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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 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19.19.3.6.3.1"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 19.19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 02, 2012 the surveyors, accompanied by the Director of Patient Safety, Facilities Maintenance, Director of Facilities Management and Plant Operations Supervisor observed the following corridor doors would not tightly close when tested three of three times.
1. Copy room by room 201 2nd floor Tower A
2. Resource Coordinators office was held open with a file cabinet (impediment)
3. Room B 367 and Med Room in B Tower
4. Soiled Utility by room 191 in the Heart Center
5. Peds 2nd floor soiled utility across from room 209
6. B Tower soiled utility

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

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

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "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 8, 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 May 02, 2012 the surveyor, accompanied by the Director of Patient Safety and Facilities Maintenance observed unsealed penetrations in the smoke barriers located by;

1. B Tower by B-265 and B-387
2. Tower A 2nd and 4th floors by the Clinical Nurse Offices

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients.

Based on observation the facility failed to maintain self closing doors in smoke barriers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles. Section A.8.3.4.1 The clearance for proper operation of smoke doors is defined as 1/8 inch.

Findings include:

On May 02, 2012 the surveyor, accompanied by the Director of Patient Services and Facilities Maintenance observed the smoke barrier doors when closed there was an approximate 1/4 inch gap between the doors in the following locations:

1. Tower A 4th floor by storage room -2
2. Tower A by the Clinical Nurses Office
3. Tower B by B-253

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation the facility failed to maintain the smoke resistance, of walls, ceilings or pipe chases in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19,. Section 19.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls, doors, and ceilings must be able to resist the passage of smoke.

Findings include:

On May 02, 2012 the surveyor, accompanied by the Director of Patient Safety, Facilities Maintenance, Director of Facilities Management and Plant Operations Supervisor observed unsealed pipe chase holes, holes in walls or ceilings in the following rooms:

1. Main Electrical room in SES-1
2. Heart Center IDF and storage room
3. Electrical room 050980 in the Heart Center
4. B Tower Air Handler room
5. Tower B ground floor IDF electrical room

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors 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 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "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 May 02, 2012 the surveyors, accompanied by the Director of Patient Safety, Facilities Maintenance, Director of Facilities Management and Plant Operations Supervisor observed storage of beds/gurney's, medical or computer equipment, printers, chairs, P.T. scale, water coolers, garbage cans, within the exit corridors blocking the exit access and reducing the eight foot corridors located in the following areas of the hospital.

1. Emergency Department
2. Peds 2nd floor by the reception desk.
3. Tower A by A-203 and A-234
4. B Tower by rooms B-252 and between rooms B-242 through B-283

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

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

Based on observation the facility failed to keep automatic sprinkler heads free of lint, grease or paint.

NFPA 101, Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.5.1, "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, Standard for the installation of Sprinkler Systems." NFPA 13, Chapter 12, Section 12-1 "General" "A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25....NFPA 25, Chapter 2, Section 2-2.1 "Sprinklers" 2-2.1.1. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g.,upright, pendant, or sidewall).

Findings Include:

On May 02, 2012 the surveyor, accompanied by the Director of Patient Safety, Facilities Maintenance observed the following locations had either paint, lint or grease on the sprinklers.

1. Tower A 2nd floor by room A 203 near the nurse station, one of one sprinklers, lint
2. Tower B room B-367, two of two sprinklers, paint
3. Main kitchen short order line two of two sprinklers in the ceiling, grease/lint
4. A-222 through A-227 one of three sprinklers lint, A-236 three of three sprinklers lint

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Grease and lint on the head could slow that response or disable the sprinkler head. This could cause harm to the patients and staff.

Based on observation the facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 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, Standard for the Installation of Sprinkler Systems. 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 May 02, 2012 the surveyor, accompanied by the Director of Patient Safety and Facilities Maintenance observed sprinklers heads in the following locations were missing escutcheon plates from the sprinkler assembly.

1. Nurse office at Pre-Admission
2. Gift shop office 1st floor

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

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

NFPA 101 Life Safety Code 2000,Chapter 19, Section 19.3.2.6 "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 May 02, 2012 the surveyor, accompanied by the Director of Patient Safety and Facilities Maintenance observed the kitchen exhaust system hood, filters and grease drip tray in the main kitchen and short order line had an excessive amount of grease buildup, grease, oil was dripping from the filters.

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a fire, which could cause damage to the kitchen and could cause harm to the patients.

Based on Observation the facility failed to separate empty and full medical gas cylinders.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "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 cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings include:

On May 02, 2012 the surveyor, accompanied by the Director of Facilities Management and Plant Operations Supervisor observed the main oxygen storage room on the loading dock. Three empty E type cylinders were mixed together with two full cylinders and not segregated from each other. A sign was posted for the storage rack marked empty cylinders. In addition, two compressed Nitrous Oxide cylinders were unsecured and not in a rack or chained.

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on Observation the facility failed to provide a medical gas cylinders free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, "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..."

Findings include:

On May 02, 2012 the surveyors, accompanied by the Director of Patient Safety, Facilities Maintenance, Director of Facilities Management and Plant Operations Supervisor observed the Heart Recovery unit. The surveyor observed twelve E type oxygen cylinders in a rack next to patient beds stored next to a bedside table and several chairs. In addition, eleven
E type oxygen cylinders in the B Tower oxygen storage room next to room B-367 were being stored next to combustibles i.e. boxes and plastics.

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.

