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Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observed penetrations in the corridor walls located in the following areas:

1. Second Floor, Electrical room by OR # 4.
2. Second Floor, Cath Lab communication room.
2. Forth Floor, 4 B, Elevators 7&8 North & South corridor.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation the facility failed to protect a vertical opening for a service dumbwaiter.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.1.1 "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating." Section 8.2.5.2 "Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Findings Include:


On April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observed the following corridor door would not tightly close when tested.

1. Clean Elevator, door would not positively latch when tested three of three times.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

Failing to provide enclosures between floors will cause harm to patients and staff.

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 April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observed unsealed penetrations in the smoke barrier, located at:

1. Third Floor, 3 A, by Dr's. Dictation

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

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 did not maintain the integrity, smoke resistance, of doors 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 and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observed hazardous area doors in the following locations:

1. OR Trash room, double rated doors, astragal torn, not smoke tight.
2. Cardiac Pulmonary/Sterile processing, two of two doors removed, rooms contain flammables; combustibles; and Oxygen.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

Failing to prevent heat and smoke from spreading into the exit corridor 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 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observations include the following findings:

1. PACU, storage room, one of one sprinkler, paint and bent.
2. SPS 10 & 11, lint on sprinklers
3. First Floor, X-Ray room four, one of two sprinklers paint.
4. Lardia Rehab office, sprinkler missing escutcheon plate.
5. second floor, staff lounge missing one of four escutcheon plates.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.


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.

Based on observation the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray, and failed to provide fire protection for a stove.

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."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."
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 April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup on eight of eight filters and the surrounding hood frame.
The surface protection nozzles were not protecting the cooking appliances as the appliances have moved and are not protected as designed.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.
Failing to protect cooking equipment could result in fire which will harm the patients.

Based on observation and staff interview the facility failed to provide a medical gas cylinder storage room free of combustible materials.

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..."

Findings include:

On April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observations include the following findings of oxygen storage rooms:

1. PACU RT storage room, two of six E-O2 bottles unsecured, all six E-O2 bottles within five feet of combustibles and a light switch. The room has a rated Oxygen storage cabinet.
2. Physical Rehab, three E-O2, stored by combustibles, seven days a week.
3. Cardiac Rehab, three E-O2, stored less than five feet from combustibles.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients.

Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observed penetrations in the corridor walls located in the following areas:

1. Second Floor, Electrical room by OR # 4.
2. Second Floor, Cath Lab communication room.
2. Forth Floor, 4 B, Elevators 7&8 North & South corridor.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation the facility failed to protect a vertical opening for a service dumbwaiter.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.1.1 "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating." Section 8.2.5.2 "Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Findings Include:


On April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observed the following corridor door would not tightly close when tested.

1. Clean Elevator, door would not positively latch when tested three of three times.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

Failing to provide enclosures between floors will cause harm to patients and staff.

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 April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observed unsealed penetrations in the smoke barrier, located at:

1. Third Floor, 3 A, by Dr's. Dictation

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

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 did not maintain the integrity, smoke resistance, of doors 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 and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observed hazardous area doors in the following locations:

1. OR Trash room, double rated doors, astragal torn, not smoke tight.
2. Cardiac Pulmonary/Sterile processing, two of two doors removed, rooms contain flammables; combustibles; and Oxygen.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

Failing to prevent heat and smoke from spreading into the exit corridor 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 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observations include the following findings:

1. PACU, storage room, one of one sprinkler, paint and bent.
2. SPS 10 & 11, lint on sprinklers
3. First Floor, X-Ray room four, one of two sprinklers paint.
4. Lardia Rehab office, sprinkler missing escutcheon plate.
5. second floor, staff lounge missing one of four escutcheon plates.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.


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.

Based on observation the facility failed to clean the kitchen exhaust hood system, filters and grease drip tray, and failed to provide fire protection for a stove.

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."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."
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 April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observed the kitchen exhaust system hood, filters and grease drip tray area had an excessive amount of grease buildup on eight of eight filters and the surrounding hood frame.
The surface protection nozzles were not protecting the cooking appliances as the appliances have moved and are not protected as designed.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

Failing to keep the entire kitchen exhaust hood system clean from grease will cause a fire, which could cause damage to the kitchen and will cause harm to the patients.
Failing to protect cooking equipment could result in fire which will harm the patients.

Based on observation and staff interview the facility failed to provide a medical gas cylinder storage room free of combustible materials.

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..."

Findings include:

On April 7, 2014, the surveyor, accompanied by the Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors, observations include the following findings of oxygen storage rooms:

1. PACU RT storage room, two of six E-O2 bottles unsecured, all six E-O2 bottles within five feet of combustibles and a light switch. The room has a rated Oxygen storage cabinet.
2. Physical Rehab, three E-O2, stored by combustibles, seven days a week.
3. Cardiac Rehab, three E-O2, stored less than five feet from combustibles.

During the exit conference on April 8, 2014, the above findings were again acknowledged by the President & CEO; Director Facility Development, Design & Construction; Engineering Director; Director of Support Services; and two Engineering Supervisors.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients.