu of properly provided outlets, in accordance with NFPA 70 (1999) Articles 400-4, 400-7(a-b), 400-8, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12.1, 9.1.2, 19.5.1, 19.7.6.


These findings were confirmed with the Chief Executive Officer, Director of Plant Operations, Assistant Facilities Director, and Administrative staff during the exit conference April 10, 2014 at 4:30 PM.