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Based upon observation and interview, it was determined that facility failed to maintain two (2) hour common walls and/or doors in accordance with regulations.

Findings include:

Observation on July 18, 2013 at 8:55 am revealed two-hour fire barrier wall with Medical Arts entrance has multiple unsealed penetrations above the door.

Interview with Maintenance Supervisor (MS) on July 18, 2013 at 8:55 am confirmed the unsealed penetrations in the fire barrier wall.

Based upon observation and interview, it was determined the facility failed to maintain doors protecting corridor openings, in other than hazardous areas, to be substantial, or smoke resistant, as per regulations in one of five wings.

Findings include:

Observation on July 18, 2013 between 8:25 am and 8:45 am revealed the following corridor doors lack positive latching:
A. Radiologist office door (8:25 am).
B. Lab receptionist 1/2 door (8:45 am).

Interview with MS on July 18, 2013 at 8:45 am confirmed the above corridor doors lack positive latching.

Based on observation and interview, the fire alarm system with approved components, devices or equipment is installed and maintained in accordance with regulations in all areas of the building.

Findings include:

Observation on July 17, 2013 at 10:30 am revealed fire alarm panel at basement Maintenance Supervisor office indicates normal condition. At the same time, another fire alarm panel at the basement vacuum pump indicates there is a trouble condition on the fire alarm (telephone line). Inspector did not witness an audible alarm for the trouble signal. (Note: Phone line trouble signal was rectified by the second day of the survey, and both panels indicated normal condition). Facility shall verify:

A. All fire alarm panels throughout the building are in-sync and communicate with each other to indicate a consistent fire alarm condition.
B. An audible alarm is present when any trouble or alarm condition is detected on the fire alarm system.

Interview with MS on July 17, 2013 at 10:30 am confirmed the fire alarm concerns.

Based on observation and interview, the fire alarm system with approved components, devices or equipment is installed and maintained in accordance with regulations in all areas of the building.

Findings include:

Observation on July 17, 2013 at 10:30 am revealed fire alarm panel at basement Maintenance Supervisor office indicates normal condition. At the same time, another fire alarm panel at the basement vacuum pump indicates there is a trouble condition on the fire alarm (telephone line). Inspector did not witness an audible alarm for the trouble signal. (Note: Phone line trouble signal was rectified by the second day of the survey, and both panels indicated normal condition). Facility shall verify:
A. All fire alarm panels throughout the building are in-sync and communicate with each other to indicate a consistent fire alarm condition.
B. An audible alarm is present when any trouble or alarm condition is detected on the fire alarm system.

Interview with Maintenance Supervisor (MS) on July 17, 2013 at 10:30 am confirmed the fire alarm concerns.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on one of five wings.

Findings include:

Observation on July 18, 2013 at 9:15 am revealed kitchen custodial room fire sprinkler head indicates evidence of possible damage (mop strings hanging from the deflector).

Interview with MS on July 18, 2013 at 9:15 am confirmed the fire sprinkler head shall be protected from damage.

Based on observation and interview, the facility failed to ensure that smoking policies are in accordance with regulations on one of two designated smoking areas.

Findings include:

Observation on July 18, 2013 at 9:00 am revealed employee entrance designated smoking area near loading dock lacks a readily available metal container with a self-closing cover device into which ashtrays can be emptied.

Interview with MS on July 18, 2013 at 9:00 am confirmed facility lacks a readily available self-closing covered cigarette butt container.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of five wings.

Findings include:

Observation on July 18, 2013 at 8:30 am revealed X-Ray file room has a toaster oven plugged into a surge protector.

Interview with MS on July 18, 2013 at 8:30 am confirmed the toaster oven is plugged into a surge protector, instead of directly into an electrical outlet.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of two floors.

Findings include:

Observation on July 17, 2013 between 8:30 am and 8:45 am revealed the facility has unauthorized items plugged into surge protectors at the following locations:
A. Second floor suite 2300 DRMC Pediatrics Consultation room; surge protector plugged into a surge protector (8:30 am).
B. Second floor suite 2200 OB/Gyn Physician Assistant office; coffee pot, microwave oven, and refrigerator plugged into a surge protector (8:45 am).

Interview with Maintenance Supervisor on July 17, 2013 at 8:45 am confirmed the above items are plugged into a surge protector, instead of directly into an electrical outlet.

Based upon observation and interview, it was determined that facility failed to maintain two (2) hour common walls and/or doors in accordance with regulations.

