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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 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 19. 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On October 19, 2011 the surveyors, accompanied by the Plant Director, and Chief Financial Officer observed the following corridor doors were not smoke resistant. The doors had a missing smoke seal on one side of the double doors which left a gap of approximately 1/4 to 1/2 inch between the double doors when closed or the doors did not positively latch when tested there of three times or had an impediment mounted on the door in the following locations:

1. Double doors two sets 20 minute rated leading from surgery to the sterile corridor, gaps
2. Storage room /data room double doors 20 minute rated doors, gaps
3. ICU double doors, gaps
4. Operating rooms one and two, gaps
5. Main kitchen corridor door did not positively latch and the door to the dining room from the main kitchen had an impediment in the door.

During the exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Plant Director, Chief Financial Officer and Chief Nursing Officer.

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 maintain the self closing/automatic-closing doors in the smoke barriers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4.1*" Doors in smoke barriers shall close the opening leaving only minimum clearance necessary for proper operation and shall be without undercuts, lovers, or grills." Section A 8.3.4.1 The clearance of proper operation of smoke doors is defined as 1/8 inch.

Findings include:

On October 19, 2011 the surveyors, accompanied by the Plant Director and Chief Financial Officer observed the following 1 1/12 hour rated smoke barrier doors when measured by the staff had a gap between the double doors when closed of approximately one half inch when measured in the following locations:

1. Smoke Barriers doors between emergency room and main hallway
2. Smoke barrier doors leading to the new surgery suite
3. In addition the corridor wall adjacent to the smoke barrier by the emergency room had a one foot circular hole in the wall and was not smoke resistant.

During the exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Director of Plant Operations and Chief Financial Officer and Chief Nursing Officer.

Failure to properly adjust or repair the smoke doors could cause harm to the residents. Non closing smoke doors could allow smoke to enter 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 October 19, 2011 the surveyors, accompanied by the Plant Director and Chief Financial Officer observed unsealed pipe chase holes, holes in walls or ceilings in the following locations in the facility.

1. Main Mechanical room
2. Housekeeping storage room for Med Surge
3. IT/Mechanical room

During the exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Director of Plant Operations and Chief Financial Officer and Chief Nursing Officer.

Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.

Based on observation the facility failed to provide a self-closing or an automatic-closing devices 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.

Findings Include:

On October 19, 2011 the surveyors accompanied by the Plant Director and Chief financial Officer observed the following doors had the self-closing devices either removed from the doors or the storage rooms were over 50 square feet and did not have a self closing device on the doors.

1. Medical records Storage room was measured to be over 50 square feet the door closure was removed from the door.
2. Main Lab, the door closure was removed from one door a second door to the lab did not positively latch when tested three of three times.
3. Housekeeping Office and storage room with cleaning supplies measured to be over 50 square feet the door to the room was not self closing.

During the exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Plant Director, Chief Financial Officer and Chief Nursing Officer.

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

Based on observation the facility failed to assure that exits from the building were each illuminated by more than a single light source two single bulbs or light fixtures.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.2.8 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, Section 7.8.1.4 "Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 Lux) in any designated area."

Findings Include:

On October 19, 2011 the surveyors, accompanied by the Plant Director and Chief Financial Officer observed served the following exits were not illuminated by more than two light fixtures or two single light bulbs fixtures at the exit discharge.

1. ICU
2. MRI West exit
3. 40 Wing exit

During the exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Plant Director, Chief Financial Offer and Chief Nursing Officer.

In an emergency during exiting out of the building by not installing two bulbs or two light fixtures could result in harm to the patients.

Based on Record review the facility failed to sound the fire alarm and 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."

Findings include:

On October 19, 2011 the surveyors, accompanied by the Chief Financial Officer and Plant Director, reviewed the facilities fire drill records. The surveyor noted the documentation did not indicate the fire alarm was sounded/activated on the fire drills and some fire drills were noted as false alarms.

Fire alarm not indicated on the facility fire drill form as activated during the fire drills for the following:

1. April 28, 2011 1st shift
2. May 23, 2011 2nd shift

The following fire drills were false alarms as indicated on the facility fire drill form for the following:

1. October 15, 2010 2nd shift
2. November 18, 2010 3rd shift
3. December 08, 2010 1st shift

During the survey and exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Plant Director , Chief Financial Officer and Chief Nursing Officer.

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

Based on observation the facility failed to keep automatic sprinkler heads free of lint, corrosion and 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 October 19, 2011 the surveyors accompanied by the Plant Director, Chief Operating Officer, Administrator and kitchen manager observed the sprinkler heads in the main kitchen. The sprinkler heads in the cooking area and freezers were corroded apparent by the green color on the sprinkler frame and assembly.

