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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 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 19.19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On August 25, 2011 the surveyors, accompanied by either the CIO, Director of Plant Services and Maintenance Tech observed the following corridor doors would not tightly close when tested.

1. 4th floor double doors to NICU missing door latching mechanism in the door.
2. Triage room wedged open
3. Clinical Nurses Leaders Office wedged open
4. Cafe Sweet Pantry door was removed from the room.
5. Main kitchen dry food storage room
6. Storage room by the Hospitalist office
7. Door from short order line to main kitchen wedged open
8. General Nuclear Medicine room door closure removed from rated door

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

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 August 25, 2011 the surveyor, accompanied by the Maintenance Tech observed unsealed penetrations in the smoke barrier/s, located or adjacent to the following locations.

1. 1st floor by the Tower
2. Volunteer Services
3. ARM office

During the exit conference on August 25, 2011 the above findings were again acknowledged by the Director, A.I.T. and the Director of Maintenance.

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 maintain the self closing/automatic-closing doors in the smoke barriers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4.1*" Doors in smoke barriers shall close the opening leaving only minimum clearance necessary for proper operation and shall be without undercuts, lovers, or grills." A 8.3.4.1 The clearance for proper operation of smoke doors is defined as 1/8 inch.

Findings include:

On August 25, 2011 the surveyor, accompanied by the CIO observed the following smoke barrier doors located by the following locations had a gap between the double doors of approximately 1/4 to one half inch. The astragal's were missing from the doors.

1. 5th floor
2. 4th floor by the elevators and East side smoke doors.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO.

Failure to properly adjust or repair the smoke doors could cause harm to the patients.
Non closing smoke doors could allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation 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 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 August 25, 2011 the surveyor, accompanied by the CIO, Director of Plant Operations and Maintenance Tech observed unsealed pipe chase holes, holes in walls or ceilings in the following Locations.

1. 4th floor data room 526
2. Pick up soiled linen room adjacent to main oxygen storage room.
3. IT room
4. Auto Clave room in surgery department
5. Main electrical room marked E-2

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Operations and Maintenance Tech.

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.

Based on observation the facility did not keep exits readily accessible at all times.

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." 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."

Findings include:

On August 25, 2011 the surveyors, accompanied by either the CIO, Director of Plant Services and Maintenance Tech observed storage within the exit corridors blocking the exit access and reducing the corridor width in the following locations.

1. Social Services exit corridor several chairs and tables in the exit corridor.
2. MRI exit corridor, four Xray shield machines, gurneys and a few pieces of miscellaneous equipment.
3. Conference room one exit corridor, four chairs, three gurneys,
4. Emergency room exit corridor the following were stored in front of the exit door, Scale,
X ray machine and blanket warmer machine.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

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

Based on observation the facility failed to maintain the battery operated emergency lighting units.

NFPA 101 Life Safety Code, 2000, Chapter 19, 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."

Findings Include:

On June 21, 2011, the surveyor, accompanied by the Maintenance Tech tested the emergency lighting unit located in Surgery room one and two would not light during the test.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the Maintenance Tech.

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


Based on observation the facility failed to document the Monthly and Annual testing of battery back up emergency lighting in the Surgery rooms and suite.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On August 25, 2011 the surveyor accompanied by the CIO and Director of Plant Services could not provide documentation of Monthly or Annual testing of the battery backup emergency lighting units for the surgery rooms.

During the exit conference on August 25, 2011, the above findings were again acknowledged by the CIO and Director of Plant Services.

Failing to test and document emergency lighting units could cause harm to the patients.

Based on observation the facility failed to maintain two illuminated exit signs.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.10, Section 19.2.10.1 " Means of egress shall have signs in accordance with Section 7.10."Section 7.10.5.1, "Every sign required by 7.10.1.2 or 7.10.1.4 other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings include:

On August 25, 2011 the surveyor, accompanied by the CIO observed the following exit signs were not illuminated.

1. 1st floor above the North east exit door.
2. 3rd floor Quality Management office.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO.

Failing to maintain illuminated exit signs could cause harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "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..

Findings Include:

On August 25, 2011 the surveyors, accompanied by either the CIO, Director of Plant Services and Maintenance Tech observed the following:

1. 5th floor doctors sleep room and room 305 bathroom sprinklers had paint or texture spray on the sprinklers.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

Failing to maintain sprinkler heads and keep the fusible links clean could allow a fire to burn longer before the sprinkler heads will activate.


