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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 September 12, 2012, the surveyor, accompanied by the Project Manager and facility staff, observed the following penetrations in corridor walls located at:

1. Nuclear Medicine
2. Data Main PBX

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.


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 maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "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 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On September 12, 2012 the surveyor, accompanied by the Project Manager and facility staff, observed that the following corridor doors would not tightly close when tested:

1. Sleep lab, door will not positively latch when tested three of three times
2. Pharmacy, door closing device disconnected
3. Cafeteria rated door, will not positively latch when tested three of three times


During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

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

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 September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff,observed unsealed penetrations in the smoke barrier, located at:

1. Nuclear Medicine/Cath Lab


During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.


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 failed to maintain self closing doors in a 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 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 necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings include:

On September 12, 2012 , the surveyor, accompanied by the Project Manager, and facility staff, observed the following corridor smoke/fire doors would not close tight when tested.

1. Rated 1 hr doors to Nuclear Medicine/Cat Scan, gap greater than approximate 1/8 in.
2. Cardio Pulmonary, double smoke barrier doors will not close tight


During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

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

Based on observation the facility failed to keep the laundry room dryers clean.
Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.
Based on observation the facility failed to maintain the smoke resistance, of walls, ceilings or pipe chases in hazardous areas.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. ", 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 September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff, observed the following areas:

A. Dryer in the laundry room had an excessive amount of lint in the dryers drum frame, and the floor area of the dryer.
B. Doors:
1. Family waiting area, office converted into storage, no self closing device
2. Housekeeping closet by ER, flammables and combustibles stored in closet, door has no self closing device
3. Cat Scan door, Closing device broken
4. OR Janitor closet ,flammables and combustibles stored in closet, door has no self closing device
5. Pulmonary Function Test Room, med gases stored in room, door has a closing device and will not positively latch when tested three of three times
6. Gift shop storage room, measured approximately fifty square feet, door does not have a self closing device
7. Main Kitchen door, does not have a self closing device
8. Housekeeping office/storage, door will not positively latch when tested three of three times
9. Equipment storage by room 17, rated door does not have a closing device
C. Data main PBX room, fill all open conduits

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.
Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.
Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.

Based on observation the facility failed to keep exit doors unlocked.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 7.2.1.5.1 "Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided , shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Findings include:

On September 12, 2012, the surveyor, accompanied by the Project Manager and facilities staff, observed that the exit, door located at, Nuclear Medicine was locked with a dead bolt and a cypher lock.

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

Failure to have all exits unlocked during a fire or emergency will cause harm to the patients.

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 September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff, observed storage of; a garbage can, respiratory equipment, IV storage rack, and a computer station reducing the exit corridor when measured from eight feet to six feet, within the exit corridor in ER.

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

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 battery operated emergency lighting.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings Include:

On September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff, tested the emergency lighting units located in the Mobil MRI unit, one of three failed to light during the test.

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.


Failure to maintain emergency lighting units in proper operating condition will cause harm to the patients during a power outage.

Based on observation the facility failed to provide directional exit signs indicating two ways out.
Based on observation the facility failed to maintain the battery back-up of an illuminated exit sign.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.10.1, " Means of egress shall have signs in accordance with Section 7.10." Section 7.10.1.2 "A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent."" Section 7.10.4 " Where emergency lighting facilities are required by the applicable provisions of Chapter 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities...


Findings include:

1. On September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff, observed that in the Family waiting area, formally purchasing, there was not any exit sign visible. No directional signs were installed to indicate a way out.
2. The Emergency battery back up exit light failed when tested in the Mobil MRI unit


During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

Failing to direct residents/patients to two ways out in case the primary exit is blocked by fire or smoke will cause harm to the patients.
Failure of the emergency back up lighting system, for the exit signs, may cause confusion during a power failure or a fire and will cause harm to the patients.

Based on Observation the facility failed to provide occupant notification devices on the fire alarm system.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.4.3.1. "Occupant Notification" "Occupant notification shall be accomplished automatically in accordance with 9.6.3." Section 9.6.3 " Section 9.6.3.1 "Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code." Section 9.6.3.2 "Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12."

Findings include:

On September 12, 2012 , the surveyor accompanied by the Project Manager an the facilities staff, inspected and tested the smoke detector at the entrance of the Mobil MRI unit, the battery operated smoke detector, failed.

