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The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the door closed and resistant to the passage of smoke.

Observation determined:

1) The Mail Room in the CPC Unit did not have a door separating the room from the corridor.

2) Two (2) of twelve (12) Patient Rooms in the Blue Unit did not have doors installed, separating the room from the corridor.

3) Nine (9) of twelve (12) Patient Room doors in the Blue Unit did not latch into the door frame.

The facility failed to ensure one (1) of (5) smoke barriers was at least one-half hour fire resistant and smoke resistant.

Observation determined:

Three (3) low voltage wires penetrating the smoke barrier near Room 316 in the Geriatric Unit were not properly sealed to provide a one-half hour fire resistance rating.

The facility failed to ensure doors to hazardous areas were equipped with self-closing/automatic latching hardware.

Observation determined:

1) Two (2) of twelve (12) Patient Room doors in the Blue Unit were being used as Store Rooms containing a higher than usual combustible load. The room doors did not have self closing devices.

2) Store Room 433 had a set of double doors that were not self closing and did not have self latching hardware installed.The north door had manual operated pins to latch the door.

The facility failed to ensure exits were marked by approved signage that is readily visible from any direction of exit access and that obviously and clearly identifies the exit. 7.10.1.2

Observation determined:

Only one (1) exit sign was visible from the corridor near the Doctor's Offices in the CPC Unit.

The facility failed to conduct quarterly fire drills on each shift.

Review of records determined:

There was no fire drill conducted in July 2012, resulting in the lack of a fire drill on the first shift for the third quarter of 2012.

The facility failed to ensure Automatic fire sprinkler systems were installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Observation determined:

1) In the Blue Unit Store Room, there was a ceiling light fixture mounted within one (1) inch of a sprinkler, obstructing the flow of water. The light fixture extended approximately four (4) inches from the ceiling.

2) In the Recieving Room, there were two (2) sprinklers approximately three (3) feet apart. The sprinklers were also different temperature rated types.

1) Records review indicated the facility failed to maintain fire dampers in a reliable operating condition as required by NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. Fire damper testing must be performed at least every six (6) years and records of the testing be available for review.

The fire dampers were last tested in 2010 and records showed that two (2) damper motors did not have power. There was no evidence to show that those two dampers were repaired and are working properly.


2) Records review indicated the facility failed to ensure transfer switches were subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.


There was no program in place to test and inspect the transfer switch quarterly.

The facility failed to ensure electrical wiring throughout a health care occupancy must comply with NFPA 70, National Electrical Code.

Observation determined:

Multiple GFCI outlets throughout the building did not trip when tested.