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Based on observation of the physical environment and interview with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not having hazardous area doors that are self-closing and positive latching in all hazardous areas.

The findings include:

1) At approximately 1230 hours during the initial survey on April 2, 2010 with the Maintenance Co-coordinator, it was observed and confirmed through interview that the corridor door to the "Liquid Oxygen (LOx) Storage Room" does not meet the requirements of this Code. The "Blast Door: is the only access/egress to this room, which stores a 3000 gallon Lox tank and 150 "H" cylinders of gaseous oxygen. This door lacks a self-closing device, positive latching feature, and proper means of egress hardware.

The lack of required hardware on hazardous area corridor doors has the potential to promote harm to occupants of the building and can allow smoke and other products of combustion to travel from one section of the facility to another in the event of a fire.

Based on observation and interviews with the facility staff, it was determined that the facility staff has failed to provide as safe an environment as possible by not installing a heat or smoke detector in all areas of the facility.

The findings include:

1) At approximately 1215 hours on April 2, 2010 during this survey, it was observed and confirmed through an interview with the Maintenance Co-coordinator that in the enclosed smoking room adjacent to the partially sprinklered "601 Building: on the Plaza Level there are no detection or initiating devices installed. This area is enclosed and is a common area open to the public. A heat detector integrated to the building fire alarm system is recommended as a practical remedy opposed to the single station battery operated smoke detector as described in the Code.

Failure to install and maintain smoke detection in this area has the potential to promote harm to residents of the facility in the event of a fire in this area.

Based on review of the facility's documents and interview with facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the sprinkler system in the manner required by this Code.

1) At approximately 1400 hours during the initial survey on March 31, 2010, it was observed and confirmed through interview with the Maintenance Co-coordinator that the sprinkler heads in the Kitchen are showing signs of corrosion.

The failure to maintain the automatic sprinkler system in a reliable manner could lead to improper operation of the sprinkler system in the event of a fire thereby promoting harm to occupants of the facility.

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 providing all items required by the Code.

The findings include:

At approximately 1215 hours during the initial survey on April 2, 2010 with the Maintenance Coordinator, it was observed and confirmed through interview that the Smoking Room on the Plaza Level of the "611 Building" had no metal containers with self-closing cover devices in which to empty ashes.

Failure to provide proper devices and procedures for the disposal of ashes and cigarette butts has the potential harm to occupants of the building.

At approximately 1210 hours on April 2, 2010 during the initial survey with the Maintenance Coordinator, it was observed and confirmed through interview with facility staff, that there was no remote generator annunciator panel at a location that is manned 24 hours per day, seven days per week, for the Caterpillar EES generator located in the basement of the "611 Building". This generator supplies emergency power to the "3 East (step down ventilator unit) and "2 North (Brain Injury unit) sections.

This could impact 100 percent of ventilator patients and could result in staff not knowing if there was trouble with the generator or if there was total failure of the generator to operate.