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Based on observation the facility failed to have smoke resistant dutch doors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.6, "Dutch doors shall be permitted where they conform to 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.

Findings Include:

On January 11, 2011, the surveyor, accompanied by the Supervisor of Plant Operations and staff, observed corridor dutch doors, located at Room 639 ,were not smoke resistant. When the upper and lower leaves were closed there is a gap, the door is not smoke resistant and does not have an astragal.

During the exit conference on January 11, 2012 the above findings were again acknowledged by the CEO, CFO, Director of Quality, and the Director of Plant Operations.

Failure to provide smoke resistant corridor doors will harm patients in time of a fire.


Based on observation 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 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On January 11, 2012 the surveyor, accompanied by the Supervisor of Plant Operations and staff, observed that the following corridor doors would not tightly close when tested.

1. Kitchen office room 205, rated door held open with an impediment
2. Room 312 when tested three of three times will not positively latch
3. Room 301 when tested three of three times will not positively latch

During the exit conference on January 11, 2012 the above findings were again acknowledged by the CEO, CFO, Director of Quality, 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 failed to fill penetrations in the smoke barrier.

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 January 11, 2012, the surveyor, accompanied by the Supervisor of Plant Operations and staff, observed unsealed penetrations in the smoke barrier/s, located by:

1. Room 307, pipe chases, and open conduits/pipes
2. Room 234, pipe chases, and open conduits/pipes.

During the exit conference on January 11, 2012 the above findings were again acknowledged by the CEO, CFO, Director of Quality, and the Director of Plant Operations.

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 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 January 11, 2012, the surveyor, accompanied by the Supervisor of Plant Operations and staff, observed the following rated doors would not close and positively latch:

1. Kitchen storage will not close and positively latch
2. Kitchen twenty minute rated double doors, with a closing device blocked in the open position by a storage rack
3. Kitchen dry food storage rated door with a closing device, held open with an impediment

During the exit conference on January 11, 2012 the above findings were again acknowledged by the CEO, CFO, Director of Quality, 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 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." ." 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."

Findings include:

On January 11, 2012, the surveyor, accompanied by the Supervisor of Plant Operations and staff, observed the sprinkler heads in the following locations did not have clearance between the deflector and the top of storage 18 in. or greater.

1. Kitchen storage
2. Door 214 clean Linen, to include missing escutcheon plate, one of two sprinklers
3. Kitchen dry food storage, three of four sprinklers
4. Central supply, three of four sprinklers
5. Shop room 233, two of two sprinklers

During the exit conference on January 11, 2012 the above findings were again acknowledged by the CEO, CFO, Director of Quality, and the Director of Plant Operations.

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 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".

Findings include:

On January 11, 2012, the surveyor, accompanied by the Supervisor of Plant Operations and staff, observed the two kitchen exhaust system hood, filters and grease drip tray areas had an excessive amount of grease buildup.

1. Main line four of seven baffles covered with black heavy grease
2. Central kitchen cook area four of fourteen baffles covered with black heavy grease

During the exit conference on January 11, 2012 the above findings were again acknowledged by the CEO, CFO, Director of Quality, and the Director of Plant Operations.


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

Based on observation the facility failed to provide a guard on the lights located in room 223.

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 January 11, 2012, the surveyor, accompanied by the Supervisor of Plant Operations and staff, observed that the lights located in room 223 storage were not protected from physical damage.

During the exit conference on January 11, 2012 the above findings were again acknowledged by the CEO, CFO, Director of Quality, 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.