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Based on review of facility records and interviews with the Facility Assistant Administrator and Maintenance Supervisor, the facility failed to provide evidence of the current annual approval of the Comprehensive Emergency Plan (CEMP) and Fire Plan (FP) by the local Emergency Management Official and Fire Official.
The findings include:
On March 15, 2012 at 9:00 a.m. while conducting records review with facility staff, Maintenance Supervisor interviewed stated that the CEMP and FP were handled by the Administration.
Upon interview with the Assistant Administrator at 3:30 p.m. during closing no evidence of a currently approved Comprehensive Emergency Plan or Fire Plan for the protection of all patients for their evacuation in the event of an emergency could be provided in accordance with NFPA 101 (2000) 19.7.1.1

Based on observation, facility failed to maintain a fully sprinklered facility with coverage for all portions of the building which could allow for a fire to spread and grow endangering the patients, staff, and other building occupants.

The findings include;

1. On March 15, 2012 at 11:46 a.m. while on tour with facility staff, Corridor 190 former water fountain alcove protected by the automatic sprinkler system coverage of the corridor has been enclosed with a door and frame creating a clean linen storage closet. The newly created closet is not provided with an automatic sprinkler head for coverage in accordance with NFPA 13 (1999) 5-1.1(1), NFPA 25 (1998) 1-4.5, 1-4.6, NFPA 101 (2000) 19.3.5.1.

2. On March 15, 2012 at 3:00 p.m. while on tour with facility staff, Exterior Main Electrical Room 32 no automatic sprinkler coverage is provided in accordance with NFPA 13 (1999) 5-1.1(1), NFPA 25 (1998) 1-4.5, 1-4.6, NFPA 101 (2000) 19.3.5.1.

Based on observation and staff interview, facility has failed to maintain the automatic sprinkler system in a reliable operating condition which could result in failure of the system to activate allowing a fire to grow endangering the patients, staff, and other building occupants.

The findings include;

1. On March 15, 2012 at 10:51 a.m. while on tour with facility staff, Room 199 to include the restroom alcove concealed cover plate assemblies have been damaged possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

2. On March 15, 2012 at 10:55 a.m. while on tour with facility staff, Maintenance Supervisor during discussion reference the damaged concealed cover plates advised that per the sprinkler contractor the manufacturer is no longer able to supply the listed concealed head covers for the style currently provided throughout the facility. They would have to have the concealed sprinklers replaced as they can no longer get replacement covers or that style of sprinkler head.

3. On March 15, 2012 at 11:02 a.m. while on tour with facility staff, Room 203 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

4. On March 15, 2012 at 11:16 a.m. while on tour with facility staff, Room 115 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

6. On March 15, 2012 at 11:18 a.m. while on tour with facility staff, Above North pod nursing station heading into Corridor 148 automatic sprinkler heads appear to have been hit and not in proper orientation possibly preventing proper activation in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

7. On March 15, 2012 at 11:21 a.m. while on tour with facility staff, Room 118 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

8. On March 15, 2012 at 11:28 a.m. while on tour with facility staff, Outside Room 152 concealed head sprinkler missing cover plate damaged possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

9. On March 15, 2012 at 11:49 a.m. while on tour with facility staff, Room 161 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

10. On March 15, 2012 at 11:51 a.m. while on tour with facility staff, Alcove outside Room 159 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

11. On March 15, 2012 at 1:27 p.m. while on tour with facility staff, Alcove outside Room 36 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

12. On March 15, 2012 at 1:29 p.m. while on tour with facility staff, Room 89 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

13. On March 15, 2012 at 1:46 p.m. while on tour with facility staff, Room 80 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

14. On March 15, 2012 at 1:53 p.m. while on tour with facility staff, Room 85 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

15. On March 15, 2012 at 2:03 p.m. while on tour with facility staff, Alcove outside Room 77 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

16. On March 15, 2012 at 2:28 while on tour with facility staff, Kitchen walk-in cooler automatic sprinkler head has a non-listed protection device installed over the head possibly interfering with the proper discharge of the sprinkler in accordance with NFPA 13 (1999) 3-2.8, 12-1, NFPA 25 (1998) 1-4.2, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

Based on observation, the facility failed to enforce the facilities smoking procedures for proper use of the provided fire resistive disposable containers for disposal of smoking materials.

The findings include:

1. On March 15, 2012 at 2:47 p.m. while on tour with facility staff, Front dining room patio area marked with No Smoking observed multiple cigarette butts disposed of in combustible plastic containers under the tables not in accordance with NFPA 101 (2000) 19.7.4 (3-4).