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

Failing to provide occupant notification during a fire or other emergency will cause harm to staff and patients

Based on Observation the facility failed to maintain the sprinkler head in the walk in refrigerator in the kitchen.
Based on observation the facility did not 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 an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 3, Section 3-2.6.1 and 3-2.6.2, Listed corrosion resistant sprinklers shall be installed in locations where chemicals, moisture, or other corrosive vapors sufficient to cause corrosion of such devices exist. Corrosion -resistant coatings shall be applied only by manufacturer of the sprinkler. 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 September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff, observed the walk in refrigerator and the freezer in the kitchen. The refrigerator has a corroded sprinkler head, this was apparent by the green color around the assembly, the freezer and Trauma room closet are missing the escutcheon plates. To include OR-A, the sprinkler cover is missing.

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

Failure to maintain sprinkler heads will not allow the head to operate correctly under fire conditions and will cause harm to the patients.
Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This will cause harm to the patients.

Based on observation and staff interview, the facility failed to mount an electrical light switch five feet from the oxygen stored in the Nuclear Medicine room.
Based on Observations the facility failed to separate empty and full medical gas cylinders.
Based on Observation the facility failed to secure medical gas cylinders/containers.


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 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
" 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. (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."

Findings include:

On September 12, 2012, the surveyor accompanied by the Project Manager and the facilities staff,observed unsecured medical gas cylinders/ containers located in the following rooms/areas to include improper storage:

1. Mobil MRI, 1 E-O2 bottle unsecured next to an electrical power strip
2. Trauma Room, 1 E-O2, in closet with combustibles
3. Nuclear Medicine, 1 H-O2 bottle stored within five feet of a 110 outlet and combustibles. The staff interviewed stated the room is only used approximately fifteen days a month.
4. Oxygen storage room has signs stating FULL/EMPTY, however the medical gases are not segregated completely
5. Eight LOX containers are not secured in the Medical gas storage area

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.


Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to patients and staff.
Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.
In an emergency, patients would be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on record Review the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings include:

On September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff reviewed the generator test records of the four generators. No documentation of the number of seconds (10 seconds or less) from normal power to emergency power was documented:

Generator number one(Hospital OR/Er) missing documentation dates: August, September, April, February, and January of 2012, December and September of 2011
Generator number two(Kitchen and medical records)No transfer documentation
Generator number three(CT) No transfer documentation
Generator number four(Patient wing) missing documentation dates: August, July, May, February, January 2012, December, November, and September 2011

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.


Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during lighting system failures.

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 September 12, 2012, the surveyor, accompanied by the Project Manager and facility staff, observed the following penetrations in corridor walls located at:

1. Nuclear Medicine
2. Data Main PBX

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.


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 maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "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 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On September 12, 2012 the surveyor, accompanied by the Project Manager and facility staff, observed that the following corridor doors would not tightly close when tested:

1. Sleep lab, door will not positively latch when tested three of three times
2. Pharmacy, door closing device disconnected
3. Cafeteria rated door, will not positively latch when tested three of three times


During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

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

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 September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff,observed unsealed penetrations in the smoke barrier, located at:

1. Nuclear Medicine/Cath Lab


During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.


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 failed to maintain self closing doors in a 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 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 necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings include:

On September 12, 2012 , the surveyor, accompanied by the Project Manager, and facility staff, observed the following corridor smoke/fire doors would not close tight when tested.

1. Rated 1 hr doors to Nuclear Medicine/Cat Scan, gap greater than approximate 1/8 in.
2. Cardio Pulmonary, double smoke barrier doors will not close tight


During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

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

Based on observation the facility failed to keep the laundry room dryers clean.
Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.
Based on observation the facility failed to maintain the smoke resistance, of walls, ceilings or pipe chases in hazardous areas.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. ", 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 September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff, observed the following areas:

A. Dryer in the laundry room had an excessive amount of lint in the dryers drum frame, and the floor area of the dryer.
B. Doors:
1. Family waiting area, office converted into storage, no self closing device
2. Housekeeping closet by ER, flammables and combustibles stored in closet, door has no self closing device
3. Cat Scan door, Closing device broken
4. OR Janitor closet ,flammables and combustibles stored in closet, door has no self closing device
5. Pulmonary Function Test Room, med gases stored in room, door has a closing device and will not positively latch when tested three of three times
6. Gift shop storage room, measured approximately fifty square feet, door does not have a self closing device
7. Main Kitchen door, does not have a self closing device
8. Housekeeping office/storage, door will not positively latch when tested three of three times
9. Equipment storage by room 17, rated door does not have a closing device
C. Data main PBX room, fill all open conduits

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.
Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.
Failing to fill pipe chases or holes could allow heat and smoke to spread into walls, attics, or exit corridors which will cause harm to the patients.

Based on observation the facility failed to keep exit doors unlocked.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 7.2.1.5.1 "Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided , shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

Findings include:

On September 12, 2012, the surveyor, accompanied by the Project Manager and facilities staff, observed that the exit, door located at, Nuclear Medicine was locked with a dead bolt and a cypher lock.

