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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. Section 18. 18.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the following corridor doors would not tightly close when tested.

1. OR six, door tested three of three times will not positively latch
2. Nourishment room door 1706 with a closing device wedged open with an impediment
3. Door 3338, will not positively latch, out of adjustment
4. Room 336, door 3314, tested three of three times, will not positively latch
5. Room 314, door tested three of three times, will not positively latch
6. Room 311, door tested three of three times, will not positively latch
7. First floor, door 1930 with a closing device, Nourishment, wedged open with an impediment
8. Room 256, door 2419 tested three of three times, will not positively latch

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

In time of a fire failing to protect residents from heat and smoke will cause harm to the
residents/patients.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 6, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke
barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.

(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the
smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

(b) It shall be protected by an approved device that is designed for the specific purpose.

(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the
following conditions:
(a) It shall be made on either side of the smoke barrier.

(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed, unsealed penetrations in the two smoke barriers, located on the second floor by the main elevators.

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

Smoke from a fire will involve other wings or possibly the whole facility if the smoke barriers provided are penetrated which will cause harm to residents/patients.

Based on observation the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.
( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the following smoke barrier doors, would not close all the way when tested.

1. Double smoke barrier doors by Room 325 tested three of three times, will not close tight and latch
2. Double smoke barrier doors by Room 3127 tested three of three times, will not close tight and latch

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

Failure to properly adjust or repair the smoke doors will cause harm to residents. Non closing smoke doors will allow smoke to enter smoke zones not directly effected by the fire.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 requires that hazardous areas be
separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the following hazardous area doors will not positively latch:

1. Equipment storage, OR, Room 1740, rated doors, one of two door leaves broken
2. Sterile storage, Room 1745, Two sets of double doors, held open by impediments, and tape
3. Housekeeping, Room 1736, No door closing device, room contain noxious chemicals and combustibles
4. Physician Dining Room, one of two doors to the corridor do not have a closing device, the heating of food with open flame was observed
5. Kitchen, trash room, 2605, no door closing device, room approximately 50 square feet, contents of the room, chemicals, bleach and other noxious chemicals
6. Gift shop, approximately 280 square feet, no door closing device, combustibles
7. Laboratory storage room, door with a closing device tied open
8. Laboratory 1351, no door closing device

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

The open door could allow heat and smoke to spread into the exit corridor which could cause harm to the patients.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.2.1 and Section 18.2.3.3 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed storage of, a shredder, two linen carts a wound cart, and a food cart within the exit corridor. The storage was blocking four of four exit access located in the ED department.

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on observation the facility failed to maintain the installed automatic sprinkler heads.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." . Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Installation of Sprinkler Systems, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Chapter 2, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation." NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the following sprinkler assemblies:

1. SPD, three of fourteen sprinklers lint
2. SPD, in back of the sterilizers, one of one sprinkler rust
3. Kitchen sprinklers, main and short order cook line, ten of thirty three sprinklers, lint to include one missing escutcheon plate

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Lint on the head or a leaking sprinkler head could slow that response or disable the sprinkler head. This will cause harm to patients by allowing the fire to grow to a size uncontrollable by the remaining sprinkler heads.

Based on observation and staff interview, the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18-3.2.6, "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the two kitchen exhaust system hood filters and grease drip tray areas have an excessive amount of grease buildup. Staff members stated the filters are cleaned one time a week.

1. Short order cook line, three of five filters grease build up and drip tray has not been emptied
2. Main cook line, five of sixteen filters grease build up

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on observation the facility failed to separate empty and full oxygen cylinders, failed to secure oxygen bottles, failed to provide a medical gas cylinder storage room free of combustible materials, and failed to locate outlets and switches 5 feet above the floor.

