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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 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. Section 18. 18.3.6.3.1 "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 18. 18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 11, 2011 the surveyors, accompanied by either the Chief Engineer or Plant Operations Director/Safety officer observed the following corridor doors would not tightly close, positively latch when tested at least three times.

1. Rooms 186, 189, 191, in the new construction
2. Room 102 in Isolation, Room 208 in ICU,

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer,Chief Operating Officer and Chief Nursing Officer.

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

Based on observation the the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.3 or Chapter 18, Section 18.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance clearance necessary for proper operation and shall be without undercuts, louvers, or grilles. The clearance for proper operation of smoke doors is defined as 1/8 inch.

Findings include:

On May 11, 2011 the surveyor accompanied by the Chief Engineer observed the astragal's in the corridor smoke/fire doors located by Pediatrics unit and in the Operating room #3 by the Equipment Storage room. It was observed that there was more than an 1/8 inch gap between the double doors when closed. The double doors had an approximate 1/4 to 1/2 inch gap between them when closed. In addition the smoke barrier doors by Med Surge did not close when tested three times.

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer, Chief Operating Officer, Chief Nursing Officer.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire,
which could cause harm to the patients.

Based on observations the facility did not maintain the integrity, smoke resistance, of walls in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 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.

Findings include:

On May 11, 2011 the surveyor accompanied by the Chief Engineer observed unsealed pipe chase holes, holes in walls or ceilings in the following rooms:

1. Two or three pipe chases were observed not to be not sealed in the walls between rooms five and six in the operating room and the Central Sterilization room.

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer, Chief Operating Officer, Chief Nursing Officer.

The pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to the patients.

Based on observations the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.6 "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 May 11, 2011 the surveyor, accompanied by the Chief Engineer and kitchen staff observed the entire kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease throughout the exhaust hood system, filters and grease drip tray.
The kitchen chef when asked by the surveyor how often the filters and hood are cleaned the staff advised the surveyor the kitchen filters and hood were cleaned approximately every ten days.

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer ,Chief Operating Officer, Chief Nursing Officer.

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


Based on observations the facility failed to provide fire protection for a deep fat fryer.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.2.6 "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial cooking equipment shall be in accordance with NFPA 96, Standard For Ventilation Control and Fire Protection of Commercial Cooking Operations." NFPA 96, Chapter 7, Section 7-1.2, "Cooking equipment that produces grease-laden vapors (such as but not limited to, deep fat fryers, ranges, griddles, and broilers, woks, tilting skillets, and braising pans) shall be protected by approved extinguishing equipment."

Findings include:

On May 11, 2011 the surveyor observed the kitchen deep fat fryer was being used without installed fire protection. The surveyor accompanied by the Chief Engineer and kitchen chef observed the deep fat fryer was approximately ten inches away from the fire protection nozzle and not directly over the deep fat fryer.

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer,Chief Operating Officer and Chief Nursing Officer.

Failing to protect cooking equipment could result in fire which could cause harm to the patients and could cause un-necessary damage to the kitchen.

Based on observations the facility failed to provide a medical gas cylinder storage rooms free of combustible materials and the receptacle outlets or switches were not mounted 5 feet above the floor.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, "Health Care Facilities", 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..."Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic fee. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2(a) 11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. above the floor to avoid physical damage."

Findings include:

On May 11, 2011 the surveyor accompanied by the Chief Engineer observed the following room or locations had storage of plastics and cardboard boxes etc: being stored within five feet of the oxygen E bottles empty or full storage racks and some locations had wall receptacles or light switches mounted less than 5 feet above the floor.

1. Med surge clean utility room
2. Emergency room
3. Clean Utility room in the Obstetrics/OB

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer,Chief Operating Officer and Chief Nursing Officer.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, and receptacles and switches could be damaged by cylinders if less than five feet above the floor, which could cause harm to the patients and staff.

Based on observations the facility allowed the use of a multiple outlet adapters, 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 May 11, 2011 the surveyor, accompanied by the Chief Engineer observed refrigerators in the Medical records room, Blood Bank room and the Director of Education office. These refrigerators were plugged directly into the multi-outlet adapters power strips and not directly into the wall outlet receptacles in the rooms.

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer ,Chief Operating Officer, Chief Nursing Officer.

