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Based on observation the entity failed to ensure doors are provided with latches or other mechanisms suitable for keeping doors in closed position.

The findings include:

A. Surveyor observed at approximately 8:00am thru 12:00am on January 13, 2011, that the facility doors did not close flush and latch in frame in the following areas:

1. Separation door by 3-144
2. Housekeeping 3-140
3. Room 3130
4. Separation door 3116
5. Room 3182
6. Separation door by 2021
7. Intensive care separation
8. B level separation door
9. Stair 9 B level door
10. Separation door by Rehabilitation

B. Surveyor observed at approximately 8:00am thru 12:00am on January 13, 2011, that the facility doors were defective in Room 3-193.

These observations were made in the presence of the Maintenance Director on January 13, 2011.

1. 2000 Life Safety Code-4.6.12.1 Maintenance and Testing (Sprinklers)
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

This Standard is not met as evidenced by:
Based on observation the entity failed to ensure all components of the automatic sprinkler system are continuously maintained in proper operating condition on one (1) of two (2) patient floors and standpipe caps throughout the facility.

The findings include:

A. Surveyor observed at approximately 8:00am thru 12:00pm on January 12, 2011, that the facility had dust laden sprinkler heads in the following area:

Nurse Station 3rd floor.

B. Surveyor observed at approximately 8:00am thru 12:00pm on January 12, 2011, that the facility's standpipe caps throughout were not hand tightened.

These observations were made in the presence of the Maintenance Director on January 12, 2011.

2. Based on observation the entity failed to ensure all components of the automatic fire alarm system are continuously maintained in proper operating condition in one (1) of two (2) patient floors and three (3) ancillary areas.


The findings include:

A. Surveyor observed at approximately 8:00am thru 12:00pm on January 12, 2011, that the facility's emergency exit lights were not illuminated on one (1) of two (2) patient floors and two (2) ancillary areas.

1. Nurse Station 2nd floor
2. Main Kitchen
3. IT basement

B. Surveyor observed an isolated occurrence, at approximately 8:00am thru 12:00pm, on January 12, 2011, that the facility's manual pull was not properly secured to the wall. This observation was made in the corridor located by the dinning/kitchen entrance ancillary area.

These observations were made in the presence of the Maintenance Director on January 12, 2011.


3. 2000 Life Safety Code-4.5.1 Multiple Safeguards
The design of every building or structure intended for human occupancy shall be such that reliance for safety to life does not depend solely on any single safeguard. An additional safeguard (s) shall be provided for life safety in case any single safeguard is ineffective due to inappropriate human actions or system failure.

Based on observation the entity failed to ensure no fire or life safety hazards exists in the facility.

The findings include:

A. Surveyor observed at approximately 8:00am thru 12:00pm on January 13, 2011, that the facility had storage of items directly on the floor in the following areas:

1. Room 3126
2. IT basement
3. Main kitchen office
4. Electrical closet by chapel
5. Administrative area throughout

B. Surveyor observed an isolated occurrence, at approximately 8:00am thru 12:00pm, on January 13, 2011, that the facility had extension cords used for permanent fixtures in the Main Kitchen located by the steam table.

C. Surveyor observed at approximately 8:00am thru 12:00am on January 13, 2011, that the facility had surge protectors that were not mounted to a permanent fixture and extension cords used for permanent fixture in the following areas:

1. Room 3134
2. IT basement
3. Administrative area
4. Rehabilitation area in basement
5. Staffs lounge respiratory
6. Library basement

D. Surveyor observed at approximately 8:00am thru 12:00am on January 13, 2011, that the facility had lockers not properly secured to the walls in the following areas:

1. Staff locker room 3rd floor
2. Room 3152
3. Room 2-102
4. Rehabilitation A

E. Surveyor observed at approximately 8:00am thru 12:00am on January 13, 2011, that the facility had storage of items to the ceiling in the following areas:

1. Room 3-193
2. Room 3182

F. Surveyor observed at approximately 8:00am thru 12:00am on January 13, 2011, that the facility had ceiling tiles missing in the following areas:

1. Library basement
2. B soil room
3. IT basement

G. Surveyor observed at approximately 8:00am thru 12:00am on January 13, 2011, that the facility had penetrations in the ceiling or walls in the following areas:

1. Room 3151 by 3103
2. By IT office exit
3. Gift shop

H. Surveyor observed at approximately 8:00am thru 12:00am on January 13, 2011, that the facility had open junction or open wiring in the following areas:

1. Nurse station 2nd floor
2. Rehabilitation cover missing
3. Cover for clock administrative area
4. Main lobby cover missing
5. Electrical panel missing in kitchen

These observations were made in the presence of the Maintenance Director on January 13, 2011.