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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 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 February 9, 2012 the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff observed that the following corridor doors would not tightly close when tested.

1. Forth floor Unit Director, rated door, closure device disconnected
2. Room 445, door blocked in the open position by soiled linen cart
3. Large Equipment storage room, rated door would not latch when tested three of three times
4. Room 309, will not positively latch when tested three of three times
5. CVICU Staff lounge, door closure removed
6. CVICU Clinical Coordinator, door closure removed
7. Surgical Services Clinical Coordinator, door closure removed
8. Surgery EVS closet, door will not positively latch when tested three of three times
9. Isolation lock down ED room, UL listed door closing device missing cover
10. Radiology, Administrative Secretary, door closure device removed
11. Radiology, Imaging Clinical Coordinator, door closure device removed
12. Radiology, restroom door closure device removed
13. Phlebotomy , 1, rated door held open with an impediment and door closing device removed
14. Nuclear Medicine, rated door, closing device removed
15. Histology, number 3, door will not positively latch when tested three of three times
16. Kitchen door to Fry Cook line, holes in rated door and UL listed closing device missing cover
17. Room door number 1514, device for double door to close tight, in proper sequence missing, to include UL listed door closure device missing cover
18. Kitchen Buyers office, rated door closure removed

During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance

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 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 February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed that the Smoke Barrier doors, east, by the staff elevators. When closed the doors had a gap and is not smoke tight.

During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance

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 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 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "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 February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed in:

1. ICU WEST, storage of two large paper shelving units, reducing the exit corridor, when measured from eight feet to six feet seven inches. To include three soiled linen containers, and two blue carts. A staff member was interviewed and confirmed this is a standard operating procedure in the unit.

2. First floor, North/South corridor entering ED. Three portable charting computer units plugged into the wall charging, reducing the exits accessibility when measured from eight feet to six feet.

3. ED Unit, All exits accessibility, when measured reduced from eight feet to five feet eight inches by:
A. two patient beds in each corridor
B. two large rubbish cans with tops
C. miscellaneous medical equipment plugged into outlets charging
The Surveyor requested from the Chief Operating Officer to take pictures of the corridors, and was denied.

4. Phlebotomy 1, two exits, accessibility obstructed by, filling cabinet and chairs


During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance


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 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 February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed the following sprinkler heads:

1. Forth floor, Nursing break/restroom, paint and misses escutcheon plate
2. Rooms, 431,430, and 428 paint on the bathroom sprinklers
3. Third floor, Nourishment/supply, paint
4. Outside of rooms 312/310 paint
5. Kitchen walk in refrigerator, one of two sprinklers lint
6. Dry food storage, one of five escutcheon plates missing
7.. Specimen processing area, missing escutcheon


During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance


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 mount a fire extinguishers below the maximum height.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6, "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. Section 9.7.4.1, "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers." NFPA 10,Chapter 1,Section 1-6.10. "Fire extinguishers having a gross weight not exceeding 40 lbs. shall be installed so that the top of the fire extinguisher is not more than 5 ft. above the floor. Fire extinguishers having a gross weight greater that 40 lbs. shall be so installed that the top of the fire extinguisher is not more than 3 ? ft. above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inches."

Findings Include:

On February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed the wall mounted fire extinguisher in Histology. The top of the fire extinguisher was 68 inches above the floor and in the exit.

During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance.

Failing to mount a fire extinguisher at the correct height will cause removal problems and will cause injuries to patients.

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

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." , 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 February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed the kitchen exhaust system hoods, filters and grease drip tray areas in the following locations had an excessive amount of grease buildup.

1. Kitchen Fry Cook line, four of seven baffles and hood have large droplets of grease, to include the drip tray was completely full
2. Main kitchen cook line, three of six baffles and hood have large droplets of grease, to include one of two drip trays with grease

The kitchen Manager was interviewed and questioned when the hood baffles were cleaned and wiped down, the surveyor was told once a week as necessary.

During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance.

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.

Based on observation the facility failed to secure medical gas cylinders.

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."

Findings include:

On February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed five E type O2 cylinders next to combustibles, one of the O2 cylinders was laying horizontal on the floor unsecured in the CVICU storage room.

During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance.


Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.

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 February 9, 2012 the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff observed that the following corridor doors would not tightly close when tested.

