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Observations, and staff interview revealed that there is 1 of several fire barriers located throughout the facility that did not meet the rated requirements for fire separations and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 1:00 PM and 6:30 PM on 09/02/2014, observation revealed that the double doors in 4-hour fire rated building separation between the 1955 building and the 1973 building did not fully close and latch in the frame.


This deficient practices was confirmed by the Director of Engineering (RA).

Based on observations and staff interview, the facility has failed to provide proper protection from multiple hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practice could negatively affect the residents, staff, and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 1:00 PM and 6:30 PM on 09/02/2014, observation revealed that the storage room by the ER Clinical Director's office that is greater than 50 square feet was not equipped with a self closing device and it also had a 1 inch diameter hole from a prior lock set that was removed.

This deficient practices was confirmed by the Director of Engineering (RA).

Based on observations and staff interview, the facility has failed to maintain their medical gases and delivery systems in compliance with NFPA 99 Health Care Facilities (99), Chapter 4. The following deficient practice could negatively affect the patients.

Findings include:

On facility tour between 1:00 PM and 6:30 PM on 09/02/2014, observation revealed that in the compressed medical gas storage room, the main oxygen service line master alarm connection above the nitrous oxide manifold is capped with a galvanized steel threaded fitting. All connections to the medical gas systems shall be brazed and this condition can cause galvanic corrosion.


This deficient practices was confirmed by the Director of Engineering (RA).

Observations, and staff interview revealed that there is 1 of several fire barriers located throughout the facility that did not meet the rated requirements for fire separations and are not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 1:00 PM and 6:30 PM on 09/02/2014, observation revealed that the double doors in 4-hour fire rated building separation between the 1955 building and the 1973 building did not fully close and latch in the frame.


This deficient practices was confirmed by the Director of Engineering (RA).

Based on observations and staff interview, the facility has failed to provide proper protection from multiple hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practice could negatively affect the residents, staff, and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 1:00 PM and 6:30 PM on 09/02/2014, observation revealed that the storage room by the ER Clinical Director's office that is greater than 50 square feet was not equipped with a self closing device and it also had a 1 inch diameter hole from a prior lock set that was removed.

This deficient practices was confirmed by the Director of Engineering (RA).

Based on observations and staff interview, the facility has failed to maintain their medical gases and delivery systems in compliance with NFPA 99 Health Care Facilities (99), Chapter 4. The following deficient practice could negatively affect the patients.

Findings include:

On facility tour between 1:00 PM and 6:30 PM on 09/02/2014, observation revealed that in the compressed medical gas storage room, the main oxygen service line master alarm connection above the nitrous oxide manifold is capped with a galvanized steel threaded fitting. All connections to the medical gas systems shall be brazed and this condition can cause galvanic corrosion.


This deficient practices was confirmed by the Director of Engineering (RA).