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Based on observation the facility failed to provide a self-closing or an automatic-closing door 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 March 29, 2011 the surveyors accompanied by the Director of Plant Operations observed the kitchen dry food storage room door was missing its self-closing device. The storage room was measured by the Director of Plant Operations to be of approximately 150 total square feet.

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

Based on observations the facility failed to provide a written plan for the protection of all patients in time of a fire or emergency.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.1.1 "The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for their evacuation to areas of refuge, and from the evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.

Findings Include:

On March 29, 2011 the surveyors, accompanied by the Director of Plant Operations asked to see the written emergency policy manual at the Sabino Nurse's Station. The written fire and emergency policy manual was not at the nursing station according the staff when asked and the Director of Plant Operations.

In time of a fire or emergency, an emergency policy manual must be readily available for the staff.
Patients could be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on observations the facility failed to secure medical gas cylinders and provide protection for the exterior oxygen cylinder storage bottles.

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 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. "NFPA 99, Chapter 4, Section 4-3.5.2.2, (3) "Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter; cylinders stored in the open shall be protected against accumulations of ice or snow. In summer; cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail."

Findings include:

On March 29, 2011 the surveyors, accompanied by the Director of Plant Operations observed the exterior bulk oxygen cylinder storage location. Twelve E type oxygen cylinders were not protected by a sun shade and five E type oxygen cylinders were not secured in a rack but observed lying flat on the ground.

Failing to secure compressed gas cylinders, which could be knocked over could cause harm to the residents and staff. Failing to protect exterior stored medical gas cylinders from rust, snow/ice or sun may cause harm to the patients.


Based on observations 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, "Health Care Facilities", Chapter 4, Section 4-3.1.1.2 "Storage Requirements (Location, Construction, Arrangement.) Section 4-3.1.1.2 (c) "Locations for supply systems shall not be used for storage purposes other than for containers of nonflammable gases. " Section 4-5.1.1.2 (b) 7 "Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen..."

Findings include

On March 29, 2011 the surveyors, accompanied by the Director of Plant Operations observed twelve oxygen bottles in a rack being stored next to plastics, paper and other combustible material in the Sabino staff lounge. The oxygen cylinders were not five feet away from combustible materials

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


Based on observations the facility failed to mount an electrical receptacle outlet five feet above the floor in the Sabino Gym.

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 March 29, 2011 the surveyors, accompanied by the Director of Plant Operations observed the E type oxygen cylinders stored in a rack were being stored right next to a wall mounted electrical receptacle outlet. The receptacle outlet was not five feet above the floor.

Failing to mount an electrical receptacle outlet five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.