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Based on observation the facility failed to fill penetrations in the smoke barriers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On June 19, 2013, the surveyor, accompanied by the Director of Facilities, and Maintenance Staff observed unsealed penetrations in the smoke barrier/s, located at:

1. Smoke barrier by Room 110, several penetrations
2, Smoke barrier across from room 113, penetrations, to include remove/replace all non rated fire calk for Health care facilities
3. Fire riser room, fill penetrations and remove/ replace all non rated fire calk for Health care facilities

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to provide a self-closing or an automatic-closing device in a hazardous area, and 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, "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. And 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 June 19, 2013, the surveyor, accompanied by the Director of Facilities and Maintenance Staff observed doors which have had the door closing devices removed and unsealed holes in the following areas:

1. MDF to laundry several penetrations above ceiling
2. Kitchen, dry storage of combustibles, no door closing device
3. Double kitchen doors, right leaf five holes, door with a door closing device tested three of three times will not positively latch
4. Kitchen, dry food storage, closing device removed
5. Ultrasound , rated door, closing device removed
6. Lab, closing device removed
7. Card. Care and Respiratory care/storage room, closing devices removed
8. Gift Shop storage, three hr. rated door, closing device removed
9. ED, soiled linen room, closing device removed
10. ED Nursing office door and Radiology film record storage rooms door no closing device
11. Hole in wall between radiological storage room
12. Nuclear Medicine, one of two doors no closing device

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.


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

The facility failed to maintain the sprinkler head in the walk in refrigerator in the kitchen, and the facility failed to maintain the sprinkler heads from obstructions.

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." Chapter 9, 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 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard." 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. "

Findings include:

On June 19, 2013, the surveyor, accompanied by the Director of Facilities and the Maintenance Staff, observed the following:

1. Walk in refrigerator in the kitchen. One of one sprinklers are corroded.. This is apparent by the brown rust on the assembly.
2. Kitchen dry storage, 18 inch obstruction clearance not maintained from the sprinkler
3. Nuclear Medicine office, protective cover was not removed from the fusible link on the sprinkler

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.


Failure to maintain sprinkler heads will not allow the head to operate correctly under fire conditions and will cause harm to the patients. Installing obstructions next to the sprinkler head may prevent it from providing adequate coverage of the hazard. This may cause harm to the patients.

Based on observation the facility failed to secure medical gas cylinders, and based on observation the facility failed to separate O2 five feet from electrical and combustibles.


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."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.

Findings include:

On June 19, 2013, the surveyor accompanied by the Director of Facilities and the Maintenance Staff, observed unsecured or improper storage of medical gas cylinders located in the following rooms/areas.

1. CT, one E-02 bottle unsecured
2. Scope room, one E-02 bottle stored
3. MRI trailer, one E-02 bottle stored within five feet of combustibles and electrical

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.

Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff, failing to separate oxygen five feet from electrical and combustibles could cause harm to the patients.

Based on record review and Staff interview 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 June 19, 2013, the surveyors, accompanied by the Director of Facilities and Maintenance Staff reviewed the generator test records. No documentation of monthly load test of thirty minutes were observed for April and May 2013. The load test completed was for twenty minutes ten minutes short of the requirement.

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, did not protect light fixtures with covers, and did not cover electrical panel blanks.

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. 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, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

Findings include:

On June 19, 2013 the surveyor, accompanied by the Director of Facilities and the Maintenance Staff, observed the following electrical deficiencies:

1. Boiler room, three electrical light fixtures no covers
2. Pharmacy, microwave plugged into power strip
3. Respiratory/storage office, refrigerator and microwave plugged into power strip
4. Fire riser room, electrical panel number MS missing one of eight blanks, exposed energized electrical

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients. Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.

Based on observation the facility failed to fill penetrations in the smoke barriers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of at least ? hour." (1 Hour New) Chapter 8, Section 8.3.6. "Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:"
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
(a) It shall be made on either side of the smoke barrier.
(b) It shall be made by an approved device that is designed for the specific purpose.

Findings include:

On June 19, 2013, the surveyor, accompanied by the Director of Facilities, and Maintenance Staff observed unsealed penetrations in the smoke barrier/s, located at:

1. Smoke barrier by Room 110, several penetrations
2, Smoke barrier across from room 113, penetrations, to include remove/replace all non rated fire calk for Health care facilities
3. Fire riser room, fill penetrations and remove/ replace all non rated fire calk for Health care facilities

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.

Failing to fill holes in smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility, which will cause harm to patients.

Based on observation the facility failed to provide a self-closing or an automatic-closing device in a hazardous area, and 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, "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. And 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 June 19, 2013, the surveyor, accompanied by the Director of Facilities and Maintenance Staff observed doors which have had the door closing devices removed and unsealed holes in the following areas:

1. MDF to laundry several penetrations above ceiling
2. Kitchen, dry storage of combustibles, no door closing device
3. Double kitchen doors, right leaf five holes, door with a door closing device tested three of three times will not positively latch
4. Kitchen, dry food storage, closing device removed
5. Ultrasound , rated door, closing device removed
6. Lab, closing device removed
7. Card. Care and Respiratory care/storage room, closing devices removed
8. Gift Shop storage, three hr. rated door, closing device removed
9. ED, soiled linen room, closing device removed
10. ED Nursing office door and Radiology film record storage rooms door no closing device
11. Hole in wall between radiological storage room
12. Nuclear Medicine, one of two doors no closing device

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.


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

The facility failed to maintain the sprinkler head in the walk in refrigerator in the kitchen, and the facility failed to maintain the sprinkler heads from obstructions.

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." Chapter 9, 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 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard." 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. "

Findings include:

On June 19, 2013, the surveyor, accompanied by the Director of Facilities and the Maintenance Staff, observed the following:

1. Walk in refrigerator in the kitchen. One of one sprinklers are corroded.. This is apparent by the brown rust on the assembly.
2. Kitchen dry storage, 18 inch obstruction clearance not maintained from the sprinkler
3. Nuclear Medicine office, protective cover was not removed from the fusible link on the sprinkler

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.


Failure to maintain sprinkler heads will not allow the head to operate correctly under fire conditions and will cause harm to the patients. Installing obstructions next to the sprinkler head may prevent it from providing adequate coverage of the hazard. This may cause harm to the patients.

Based on observation the facility failed to secure medical gas cylinders, and based on observation the facility failed to separate O2 five feet from electrical and combustibles.


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."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.

Findings include:

On June 19, 2013, the surveyor accompanied by the Director of Facilities and the Maintenance Staff, observed unsecured or improper storage of medical gas cylinders located in the following rooms/areas.

1. CT, one E-02 bottle unsecured
2. Scope room, one E-02 bottle stored
3. MRI trailer, one E-02 bottle stored within five feet of combustibles and electrical

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.

Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff, failing to separate oxygen five feet from electrical and combustibles could cause harm to the patients.

Based on record review and Staff interview 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 June 19, 2013, the surveyors, accompanied by the Director of Facilities and Maintenance Staff reviewed the generator test records. No documentation of monthly load test of thirty minutes were observed for April and May 2013. The load test completed was for twenty minutes ten minutes short of the requirement.

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, did not protect light fixtures with covers, and did not cover electrical panel blanks.

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. 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, SECTION 110-12 (a) Unused Openings. "Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment."

Findings include:

On June 19, 2013 the surveyor, accompanied by the Director of Facilities and the Maintenance Staff, observed the following electrical deficiencies:

1. Boiler room, three electrical light fixtures no covers
2. Pharmacy, microwave plugged into power strip
3. Respiratory/storage office, refrigerator and microwave plugged into power strip
4. Fire riser room, electrical panel number MS missing one of eight blanks, exposed energized electrical

During the exit conference on June 19, 2013, the above findings were again acknowledged by the Executive Director and the Director of Facilities.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients. Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patient.