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The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically, as required by section # 19.7.6 of the referenced " Life Safety Code ".


1. On 09/09/14 at 9:00 AM, the surveyor while accompanied by the Supervisor I observed that the sprinkler heads located within the alcoves near the electrical service panels at the " C & D Upper " Nursing Units were not free of foreign materials and not replaced, as required by section # 2-2.1.1 of NFPA 25, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems " ;i.e: sprinkler heads have paint affixed to their heat-links;


2. On 09/09/14 at 9:30 AM, the surveyor while accompanied by the Supervisor I observed that the sprinkler head located within the Janitor ' s Closet at the " C Upper " Nursing Unit was not free of foreign materials , as required by section # 2-2.1.1 of NFPA 25, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems " ;i.e: sprinkler head has a plastic heat-link protector that was never removed ;


3. On 09/09/14 at 10:00 AM, the surveyor while accompanied by the Supervisor I observed that the sprinkler head located within the storage closet in the Chapel was not installed at/near the ceiling, as required by section# 5-1.1 of NFPA 13, " Standard for the Installation of Sprinkler Systems " ;i.e: fire sprinkler head is installed in excess of three (3) feet below the deck above;

The facility did not ensure that flammable and combustible liquids are used from and stored in approved containers in accordance with NFPA 30, "Flammable and Combustible Liquids Code " and NFPA 45, " Standard on Fire Protection for Laboratories Using Chemicals ".


On 09/09/14 at 11:30 AM, the surveyor while accompanied by the Supervisor I observed that the facility Laboratory was not provided with a storage cabinet for flammable and combustible liquids that complies with section # 4-3 of NFPA 30, "Flammable and Combustible Liquids Code ", as required by section # 10-7.2 of NFPA 99, " Health Care Facility ' s " ; i.e. staff is storing flammable and combustible liquids in vanity under a sink.

The facility did not ensure that transferring and storage of oxygen is in compliance with the requirements of NFPA 99, " Health Care Facility ' s ".


On 09/09/14 at 2:00 PM, the surveyor while accompanied by the Supervisor I observed that the walls, floors, ceilings, roofs, doors, interior finish, shelves, racks and supports in both the Liquid Oxygen Storage and Trans filling Rooms located on the lower level of the facility (rooms A111 & A143) were not constructed of non-combustible or limited combustible materials , as required by section # 4-3.1.1.2 (11)(a) of NFPA 99, " Health Care Facility ' s " i.e. vinyl, base molding not removed from walls;