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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 maintaining self closing doors in hazardous areas.

The findings include:

During the initial survey on April 30, 2013 with the VP/CFO, Maintenance Director, and other staff, it was observed between 9:00 am and 1:30 pm that:

1.) the corridor door to a soiled linen room on the 4th floor was held open by a wooden wedge - the wedge was discarded during the survey;

2.) the corridor door to a soiled utility room on the 3rd floor was held open by a towel wedged between the door and frame - the towel was removed during the survey;

3.) the corridor door to storage room # 1B137 had a damaged strike plate and would not self-close and latch.

All doors to the exit corridors from hazardous areas must be self-closing in the event of an emergency and must not be held open unless by an approved device that is connected to the alarm system.

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 initial survey on April 30, 2013 with the VP/CFO, Maintenance Director, and other staff, it was observed between 9:00 am and 1:30 pm that:

1.) multiple exterior sprinkler heads above the loading dock were showing signs of significant corrosion - greenish discoloration on the metal parts;

2.) two sprinkler heads in the loading dock corridor near the kitchen appeared to be recessed too far into the ceiling; staff reported that these were spring loaded but they did not have cover plates; one head appeared to have traces of paint on the deflector;

3.) one recessed sprinkler head in the oxygen/medical gas storage room was missing its cover plate;

4.) all exterior fire department connections (FDC's) had no reflective signs indicating their locations.

These items could lead to improper operation of the sprinkler system in the event of an 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 maintaining proper signs at oxygen storage locations.

The findings include:

During the initial survey on April 30, 2013 with the VP/CFO, Maintenance Director, and other staff, it was observed between 9:00 am and 1:30 pm that in the operating suite, one utility room with oxygen and medical gas storage had no signs indicating "Caution - Oxygen Stored Within." Oxygen storage signs shall be conspicuously displayed on each door of a storage room and shall be readable from a distance of 5 feet.

This could result in staff, visitors, or firefighters not knowing where oxygen was in use and/or stored.

Based on observation of the physical environment, it was determined that the facility staff failed to insure that the generator had backup emergency lighting.

The findings include:

During the initial survey on April 30, 2013 with the VP/CFO, Maintenance Director, and other staff, it was observed between 9:00 am and 1:30 pm that one emergency generator, which was located inside a mechanical room in the power plant building, did not have battery operated backup emergency lighting in close proximity.

This could result in staff having difficulty operating the generator or failure of the generator during a power outage if the generator did not start or was not operating properly and there was no other form of lighting available.

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 self closing doors in hazardous areas.

The findings include:

During the initial survey on April 30, 2013 with the VP/CFO, Maintenance Director, and other staff, it was observed between 9:00 am and 1:30 pm that:

1.) the corridor door to a soiled linen room on the 4th floor was held open by a wooden wedge - the wedge was discarded during the survey;

2.) the corridor door to a soiled utility room on the 3rd floor was held open by a towel wedged between the door and frame - the towel was removed during the survey;

3.) the corridor door to storage room # 1B137 had a damaged strike plate and would not self-close and latch.

All doors to the exit corridors from hazardous areas must be self-closing in the event of an emergency and must not be held open unless by an approved device that is connected to the alarm system.

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 initial survey on April 30, 2013 with the VP/CFO, Maintenance Director, and other staff, it was observed between 9:00 am and 1:30 pm that:

1.) multiple exterior sprinkler heads above the loading dock were showing signs of significant corrosion - greenish discoloration on the metal parts;

2.) two sprinkler heads in the loading dock corridor near the kitchen appeared to be recessed too far into the ceiling; staff reported that these were spring loaded but they did not have cover plates; one head appeared to have traces of paint on the deflector;

3.) one recessed sprinkler head in the oxygen/medical gas storage room was missing its cover plate;

4.) all exterior fire department connections (FDC's) had no reflective signs indicating their locations.

These items could lead to improper operation of the sprinkler system in the event of an 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 maintaining proper signs at oxygen storage locations.

The findings include:

During the initial survey on April 30, 2013 with the VP/CFO, Maintenance Director, and other staff, it was observed between 9:00 am and 1:30 pm that in the operating suite, one utility room with oxygen and medical gas storage had no signs indicating "Caution - Oxygen Stored Within." Oxygen storage signs shall be conspicuously displayed on each door of a storage room and shall be readable from a distance of 5 feet.

This could result in staff, visitors, or firefighters not knowing where oxygen was in use and/or stored.

Based on observation of the physical environment, it was determined that the facility staff failed to insure that the generator had backup emergency lighting.

The findings include:

During the initial survey on April 30, 2013 with the VP/CFO, Maintenance Director, and other staff, it was observed between 9:00 am and 1:30 pm that one emergency generator, which was located inside a mechanical room in the power plant building, did not have battery operated backup emergency lighting in close proximity.

This could result in staff having difficulty operating the generator or failure of the generator during a power outage if the generator did not start or was not operating properly and there was no other form of lighting available.