2. On March 15, 2012 at 2:50 p.m. while on tour with facility staff, Behind Trash Dumpster in combustible vegetation area marked No Smoking observed multiple cigarette butts disposed of in combustible vegetation not in accordance with NFPA 101 (2000) 19.7.4 (3-4).

3. On March 15, 2012 at 3:03 p.m. while on tour with facility staff, Southwest wing exterior in marked No Smoking area observed multiple cigarette butts disposed of improperly along the area and around combustibles not in accordance with NFPA 101 (2000) 19.7.4 (3-4).

4. On March 15, 2012 at 3:05 p.m. while on tour with facility staff, Southwest exterior employee smoking area observed multiple cigarette butts disposed of in combustible vegetation and combustible waste container not in accordance with NFPA 101 (2000) 19.7.4 (3-4).

Based on observation, facility failed to maintain proper signage for storage areas of medical gas which in a emergency event result in the injury or loss of patients, staff, or other building occupants.

The findings include;

1. On March 15, 2012 at 1:13 p.m. while on tour with facility staff, Room 164 was being utilized to store Oxygen cylinders but did not have the required signage to warn of storage within in accordance with NFPA 99 (1999) 8-3.1.11.3, NFPA 101 (2000) 19.3.2.4.

2. On March 15, 2012 at 1:45 p.m. while on tour with facility staff, Room 76 was being utilized to store Oxygen cylinders but did not have the required signage to warn of storage within in accordance with NFPA 99 (1999) 8-3.1.11.3, NFPA 101 (2000) 19.3.2.4.

Based on observation and interview, the facility failed to maintain electrical equipment and wiring in accordance with the National Electric Code (N.E.C.), NFPA 70 which could result in injury or harm of patients, staff, or other building occupants.

The findings include:

1. On March 15, 2012 at 10:53 a.m. while on tour with facility staff, Administration offices main electrical panel N5 breakers 20, 22, and 37 conductors not properly labeled as to items controlled in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

2. On March 15, 2012 at 10:59 a.m. while on tour with facility staff, Room 202 found a refrigerator utilizing a power-strip device not in accordance with NFPA 70 (1999) Articles 110.12(C),440.55(A-C), NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

3. On March 15, 2012 at 11:42 a.m. while on tour with facility staff, Room 169A main electrical panels N4 breakers 26, 31, 42, and panel C4 breakers 34, and 36 conductors not properly labeled as to items controlled in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1

4. On March 15, 2012 at 1:08 p.m. while on tour with facility staff, Room 111 Microwave and Refrigerator found utilizing a power-strip tapped into another power-strip not in accordance with NFPA 70 (1999) Article 110.12(C),400.4, 400.7(B), 440.55(A-C), NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

5. On March 15, 20121 at 1:39 while on tour with facility staff, Room 75 main electrical panel C3 breakers 18, 22, 28, 30, and 32 conductors not properly labeled as to items controlled in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

6. On March 15, 2012 at 2:01 p.m. while on tour with facility staff, Room 77 observed (3) three power-strips powered in series one off of another off of another not in accordance with NFPA 70 (1999) Article 400.4, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2006) 9.1.2, 19.5.1.

7. On March 15, 2012 at 2:32 p.m. while on tour with facility staff, Kitchen under the fryer found a damaged flex-pipe conduit exposing internal electrical wires not in accordance with NFPA 70 (1999) Article110.12(c), NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2006) 9.1.2, 19.5.1

8. On March 15, 2012 at 2:46 p.m. while on tour with facility staff, Kitchen electrical panel N1 breakers 12, 13, 23, 25, and 27 conductors not properly labeled as to items controlled in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

9. On March 15, 2012 at 2:59 pm while on tour with facility staff, Room 32 Exterior electrical room Panels EDPL breakers 8, 10, 12 and panel EDPC breakers 14, 16, 18,19, 21, and 23 conductors not properly labeled as to items controlled in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

These findings were re-confirmed with the Assistant Administrator and Maintenance Supervisor during the closing conference at 3:30 p.m. on March 15, 2012.

