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Based on observation the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

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."

Findings include:

On April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support services and a Maintenance Technician observed the following smoke barrier doors are out of adjustment, and are not smoke tight.

1. Smoke barrier door by Ultrasound, gap 3/8 of an inch when measured
2. Main OR smoke barrier not smoke tight

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services.

Failure to properly adjust or repair the smoke doors could cause harm to residents.
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 provide a self-closing or an automatic-closing device in a hazardous area.

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.

Findings Include:

On April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support services and a Maintenance Technician observed the clean utility storage door closing device was removed.

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services.

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

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 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "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."

Findings include:

On April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support Services and a Maintenance Technician observed storage in the following exit access corridors:

1. Ten items to include chairs, and tables, within the exit corridor. The storage was blocking the exit access by reducing when measure the corridor from eight feet to five feet five inches. The exit access is located in Out Patient Recovery.
2. Seven Chairs and two tables reducing the corridor when measured from eight feet to five feet ten inches. The exit access is located in the ICU Waiting Area
3. Computers reducing exit access when measured from eight feet to six feet in the PACS Processor corridor

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services.

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

Findings Include:

On April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support Services and a Maintenance Technician, observations include the following findings:

1. CT Scan room, two of two sprinklers lint
2. Tech work room. one of one sprinkler lint
3. Business office, four of six sprinklers lint
4. Micro, one of one sprinkler lint

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services.

Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

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.


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 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 April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support Services and a Maintenance Technician, observed oxygen storage in the following areas:

1. OR utility room, two E-O2 bottles stored within five feet of electrical and combustibles
2. Main OR corridor, six E- O2 bottles stored within five feet of electrical and combustibles

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients and 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 Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

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.

Findings include:

On April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support Services and a Maintenance Technician, observed refrigerators plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. Cardio break room, refrigerator plugged into power strip
2. Impinging office, refrigerator plugged into power strip

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services

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.

Based on observation the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

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."

Findings include:

On April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support services and a Maintenance Technician observed the following smoke barrier doors are out of adjustment, and are not smoke tight.

1. Smoke barrier door by Ultrasound, gap 3/8 of an inch when measured
2. Main OR smoke barrier not smoke tight

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services.

Failure to properly adjust or repair the smoke doors could cause harm to residents.
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 provide a self-closing or an automatic-closing device in a hazardous area.

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.

Findings Include:

On April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support services and a Maintenance Technician observed the clean utility storage door closing device was removed.

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services.

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

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 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "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."

Findings include:

On April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support Services and a Maintenance Technician observed storage in the following exit access corridors:

1. Ten items to include chairs, and tables, within the exit corridor. The storage was blocking the exit access by reducing when measure the corridor from eight feet to five feet five inches. The exit access is located in Out Patient Recovery.
2. Seven Chairs and two tables reducing the corridor when measured from eight feet to five feet ten inches. The exit access is located in the ICU Waiting Area
3. Computers reducing exit access when measured from eight feet to six feet in the PACS Processor corridor

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services.

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

Findings Include:

On April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support Services and a Maintenance Technician, observations include the following findings:

1. CT Scan room, two of two sprinklers lint
2. Tech work room. one of one sprinkler lint
3. Business office, four of six sprinklers lint
4. Micro, one of one sprinkler lint

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services.

Failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

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.


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 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 April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support Services and a Maintenance Technician, observed oxygen storage in the following areas:

1. OR utility room, two E-O2 bottles stored within five feet of electrical and combustibles
2. Main OR corridor, six E- O2 bottles stored within five feet of electrical and combustibles

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients and 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 Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

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.

Findings include:

On April 29, 2013, the surveyor, accompanied by the Director of Maintenance, Support Services and a Maintenance Technician, observed refrigerators plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. Cardio break room, refrigerator plugged into power strip
2. Impinging office, refrigerator plugged into power strip

During the exit conference on April 29, 2013, the above findings were again acknowledged by the CEO, the Director of Maintenance and Support Services

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.