NFPA 101 Life Safety Code 2000, Chapter 18, Section "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care facilities, NFPA 99 Chapter 4 Section 4-3.5.2.2 (a)(2) " If stored within the same enclosure, empty and full cylinder shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly, Chapter 18, Section 18.3.2.4 " Section 4-3.5.2.1 (b) "Special Precautions - Oxygen Cylinders and Manifolds". (27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart." "Health Care Facilities", Chapter 4, Section 4-5.1.1.2 "Storage Requirements (Location, Construction, Arrangement.) Section 4-5.1.1.2 (b) 5 "Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials." Section 4-5.1.1.2 (b) 7 "Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen..." NFPA 99, "Health Care Facilities", Chapter 8, Section 8-3.1.11 "Storage Requirements, Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic, feet. " (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system...."Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic fee. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2(a) 11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. above the floor to avoid physical damage."

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the following oxygen storage areas:

1. OR 9, (Rattlers) door held open with an E-O2 bottle, (K18) bottle could be knocked over
2. Clean utility, 1703, 3 full E-O2, and 11 empty E-O2 surrounded by combustibles, light switch measured 44 inches
3. Room 3017, storage, 10 unsecured E-O2 bottles, 18 E-O2 bottles not marked FULL/EMPTY, next to combustibles and electrical outlets
4. Room 3247, 3 empty E O-2, 2 full E O-2 within 60 inches of electrical and combustibles
5. Rooms 3137 and 3138, total of both storage room 33 E-O2 bottles, empty and fulls not marked within 60 inches of electrical and combustibles
6. Equipment storage room 2442, 2 empty E O2 bottles, 4 full E-O2 bottles, not marked FULL/EMPTY, with in 60 inches of electrical and combustibles
7. Equipment storage room 2142, 6 E-O2 bottles next light switch not 60 inches off the floor
8. Point of Use room, door 1934, 8 E O2 bottles only marked empty, within 60 inches of combustibles
9. Room 1977, Storage, 11 E- O-2 bottles within 60 inches of electrical and combustibles

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area, Leaking oxygen will penetrate combustible material and create an extreme fire hazard, and receptacles and switches could be damaged by cylinders if less than five feet above the floor, which will cause harm to the patients and staff.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. Section 18. 18.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the following corridor doors would not tightly close when tested.

1. OR six, door tested three of three times will not positively latch
2. Nourishment room door 1706 with a closing device wedged open with an impediment
3. Door 3338, will not positively latch, out of adjustment
4. Room 336, door 3314, tested three of three times, will not positively latch
5. Room 314, door tested three of three times, will not positively latch
6. Room 311, door tested three of three times, will not positively latch
7. First floor, door 1930 with a closing device, Nourishment, wedged open with an impediment
8. Room 256, door 2419 tested three of three times, will not positively latch

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

In time of a fire failing to protect residents from heat and smoke will cause harm to the
residents/patients.

Based on observation the facility failed to fill penetrations in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 6, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke
barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.

(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the
smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

(b) It shall be protected by an approved device that is designed for the specific purpose.

(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the
following conditions:
(a) It shall be made on either side of the smoke barrier.

(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed, unsealed penetrations in the two smoke barriers, located on the second floor by the main elevators.

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

Smoke from a fire will involve other wings or possibly the whole facility if the smoke barriers provided are penetrated which will cause harm to residents/patients.

Based on observation the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.
( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the following smoke barrier doors, would not close all the way when tested.

1. Double smoke barrier doors by Room 325 tested three of three times, will not close tight and latch
2. Double smoke barrier doors by Room 3127 tested three of three times, will not close tight and latch

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

Failure to properly adjust or repair the smoke doors will cause harm to residents. Non closing smoke doors will allow smoke to enter smoke zones not directly effected by the fire.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 requires that hazardous areas be
separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the following hazardous area doors will not positively latch:

1. Equipment storage, OR, Room 1740, rated doors, one of two door leaves broken
2. Sterile storage, Room 1745, Two sets of double doors, held open by impediments, and tape
3. Housekeeping, Room 1736, No door closing device, room contain noxious chemicals and combustibles
4. Physician Dining Room, one of two doors to the corridor do not have a closing device, the heating of food with open flame was observed
5. Kitchen, trash room, 2605, no door closing device, room approximately 50 square feet, contents of the room, chemicals, bleach and other noxious chemicals
6. Gift shop, approximately 280 square feet, no door closing device, combustibles
7. Laboratory storage room, door with a closing device tied open
8. Laboratory 1351, no door closing device

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

The open door could allow heat and smoke to spread into the exit corridor which could cause harm to the patients.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.2.1 and Section 18.2.3.3 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed storage of, a shredder, two linen carts a wound cart, and a food cart within the exit corridor. The storage was blocking four of four exit access located in the ED department.

