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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 19.3.6.1 "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. 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."

On September 01, 2010 the surveyor, accompanied either the Director of Facilities Services, Facilities Supervisor or Security Manager observed the following two corridor doors would not close tightly when tested.

1. Room -2 Operating Room
2. Ground floor fire doors outside of the PBX room.

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

The facility failed to maintain the battery operated emergency lighting unit.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 Section 19.2.9.1, " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

On September 01, 2010 the surveyor, accompanied by the Facilities Maintenance Supervisor tested the emergency lighting unit located in Operating room one (1). The lighting unit would not light during the test.

Failure to maintain emergency lighting units in proper operating condition will cause harm to the patients during a power outage.

The facility failed to maintain the sprinkler heads.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and 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, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..."

On September 01, 2010 the surveyors, accompanied by either the Director of Facilities Services, Facilities Supervisor or Security Manager observed the following locations had either A corroded or painted sprinkler head.

1. Colonoscopy janitors closet painted sprinkler
2. Corridor by Med West Director corroded sprinkler

Failing to maintain sprinkler heads and keep the fusible link clean will allow a fire to burn longer before the sprinkler head will activate. This will cause harm to the patients.


The facility failed to assure that all parts of the facility were provided sprinkler system coverage.

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 5-5.6, " The clearance between the deflector and the top of storage shall be 18 in. or greater."

On September 01, 2010 the surveyors accompanied by either the Director of Facilities Services, Facilities Supervisor or Security Manager observed the following locations had storage either above the sprinkler heads or not 18 inches or greater below the sprinklers.

1. 2nd floor Clinical storage
2. North Emergency room closet marked #28
3. Main Lab wash room

Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads will result in injury to patients.


The facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "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. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

On September 01, 2010 the surveyors, accompanied by either the Director of Facilities Services, Facilities Supervisor or Security Manager observed the Escutcheon plates were missing from the sprinkler assembly in the following locations.

1. Emergency room Lab
2. Directors Office in the Main laboratory

Failing to maintain the sprinkler escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This 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 19.3.6.1 "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. 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."

On September 01, 2010 the surveyor, accompanied either the Director of Facilities Services, Facilities Supervisor or Security Manager observed the following two corridor doors would not close tightly when tested.

1. Room -2 Operating Room
2. Ground floor fire doors outside of the PBX room.

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

The facility failed to maintain the battery operated emergency lighting unit.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 Section 19.2.9.1, " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

On September 01, 2010 the surveyor, accompanied by the Facilities Maintenance Supervisor tested the emergency lighting unit located in Operating room one (1). The lighting unit would not light during the test.

Failure to maintain emergency lighting units in proper operating condition will cause harm to the patients during a power outage.

The facility failed to maintain the sprinkler heads.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "Buildings containing health care facilities shall be protected throughout by and 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, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..."

On September 01, 2010 the surveyors, accompanied by either the Director of Facilities Services, Facilities Supervisor or Security Manager observed the following locations had either A corroded or painted sprinkler head.

1. Colonoscopy janitors closet painted sprinkler
2. Corridor by Med West Director corroded sprinkler

Failing to maintain sprinkler heads and keep the fusible link clean will allow a fire to burn longer before the sprinkler head will activate. This will cause harm to the patients.


The facility failed to assure that all parts of the facility were provided sprinkler system coverage.

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 5-5.6, " The clearance between the deflector and the top of storage shall be 18 in. or greater."

On September 01, 2010 the surveyors accompanied by either the Director of Facilities Services, Facilities Supervisor or Security Manager observed the following locations had storage either above the sprinkler heads or not 18 inches or greater below the sprinklers.

1. 2nd floor Clinical storage
2. North Emergency room closet marked #28
3. Main Lab wash room

Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads will result in injury to patients.


The facility did not assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.1.5, "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. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

On September 01, 2010 the surveyors, accompanied by either the Director of Facilities Services, Facilities Supervisor or Security Manager observed the Escutcheon plates were missing from the sprinkler assembly in the following locations.

1. Emergency room Lab
2. Directors Office in the Main laboratory

Failing to maintain the sprinkler escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This could cause harm to the patients.