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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 one inch 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 September 24, 2010 the surveyor, accompanied by the Facility Safety Director observed the following corridor doors would not tightly close when tested a few times or were missing self closing latching mechanisms on the doors..

1. Server room corridor door.
2. Twenty minute rated corridor door from the lobby to the training room.
3. Admitting room office door had an impediment under the door.
3. Central Supply scrub room door had an impediment under the door.
4. The following two rooms housekeeping hot water heater room in the Emergency room and the film storage room did not have self closing hardware on these two doors.
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During the exit conference on November 09, 2011 the above findings were again acknowledged by the CEO and Facilities Safety Director.

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 keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On November 09, 2011 the surveyor, accompanied by the Facility Safety Director observed storage of a gurney bed, blanket warmer cabinet and casting material cabinet in the Emergency room exit corridor. The storage items reduced the corridor width to approximately six feet.

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and Facilities Safety Director.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and could cause harm to the patients.

Based on record review the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

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 9.7.5 "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, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

Findings include:

On November 09, 2011 the surveyor, accompanied by the Facilities Safety Director reviewed the current and past year sprinkler inspection maintenance and test reports by United Fire. Documentation shown to the surveyor on site was Annual sprinkler inspections from November 2008 to February 06, 2011 from United Fire. No other documentation for Quarterly Inspectors tests was provided to the surveyor while on site.

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and Facilities Safety Director.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on Observation the facility failed to secure two 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 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."

Findings include:

On November 09, 2011 the surveyor accompanied by the Facilities Safety Director observed two unsecured medical gas cylinders E type located in the service corridor oxygen storage room

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and Facilities Safety Director.

Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.

Based on Observations the facility failed to provide a medical gas cylinder storage room free of combustible materials.

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 November 09, 2011 the surveyor accompanied by the Facility Safety Director observed the Respiratory storage room had two E type oxygen cylinders stored next to medical supplies, plastics, boxes, etc:

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and the Facilities Safety Director.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.

The facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6" Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings include:

On November 09, 2011 the surveyor, accompanied by the Facility Safety Director reviewed the current and past year generator test records.No documentation of the number of seconds (10 seconds or less) from normal power to emergency power was documented on the facility monthly generator load tests form.

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and the Facilities Safety Director.

Failure to document the time from normal power to emergency power could result in harm to patients during lighting system failures.

Based on observation the facility failed to provide a guard on an exposed light bulbs

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

Findings Include:

On November 09, 2011 the surveyor, accompanied by Facilities Safety Director observed light bulbs located in the following rooms were not protected from physical damage.

1. Housekeeping in the Maternity wing has an un-protected light bulb.

2. Radio room has an un-protected light bulb.

During the exit conference on November 09, 2011 the above findings were again acknowledged by the CEO and Facilities safety Director.

Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.


The facility allowed the use of an 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.

Findings include:

On November 09, 2011 the surveyor accompanied by the Facilities Safety Director observed the Professional Support Services Office had an extension cord in use for an appliance space heater.

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and Facilities Safety Director.

The use of an extension cord could create an overload of the electrical system and cause a fire or an electrical hazard. A fire could 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 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 one inch 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 September 24, 2010 the surveyor, accompanied by the Facility Safety Director observed the following corridor doors would not tightly close when tested a few times or were missing self closing latching mechanisms on the doors..

1. Server room corridor door.
2. Twenty minute rated corridor door from the lobby to the training room.
3. Admitting room office door had an impediment under the door.
3. Central Supply scrub room door had an impediment under the door.
4. The following two rooms housekeeping hot water heater room in the Emergency room and the film storage room did not have self closing hardware on these two doors.
.
During the exit conference on November 09, 2011 the above findings were again acknowledged by the CEO and Facilities Safety Director.

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 keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On November 09, 2011 the surveyor, accompanied by the Facility Safety Director observed storage of a gurney bed, blanket warmer cabinet and casting material cabinet in the Emergency room exit corridor. The storage items reduced the corridor width to approximately six feet.

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and Facilities Safety Director.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and could cause harm to the patients.

Based on record review the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

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 9.7.5 "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, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

Findings include:

On November 09, 2011 the surveyor, accompanied by the Facilities Safety Director reviewed the current and past year sprinkler inspection maintenance and test reports by United Fire. Documentation shown to the surveyor on site was Annual sprinkler inspections from November 2008 to February 06, 2011 from United Fire. No other documentation for Quarterly Inspectors tests was provided to the surveyor while on site.

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and Facilities Safety Director.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on Observation the facility failed to secure two 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 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."

Findings include:

On November 09, 2011 the surveyor accompanied by the Facilities Safety Director observed two unsecured medical gas cylinders E type located in the service corridor oxygen storage room

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and Facilities Safety Director.

Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.

Based on Observations the facility failed to provide a medical gas cylinder storage room free of combustible materials.

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 November 09, 2011 the surveyor accompanied by the Facility Safety Director observed the Respiratory storage room had two E type oxygen cylinders stored next to medical supplies, plastics, boxes, etc:

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and the Facilities Safety Director.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.

The facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6" Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings include:

On November 09, 2011 the surveyor, accompanied by the Facility Safety Director reviewed the current and past year generator test records.No documentation of the number of seconds (10 seconds or less) from normal power to emergency power was documented on the facility monthly generator load tests form.

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and the Facilities Safety Director.

Failure to document the time from normal power to emergency power could result in harm to patients during lighting system failures.

Based on observation the facility failed to provide a guard on an exposed light bulbs

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

Findings Include:

On November 09, 2011 the surveyor, accompanied by Facilities Safety Director observed light bulbs located in the following rooms were not protected from physical damage.

1. Housekeeping in the Maternity wing has an un-protected light bulb.

2. Radio room has an un-protected light bulb.

During the exit conference on November 09, 2011 the above findings were again acknowledged by the CEO and Facilities safety Director.

Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.


The facility allowed the use of an 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.

Findings include:

On November 09, 2011 the surveyor accompanied by the Facilities Safety Director observed the Professional Support Services Office had an extension cord in use for an appliance space heater.

During the exit conference on November 04, 2011 the above findings were again acknowledged by the CEO and Facilities Safety Director.

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