Based on review of facility records and interviews with the Facility Assistant Administrator and Maintenance Supervisor, the facility failed to provide evidence of the current annual approval of the Comprehensive Emergency Plan (CEMP) and Fire Plan (FP) by the local Emergency Management Official and Fire Official.
The findings include:
On March 15, 2012 at 9:00 a.m. while conducting records review with facility staff, Maintenance Supervisor interviewed stated that the CEMP and FP were handled by the Administration.
Upon interview with the Assistant Administrator at 3:30 p.m. during closing no evidence of a currently approved Comprehensive Emergency Plan or Fire Plan for the protection of all patients for their evacuation in the event of an emergency could be provided in accordance with NFPA 101 (2000) 19.7.1.1

Based on observation, facility failed to maintain a fully sprinklered facility with coverage for all portions of the building which could allow for a fire to spread and grow endangering the patients, staff, and other building occupants.

The findings include;

1. On March 15, 2012 at 11:46 a.m. while on tour with facility staff, Corridor 190 former water fountain alcove protected by the automatic sprinkler system coverage of the corridor has been enclosed with a door and frame creating a clean linen storage closet. The newly created closet is not provided with an automatic sprinkler head for coverage in accordance with NFPA 13 (1999) 5-1.1(1), NFPA 25 (1998) 1-4.5, 1-4.6, NFPA 101 (2000) 19.3.5.1.

2. On March 15, 2012 at 3:00 p.m. while on tour with facility staff, Exterior Main Electrical Room 32 no automatic sprinkler coverage is provided in accordance with NFPA 13 (1999) 5-1.1(1), NFPA 25 (1998) 1-4.5, 1-4.6, NFPA 101 (2000) 19.3.5.1.

Based on observation and staff interview, facility has failed to maintain the automatic sprinkler system in a reliable operating condition which could result in failure of the system to activate allowing a fire to grow endangering the patients, staff, and other building occupants.

The findings include;

1. On March 15, 2012 at 10:51 a.m. while on tour with facility staff, Room 199 to include the restroom alcove concealed cover plate assemblies have been damaged possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

2. On March 15, 2012 at 10:55 a.m. while on tour with facility staff, Maintenance Supervisor during discussion reference the damaged concealed cover plates advised that per the sprinkler contractor the manufacturer is no longer able to supply the listed concealed head covers for the style currently provided throughout the facility. They would have to have the concealed sprinklers replaced as they can no longer get replacement covers or that style of sprinkler head.

3. On March 15, 2012 at 11:02 a.m. while on tour with facility staff, Room 203 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

4. On March 15, 2012 at 11:16 a.m. while on tour with facility staff, Room 115 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

6. On March 15, 2012 at 11:18 a.m. while on tour with facility staff, Above North pod nursing station heading into Corridor 148 automatic sprinkler heads appear to have been hit and not in proper orientation possibly preventing proper activation in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

7. On March 15, 2012 at 11:21 a.m. while on tour with facility staff, Room 118 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

8. On March 15, 2012 at 11:28 a.m. while on tour with facility staff, Outside Room 152 concealed head sprinkler missing cover plate damaged possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

9. On March 15, 2012 at 11:49 a.m. while on tour with facility staff, Room 161 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

10. On March 15, 2012 at 11:51 a.m. while on tour with facility staff, Alcove outside Room 159 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

11. On March 15, 2012 at 1:27 p.m. while on tour with facility staff, Alcove outside Room 36 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

12. On March 15, 2012 at 1:29 p.m. while on tour with facility staff, Room 89 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

13. On March 15, 2012 at 1:46 p.m. while on tour with facility staff, Room 80 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

14. On March 15, 2012 at 1:53 p.m. while on tour with facility staff, Room 85 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

15. On March 15, 2012 at 2:03 p.m. while on tour with facility staff, Alcove outside Room 77 concealed head sprinkler missing cover plate and loaded with foreign material possibly preventing proper activation of the sprinkler in accordance with NFPA 13 (1999) 12.-1, NFPA 25 (1998) 1-4.2, 1-4.4, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

16. On March 15, 2012 at 2:28 while on tour with facility staff, Kitchen walk-in cooler automatic sprinkler head has a non-listed protection device installed over the head possibly interfering with the proper discharge of the sprinkler in accordance with NFPA 13 (1999) 3-2.8, 12-1, NFPA 25 (1998) 1-4.2, 1-11.3, 2-2.1.1, 2-4.1.1, NFPA 101 (2000) 4.6.12, 9.7.1, 9.7.5, 19.1.6, 19.3.5.1, 19.7.6.

Based on observation, the facility failed to enforce the facilities smoking procedures for proper use of the provided fire resistive disposable containers for disposal of smoking materials.

