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Based on observations and tour of the facility, it was determined that the facility failed to meet the requirements for sprinkler coverage in all areas. This could endanger building occupants and staff, in the event of a fire.


The findings include:


During the facility tour with the Maintenance Director on 8/11/2015 4:45 PM, it was found that the facility was not in substantial compliance with the requirements of sprinkler coverage in all areas. There was no proper sprinkler coverage in the closet of Accounts Payable office. The closet was repurposed to house an IT server; the facility removed the drop ceiling and the recessed sprinkler head was not relocated to a proper location.


NFPA-101-2000-Chap.9-7.5,--4.6.12.1,-4.6.12.4
NFPA-25-
NFPA-99--Health Facilities Code.
NFPA-13- Automatic Fire Sprinkler Code

An exit conference was held on 8/11/15 at the conclusion of the survey, with the Administrator and Maintenance Director. All non-compliance was confirmed.

Based on observations and staff interview during facility tour on August 11, 2015, the facility failed to maintain proper storage for oxygen cylinders. Proper storage and handling of compressed gases is vital to the safety of staff, patients, and visitors within the facility.


The findings include:


During the facility tour with the Maintenance Director on 8/11/2015 between 10:55 am-4:30 PM, it was observed the facility was not in substantial compliance with the requirements for the storage of oxygen cylinders.

Oxygen cylinders in the Physical Therapy, Respiratory Therapy and Operating Rooms were not stored correctly.

Cylinder carts were missing the set screw to secure the tank in the cart.

Oxygen storage signage was missing in all three areas.

NFPA 99-Chapter --11.5.1.3.1,--11.6.2.3( 1) through (12) --11.3.4.1,--11.3.4.2,---11.3.3.3
NFPA 101 (2000)- Chapter-- 18.3.2.4,-- 8.7.1.1,--8.7.3.1,--8.7.3.2



An exit conference was held on 8/11/15 at the conclusion of the survey, with the Administrator and Maintenance Director. All non-compliance was confirmed.

Based on observations and interview with the Maintenance Director during the facility tour, the facility failed to prohibit the use of electrical strips (surge protectors). The use of surge protectors and extension cords allow the possibility of overloading the wiring dedicated to the outlet which can cause a fire hazard. Electrical fires can start in the walls or attic where it can go undetected, giving the hazard time to spread without being identified, placing the entire facility at risk.


The findings include:


During the facility tour on the day of survey, 8/11/2015, between 10:00 AM and 4:45 PM, the facility was found to be NOT in substantial compliance with the requirements of electrical safety. There was improper uses of electrical power strips in Operating Room 1, Physical Therapy, and Respiratory Therapy.

NFPA-101-LSC-2000--4.6.12.1,--9.1.2,--19.5.1,--10.7.6.
NFPA-70--Article 400-7(b),--400-8,--440-55(a-c)
NFPA-99



An exit conference was held on 8/11/15 at the conclusion of the survey, with the Administrator and Maintenance Director. All non-compliance was confirmed.

Based on observations and tour of the facility, it was determined that the facility failed to meet the requirements for sprinkler coverage in all areas. This could endanger building occupants and staff, in the event of a fire.


The findings include:


During the facility tour with the Maintenance Director on 8/11/2015 4:45 PM, it was found that the facility was not in substantial compliance with the requirements of sprinkler coverage in all areas. There was no proper sprinkler coverage in the closet of Accounts Payable office. The closet was repurposed to house an IT server; the facility removed the drop ceiling and the recessed sprinkler head was not relocated to a proper location.


NFPA-101-2000-Chap.9-7.5,--4.6.12.1,-4.6.12.4
NFPA-25-
NFPA-99--Health Facilities Code.
NFPA-13- Automatic Fire Sprinkler Code

An exit conference was held on 8/11/15 at the conclusion of the survey, with the Administrator and Maintenance Director. All non-compliance was confirmed.

Based on observations and staff interview during facility tour on August 11, 2015, the facility failed to maintain proper storage for oxygen cylinders. Proper storage and handling of compressed gases is vital to the safety of staff, patients, and visitors within the facility.


The findings include:


During the facility tour with the Maintenance Director on 8/11/2015 between 10:55 am-4:30 PM, it was observed the facility was not in substantial compliance with the requirements for the storage of oxygen cylinders.

Oxygen cylinders in the Physical Therapy, Respiratory Therapy and Operating Rooms were not stored correctly.

Cylinder carts were missing the set screw to secure the tank in the cart.

Oxygen storage signage was missing in all three areas.

NFPA 99-Chapter --11.5.1.3.1,--11.6.2.3( 1) through (12) --11.3.4.1,--11.3.4.2,---11.3.3.3
NFPA 101 (2000)- Chapter-- 18.3.2.4,-- 8.7.1.1,--8.7.3.1,--8.7.3.2



An exit conference was held on 8/11/15 at the conclusion of the survey, with the Administrator and Maintenance Director. All non-compliance was confirmed.

Based on observations and interview with the Maintenance Director during the facility tour, the facility failed to prohibit the use of electrical strips (surge protectors). The use of surge protectors and extension cords allow the possibility of overloading the wiring dedicated to the outlet which can cause a fire hazard. Electrical fires can start in the walls or attic where it can go undetected, giving the hazard time to spread without being identified, placing the entire facility at risk.


The findings include:


During the facility tour on the day of survey, 8/11/2015, between 10:00 AM and 4:45 PM, the facility was found to be NOT in substantial compliance with the requirements of electrical safety. There was improper uses of electrical power strips in Operating Room 1, Physical Therapy, and Respiratory Therapy.

NFPA-101-LSC-2000--4.6.12.1,--9.1.2,--19.5.1,--10.7.6.
NFPA-70--Article 400-7(b),--400-8,--440-55(a-c)
NFPA-99



An exit conference was held on 8/11/15 at the conclusion of the survey, with the Administrator and Maintenance Director. All non-compliance was confirmed.