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on observation the facility failed to maintain the installed automatic sprinkler heads.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved supervised automatic sprinkler system in accordance with 9.7." . Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Installation of Sprinkler Systems, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Chapter 2, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation." NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the following sprinkler assemblies:

1. SPD, three of fourteen sprinklers lint
2. SPD, in back of the sterilizers, one of one sprinkler rust
3. Kitchen sprinklers, main and short order cook line, ten of thirty three sprinklers, lint to include one missing escutcheon plate

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Lint on the head or a leaking sprinkler head could slow that response or disable the sprinkler head. This will cause harm to patients by allowing the fire to grow to a size uncontrollable by the remaining sprinkler heads.

Based on observation and staff interview, the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18-3.2.6, "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the two kitchen exhaust system hood filters and grease drip tray areas have an excessive amount of grease buildup. Staff members stated the filters are cleaned one time a week.

1. Short order cook line, three of five filters grease build up and drip tray has not been emptied
2. Main cook line, five of sixteen filters grease build up

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a delay in the fire suppression system to activate which could cause more damage to the kitchen and could cause harm to the residents.

Based on observation the facility failed to separate empty and full oxygen cylinders, failed to secure oxygen bottles, failed to provide a medical gas cylinder storage room free of combustible materials, and failed to locate outlets and switches 5 feet above the floor.

NFPA 101 Life Safety Code 2000, Chapter 18, Section "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care facilities, NFPA 99 Chapter 4 Section 4-3.5.2.2 (a)(2) " If stored within the same enclosure, empty and full cylinder shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly, Chapter 18, Section 18.3.2.4 " Section 4-3.5.2.1 (b) "Special Precautions - Oxygen Cylinders and Manifolds". (27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart." "Health Care Facilities", Chapter 4, Section 4-5.1.1.2 "Storage Requirements (Location, Construction, Arrangement.) Section 4-5.1.1.2 (b) 5 "Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials." Section 4-5.1.1.2 (b) 7 "Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen..." NFPA 99, "Health Care Facilities", Chapter 8, Section 8-3.1.11 "Storage Requirements, Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic, feet. " (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system...."Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic fee. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2(a) 11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. above the floor to avoid physical damage."

Findings include:

On December 3rd and 4th, of 2013 the surveyor, accompanied by the Plant Operations Director, observed the following oxygen storage areas:

1. OR 9, (Rattlers) door held open with an E-O2 bottle, (K18) bottle could be knocked over
2. Clean utility, 1703, 3 full E-O2, and 11 empty E-O2 surrounded by combustibles, light switch measured 44 inches
3. Room 3017, storage, 10 unsecured E-O2 bottles, 18 E-O2 bottles not marked FULL/EMPTY, next to combustibles and electrical outlets
4. Room 3247, 3 empty E O-2, 2 full E O-2 within 60 inches of electrical and combustibles
5. Rooms 3137 and 3138, total of both storage room 33 E-O2 bottles, empty and fulls not marked within 60 inches of electrical and combustibles
6. Equipment storage room 2442, 2 empty E O2 bottles, 4 full E-O2 bottles, not marked FULL/EMPTY, with in 60 inches of electrical and combustibles
7. Equipment storage room 2142, 6 E-O2 bottles next light switch not 60 inches off the floor
8. Point of Use room, door 1934, 8 E O2 bottles only marked empty, within 60 inches of combustibles
9. Room 1977, Storage, 11 E- O-2 bottles within 60 inches of electrical and combustibles

During the exit conference on December 4, 2013, the above findings were again acknowledged by the, CEO, COO, and the Plant Operations Director.

In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area, Leaking oxygen will penetrate combustible material and create an extreme fire hazard, and receptacles and switches could be damaged by cylinders if less than five feet above the floor, which will cause harm to the patients and staff.