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(A) Based on observation, it was determined that the facility failed to maintain escutcheons on various sprinkler heads.

Findings were

Observations revealed that escutcheons were missing from sprinkler heads at the following locations:
(1) In the small storage room off the main IT room;
(2) In the ER storage room;
(3) In the hallway outside the ER storage room; and
(4) In the hallway outside of Trauma 1.


(B) Based on observation, it was determined that the facility failed to maintain all sprinkler heads free of obstruction.

Findings were:

Observation revealed that a light fixture in room FT 5 obstructed the spray pattern of one sprinkler head.


(C) Based on observation, it was determined that the facility failed to provide sprinkler protection for the main IT room.

Findings were:

Observation revealed that there were no sprinkler heads noted in the main IT room. No alternative protection was noted or confirmed.

Based on observation, it was determined that the facility failed to sprinkler protect the computer room or to provide approved alternative protection.

Findings were:

Observation and interview with Staff M revealed that the computer room was not sprinkler protected. No approved alternative fire suppression system was present, nor was the space separated from sprinkler protected areas by at least a 2-hour fire rated construction.

(A) Based on observation, it was determined that the facility failed to maintain the sleep area on the 3rd floor free of a dead-end corridor condition.

Findings were:

Observation and calculations revealed that there is a dead-end corridor condition in excess of 30 feet in the sleep lab area on the 3rd floor.


(B) Based on observation, the facility failed to provide smoke detectors in the sleep rooms in the sleep lab on the 3rd floor.

Findings were:

Observation revealed that there were no smoke detectors installed in the sleep rooms of the sleep lab on the 3rd floor.

Based on observation, it was determined that the facility failed to protect an electrical breaker panel free of hazard.

Findings were:

Observation revealed that an open breaker slot was left open without a protective cover in an electrical room across from dialysis. The panel is NL-1A.

(A) Based on observation, it was determined that the facility failed to maintain escutcheons on various sprinkler heads.

Findings were

Observations revealed that escutcheons were missing from sprinkler heads at the following locations:
(1) In the small storage room off the main IT room;
(2) In the ER storage room;
(3) In the hallway outside the ER storage room; and
(4) In the hallway outside of Trauma 1.


(B) Based on observation, it was determined that the facility failed to maintain all sprinkler heads free of obstruction.

Findings were:

Observation revealed that a light fixture in room FT 5 obstructed the spray pattern of one sprinkler head.


(C) Based on observation, it was determined that the facility failed to provide sprinkler protection for the main IT room.

Findings were:

Observation revealed that there were no sprinkler heads noted in the main IT room. No alternative protection was noted or confirmed.

Based on observation, it was determined that the facility failed to sprinkler protect the computer room or to provide approved alternative protection.

Findings were:

Observation and interview with Staff M revealed that the computer room was not sprinkler protected. No approved alternative fire suppression system was present, nor was the space separated from sprinkler protected areas by at least a 2-hour fire rated construction.

(A) Based on observation, it was determined that the facility failed to maintain the sleep area on the 3rd floor free of a dead-end corridor condition.

Findings were:

Observation and calculations revealed that there is a dead-end corridor condition in excess of 30 feet in the sleep lab area on the 3rd floor.


(B) Based on observation, the facility failed to provide smoke detectors in the sleep rooms in the sleep lab on the 3rd floor.

Findings were:

Observation revealed that there were no smoke detectors installed in the sleep rooms of the sleep lab on the 3rd floor.

Based on observation, it was determined that the facility failed to protect an electrical breaker panel free of hazard.

Findings were:

Observation revealed that an open breaker slot was left open without a protective cover in an electrical room across from dialysis. The panel is NL-1A.