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The facility failed to maintain the smoke/fire resistive rating of certain corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

On August 25, 2010 the surveyors, accompanied by Manager Environmental Service and the Director Human Resources Environmental Services observed penetrations in the corridor wall located on the corridor wall communication /electrical room marked room 621. There were four conduit penetrations not sealed.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat could cause harm to the patients.

The facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, 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."

On August 25, 2010 the surveyors, accompanied by the Manager Environmental Service and the Director Human Resources Environmental Services observed that the following corridor doors would not tightly close.

1. Rooms 115, 116, 117, 119, 122, 516.

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

The facility failed to provide a self-closing or an automatic-closing door in a hazardous area and maintain the integrity, smoke resistance, of walls, ceilings and unfilled pipe chases in hazardous areas.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 or 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.

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.

On August 22, 2010 the surveyors accompanied by the Manager of Environmental Services Director and Director of Human Resources Services inspected the Kitchen dry food storage room, basement Paint storage room and Central Supply. The doors to these rooms were either missing its self-closing device or did not close tightly. In addition the surveyors observed unsealed pipe chase holes, holes in walls or ceilings in the basement above the fire smoke doors and basement laundry room.

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to the residents in time of a fire. Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to the patients.

The facility failed to provide fire protection for a grill.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial cooking equipment shall be in accordance with NFPA 96, Standard For Ventilation Control and Fire Protection of Commercial Cooking Operations." NFPA 96, Chapter 7, Section 7-1.2, "Cooking equipment that produces grease-laden vapors (such as but not limited to, deep fat fryers, ranges, griddles, and broilers, woks, tilting skillets, and braising pans) shall be protected by approved extinguishing equipment."

On August 25, 2010 the surveyors, accompanied by by the Manager Environmental Service and the Director Human Resources Environmental Services observed the kitchen a stove grill was being used without installed fire protection. The nozzle was not directly over the grill but to the side of the grill.

Failing to protect cooking equipment could result in fire which could cause harm to the patients.


The facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

On August 25, 2010 the surveyors, accompanied by the Manager Environmental Service and the Director Human Resources Environmental Services observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a fire, which could cause damage to the kitchen and could cause harm to the patients.

The facility failed to maintain the smoke/fire resistive rating of certain corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

On August 25, 2010 the surveyors, accompanied by Manager Environmental Service and the Director Human Resources Environmental Services observed penetrations in the corridor wall located on the corridor wall communication /electrical room marked room 621. There were four conduit penetrations not sealed.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat could cause harm to the patients.

The facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, 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."

On August 25, 2010 the surveyors, accompanied by the Manager Environmental Service and the Director Human Resources Environmental Services observed that the following corridor doors would not tightly close.

1. Rooms 115, 116, 117, 119, 122, 516.

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

The facility failed to provide a self-closing or an automatic-closing door in a hazardous area and maintain the integrity, smoke resistance, of walls, ceilings and unfilled pipe chases in hazardous areas.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 or 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.

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.

On August 22, 2010 the surveyors accompanied by the Manager of Environmental Services Director and Director of Human Resources Services inspected the Kitchen dry food storage room, basement Paint storage room and Central Supply. The doors to these rooms were either missing its self-closing device or did not close tightly. In addition the surveyors observed unsealed pipe chase holes, holes in walls or ceilings in the basement above the fire smoke doors and basement laundry room.

Failing to install self-closing hardware on a smoke/fire resistance door could cause harm to the residents in time of a fire. Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to the patients.

The facility failed to provide fire protection for a grill.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial cooking equipment shall be in accordance with NFPA 96, Standard For Ventilation Control and Fire Protection of Commercial Cooking Operations." NFPA 96, Chapter 7, Section 7-1.2, "Cooking equipment that produces grease-laden vapors (such as but not limited to, deep fat fryers, ranges, griddles, and broilers, woks, tilting skillets, and braising pans) shall be protected by approved extinguishing equipment."

On August 25, 2010 the surveyors, accompanied by by the Manager Environmental Service and the Director Human Resources Environmental Services observed the kitchen a stove grill was being used without installed fire protection. The nozzle was not directly over the grill but to the side of the grill.

Failing to protect cooking equipment could result in fire which could cause harm to the patients.


The facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.2.6 "Cooking facilities shall be protected in accordance with 9-2.3" Section 9-2.3 "Commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations." , Chapter 8, Section 8-3.1, " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge".

On August 25, 2010 the surveyors, accompanied by the Manager Environmental Service and the Director Human Resources Environmental Services observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup.

Failing to keep the entire kitchen exhaust hood system clean from grease could cause a fire, which could cause damage to the kitchen and could cause harm to the patients.