Based on Observation the facility failed to maintain the exterior fire department connection.

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." NFPA 13 Chapter 2, Section 3-9 Fire Department Connections, Section 3-9.2 " Fire department connections shall be equipped with listed plugs or caps, properly secured and arranged for easy removal by fire departments."

Findings include:

On August 25, 2011 the surveyors, accompanied by the CIO observed the outside free standing fire department connection by the 1st floor South East side of the building had a missing cap.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

Failure to provide caps for the fire department connection could allow a person to insert material which will block the ability for the fire department to pump into the automatic sprinkler system. This could cause harm to the patients.


Based on Observation 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 August 25, 2011 the surveyors, accompanied by the Maintenance Tech observed the storage above the sprinkler deflectors.

1. Training conference room, room two.
2. Cafe sweet shop

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads will result in injury to 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 August 25, 2011 the surveyors, accompanied by the CIO, Director of Plant Services and Maintenance Tech observed the kitchen exhaust system hood, filters and grease drip tray area for the main line and short order line had an excessive amount of grease buildup on several of the kitchen hood baffle plates .

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

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

Based on Observation the facility failed to provide a medical gas cylinder storage room free of combustible materials and failed to mount an electrical light switch five feet above the floor in the oxygen storage room or oxygen bottles were found unsecured and not stored in racks or chained securely.

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.

Findings include:

On August 25, 2011 the surveyors, accompanied by either the CIO, Director of Plant Services and Maintenance Tech observed in several locations in the facility had oxygen storage rooms with storage of plastics, medical supplies, cardboard boxes, etc: stored within 5 feet of combustibles or had oxygen bottles stored under wall mounted electric light switches which were not mounted five feet above the floor. .

1. Clean Utility NCIU
2. 2nd floor main storage room
3. 1st floor main storage room by staff lounge
4. Old Cath Lab
5. Clean utility storage in the Emergency recovery room and the Emergency room main storage room.
6. Five unsecured oxygen bottles not chained or in racks in the Main oxygen storage room E and D type.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

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

Based on Record Review the facility failed to document the required testing of the emergency generators.

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 August 25, 2011 the surveyor, accompanied by the CIO and Director of Plant Operations reviewed the generator test records. No documentation of weekly inspections or monthly load tests and transfer time number of seconds (10 seconds or less) from normal power to emergency power was provided to the surveyor on site during the survey for the following:

Weekly visual inspections missing Cummings generator .

1. First three weeks of January 2011
2. Two weeks in February 2011
3. One week in April 2011

Weekly visual inspections missing for the Kohler generator

1. Three weeks in January 2011
2. Two weeks in February 2011
3. One week in March 2011
4. One week in July 2011

Weekly visual inspections missing for the Cat Generator

1. Three weeks in June 2011 and all of July 2011.

Monthly load tests and transfer time not documented was from January through June of 2011 for all three generators.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

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 lighting system failures.

Based on Observation the facility failed to identify panel board circuits.

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 384, Section 384-13 General "All panel board circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors."

Findings Include:

On August 25, 2011 the surveyor, accompanied by the CIO observed the circuit breaker panel marked EC5B on the fifth floor did not have the breakers identified.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO.

Failing to identified electrical circuits in an emergency could cause a fire or electrical shock, which may cause harm to the patients.


Based on Observation facility failed to provide protection from electrical shock.

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 110-12 (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 August 25, 2011 the surveyor accompanied by the CIO or Maintenance Tech observed the following:

1. J box covers on the wall mounted electrical box were missing in the following locations: Data room 1st and 3rd floor and the Pick up soiled linen room.
2. Electrical panel located in the main kitchen marked KP4 had an unprotected opening opening electrical wires exposed in the lower portion of the panel.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO and Maintenance Tech.

Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patients.

Based on Observation the facility failed to allow access to the electrical equipment/panels.

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 shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

On August 25, 2011 the surveyor, accompanied by the Maintenance Tech observed storage (boxes) in front of the electrical panel (s) located in the following locations:

1. Pharmacy IV storage and Prep room.
2. Surgery and Pre-0p

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO and Maintenance Tech.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 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 19.19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On August 25, 2011 the surveyors, accompanied by either the CIO, Director of Plant Services and Maintenance Tech observed the following corridor doors would not tightly close when tested.

