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Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having the required emergency lighting operating properly.

The findings include:

During the validation survey on November 18, 2014 with the Director of Engineering & Safety and the Vice President Financial Services/CFO, it was observed between 8:30 am and 3:00 pm that one wall-mounted emergency lamp failed to operate when tested - it was located in an electrical panel room identified as #T104A.

The failure of the emergency lighting in these areas has the potential to promote harm to occupants of the facility in the event of a fire, power failure, or other type of emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having a sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building.

The findings include:

During the validation survey on November 18, 2014 with the Director of Engineering & Safety and the Vice President Financial Services/CFO, it was observed between 8:30 am and 3:00 pm that several in-patient areas of the hospital were not fully protected by automatic sprinklers including, but not limited to, the following: storage closets in two physical therapy suites; main kitchen walk-in refrigerators and freezer; exterior medical gas storage room at loading dock area.

A fire in any one of these locations could spread since there is no automatic sprinkler coverage and could impact patients and staff of the facility.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.

The findings include:

During the validation survey on November 18, 2014 with the Director of Engineering & Safety and the Vice President Financial Services/CFO, it was observed between 8:30 am and 3:00 pm that:

1.) There was no sprinkler wrench in the spare sprinkler head box at the main sprinkler riser;

2.) Multiple escutcheon rings were missing or partially falling out, including, but not limited to, one located in the ceiling of the pain clinic and one located in room G-911;

3.) Several high mounted tamper/flow covers were unsecured with their tamper-resistant screws on the ground floor and upper floor levels in stairwells #2 and #6;

4.) Exterior fire department connection (FDC) fittings were not moveable by hand - 6 caps on one FDC and 2 caps on second FDC;

5.) There was no record of a 5 year sprinkler system internal obstruction test;

6.) There was no record of 3 - 5 year stand pipe inspection, testing, and maintenance;

7.) Multiple pendant sprinkler heads in the facility were showing signs of moderate loading (lint and debris buildup.)

These items could lead to improper operation of the sprinkler system in the event of an emergency and could effect up to 50% of the facility's patients and staff.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the exhaust flue(s) from a fuel-fired appliance in proper working order.

The findings include:

During the validation survey on November 18, 2014 with the Director of Engineering & Safety and the Vice President Financial Services/CFO, it was observed between 8:30 am and 3:00 pm that one natural gas fired hot water boiler (DWH-1) had all seams in its exhaust flue sealed with foil-backed duct tape. Foil backed duct tape degrades over time in high heat conditions. (Connections shall be made with screws, rivets, or high temperature silicon sealant.)

Installation of a CO monitor/alarm is recommended in the vicinity of this hot water boiler.

Openings in the flue on an operating fuel-fired appliance could impact up to 100% of the patients and staff. It could result in carbon monoxide poisoning resulting in illness or death.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications. NFPA 70, National Electrical Code 9.1.2, 20.5.1.

The findings include:

During the validation survey on November 18, 2014 with the Director of Engineering & Safety and the Vice President Financial Services/CFO, it was observed between 8:30 am and 3:00 pm that:

1.) One electrical outlet in the Pain Management Unit mechanical room that was powering a sump pump was not ground fault circuit interrupter (GFCI) protected - this was a potentially wet location;

2.) The stove top and range in the therapy suite in the Traumatic Brain Injury unit had no remote shut-off switch;

2.) An electrical panel (LPGD) had two open circuit breaker slots;

3.) One inexpensive, unprotected power strip in the main pharmacy was powering a coffee maker - it was removed during the survey;

4.) One GFCI outlet located outside at the main loading dock had no protective cover plate.

These items could cause overheating or electrical short circuits resulting in fire. Absence of a GFCI protected outlet in a wet location increases the potential for electrical shock to staff members.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having the required emergency lighting operating properly.

The findings include:

During the validation survey on November 18, 2014 with the Director of Engineering & Safety and the Vice President Financial Services/CFO, it was observed between 8:30 am and 3:00 pm that one wall-mounted emergency lamp failed to operate when tested - it was located in an electrical panel room identified as #T104A.

The failure of the emergency lighting in these areas has the potential to promote harm to occupants of the facility in the event of a fire, power failure, or other type of emergency.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having a sprinkler system installed in accordance with NFPA 13 to provide complete coverage for all portions of the building.

The findings include:

During the validation survey on November 18, 2014 with the Director of Engineering & Safety and the Vice President Financial Services/CFO, it was observed between 8:30 am and 3:00 pm that several in-patient areas of the hospital were not fully protected by automatic sprinklers including, but not limited to, the following: storage closets in two physical therapy suites; main kitchen walk-in refrigerators and freezer; exterior medical gas storage room at loading dock area.

A fire in any one of these locations could spread since there is no automatic sprinkler coverage and could impact patients and staff of the facility.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in a reliable operating condition.

The findings include:

During the validation survey on November 18, 2014 with the Director of Engineering & Safety and the Vice President Financial Services/CFO, it was observed between 8:30 am and 3:00 pm that:

1.) There was no sprinkler wrench in the spare sprinkler head box at the main sprinkler riser;

2.) Multiple escutcheon rings were missing or partially falling out, including, but not limited to, one located in the ceiling of the pain clinic and one located in room G-911;

3.) Several high mounted tamper/flow covers were unsecured with their tamper-resistant screws on the ground floor and upper floor levels in stairwells #2 and #6;

4.) Exterior fire department connection (FDC) fittings were not moveable by hand - 6 caps on one FDC and 2 caps on second FDC;

5.) There was no record of a 5 year sprinkler system internal obstruction test;

6.) There was no record of 3 - 5 year stand pipe inspection, testing, and maintenance;

7.) Multiple pendant sprinkler heads in the facility were showing signs of moderate loading (lint and debris buildup.)

These items could lead to improper operation of the sprinkler system in the event of an emergency and could effect up to 50% of the facility's patients and staff.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the exhaust flue(s) from a fuel-fired appliance in proper working order.

The findings include:

During the validation survey on November 18, 2014 with the Director of Engineering & Safety and the Vice President Financial Services/CFO, it was observed between 8:30 am and 3:00 pm that one natural gas fired hot water boiler (DWH-1) had all seams in its exhaust flue sealed with foil-backed duct tape. Foil backed duct tape degrades over time in high heat conditions. (Connections shall be made with screws, rivets, or high temperature silicon sealant.)

Installation of a CO monitor/alarm is recommended in the vicinity of this hot water boiler.

Openings in the flue on an operating fuel-fired appliance could impact up to 100% of the patients and staff. It could result in carbon monoxide poisoning resulting in illness or death.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications. NFPA 70, National Electrical Code 9.1.2, 20.5.1.

The findings include:

During the validation survey on November 18, 2014 with the Director of Engineering & Safety and the Vice President Financial Services/CFO, it was observed between 8:30 am and 3:00 pm that:

1.) One electrical outlet in the Pain Management Unit mechanical room that was powering a sump pump was not ground fault circuit interrupter (GFCI) protected - this was a potentially wet location;

2.) The stove top and range in the therapy suite in the Traumatic Brain Injury unit had no remote shut-off switch;

2.) An electrical panel (LPGD) had two open circuit breaker slots;

3.) One inexpensive, unprotected power strip in the main pharmacy was powering a coffee maker - it was removed during the survey;

4.) One GFCI outlet located outside at the main loading dock had no protective cover plate.

These items could cause overheating or electrical short circuits resulting in fire. Absence of a GFCI protected outlet in a wet location increases the potential for electrical shock to staff members.