The findings include:

1. On March 15, 2012 at 2:47 p.m. while on tour with facility staff, Front dining room patio area marked with No Smoking observed multiple cigarette butts disposed of in combustible plastic containers under the tables not in accordance with NFPA 101 (2000) 19.7.4 (3-4).

2. On March 15, 2012 at 2:50 p.m. while on tour with facility staff, Behind Trash Dumpster in combustible vegetation area marked No Smoking observed multiple cigarette butts disposed of in combustible vegetation not in accordance with NFPA 101 (2000) 19.7.4 (3-4).

3. On March 15, 2012 at 3:03 p.m. while on tour with facility staff, Southwest wing exterior in marked No Smoking area observed multiple cigarette butts disposed of improperly along the area and around combustibles not in accordance with NFPA 101 (2000) 19.7.4 (3-4).

4. On March 15, 2012 at 3:05 p.m. while on tour with facility staff, Southwest exterior employee smoking area observed multiple cigarette butts disposed of in combustible vegetation and combustible waste container not in accordance with NFPA 101 (2000) 19.7.4 (3-4).

Based on observation, facility failed to maintain proper signage for storage areas of medical gas which in a emergency event result in the injury or loss of patients, staff, or other building occupants.

The findings include;

1. On March 15, 2012 at 1:13 p.m. while on tour with facility staff, Room 164 was being utilized to store Oxygen cylinders but did not have the required signage to warn of storage within in accordance with NFPA 99 (1999) 8-3.1.11.3, NFPA 101 (2000) 19.3.2.4.

2. On March 15, 2012 at 1:45 p.m. while on tour with facility staff, Room 76 was being utilized to store Oxygen cylinders but did not have the required signage to warn of storage within in accordance with NFPA 99 (1999) 8-3.1.11.3, NFPA 101 (2000) 19.3.2.4.

Based on observation and interview, the facility failed to maintain electrical equipment and wiring in accordance with the National Electric Code (N.E.C.), NFPA 70 which could result in injury or harm of patients, staff, or other building occupants.

The findings include:

1. On March 15, 2012 at 10:53 a.m. while on tour with facility staff, Administration offices main electrical panel N5 breakers 20, 22, and 37 conductors not properly labeled as to items controlled in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

2. On March 15, 2012 at 10:59 a.m. while on tour with facility staff, Room 202 found a refrigerator utilizing a power-strip device not in accordance with NFPA 70 (1999) Articles 110.12(C),440.55(A-C), NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

3. On March 15, 2012 at 11:42 a.m. while on tour with facility staff, Room 169A main electrical panels N4 breakers 26, 31, 42, and panel C4 breakers 34, and 36 conductors not properly labeled as to items controlled in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1

4. On March 15, 2012 at 1:08 p.m. while on tour with facility staff, Room 111 Microwave and Refrigerator found utilizing a power-strip tapped into another power-strip not in accordance with NFPA 70 (1999) Article 110.12(C),400.4, 400.7(B), 440.55(A-C), NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

5. On March 15, 20121 at 1:39 while on tour with facility staff, Room 75 main electrical panel C3 breakers 18, 22, 28, 30, and 32 conductors not properly labeled as to items controlled in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

6. On March 15, 2012 at 2:01 p.m. while on tour with facility staff, Room 77 observed (3) three power-strips powered in series one off of another off of another not in accordance with NFPA 70 (1999) Article 400.4, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2006) 9.1.2, 19.5.1.

7. On March 15, 2012 at 2:32 p.m. while on tour with facility staff, Kitchen under the fryer found a damaged flex-pipe conduit exposing internal electrical wires not in accordance with NFPA 70 (1999) Article110.12(c), NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2006) 9.1.2, 19.5.1

8. On March 15, 2012 at 2:46 p.m. while on tour with facility staff, Kitchen electrical panel N1 breakers 12, 13, 23, 25, and 27 conductors not properly labeled as to items controlled in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

9. On March 15, 2012 at 2:59 pm while on tour with facility staff, Room 32 Exterior electrical room Panels EDPL breakers 8, 10, 12 and panel EDPC breakers 14, 16, 18,19, 21, and 23 conductors not properly labeled as to items controlled in accordance with NFPA 70 (1999) Article 110-22, NFPA 99 (1999) 3-3.2.1.1, NFPA 101 (2000) 4.6.12, 9.1.2, 19.5.1.

These findings were re-confirmed with the Assistant Administrator and Maintenance Supervisor during the closing conference at 3:30 p.m. on March 15, 2012.