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

Failure to have all exits unlocked during a fire or emergency will cause harm to the patients.

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 September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff, observed storage of; a garbage can, respiratory equipment, IV storage rack, and a computer station reducing the exit corridor when measured from eight feet to six feet, within the exit corridor in ER.

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

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 battery operated emergency lighting.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.9.1 " Emergency lighting shall be provided in accordance with Section 7.9."Section 7.9.2.4 "Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition."

Findings Include:

On September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff, tested the emergency lighting units located in the Mobil MRI unit, one of three failed to light during the test.

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.


Failure to maintain emergency lighting units in proper operating condition will cause harm to the patients during a power outage.

Based on observation the facility failed to provide directional exit signs indicating two ways out.
Based on observation the facility failed to maintain the battery back-up of an illuminated exit sign.


NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.2.10.1, " Means of egress shall have signs in accordance with Section 7.10." Section 7.10.1.2 "A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent."" Section 7.10.4 " Where emergency lighting facilities are required by the applicable provisions of Chapter 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities...


Findings include:

1. On September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff, observed that in the Family waiting area, formally purchasing, there was not any exit sign visible. No directional signs were installed to indicate a way out.
2. The Emergency battery back up exit light failed when tested in the Mobil MRI unit


During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

Failing to direct residents/patients to two ways out in case the primary exit is blocked by fire or smoke will cause harm to the patients.
Failure of the emergency back up lighting system, for the exit signs, may cause confusion during a power failure or a fire and will cause harm to the patients.

Based on Observation the facility failed to provide occupant notification devices on the fire alarm system.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.4.3.1. "Occupant Notification" "Occupant notification shall be accomplished automatically in accordance with 9.6.3." Section 9.6.3 " Section 9.6.3.1 "Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code." Section 9.6.3.2 "Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12."

Findings include:

On September 12, 2012 , the surveyor accompanied by the Project Manager an the facilities staff, inspected and tested the smoke detector at the entrance of the Mobil MRI unit, the battery operated smoke detector, failed.

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

Failing to provide occupant notification during a fire or other emergency will cause harm to staff and patients

Based on Observation the facility failed to maintain the sprinkler head in the walk in refrigerator in the kitchen.
Based on observation the facility did not 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 an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 3, Section 3-2.6.1 and 3-2.6.2, Listed corrosion resistant sprinklers shall be installed in locations where chemicals, moisture, or other corrosive vapors sufficient to cause corrosion of such devices exist. Corrosion -resistant coatings shall be applied only by manufacturer of the sprinkler. 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 September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff, observed the walk in refrigerator and the freezer in the kitchen. The refrigerator has a corroded sprinkler head, this was apparent by the green color around the assembly, the freezer and Trauma room closet are missing the escutcheon plates. To include OR-A, the sprinkler cover is missing.

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.

Failure to maintain sprinkler heads will not allow the head to operate correctly under fire conditions and will cause harm to the patients.
Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, will allow heat and smoke to effect other areas of the building. This will cause harm to the patients.

Based on observation and staff interview, the facility failed to mount an electrical light switch five feet from the oxygen stored in the Nuclear Medicine room.
Based on Observations the facility failed to separate empty and full medical gas cylinders.
Based on Observation the facility failed to secure medical gas cylinders/containers.


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 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
" 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. (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."

Findings include:

On September 12, 2012, the surveyor accompanied by the Project Manager and the facilities staff,observed unsecured medical gas cylinders/ containers located in the following rooms/areas to include improper storage:

1. Mobil MRI, 1 E-O2 bottle unsecured next to an electrical power strip
2. Trauma Room, 1 E-O2, in closet with combustibles
3. Nuclear Medicine, 1 H-O2 bottle stored within five feet of a 110 outlet and combustibles. The staff interviewed stated the room is only used approximately fifteen days a month.
4. Oxygen storage room has signs stating FULL/EMPTY, however the medical gases are not segregated completely
5. Eight LOX containers are not secured in the Medical gas storage area

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.


Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to patients and staff.
Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.
In an emergency, patients would be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on record Review the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings include:

On September 12, 2012, the surveyor, accompanied by the Project Manager and the facilities staff reviewed the generator test records of the four generators. No documentation of the number of seconds (10 seconds or less) from normal power to emergency power was documented:

Generator number one(Hospital OR/Er) missing documentation dates: August, September, April, February, and January of 2012, December and September of 2011
Generator number two(Kitchen and medical records)No transfer documentation
Generator number three(CT) No transfer documentation
Generator number four(Patient wing) missing documentation dates: August, July, May, February, January 2012, December, November, and September 2011

During the exit conference on September 12, 2012, the above findings were again acknowledged by the Project Manager, Plant Manager, and the Plant Operator.


Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during lighting system failures.