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Based on observation, the facility failed to provide 1 out of 8 smoke barrier walls construction that meets the requirements of NFPA 101 - 2000 edition, Sections 19-3.7.3 and 8.3. This deficient practice could affect all occupants including residents, staff and visitors


Findings include:

On facility tour between 9:00 AM and 2:30 PM on 3/1/10, it was observed that the Oncology hall smoke barrier wall above the smoke barrier doors, were penetrated by low voltage wires, conduit and piping and not sealed with a listed through-penetration fire-stop system to maintain the required fire/smoke resistance of the wall in accordance with 19.3.7.3.

This was confirmed by Maintenance staff (DJ).

Based on observation, the facility failed to provide protection of hazardous areas in accordance with the requirements of NFPA 101 -2000 edition, Section 18.3.2.1 and 8.4.1 This deficient practice could affect all patients, guests and staff.

Findings include:

On facility tour between 9:00 AM and 2:30 PM on 3/1/10, observation revealed and were confirmed by staff that the door to the 2nd floor mechanical room was not equipped with the required door closer.


This was confirmed by Maintenance staff (DJ).

Based on observation, the facility failed to provide protection of hazardous areas in accordance with the requirements of NFPA 101 -2000 edition, Section 18.3.2.1 and 8.4.1 This deficient practice could affect all patients, guests and staff.

Findings include:

On facility tour between 9:00 AM and 2:30 PM on 3/1/10, observation revealed and were confirmed by staff that the following deficient conditions were found affecting the listed hazardous areas throughout the facility.

1. The 2nd floor Oncology storage room door had two bolt hole penetration through the door left by prior door hardware,
2. The 2nd floor Oncology storage room door is not equipped with a required door closure devise,
3. There is a 12 inch by 12 inch opening in the wall above the Purchasing storage room corridor door,
4. The door to the Purchasing storage room is not equipped with a required door closure device.


This was confirmed by Maintenance staff (DJ).

Based on review of reports and records, it was determined that the facility failed to provide the required number of fire drills for each shift in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all residents, visitors and staff.

Findings include:

On facility tour between 9:00 AM and 2:30 PM on 3/1/10, during a review of the available fire drill reports and an interview with the Maintenance staff the facility failed to vary the fire drill as follows,

1. Two fire drills held for the day shift in the 1 PM hour,
2. Two fire drills held for the evening shift in the 3 PM hour,
3. Two fire drills held for the night shift in the 6 AM hour.


This was confirmed by Maintenance staff (DJ).

Based on observations and interview with staff, the facility has failed to properly maintain 1 of several smoke detectors that is part of the buildings the fire alarm system. This deficient practice could affect the safety of all residents, staff and visitors in the event the alarm system failed activate properly and quickly.

Findings include:

On facility tour between 9:00 AM and 2:30 PM on 3/1/10, observations reveled that the smoke detector located in the 2nd floor storage room had a dust covers on it.


This was confirmed by Maintenance staff (DJ).

Based on observations and interview with staff, the facility has failed to properly maintain 1 of several smoke detectors that is part of the buildings the fire alarm system. This deficient practice could affect the safety of all residents, staff and visitors in the event the alarm system failed activate properly and quickly.

Findings include:

On facility tour between 9:00 AM and 2:30 PM on 3/1/10, observations reveled that the smoke detector located in the basement oxygen storage room had a dust covers on it.


This was confirmed by Maintenance staff (DJ).

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system in accordance with NFPA 72 (99), Sec. 7-3.2.1. This deficient practice could affect all residents, visitors, and staff.

Findings include:

On facility tour between 9:00 AM and 2:30 PM on 3/1/10, a review of the facility's available fire alarm test documentation revealed that the facility failed to conducted the required sensitivity test of each smoke detector, the facility also could not provide any past smoke detector sensitivity testing documentation at the time of the inspection as required by NFPA 72(99), Sec. 7-3.2.1.


This was confirmed by Maintenance staff (DJ).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could affect the proper operation and coverage of the fire sprinkler system. Failures to the system will affect the safety of all the patients, visitors and staff of the facility.

Findings include:

On facility tour between 9:00 AM and 2:30 PM on 3/1/10, it was observed that the facility failed to remove the sprinkler drops that were in place under the recently removal of HVAC ductwork located in the Purchasing storage room. These sprinkler drops are positioned under the sprinkler head that is located in the branch line above it, this condition will cold solder that sprinkler head creating gaps in sprinkler coverage and delay sprinkler activation.


This was confirmed by Maintenance staff (DJ).

Observations revealed that the oxygen storage room is not in accordance with NFPA 99 Standards for Health Care Facilities (1999 edition) section 4-3.5.2.2 and 8-3.1.11.2. This deficient practice could create confusion and delay in an emergency situation when oxygen is needed in a hurry. This could negatively impact the residents and staff in an emergency where some one needs oxygen quickly.

Findings include:

On facility tour between 9:00 AM and 2:30 PM on 3/1/10, it was observed, in the oxygen storage room, that:

1. 2 of 4 E-size oxygen cylinders were not secured to prevent them form being knocked over in the ambulance garage,
2. 20 of 20 H-size medical gas cylinders were not secured in the basement oxygen storage room,
3. There is an unsealed penetration in the 3 of the 4 walls of the oxygen storage room, and
4. The oxygen cylinders in the storage room were not separated by signage indicating empty and full.

This was confirmed by Maintenance staff (DJ).

appliances found not in accordance with NFPA 70 (99), National Electrical Code. This deficient practice could negatively affect all residents, staff and visitors.


Findings include:

On facility tour between 9:00 AM and 2:30 PM on 3/1/10, observations revealed that the facility failed to limit the use of several extension cords adaptor throughout the facility.


This was confirmed by Maintenance staff (DJ).