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Based on observations, the facility failed to comply with the the general requirements.

The findings included:

Observation on 07/10/2018 at 10:04 AM and 10:57 AM, revealed a sprinkler installed the in Dietary paper goods storage room and the Night Pharmacy that is not in service. NFPA 101, 19.1.1.1.3 (2012 Edition) NFPA 101, 4.6.12.3 (2012 Edition)

Maintenance staff were present when the deficiency was identified, and were later acknowledged by the administrator during the exit conference on 7/10/2018.

Based on observation, the facility failed to maintian Aisle, Corridor or Ramp Width.

The findings included:

Observation on 07/10/2018 at 1:38 PM, revealed storage of equipment in the OR surgical suite corridor. NFPA 101, 19.2.3.4 (2012 Edition)

Maintenance staff were present when the deficiency was identified, and were later acknowledged by the administrator during the exit conference on 7/10/2018.

Based on observations, the facilty failed to protect the hazardous areas.

The findings included:

Observation on 07/10/2018 at 9:31 AM, revealed the ceiling to the 50 Hallway mechincal room, across from the rehabilation gym, did not resist the passage of smoke (large holes and missing pieces of ceiling tiles). NFPA 101, 19.3.2.1.2* (2012 Edition) NFPA 101, 8.4.2 (2012 Edition)

Maintenance staff were present when the deficiency was identified, and were later acknowledged by the administrator during the exit conference on 7/10/2018.

Based on observation, the facility ailed to maintain the fire extinguishers.

The findings included:

Observation on 07/10/2018 at 11:24 AM, revealed the BC Carbon Dioxide fire extinguisher in the ICU medical vacuum pump/boiler room had not been hydrostatically tested in the past 5 years. NFPA 101, 19.3.5.12 (2012 Edition) NFPA 10, 8.3.1 (2010 Edition)

Maintenance staff were present when the deficiency was identified, and were later acknowledged by the administrator during the exit conference on 7/10/2018.

Based on observations, the facility failed to maintain corridor walls.

The findings included:

1. Observation on 07/10/2018 at 11:35 AM, revealed the walls and ceiling of the sprinkler riser room did not resist the passage of smoke (gypsum board missing and holes filled with a foam material). NFPA 101, 19.3.6.2.4* (2012 Edition)

2. Observation on 07/10/2018 at 1:23 PM, revealed the janitorial closet in the Operating Rooms suite did not have a ceiling that resisted the passage of smoke. NFPA 101, 19.3.6.2.4* (2012 Edition)

3. Observation on 07/10/2018 at 1:32 PM, revealed the Main Sterilizer Mechanical room in the Operating Rooms suite did not have a ceiling that resisted the passage of smoke. NFPA 101, 19.3.6.2.4* (2012 Edition)

4. Observation on 07/20/2018 at 1:40 PM, revealed the walls and ceiling of the electrical room in the old conference room did not resist the passage of smoke (holes in wall filled with foam and missing pieces of the ceiling). NFPA 101, 19.3.6.2.4* (2012 Edition)

Maintenance staff was present when these findings were identified, and were later acknowledged by the administrator during the exit conference on 07/10/2018.

Based on observations, the facility failed to maintain the utilities.

The findings included:

1. Observation on 07/10/2018 at 9:47 AM, revealed an extension cord used as permanent wiring in the sleep center control room. NFPA 101, 19.5.1.1 (2012 Edition) NFPA 101, 9.1.2 (2012 Edition) NFPA 70, 590.3 (2011 Edition)

2. Observation on 07/10/2018 at 10:23 AM, revealed the high to low voltage power supply of the access control system in the fire alarm control panel room was hot to the touch and the protective cover was discolored and appeared degraded. NFPA 101, 19.5.1.1 (2012 Edition) NFPA 101, 9.1.2 (2012 Edition NFPA 70, 110.12 (2011 Edition)

3. Observation on 07/10/2018 at 1:23 PM and 1:32 PM, revealed electrical junction boxes missing covers in the OR janitorial closet and the OR main sterilizer room. NFPA 101, 19.5.1.1 (2012 Edition) NFPA 101, 9.1.2 (2012 Edition) NFPA 70, 314.28 (2011 Edition)

Maintenance staff were present when the deficiency was identified, and were later acknowledged by the administrator during the exit conference on 7/10/2018.

5.1.3.3.2* Design and Construction. Locations for central supply
systems and the storage of positive-pressure gases shall
meet the following requirements:
(1) They shall be constructed with access to move cylinders,
equipment, and so forth, in and out of the location on
hand trucks complying with 11.4.3.1.1.
(2) They shall be secured with lockable doors or gates or
otherwise secured.
(3) If outdoors, they shall be provided with an enclosure
(wall or fencing) constructed of noncombustible materials
with a minimum of two entry/exits.
(4) If indoors, they shall be constructed and use interior finishes
of noncombustible or limited-combustible materials
such that all walls, floors, ceilings, and doors are of a
minimum 1-hour fire resistance rating.
(5)*They shall be compliant with NFPA 70, National Electrical
Code, for ordinary locations.
(6) They shall be heated by indirect means (e.g., steam, hot
water) if heat is required.
(7) They shall be provided with racks, chains, or other fastenings
to secure all cylinders from falling, whether connected,
unconnected, full, or empty.
(8)*They shall be supplied with electrical power compliant
with the requirements for essential electrical systems as
described in Chapter 6.
(9) They shall have racks, shelves, and supports, where provided,
constructed of noncombustible materials or
limited-combustible materials.

Based on observations, the facility failed to maintain the Gas and Vacuum Piped Systems.

The finding included:

1. Observations on 07/10/2018 between 9:32 AM - 1:10 PM, revealed the corridor ran medical gas lines where load bearing (cables wrapped around the piping).
NFPA 99, 5.1.10.11.4.2 (2012 Edition)

2. Observation on 07/10/2018 at 11:22 AM, revealed penetrations by metallic conduits in the 1 hour concrete block fire barrier of the medical vaccum/boiler in thre ICU suite not sealed (above the vaccum pump). NFPA 101, 5.1.3.3.2* (4) (2012 Edition) NFPA 101, 8.3.5.1 (2012 Edition)

Maintenance staff were present when the deficiency was identified, and were later acknowledged by the administrator during the exit conference on 7/10/2018.

Based on observations, the facility failed to comply with power cord and extension cord regulations.

The findings included:

1. Observation on 07/10/2018 at 1:12 PM, revealed the a power strip powering a moblie work station computer outside of the OB OR that was not labeled UL 1363 (facility did not provide documention for the listing of the power strip). NFPA 99, 10.2.4.2.3 (2012 Edition) CMS S&C 14-46

2. Observation on 07/10/2018 at 1:24 PM, revealed the a UPS power strip powering a moblie work station comper in OR 4 that was not labeled UL 1363 (facility did not provide documention for the listing of the power strip). NFPA 99, 10.2.4.2.3 (2012 Edition) CMS S&C 14-46

3. Observation on 07/10/2018 at 1:25 PM, revealed the a UPS power strip powering a moblie work station comper in OR 5 that was not labeled UL 1363 (facility did not provide documention for the listing of the power strip). NFPA 99, 10.2.4.2.3 (2012 Edition) CMS S&C 14-46

Maintenance staff were present when the deficiency was identified, and were later acknowledged by the administrator during the exit conference on 7/10/2018.