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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 sealing holes and gaps in ceilings and/or walls or by not ensuring that ceilings have full integrity and/or proper flame spread ratings.

The findings include:

During the initial survey on February 19, 2013 with the Director of Facilities, it was observed between 9:00 am and 12:00 noon that there were missing and/or partially installed ceiling tiles in the secondary kitchen.

These penetrations and/or deficient ceiling tiles could have the possibility of affecting 25% of the occupants of the facility and could allow smoke or flames to travel above the ceiling or from one section of the building to another 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 the sprinkler system in a reliable operating condition.

The findings include:

During the initial survey on February 19, 2013 with the Director of Facilities, it was observed between 9:00 am and 12:00 noon that:

1.) Escutcheon plates were either missing or falling off in the following locations: room #2327; 2nd floor room #3; the 1st floor corridor;

2.) A concealed sprinkler head cover plate was missing in the corridor of building #14907;

3.) Several sprinkler heads in at least two stairwells appeared to have been partially painted;

4.) Closet #2103 had towels stored on the top shelf too close to the sprinkler head.

These items could lead to improper operation of the sprinkler system in the event of an emergency and could effect up to 50% of the facility's patients and staff.

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 ensuring that all means of egress (corridors leading to exit doors) remain free of obstructions and impediments to full and instant use in case of a fire, smoke conditions, low/ light conditions, or other emergencies.

The findings include:

During the initial survey on February 19, 2013 with the Director of Facilities, it was observed between 9:00 am and 12:00 noon that the service corridor that leads to the loading dock and the exit door by the main kitchen in building #14901 was obstructed by five covered linen carts, food service carts, and new food deliveries - the exit door itself was obstructed by a large food cart.

This could effect or delay staff who would use this exit in case of an emergency and could impede the entry of firefighters in the event of a fire or other type of 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 medical gas storage areas in accordance with NFPA 99.

The findings include:

During the initial survey on February 19, 2013 with the Director of Facilities, it was observed between 9:00 am and 12:00 noon that one "E" size oxygen tank was found on the floor unprotected from falling in the Shenandoah Wing nurse's station.

Unsecured oxygen tanks could lead to damage or personal injury in the event that one or more would fall.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by failing to address the following miscellaneous safety issue:

The findings include:

During the initial survey on February 19, 2013 with the Director of Facilities, it was observed between 9:00 am and 12:00 noon that there was an acetylene torch set (compressed oxygen and acetylene tanks) located in the main mechanical room - it was not in use.

Failure to remove pressurized vessels of extremely flammable gases from the interior of the facility creates a potentially hazardous condition to staff and patients.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by having locations where there were non-compliant electrical applications.

The findings include:

During the initial survey on February 19, 2013 with the Director of Facilities, it was observed between 9:00 am and 12:00 noon that:

1.) electrical panel #11176 had two open circuit breaker slots with no protective covers;

2.) electrical outlets in the small laundry, #1623, had no ground fault circuit interrupter (GFCI) protection - this is a wet location;

3.) small laundry rooms in Indigo and Chesapeake Units also did not have GFCI outlets - it could not be determined if the breakers for these laundry rooms were GFCI protected - all were wet locations;

4.) the secondary kitchen in building #14907 had the power supply for the commercial dish washing machine provided by a heavy duty extension cord and was not wired directly to a junction box;

5.) the main kitchen in building #14901 had the power supply for a booster heater to the dish machine unmounted and lying on the floor with the potential for becoming wet;

6.) there was a damaged electrical outlet with no cover plate located below the cereal shelf in the food assembly area of the main kitchen.

These items could cause overheating, electrical short circuits resulting in fire, or shock hazards. NFPA 70, National Electrical Code states that: 1.) extension cords shall not be used as a substitute for permanent wiring. 11.1.5; 2.) extension cords and flexible cords shall not be affixed to structures, extend through walls, ceilings or floors, or be subject to environmental or physical damage. 11.1.5.3.5. 3.) multi-plug adapters, such as multi-plug extension cords, cube adapters, strip plugs, and other devices, shall be listed and used in accordance with their listing.