1. 4th floor double doors to NICU missing door latching mechanism in the door.
2. Triage room wedged open
3. Clinical Nurses Leaders Office wedged open
4. Cafe Sweet Pantry door was removed from the room.
5. Main kitchen dry food storage room
6. Storage room by the Hospitalist office
7. Door from short order line to main kitchen wedged open
8. General Nuclear Medicine room door closure removed from rated door

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

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 August 25, 2011 the surveyor, accompanied by the Maintenance Tech observed unsealed penetrations in the smoke barrier/s, located or adjacent to the following locations.

1. 1st floor by the Tower
2. Volunteer Services
3. ARM office

During the exit conference on August 25, 2011 the above findings were again acknowledged by the Director, A.I.T. and the Director of Maintenance.

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 maintain the self closing/automatic-closing doors in the smoke barriers.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4.1*" Doors in smoke barriers shall close the opening leaving only minimum clearance necessary for proper operation and shall be without undercuts, lovers, or grills." A 8.3.4.1 The clearance for proper operation of smoke doors is defined as 1/8 inch.

Findings include:

On August 25, 2011 the surveyor, accompanied by the CIO observed the following smoke barrier doors located by the following locations had a gap between the double doors of approximately 1/4 to one half inch. The astragal's were missing from the doors.

1. 5th floor
2. 4th floor by the elevators and East side smoke doors.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO.

Failure to properly adjust or repair the smoke doors could cause harm to the patients.
Non closing smoke doors could allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation 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 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 August 25, 2011 the surveyor, accompanied by the CIO, Director of Plant Operations and Maintenance Tech observed unsealed pipe chase holes, holes in walls or ceilings in the following Locations.

1. 4th floor data room 526
2. Pick up soiled linen room adjacent to main oxygen storage room.
3. IT room
4. Auto Clave room in surgery department
5. Main electrical room marked E-2

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Operations and Maintenance Tech.

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.

Based on observation the facility did not keep exits readily accessible at all times.

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." 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."

Findings include:

On August 25, 2011 the surveyors, accompanied by either the CIO, Director of Plant Services and Maintenance Tech observed storage within the exit corridors blocking the exit access and reducing the corridor width in the following locations.

1. Social Services exit corridor several chairs and tables in the exit corridor.
2. MRI exit corridor, four Xray shield machines, gurneys and a few pieces of miscellaneous equipment.
3. Conference room one exit corridor, four chairs, three gurneys,
4. Emergency room exit corridor the following were stored in front of the exit door, Scale,
X ray machine and blanket warmer machine.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

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

Based on observation the facility failed to maintain the battery operated emergency lighting units.

NFPA 101 Life Safety Code, 2000, Chapter 19, 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."

Findings Include:

On June 21, 2011, the surveyor, accompanied by the Maintenance Tech tested the emergency lighting unit located in Surgery room one and two would not light during the test.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the Maintenance Tech.

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


Based on observation the facility failed to document the Monthly and Annual testing of battery back up emergency lighting in the Surgery rooms and suite.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On August 25, 2011 the surveyor accompanied by the CIO and Director of Plant Services could not provide documentation of Monthly or Annual testing of the battery backup emergency lighting units for the surgery rooms.

During the exit conference on August 25, 2011, the above findings were again acknowledged by the CIO and Director of Plant Services.

Failing to test and document emergency lighting units could cause harm to the patients.

Based on observation the facility failed to maintain two illuminated exit signs.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.10, Section 19.2.10.1 " Means of egress shall have signs in accordance with Section 7.10."Section 7.10.5.1, "Every sign required by 7.10.1.2 or 7.10.1.4 other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings include:

On August 25, 2011 the surveyor, accompanied by the CIO observed the following exit signs were not illuminated.

1. 1st floor above the North east exit door.
2. 3rd floor Quality Management office.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO.

Failing to maintain illuminated exit signs could cause harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.5.1 "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..

Findings Include:

On August 25, 2011 the surveyors, accompanied by either the CIO, Director of Plant Services and Maintenance Tech observed the following:

1. 5th floor doctors sleep room and room 305 bathroom sprinklers had paint or texture spray on the sprinklers.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

Failing to maintain sprinkler heads and keep the fusible links clean could allow a fire to burn longer before the sprinkler heads will activate.


