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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 18. 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 October 25, 2012, the surveyor, accompanied by the Chief Executive Officer, and the Director of Plant Operations, observed that the following corridor doors would not tightly close when tested.

1. Nurses Station 200,by room 201, closing device removed from door
2. Door 71, rated door, with a closing device, when tested three of three times would not positively latch
During the exit conference on October 26, 2012, the above findings were again acknowledged by the Chief Executive Officer, Corporate Chief Nursing Officer, and the Director of Plant Operations.

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

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 October 25, 2012, the surveyor, accompanied by the Chief Executive Officer, and the Director of Plant Operations, observed the rated kitchen door to the serving line has a closing device and was wedged in the open position with an impediment.

During the exit conference on October 26, 2012, the above findings were again acknowledged by the Chief Executive Officer, Corporate Chief Nursing Officer, and the Director of Plant Operations.

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 head in the walk in refrigerator in the kitchen.

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." 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." Chapter 3, Section 3-2.6.1 and 3-2.6.2, Listed corrosion resistant sprinklers shall be installed in locations where chemicals, moisture, or other corrosive vapors sufficient to cause corrosion of such devices exist. Corrosion -resistant coatings shall be applied only by manufacturer of the sprinkler.

Findings include:

On October 25, 2012, the surveyor, accompanied by the Chief Executive Officer, and the Director of Plant Operations, observed the walk in refrigerator in the kitchen. The refrigerator has a corroded sprinkler head and frame assembly. This was apparent by the rust color around the assembly.

During the exit conference on October 26, 2012, the above findings were again acknowledged by the Chief Executive Officer, Corporate Chief Nursing Officer, and the Director of Plant Operations.


Failure to maintain sprinkler heads will not allow the head to operate correctly under fire conditions and will 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 October 25, 2012, the surveyor, accompanied by the Chief Executive Officer, and the Director of Plant Operations, observed medical gas storage in the following areas were not segregated from each other. And signs were posted for the empty and full oxygen storage racks.

1. Room 114 twelve E O2, bottles, marked full, four were empty mixed with the fulls
2. E O2 bottle storage area outside on the loading dock, fifty eight full E O2 bottles mixed, with six empty EO2 bottles and not marked Full/Empty

During the exit conference on October 26, 2012, the above findings were again acknowledged by the Chief Executive Officer, Corporate Chief Nursing Officer, and the Director of Plant Operations.

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 guard on the light bulb located over the cooking grill. And based on observation the facility failed to provide receptacle in good working order.


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 NEC, 1999, Article 410, Section 410-56 (e) Position of Receptacle Faces. "3. After installation, receptacle faces shall be flush with or project from faceplate of insulating material and shall project a minimum of 0.015 in. From metal faceplate. Faceplate shall be installed so as to completely cover the opening and seat against the mounting surface."

Findings Include:

On October 25, 2012, the surveyor, accompanied by the Chief Executive Officer, and the Director of Plant Operations, observed that the light bulb located above the cooking grill was not protected from physical damage. And the 110 outlet by the kitchen service door is cracked.

During the exit conference on October 26, 2012, the above findings were again acknowledged by the Chief Executive Officer, Corporate Chief Nursing Officer, and the Director of Plant Operations.

Failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients.
Failing to repair broken receptacles and face plates may contribute to starting a fire by allowing the electrical wiring to short when an electrical appliance is plugged in or removed from the receptacle. A fire in the facility may cause harm to the patients.