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The facility failed to maintain the smoke/fire resistive rating of certain corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

On July 28, 2010, the surveyors, accompanied by Maintenance personnel, observed there were penetrations in the corridor walls located by the Chief Nursing office and Temporary nurses station across from the Chief Nursing office.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat could cause harm to the patients.

The facility failed to fill penetrations in the smoke barrier.

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.


On July 28, 2010, the surveyors, accompanied by Maintenance personal, observed unsealed penetrations in the smoke barrier, located at the Cardio hallway smoke barrier doors leading to the main lobby.

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 patients.



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 patients.

The facility failed to provide a self-closing or an automatic-closing door in a hazardous area.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.1, "Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

On July 28, 2010, the surveyors accompanied by the Maintenance personal, inspected the Emergency Room storage room which measured approximately 16' x 6'. The door to the storage room was missing it's self-closing device.

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to residents in time of a fire.

The facility failed to provide a safe means of egress from an exit to a public way.


NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1
" Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 18.2.7 or 19.2.7 "Discharge from exits shall be arranged in accordance with Section 7.7." Section 7.7.1 "Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way."

On July 28, 2010, the surveyors, accompanied by Maintenance personal, observed the exit egress from Physical Therapy by rooms one and eight were partially blocked by parallel bars and physical therapy stairs. These items were obstructing the exit access and reducing the corridor width.

Failure to provide a clear and unimpeded means of egress could cause harm to the patients.

The facility failed to document the Monthly and Annual testing of battery back up emergency lighting.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

On July 28, 2010, the surveyors accompanied by Maintenance personal, tested all emergency lighting units located in the business office. All of the lighting units were functional, but no documentation of Monthly 30 second test or Annual 90 minute testing were provided to the surveyors.

Failing to test and maintain emergency lighting units could cause harm to the patients.

The facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions."

On July 28, 2010, the surveyors, accompanied by Maintenance personel, reviewed the facility's fire drill records. The surveyor noted there were no reports for the second shift of the third quarter in 2009 as well as the second shift of the second quarter in 2010.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

The facility failed to assure that all sprinkler head deflectors were installed parallel to the ceiling or roof.

NFPA 101 Life Safety Code, 2000, 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 Section 9.7." ." Chapter 9, 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 5, Section 5-8.4.2, "Deflector Orientation. Deflectors of sprinklers shall be aligned parallel to ceilings or roofs."

On July 28, 2010, the surveyors, accompanied by the Maintenance personal, observed the sidewall sprinkler head located in the skylight in the Physical Therapy corridor by room one and eight. The sidewall sprinkler head deflector was installed upside down parallel to the floor.

Failure to ensure sprinklers are installed where the deflector is parallel to the ceiling or roof could allow the sprinkler head to not operate as it is intended and not extinguish the fire which could cause harm to patients.


The facility failed to maintain the sprinkler heads.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..."

On July 28, 2010, the surveyors, accompanied by the Maintenance personal, observed the sprinkler heads in the following locations appeared to have a coating of grease, paint and or lint.

1. Main Kitchen by dishwasher area and by freezer.
2. Canopy outside of employee break room entrance exit door.
3. X-ray room 1, X-ray reading room and X-ray bath.
4. Activity room.
5. ER storage room.
6. Special procedures room.
7. Room 110 bath.
8. Courtyard canopy area adjacent to foyer for Information Services.
9. Wellness exercise room.
10. Lobby corridor by Hospital Clinic suite B.
11. Doctors sleeping quarters bath.

Failing to maintain sprinkler heads and keep the fusible link clean will allow a fire to burn longer before the sprinkler head will activate. This could cause harm to the patients.


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."

On July 28, 2010, the surveyors, accompanied by the Maintenance personal, observed the Podiatrist office had an Escutcheon plate missing from the sprinkler assembly.

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.


The facility failed to maintain the sprinkler heads from obstructions.

NFPA 101 Life Safety Code, 2000, 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 Section 9.7." ." Chapter 9, 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 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard."

On July 28, 2010, the surveyors, accompanied by the Maintenance personal, observed three sprinkler heads located in the Laboratory/ Blood Draw Processing room to be located within one inch of the oblong horizontal light fixture. The bottom of the light fixture was approximately two inches in depth lower than the pendent sprinkler head.

Installing obstructions next to the sprinkler head may prevent it from providing adequate coverage of the hazard. This may cause harm to the patients.


The facility failed to maintain the proper area of coverage.

NFPA 101 Life Safety Code, 2000, 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 Section 9.7." ." Chapter 9, 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 5, Section 5-11.3.2, "Maximum Distance from Walls. The distance from sprinklers to walls shall not exceed one-half of the allowable distance permitted between sprinklers as indicated in Table 5-11.2.2."

On July 28, 2010, the surveyors, accompanied by the Maintenance personal, observed the Quality Assurance office located in the Emergency Room had the sprinkler head approximately fourteen feet from a wall.

Failing to maintain proper sprinkler head placement could allow a fire to burn longer and potentially overtake the sprinkler system. This could cause harm to the patients.

The facility failed to identify panel board circuits.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1."Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code.... " NEC, 1999, Article 384, Section 384-13 General "All panel board circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors."

On July 28, 2010, the surveyors, accompanied by the Maintenance personal, observed the electrical panels in the Activities storage room marked P-1, in Radiology and electrical room breakers were not marked.

Failing to identified electrical circuits in an emergency could cause a fire or electrical shock, which may cause harm to patients.


The facility allowed the use of a multiple outlet adapter/extension cord.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

On July 28, 2010, the surveyors, accompanied by the Maintenance personal, observed the use of a multiple outlet adapter plugged into another multiple outlet adapter at the reception desk of Physical Therapy. The surveyors also found an extension cord in use in the Emergency Room nurses station.

The use of multiple outlet adapters/extension cord could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.