Based on Observation the facility failed to maintain the exterior fire department connection.

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." NFPA 13 Chapter 2, Section 3-9 Fire Department Connections, Section 3-9.2 " Fire department connections shall be equipped with listed plugs or caps, properly secured and arranged for easy removal by fire departments."

Findings include:

On August 25, 2011 the surveyors, accompanied by the CIO observed the outside free standing fire department connection by the 1st floor South East side of the building had a missing cap.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

Failure to provide caps for the fire department connection could allow a person to insert material which will block the ability for the fire department to pump into the automatic sprinkler system. This could cause harm to the patients.


Based on Observation 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 August 25, 2011 the surveyors, accompanied by the Maintenance Tech observed the storage above the sprinkler deflectors.

1. Training conference room, room two.
2. Cafe sweet shop

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

Failing to provide sprinkler coverage in storage areas by blocking the sprinkler heads will result in injury to 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 August 25, 2011 the surveyors, accompanied by the CIO, Director of Plant Services and Maintenance Tech observed the kitchen exhaust system hood, filters and grease drip tray area for the main line and short order line had an excessive amount of grease buildup on several of the kitchen hood baffle plates .

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

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

Based on Observation the facility failed to provide a medical gas cylinder storage room free of combustible materials and failed to mount an electrical light switch five feet above the floor in the oxygen storage room or oxygen bottles were found unsecured and not stored in racks or chained securely.

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.

Findings include:

On August 25, 2011 the surveyors, accompanied by either the CIO, Director of Plant Services and Maintenance Tech observed in several locations in the facility had oxygen storage rooms with storage of plastics, medical supplies, cardboard boxes, etc: stored within 5 feet of combustibles or had oxygen bottles stored under wall mounted electric light switches which were not mounted five feet above the floor. .

1. Clean Utility NCIU
2. 2nd floor main storage room
3. 1st floor main storage room by staff lounge
4. Old Cath Lab
5. Clean utility storage in the Emergency recovery room and the Emergency room main storage room.
6. Five unsecured oxygen bottles not chained or in racks in the Main oxygen storage room E and D type.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

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

Based on Record Review the facility failed to document the required testing of the emergency generators.

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 August 25, 2011 the surveyor, accompanied by the CIO and Director of Plant Operations reviewed the generator test records. No documentation of weekly inspections or monthly load tests and transfer time number of seconds (10 seconds or less) from normal power to emergency power was provided to the surveyor on site during the survey for the following:

Weekly visual inspections missing Cummings generator .

1. First three weeks of January 2011
2. Two weeks in February 2011
3. One week in April 2011

Weekly visual inspections missing for the Kohler generator

1. Three weeks in January 2011
2. Two weeks in February 2011
3. One week in March 2011
4. One week in July 2011

Weekly visual inspections missing for the Cat Generator

1. Three weeks in June 2011 and all of July 2011.

Monthly load tests and transfer time not documented was from January through June of 2011 for all three generators.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO, Director of Plant Services and Maintenance Tech.

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 lighting system failures.

Based on Observation the facility failed to identify panel board circuits.

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 384, Section 384-13 General "All panel board circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors."

Findings Include:

On August 25, 2011 the surveyor, accompanied by the CIO observed the circuit breaker panel marked EC5B on the fifth floor did not have the breakers identified.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO.

Failing to identified electrical circuits in an emergency could cause a fire or electrical shock, which may cause harm to the patients.


Based on Observation facility failed to provide protection from electrical shock.

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 110-12 (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 August 25, 2011 the surveyor accompanied by the CIO or Maintenance Tech observed the following:

1. J box covers on the wall mounted electrical box were missing in the following locations: Data room 1st and 3rd floor and the Pick up soiled linen room.
2. Electrical panel located in the main kitchen marked KP4 had an unprotected opening opening electrical wires exposed in the lower portion of the panel.

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO and Maintenance Tech.

Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the patients.

Based on Observation the facility failed to allow access to the electrical equipment/panels.

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 shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

On August 25, 2011 the surveyor, accompanied by the Maintenance Tech observed storage (boxes) in front of the electrical panel (s) located in the following locations:

1. Pharmacy IV storage and Prep room.
2. Surgery and Pre-0p

During the exit conference on August 25, 2011 the above findings were again acknowledged by the CIO and Maintenance Tech.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation. Patients will be harmed if a fire should start because of a delay.