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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 a closed position.

The findings include:

NFPA 101 Life Safety Code Standard

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous area are substantial doors, such as those constructed of 1 3/4 inch solid-bond core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted 19.3.6.3

Roller latches are prohibited by CMS regulations in all health care facilities.

a. Surveyors observed at approximately 10:30AM to 1:30PM on April 14, 2010 that the facility's doors did not close and latch in the following areas: 2150, 2110, atrium door next to 3180, 3224, 3436, 1st floor compartment door to outpatient therapy room, 1st floor separation doors leading to the gym, separation doors next to 1227, separation door next to 1068.

b. Surveyors observed at approximately 10:30AM to 1:30PM on April 14, 2010 that the facility room(room 2019) is incorrectly labeled.

c. Surveyors observed at approximally 10:30AM to 1:30 PM on April 14, 2010 that the facility's door for G122 had holes (where locks were removed)

1. Based on observation the entity failed to ensure all components of the automatic sprinkler system are continuously maintained in proper operating condition.


2000 Life Safety Code- 4.6.12.1 Maintenance and Testing

Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of the 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.


The findings include:

1. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 that the facility's heat detector labeled #5, outside the elevator machine room, was hanging from the ceiling with one of six (6) exposed wires.


2. Based on observation the entity failed to ensure all components of the automatic sprinkler system are continuously maintained in proper operating condition.

The finding include:

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 the 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.


a. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 , that the facility's storage closet 1115 has no sprinkler head.

b. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 , that the facility had sprinkler head that were painted in the following area: 3017, and 3204.

c. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 , that the facility had sprinkler heads in the main kitchen that were dust laden and have a grease build up.

d. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 , that the facility's escutcheon plate was missing in room 220.

3. Based on observation the entity failed to ensure no fire and life safety hazards exit in the facility.

The findings include:

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 like does not depend solely on any single safeguard. An additional safeguard (s) shall be provided for life safety in case any single safeguard is effective due to inappropriate human actions or system failure.

a. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 that the facility had storage directly on the floor in the following areas: East penthouse, 2019, 2152, G006, G101, G097, G103, G112, G114, G075, G123, G135.

b. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 , that the facility had storage stacked to the ceiling in the following areas: 2018, 2019, G068A, G068B, G058, G101, G098, G103, G112, G075, G135, storage closet 1203.

c. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 that the facility had ceiling tiles missing in the following areas: Outside room 3009, atrium storage room 3174, electrical closet 1063, storage closet 1080, G068A.

d. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 that the facility had extension cords used for permanent wiring in the following areas: G114 and G126.

e. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 that the facility's surge protectors are not mounted to permanent fixtures throughout the building.

e. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 that the facility had open junction boxes with exposed wiring in the following area: Penthouse ceiling across from carpentry room, 2020, stairwell 2 East, telephone closet 3022 and electrical closet 1025.

f. Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 that the facility had penetrations in the walls or ceiling in the following areas: Electrical closet 3010 (wall), telephone closet next to 1115 (wall), electrical closet 1025, fire alarm control room, G066 (ceiling).

g. Surveyors observed at approximately 10:30 Am to 1:30 PM on April 14, 2010 that the facility needed house cleaning in the following areas: 2104, G063, and G092.

h. Surveyors observed at approximately 10:30 Am to 1:30 PM on April 14, 2010 that the facility had her storage in the stairs (G067).

4. Based on observation the entity failed to ensure all fire protection equipment was in proper operation condition.

The finding include:

2000 Life Safety Code-4.5.7 Maintenance

Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of the Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

Surveyors observed at approximately 10:30 AM to 1:30 PM on April 14, 2010 that the facility's fire extinguisher in the carpentry room required service (tag expired).