The use of multiple outlet adapters/power strips 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 corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. Section 18. 18.3.6.3.1 "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 18. 18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18. 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 11, 2011 the surveyors, accompanied by either the Chief Engineer or Plant Operations Director/Safety officer observed the following corridor doors would not tightly close, positively latch when tested at least three times.

1. Rooms 186, 189, 191, in the new construction
2. Room 102 in Isolation, Room 208 in ICU,

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer,Chief Operating Officer and Chief Nursing Officer.

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

Based on observation the the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.7.3 or Chapter 18, Section 18.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance clearance necessary for proper operation and shall be without undercuts, louvers, or grilles. The clearance for proper operation of smoke doors is defined as 1/8 inch.

Findings include:

On May 11, 2011 the surveyor accompanied by the Chief Engineer observed the astragal's in the corridor smoke/fire doors located by Pediatrics unit and in the Operating room #3 by the Equipment Storage room. It was observed that there was more than an 1/8 inch gap between the double doors when closed. The double doors had an approximate 1/4 to 1/2 inch gap between them when closed. In addition the smoke barrier doors by Med Surge did not close when tested three times.

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer, Chief Operating Officer, Chief Nursing Officer.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire,
which could cause harm to the patients.

Based on observations the facility did not maintain the integrity, smoke resistance, of walls in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 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.

Findings include:

On May 11, 2011 the surveyor accompanied by the Chief Engineer observed unsealed pipe chase holes, holes in walls or ceilings in the following rooms:

1. Two or three pipe chases were observed not to be not sealed in the walls between rooms five and six in the operating room and the Central Sterilization room.

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer, Chief Operating Officer, Chief Nursing Officer.

The pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to the patients.

Based on observations the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.6 "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 May 11, 2011 the surveyor, accompanied by the Chief Engineer and kitchen staff observed the entire kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease throughout the exhaust hood system, filters and grease drip tray.
The kitchen chef when asked by the surveyor how often the filters and hood are cleaned the staff advised the surveyor the kitchen filters and hood were cleaned approximately every ten days.

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer ,Chief Operating Officer, Chief Nursing Officer.

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


Based on observations the facility failed to provide fire protection for a deep fat fryer.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.2.6 "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial cooking equipment shall be in accordance with NFPA 96, Standard For Ventilation Control and Fire Protection of Commercial Cooking Operations." NFPA 96, Chapter 7, Section 7-1.2, "Cooking equipment that produces grease-laden vapors (such as but not limited to, deep fat fryers, ranges, griddles, and broilers, woks, tilting skillets, and braising pans) shall be protected by approved extinguishing equipment."

Findings include:

On May 11, 2011 the surveyor observed the kitchen deep fat fryer was being used without installed fire protection. The surveyor accompanied by the Chief Engineer and kitchen chef observed the deep fat fryer was approximately ten inches away from the fire protection nozzle and not directly over the deep fat fryer.

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer,Chief Operating Officer and Chief Nursing Officer.

Failing to protect cooking equipment could result in fire which could cause harm to the patients and could cause un-necessary damage to the kitchen.

Based on observations the facility failed to provide a medical gas cylinder storage rooms free of combustible materials and the receptacle outlets or switches were not mounted 5 feet above the floor.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, "Health Care Facilities", 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..."Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic fee. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2(a) 11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. above the floor to avoid physical damage."

Findings include:

On May 11, 2011 the surveyor accompanied by the Chief Engineer observed the following room or locations had storage of plastics and cardboard boxes etc: being stored within five feet of the oxygen E bottles empty or full storage racks and some locations had wall receptacles or light switches mounted less than 5 feet above the floor.

1. Med surge clean utility room
2. Emergency room
3. Clean Utility room in the Obstetrics/OB

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer,Chief Operating Officer and Chief Nursing Officer.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, and receptacles and switches could be damaged by cylinders if less than five feet above the floor, which could cause harm to the patients and staff.

Based on observations the facility allowed the use of a multiple outlet adapters, 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 May 11, 2011 the surveyor, accompanied by the Chief Engineer observed refrigerators in the Medical records room, Blood Bank room and the Director of Education office. These refrigerators were plugged directly into the multi-outlet adapters power strips and not directly into the wall outlet receptacles in the rooms.

The findings were again acknowledged at the exit interview with the Chief Engineer, Plant Operations Director/Safety Officer, Interim Chief Nursing Officer ,Chief Operating Officer, Chief Nursing Officer.

The use of multiple outlet adapters/power strips 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.