1. Forth floor Unit Director, rated door, closure device disconnected
2. Room 445, door blocked in the open position by soiled linen cart
3. Large Equipment storage room, rated door would not latch when tested three of three times
4. Room 309, will not positively latch when tested three of three times
5. CVICU Staff lounge, door closure removed
6. CVICU Clinical Coordinator, door closure removed
7. Surgical Services Clinical Coordinator, door closure removed
8. Surgery EVS closet, door will not positively latch when tested three of three times
9. Isolation lock down ED room, UL listed door closing device missing cover
10. Radiology, Administrative Secretary, door closure device removed
11. Radiology, Imaging Clinical Coordinator, door closure device removed
12. Radiology, restroom door closure device removed
13. Phlebotomy , 1, rated door held open with an impediment and door closing device removed
14. Nuclear Medicine, rated door, closing device removed
15. Histology, number 3, door will not positively latch when tested three of three times
16. Kitchen door to Fry Cook line, holes in rated door and UL listed closing device missing cover
17. Room door number 1514, device for double door to close tight, in proper sequence missing, to include UL listed door closure device missing cover
18. Kitchen Buyers office, rated door closure removed

During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance

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 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 February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed that the Smoke Barrier doors, east, by the staff elevators. When closed the doors had a gap and is not smoke tight.

During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance

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 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 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "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 February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed in:

1. ICU WEST, storage of two large paper shelving units, reducing the exit corridor, when measured from eight feet to six feet seven inches. To include three soiled linen containers, and two blue carts. A staff member was interviewed and confirmed this is a standard operating procedure in the unit.

2. First floor, North/South corridor entering ED. Three portable charting computer units plugged into the wall charging, reducing the exits accessibility when measured from eight feet to six feet.

3. ED Unit, All exits accessibility, when measured reduced from eight feet to five feet eight inches by:
A. two patient beds in each corridor
B. two large rubbish cans with tops
C. miscellaneous medical equipment plugged into outlets charging
The Surveyor requested from the Chief Operating Officer to take pictures of the corridors, and was denied.

4. Phlebotomy 1, two exits, accessibility obstructed by, filling cabinet and chairs


During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance


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 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 February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed the following sprinkler heads:

1. Forth floor, Nursing break/restroom, paint and misses escutcheon plate
2. Rooms, 431,430, and 428 paint on the bathroom sprinklers
3. Third floor, Nourishment/supply, paint
4. Outside of rooms 312/310 paint
5. Kitchen walk in refrigerator, one of two sprinklers lint
6. Dry food storage, one of five escutcheon plates missing
7.. Specimen processing area, missing escutcheon


During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance


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 mount a fire extinguishers below the maximum height.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.6, "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. Section 9.7.4.1, "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed in accordance with NFPA 10 Standard for the Installation of Portable Fire Extinguishers." NFPA 10,Chapter 1,Section 1-6.10. "Fire extinguishers having a gross weight not exceeding 40 lbs. shall be installed so that the top of the fire extinguisher is not more than 5 ft. above the floor. Fire extinguishers having a gross weight greater that 40 lbs. shall be so installed that the top of the fire extinguisher is not more than 3 ? ft. above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inches."

Findings Include:

On February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed the wall mounted fire extinguisher in Histology. The top of the fire extinguisher was 68 inches above the floor and in the exit.

During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance.

Failing to mount a fire extinguisher at the correct height will cause removal problems and will cause injuries to patients.

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

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." , 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 February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed the kitchen exhaust system hoods, filters and grease drip tray areas in the following locations had an excessive amount of grease buildup.

1. Kitchen Fry Cook line, four of seven baffles and hood have large droplets of grease, to include the drip tray was completely full
2. Main kitchen cook line, three of six baffles and hood have large droplets of grease, to include one of two drip trays with grease

The kitchen Manager was interviewed and questioned when the hood baffles were cleaned and wiped down, the surveyor was told once a week as necessary.

During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance.

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.

Based on observation the facility failed to secure medical gas cylinders.

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."

Findings include:

On February 9, 2012 , the surveyor, accompanied by the Chief Operating Officers, Director of Engineering, and staff, observed five E type O2 cylinders next to combustibles, one of the O2 cylinders was laying horizontal on the floor unsecured in the CVICU storage room.

During the exit conference on February 9, 2012, the above findings were again acknowledged by the President & Chief Executive Officer, Chief Operating Officers, Chief Nursing Officer, Director of Engineering, Engineering Supervisor West Campus, Director Support Services, and Risk Management/Quality Assurance.


Failing to secure compressed gas cylinders, which could be knocked over, will cause harm to residents and staff.