On October 19, 2011 the surveyor accompanied by either the Plant Director or Chief Financial Officer observed corroded, painted or lint on the sprinklers heads in the following locations:

1. Cafeteria lint on three sprinklers.
2. Radiology and Cardiopulmonary paint on one or two sprinklers.
3. Old Lobby two corroded sprinklers.

During the exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Plant Director, Chief Financial officer and Chief Nursing Officer.

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. Malfunctioning or delay of the sprinklers to activate could result in harm to the patients and staff.

Based on observation the facility failed to mount a fire extinguishers below the maximum height.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6, "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. Section 9.7.4.1, "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers." NFPA 10,Chapter 1,Section 1-6.10. "Fire extinguishers having a gross weight not exceeding 40 lbs. shall be installed so that the top of the fire extinguisher is not more than 5 ft. above the floor. Fire extinguishers having a gross weight greater that 40 lbs. shall be so installed that the top of the fire extinguisher is not more than 3 ½ ft. above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inches."

Findings Include:

On October 19, 2011 the surveyors, accompanied by the Plant Director and Chief Financial Officer observed the wall mounted ABC fire extinguishers in the following locations were mounted above five feet when measured by the maintenance staff. The top of the fire extinguishers were 62 inches and above from the the floor in the following locations.

1. Medical Records
2. Main Pharmacy

During the exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Plant Director, Chief Financial Officer ,and Chief Nursing Officer.

Failing to mount a fire extinguisher at the correct height could cause injuries if needed in an emergency and could cause harm to the staff and patients.

Based on Observation the facility failed to provide a medical gas cylinder storage room free of combustible materials and post empty and full signs.

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, Section 8-3.1.11 "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 October 19, 2011 the surveyors, accompanied by the Plant Director or Chief Financial Officer observed the following locations in the facility had oxygen storage rooms with storage of plastics, medical supplies, cardboard boxes, etc: stored within 5 feet of combustibles or were missing the empty and full signs or the doors were not self closing or removed.

1. Cardio Pulmonary storage room and office. The oxygen bottles were stored next to combustibles and the double doors to the room did not self close and latch.
2. Old special Procedures oxygen room, missing empty and full signs and the door to the room does not self close.
3. The ABG Lab /Cardio Pulmonary room had five compressed nitrogen bottles in the room, the door to the room was removed.
4. The exterior oxygen storage area by the helipad had rags and aircraft cleaning solution stored in the same fenced in location within five feet of the oxygen bottles.
5. Emergency room supply storage room the oxygen bottles were stored next to combustibles in the room.

During the exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Plant Director, Chief Financial Officer and Chief Nursing Officer.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients. Failing to provide empty and full signs to a medical gas storage room could result in harm to the patients.


Based on Observation the facility failed to provide protection for the exterior oxygen cylinder storage.

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, (3) "Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter; cylinders stored in the open shall be protected against accumulations of ice or snow. In summer; cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail."

Findings include:

On October 19, 2011 the surveyors, accompanied by the Plant Director and Chief Financial Officer observed the exterior oxygen cylinder storage H tanks by the liquid oxygen tank was not protected by a sun shade.

During the exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Plant Director, Chief Financial Officer and Chief Nursing Officer.

Failing to protect exterior stored medical gas cylinders from rust, snow/ice or sun may cause harm to the patients.

Based on Observation and conversation with the Plant Director the facility failed to provide an alarm annunciator for the generator at a working nurses station or a continuously monitored location in the facility.

NFPA 99 "Standard for Health Care Facilities."Chapter #3 Electrical Systems, Section 3-4.1.1.14 Requirements for Safety Devices. Section 3-4.1.1.15 Alarm Annunciator."A remote annunciator storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station.(see NFPA 70,National Electrical code, 700-12). The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows,

(a) Individual visual signals shall indicate the following:
(1) When the emergency or auxiliary power source is operating to supply power to load.
(2) When the battery charger is malfunctioning
(b) Individual signals plus a common audible signal to warn of an engine-generator alarm condition shall
indicate the following:
(1) Low lubricating oil pressure
(2) Low water temperature(below those required in (3-4.1.1.9)
(3) Excessive water temperature
(4) Low fuel-when the main fuel storage tank contains less than a 3 hour operating supply.
(5) Overcrank (failed to start)
(6) Overspeed

Findings include:

On October 19, 2011 the surveyors, accompanied by the Plant Director and Chief Financial Officer, observed the generator alarm annunciator panel was not provided at a continuously monitored location. The generator annunciator was observed to be mounted in there boiler room. The Plant Director advised the new generator and alarm annunciator panel was installed approximately six years ago.

During the survey and exit conference on October 19, 2011 the above findings were again acknowledged by the Administrator, Plant Director , Chief Financial Officer and Chief Nursing Officer.

Failure to provide a remote alarm annunciator panel in a readily observed location may result in harm to the patients in time of a fire or emergency.