Findings include:

Observation on July 18, 2013 at 8:55 am revealed two-hour fire barrier wall with Medical Arts entrance has multiple unsealed penetrations above the door.

Interview with Maintenance Supervisor (MS) on July 18, 2013 at 8:55 am confirmed the unsealed penetrations in the fire barrier wall.

Based upon observation and interview, it was determined the facility failed to maintain doors protecting corridor openings, in other than hazardous areas, to be substantial, or smoke resistant, as per regulations in one of five wings.

Findings include:

Observation on July 18, 2013 between 8:25 am and 8:45 am revealed the following corridor doors lack positive latching:
A. Radiologist office door (8:25 am).
B. Lab receptionist 1/2 door (8:45 am).

Interview with MS on July 18, 2013 at 8:45 am confirmed the above corridor doors lack positive latching.

Based on observation and interview, the fire alarm system with approved components, devices or equipment is installed and maintained in accordance with regulations in all areas of the building.

Findings include:

Observation on July 17, 2013 at 10:30 am revealed fire alarm panel at basement Maintenance Supervisor office indicates normal condition. At the same time, another fire alarm panel at the basement vacuum pump indicates there is a trouble condition on the fire alarm (telephone line). Inspector did not witness an audible alarm for the trouble signal. (Note: Phone line trouble signal was rectified by the second day of the survey, and both panels indicated normal condition). Facility shall verify:

A. All fire alarm panels throughout the building are in-sync and communicate with each other to indicate a consistent fire alarm condition.
B. An audible alarm is present when any trouble or alarm condition is detected on the fire alarm system.

Interview with MS on July 17, 2013 at 10:30 am confirmed the fire alarm concerns.

Based on observation and interview, the fire alarm system with approved components, devices or equipment is installed and maintained in accordance with regulations in all areas of the building.

Findings include:

Observation on July 17, 2013 at 10:30 am revealed fire alarm panel at basement Maintenance Supervisor office indicates normal condition. At the same time, another fire alarm panel at the basement vacuum pump indicates there is a trouble condition on the fire alarm (telephone line). Inspector did not witness an audible alarm for the trouble signal. (Note: Phone line trouble signal was rectified by the second day of the survey, and both panels indicated normal condition). Facility shall verify:
A. All fire alarm panels throughout the building are in-sync and communicate with each other to indicate a consistent fire alarm condition.
B. An audible alarm is present when any trouble or alarm condition is detected on the fire alarm system.

Interview with Maintenance Supervisor (MS) on July 17, 2013 at 10:30 am confirmed the fire alarm concerns.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system in reliable operating condition on one of five wings.

Findings include:

Observation on July 18, 2013 at 9:15 am revealed kitchen custodial room fire sprinkler head indicates evidence of possible damage (mop strings hanging from the deflector).

Interview with MS on July 18, 2013 at 9:15 am confirmed the fire sprinkler head shall be protected from damage.

Based on observation and interview, the facility failed to ensure that smoking policies are in accordance with regulations on one of two designated smoking areas.

Findings include:

Observation on July 18, 2013 at 9:00 am revealed employee entrance designated smoking area near loading dock lacks a readily available metal container with a self-closing cover device into which ashtrays can be emptied.

Interview with MS on July 18, 2013 at 9:00 am confirmed facility lacks a readily available self-closing covered cigarette butt container.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of five wings.

Findings include:

Observation on July 18, 2013 at 8:30 am revealed X-Ray file room has a toaster oven plugged into a surge protector.

Interview with MS on July 18, 2013 at 8:30 am confirmed the toaster oven is plugged into a surge protector, instead of directly into an electrical outlet.

Based upon observation and interview, it was determined the electrical wiring and/or equipment failed to comply with Life Safety Code requirements or electrical safety policies on one of two floors.

Findings include:

Observation on July 17, 2013 between 8:30 am and 8:45 am revealed the facility has unauthorized items plugged into surge protectors at the following locations:
A. Second floor suite 2300 DRMC Pediatrics Consultation room; surge protector plugged into a surge protector (8:30 am).
B. Second floor suite 2200 OB/Gyn Physician Assistant office; coffee pot, microwave oven, and refrigerator plugged into a surge protector (8:45 am).

Interview with Maintenance Supervisor on July 17, 2013 at 8:45 am confirmed the above items are plugged into a surge protector, instead of directly into an electrical outlet.