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

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19.19.3.6.3.1"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 19.19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 02, 2012 the surveyors, accompanied by the Director of Patient Safety, Facilities Maintenance, Director of Facilities Management and Plant Operations Supervisor observed the following corridor doors would not tightly close when tested three of three times.
1. Copy room by room 201 2nd floor Tower A
2. Resource Coordinators office was held open with a file cabinet (impediment)
3. Room B 367 and Med Room in B Tower
4. Soiled Utility by room 191 in the Heart Center
5. Peds 2nd floor soiled utility across from room 209
6. B Tower soiled utility

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

In time of a fire, failing to protect patients from heat and smoke could cause harm to the patients.

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

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "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 8, 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 May 02, 2012 the surveyor, accompanied by the Director of Patient Safety and Facilities Maintenance observed unsealed penetrations in the smoke barriers located by;

1. B Tower by B-265 and B-387
2. Tower A 2nd and 4th floors by the Clinical Nurse Offices

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which could cause harm to the patients.

Based on observation the facility failed to maintain self closing doors in smoke barriers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles. Section A.8.3.4.1 The clearance for proper operation of smoke doors is defined as 1/8 inch.

Findings include:

On May 02, 2012 the surveyor, accompanied by the Director of Patient Services and Facilities Maintenance observed the smoke barrier doors when closed there was an approximate 1/4 inch gap between the doors in the following locations:

1. Tower A 4th floor by storage room -2
2. Tower A by the Clinical Nurses Office
3. Tower B by B-253

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation the facility failed to maintain the smoke resistance, of walls, ceilings or pipe chases in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19,. Section 19.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls, doors, and ceilings must be able to resist the passage of smoke.

Findings include:

On May 02, 2012 the surveyor, accompanied by the Director of Patient Safety, Facilities Maintenance, Director of Facilities Management and Plant Operations Supervisor observed unsealed pipe chase holes, holes in walls or ceilings in the following rooms:

1. Main Electrical room in SES-1
2. Heart Center IDF and storage room
3. Electrical room 050980 in the Heart Center
4. B Tower Air Handler room
5. Tower B ground floor IDF electrical room

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors 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 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "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 May 02, 2012 the surveyors, accompanied by the Director of Patient Safety, Facilities Maintenance, Director of Facilities Management and Plant Operations Supervisor observed storage of beds/gurney's, medical or computer equipment, printers, chairs, P.T. scale, water coolers, garbage cans, within the exit corridors blocking the exit access and reducing the eight foot corridors located in the following areas of the hospital.

1. Emergency Department
2. Peds 2nd floor by the reception desk.
3. Tower A by A-203 and A-234
4. B Tower by rooms B-252 and between rooms B-242 through B-283

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

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

Based on observation the facility failed to keep automatic sprinkler heads free of lint, grease or paint.

NFPA 101, Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.5.1, "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, Standard for the installation of Sprinkler Systems." NFPA 13, Chapter 12, Section 12-1 "General" "A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25....NFPA 25, Chapter 2, Section 2-2.1 "Sprinklers" 2-2.1.1. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g.,upright, pendant, or sidewall).

Findings Include:

On May 02, 2012 the surveyor, accompanied by the Director of Patient Safety, Facilities Maintenance observed the following locations had either paint, lint or grease on the sprinklers.

1. Tower A 2nd floor by room A 203 near the nurse station, one of one sprinklers, lint
2. Tower B room B-367, two of two sprinklers, paint
3. Main kitchen short order line two of two sprinklers in the ceiling, grease/lint
4. A-222 through A-227 one of three sprinklers lint, A-236 three of three sprinklers lint

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are U.L. listed to respond to a calculated ceiling temperature. Grease and lint on the head could slow that response or disable the sprinkler head. This could cause harm to the patients and staff.

Based on observation the facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 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, Standard for the Installation of Sprinkler Systems. 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 May 02, 2012 the surveyor, accompanied by the Director of Patient Safety and Facilities Maintenance observed sprinklers heads in the following locations were missing escutcheon plates from the sprinkler assembly.

1. Nurse office at Pre-Admission
2. Gift shop office 1st floor

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

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

NFPA 101 Life Safety Code 2000,Chapter 19, Section 19.3.2.6 "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 May 02, 2012 the surveyor, accompanied by the Director of Patient Safety and Facilities Maintenance observed the kitchen exhaust system hood, filters and grease drip tray in the main kitchen and short order line had an excessive amount of grease buildup, grease, oil was dripping from the filters.

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a fire, which could cause damage to the kitchen and could cause harm to the patients.

Based on Observation the facility failed to separate empty and full medical gas cylinders.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "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 cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings include:

On May 02, 2012 the surveyor, accompanied by the Director of Facilities Management and Plant Operations Supervisor observed the main oxygen storage room on the loading dock. Three empty E type cylinders were mixed together with two full cylinders and not segregated from each other. A sign was posted for the storage rack marked empty cylinders. In addition, two compressed Nitrous Oxide cylinders were unsecured and not in a rack or chained.

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on Observation the facility failed to provide a medical gas cylinders free of combustible materials.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, Chapter 8, "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..."

Findings include:

On May 02, 2012 the surveyors, accompanied by the Director of Patient Safety, Facilities Maintenance, Director of Facilities Management and Plant Operations Supervisor observed the Heart Recovery unit. The surveyor observed twelve E type oxygen cylinders in a rack next to patient beds stored next to a bedside table and several chairs. In addition, eleven
E type oxygen cylinders in the B Tower oxygen storage room next to room B-367 were being stored next to combustibles i.e. boxes and plastics.

During the exit conference on May 02, 2012 the above findings were again acknowledged by the Chief Financial Officer, Corporate Compliance Officer, Director of Patient Safety and Director of Facilities Management.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.