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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, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke... Section 19.3.6.4 "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Findings Include:

On August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observed the following corridor doors have vents installed.

1. OR/Environmental work room sterilizer, Vents in the door
2. Room 300, Bone density, Vents in the door
3. MIS, vents in the door

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.

The facility failed to protect patients from heat and smoke.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors 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 and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observed Room 220, Janitors closet has flammable and combustibles stored in the room, the door does not have a closing device

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.


Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "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..." 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 August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observations include the following findings:

1. Kitchen by the freezer, one of three sprinklers lint
2. Room 212, one of one sprinkler lint
3. Pre/Post op, beds A and C, sprinklers covered with paint

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.


Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could 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 mount an electrical light switch five feet above the floor in the oxygen storage room, failed to secure medical gas cylinders, and failed to separate empty and full medical gas cylinders.

NFPA 101 Life Safety Code, 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 for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.
NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."
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 August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observed medical gas stored in the following locations:

1. O2 storage by room 140 A, No empty /full signs, light switch lower than sixty inches
2. Room 408, two EO2 bottles stored within five feet of combustibles
3. Room 127, equipment storage, one EO2 bottle laying on the floor unsecured

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.

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

Based on observation the facility does not have a emergency eye shower.

NFPA 99, Health Care Facilities, Chapter 10, Section 10-6* "Emergency Shower." "Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching of flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths shall be designed and installed to avoid injurious water pressure.

Findings include:

On August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observed the Lab does not have an installed eye wash station.

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.

Failing to provide an emergency shower with in the worked place will cause harm to Staff, if a spill should occur.

Based on observation the facility failed to provide a guards on the lights, and allowed the use of a multiple outlet adapter/extension cord.

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 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage
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.

Findings Include:

On August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observed unprotected lights, and extension cords in the following locations:

1. Room 126, refrigerator and microwave plugged into a four way adapter and an extension cord
2. Basement central supply, ten light units no covers

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients and the use of multiple outlet adapters/extension cord will create an overload of the electrical system and will cause a fire or an electrical hazard. A fire will 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, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke... Section 19.3.6.4 "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Findings Include:

On August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observed the following corridor doors have vents installed.

1. OR/Environmental work room sterilizer, Vents in the door
2. Room 300, Bone density, Vents in the door
3. MIS, vents in the door

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.

The facility failed to protect patients from heat and smoke.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors 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 and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observed Room 220, Janitors closet has flammable and combustibles stored in the room, the door does not have a closing device

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.


Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "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..." 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 August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observations include the following findings:

1. Kitchen by the freezer, one of three sprinklers lint
2. Room 212, one of one sprinkler lint
3. Pre/Post op, beds A and C, sprinklers covered with paint

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.


Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could 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 mount an electrical light switch five feet above the floor in the oxygen storage room, failed to secure medical gas cylinders, and failed to separate empty and full medical gas cylinders.

NFPA 101 Life Safety Code, 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 for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.
NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."
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 August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observed medical gas stored in the following locations:

1. O2 storage by room 140 A, No empty /full signs, light switch lower than sixty inches
2. Room 408, two EO2 bottles stored within five feet of combustibles
3. Room 127, equipment storage, one EO2 bottle laying on the floor unsecured

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.

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

Based on observation the facility does not have a emergency eye shower.

NFPA 99, Health Care Facilities, Chapter 10, Section 10-6* "Emergency Shower." "Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching of flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths shall be designed and installed to avoid injurious water pressure.

Findings include:

On August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observed the Lab does not have an installed eye wash station.

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.

Failing to provide an emergency shower with in the worked place will cause harm to Staff, if a spill should occur.

Based on observation the facility failed to provide a guards on the lights, and allowed the use of a multiple outlet adapter/extension cord.

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 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage
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.

Findings Include:

On August 28, 2013, the surveyor, accompanied by the Director and Manager of Environmental Services, observed unprotected lights, and extension cords in the following locations:

1. Room 126, refrigerator and microwave plugged into a four way adapter and an extension cord
2. Basement central supply, ten light units no covers

During the exit conference on August 28, 2013, the above findings were again acknowledged by the CEO, Director and Manager of Environmental Services.

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients and the use of multiple outlet adapters/extension cord will create an overload of the electrical system and will cause a fire or an electrical hazard. A fire will cause harm to the patients.