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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 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 3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

On March 19, 2010 the surveyor, accompanied by the Director of Maintenance observed the following corridor doors were wedged open , would not tightly close. or were not smoke resistant.


1. Xray and Pharmacy Dutch door had approximately 1/4 to 1/2 inch holes in the door which went all the way through the corridor doors by the door latch mechanism. The doors were not smoke resistant.
2. Admissions office dutch door no smoke seal the astragal was missing.
3. Operating room, Sleep Lab and Gift shop had impediments on the doors holding them open.
4. The Emergency room, Operating room and Sleep Lab corridor doors were missing positive latching hardware on the doors. The doors had key latch locks only on the corridor doors.
5. Room 111 not closing tightly
6. The Soiled Utility room had a few holes of approximately 1/4 to 1/2 inch which went through the entire corridor door and the door not smoke resistant.










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

The facility failed to assemble the laundry room dryer vents correctly.

NFPA 101 Life Safety Code, 2000, Chapter 18 or Chapter 19, Section 18.5.1.1 "Utilities shall comply with the provisions of Section 9.1. Chapter 9, Section 9.1.1 "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58 Liquefied Petroleum Gas Code. NFPA 54 Chapter 6, Section 6.4.5 Exhaust ducts for type 2 Clothes Dryers shall comply with 6.4.4(b) "Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system".

On March 19, 2010 the surveyor, accompanied by the Director of Maintenance observed the dryers in the laundry room, one exhaust duct had screws in the vent piping.

Failure to remove screws in the exhaust vent duct can reduce the efficiency of the dryer by catching the lint, which may cause a fire and could cause harm to the patients.

The facility failed to maintain a clear exit access and keep the exits readily accessible at all times which provides a continuous way out of the building.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency". Section 7.1.10.2.1 "No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof."

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."

On March 19, 2010 the surveyor, accompanied by the Director of Maintenance observed storage within the exit corridors by the rear Emergency room exit which was blocking the exit access to the exit door by a gurney bed, table and chairs, and the service hallway had a few yellow soiled linen barrels stored directly placed in front of the exit door in the hallway .

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

The facility failed to provide medical gas cylinder storage free of combustible materials and mount a light switch five feet above the floor .

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..."

NFPA 101 Life Safety Code, 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, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

On March 19, 2010 the surveyor, accompanied by the Director of Maintenance, observed the ten oxygen bottles in a rack being stored up against a wall by the entrance to the Respiratory Care and storage room where the wall mounted electric light switch in the room was approximately three and a half feet (3.5ft) above the floor. In addition the bottles were not a minimum distance 5 feet from combustibles in the room i.e. paper plastics boxes etc:

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients. Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which 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 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 3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

On March 19, 2010 the surveyor, accompanied by the Director of Maintenance observed the following corridor doors were wedged open , would not tightly close. or were not smoke resistant.


1. Xray and Pharmacy Dutch door had approximately 1/4 to 1/2 inch holes in the door which went all the way through the corridor doors by the door latch mechanism. The doors were not smoke resistant.
2. Admissions office dutch door no smoke seal the astragal was missing.
3. Operating room, Sleep Lab and Gift shop had impediments on the doors holding them open.
4. The Emergency room, Operating room and Sleep Lab corridor doors were missing positive latching hardware on the doors. The doors had key latch locks only on the corridor doors.
5. Room 111 not closing tightly
6. The Soiled Utility room had a few holes of approximately 1/4 to 1/2 inch which went through the entire corridor door and the door not smoke resistant.










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

The facility failed to assemble the laundry room dryer vents correctly.

NFPA 101 Life Safety Code, 2000, Chapter 18 or Chapter 19, Section 18.5.1.1 "Utilities shall comply with the provisions of Section 9.1. Chapter 9, Section 9.1.1 "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58 Liquefied Petroleum Gas Code. NFPA 54 Chapter 6, Section 6.4.5 Exhaust ducts for type 2 Clothes Dryers shall comply with 6.4.4(b) "Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system".

On March 19, 2010 the surveyor, accompanied by the Director of Maintenance observed the dryers in the laundry room, one exhaust duct had screws in the vent piping.

Failure to remove screws in the exhaust vent duct can reduce the efficiency of the dryer by catching the lint, which may cause a fire and could cause harm to the patients.

The facility failed to maintain a clear exit access and keep the exits readily accessible at all times which provides a continuous way out of the building.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency". Section 7.1.10.2.1 "No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof."

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."

On March 19, 2010 the surveyor, accompanied by the Director of Maintenance observed storage within the exit corridors by the rear Emergency room exit which was blocking the exit access to the exit door by a gurney bed, table and chairs, and the service hallway had a few yellow soiled linen barrels stored directly placed in front of the exit door in the hallway .

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

The facility failed to provide medical gas cylinder storage free of combustible materials and mount a light switch five feet above the floor .

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..."

NFPA 101 Life Safety Code, 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, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

On March 19, 2010 the surveyor, accompanied by the Director of Maintenance, observed the ten oxygen bottles in a rack being stored up against a wall by the entrance to the Respiratory Care and storage room where the wall mounted electric light switch in the room was approximately three and a half feet (3.5ft) above the floor. In addition the bottles were not a minimum distance 5 feet from combustibles in the room i.e. paper plastics boxes etc:

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients. Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which could cause harm to the patients.