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Based on observations and records review, the critical access hospital failed to maintain 1 of 3 two hour fire rated barriers.

Findings:

On 06/04/2019, surveyors with the maintenance director present, observed the following:

1. 10:37 AM the two hour rated wall located in the attic area had pipe penetrations, gaps where it meets the roof deck with no fire stopping material present.

2. The two hour wall had four wooden roof trusses that penetrated the rated wall and would not prevent the passage of fire/smoke.

3. The number of the 2 hour assemblies or UL rated assemblies used to achieve the 2 hour separation in the facility is not documented, no current life safety drawings could be provided.


The surveyors confirmed these observations with the maintenance director at the time of the observations.

Based on observations and interview, the critical acess hospital failed to ensure that the 2-hour fire rated wall was free from penetrations above 7 out of 8 sets of fire barrier doors, that correct fire stopping materials were used or documented and open penetrations were sealed.

Findings:

1. On 6/4/19 between 11:00 am and 3:00 pm, surveyors, with the Engineering Supervisor present, observed the following:

a. At 11:01 am, two cable wall penetrations were not sealed above the FRD 3/FRD 4 doors on Level 1.
b. At 11:02 am, vertical hole was not sealed in masonry block between FRD 3/FRD 4 and FRD 10/FRD 11 doors on Level 1.
c. At 11:11 am, wall holes and oxygen pipe wall penetration were not sealed above the FRD 10/FRD 11 doors on Level 1.
d. At 11:17 am, conduit wall penetration and wall assembly for grouped cables were not sealed above the FRD 14/FRD 15 doors on Level 1.
e. At 11:18 am, wall hole penetration was not sealed above the ceiling at FRD 14/FRD 15 doors on Level 1.
f. At 12:25 pm, wall hole penetration next to Oxygen pipe above the ceiling on the CSR side of FRD 45 doors on Level 3.

The surveyors confirmed these observations with the Engineering Supervisor at the time of the observation.


2. On 6/4/19 between 11:00 am and 3:00 pm, surveyors, with the Engineering Supervisor and Master Electrician present, observed the following:

a. At 11:25 am, wall holes was not sealed through masonry block above the ceiling on the Break Room side of FRD 34/FRD 35 doors on Level 2.
b. At 11:26 am, conduit and cable wall penetrations were not sealed above the ceiling on the Classroom side of FRD 34/35 doors on Level 2.
c. At 11:29 am, fire barrier door FRD 35 did not positively latch when released from the approved hold open device on Level 2.
d. At 11:35 am, sprinkler pipe wall penetration was not sealed above the ceiling at FRD 39/FRD 40 doors on Level 2.
e. At 11:35 am,the approved hold open device for fire barrier door FRD 40 was unable to hold the door open on Level 2.
f. At 12:32 pm, wall hole was not sealed above the ceiling on the Electric Sterilizer side of FRD 45 doors on Level 3.
g. At 12:41 pm, fire barrier door FRD 50 is missing the end piece of the panic hardware and is not securely attached to the door on Level 3.
h. At 12:41 pm, fire barrier door FRD 50 is missing the electrical box cover for the magnetic hardware on Level 3.

The surveyors confirmed these observations with the Engineering Supervisor at the time of observation.


3. On 6/4/19 at 2:39 pm, surveyors, with surgical staff present, observed the following:

a. Spray foam product found sealing the wall pipe penetrations in the Dirty Room/Eye Wash Station in the Sterile Area on Level 3.

The surveyors confirmed theses observations with the surgical staff and Engineering Supervisor at the time of observation.

Based on observations, the critical access hospital failed to maintain the means of egress was free from all obstructions.

Findings:

On 06/04/2019, surveyors with the maintenance director present, observed the following:


1. 12:37 AM, a 55 gallon container being used for recyclable paper was stored in the exit corridor located outside of the pharmacy.


2. 1:39 PM, the emergency department exit discharge enclosure (ambulance entrance) had items stored, that did not allow egress doors to open properly.


The surveyors confirmed these observations with the maintenance director at the time of the observations

Based on observations, the Critical Access Hospital failed to maintain self closing devices.

Findings:

On 06/04/2019, surveyors with the maintenance director present, observed the following:


1. 11:17 AM mechanical room number 3 was not a self closing positive latching door.

This was confirmed by the Maintenance Director at the time of the observation.

Based on observations, the critical access hospital failed to maintain horizontal sliding exit doors.

Finding:

On 06/04/2019, surveyors with the maintenance director present, observed the following:

At 1:39 PM, the horizontal sliding exit doors located in the emergency department had storage on the non egress side that would prohibit the proper operation of the emergency breakaway feature which allows the door to swing open during an emergency.


The surveyors confirmed these observations with the maintenance director at the time of the observations

Based on observations and interviews, the critical access hospital failed to ensure 1-hour fire rated stairwells were free from penetrations in 5 of 5 rated stairwells.

Findings:

1. On 06/04/2019 at 11:03 AM, surveyors with the maintenance director present, observed no fire stopping material present WHERE in the "sixty-two"stairwell located on the third floor.

The surveyors confirmed this finding with the Maintenance Director at the time of the observation.

2. On 6/4/19 between 12:00 pm and 2:00 pm, surveyors, with the Engineering Supervisor present, observed the following:

a. At 12:55 pm, hole was not sealed in 90 minute fire-rated door FRD 46 in the Central Stairwell on Level 3.
b. At 12:58 pm, the end piece of the panic hardware for fire-rated door FRD 48 is missing and is not securely attached to the door in the 62 Short Stairwell on Level 3.
c. At 12:59 pm, conduit penetration was not sealed in ceiling above fire-rated door FRD 48 in the 62 Short Stairwell on Level 3.

The surveyors confirmed these observations with the Engineering Supervisor at the time of the observation.

3. On 6/4/19 between 12:00 pm and 2:00 pm, surveyors with the Engineering Supervisor and Master Electrician present, observed the following:

a. At 12:48 pm, ceiling hole was not sealed from damage done by the opening of the top of fire-rated door FRD 53 in the 37 Stairwell on the Attic Level.
b. At 12:51 pm, two ceiling holes were not sealed above fire-rated door FRD 36 in the Central Stairwell on Level 2.
c. At 12:52 pm, two conduit wall penetrations were not sealed above fire-rated door FRD 2 in the Central Stairwell on Level 1.
d. At 1:02 pm, access panel to cable chasseway was not secured closed adjacent to fire-rated door FRD 38 in the 62 Short Stairwell on Level 2. Master Electrician secured the panel during inspection.
e. At 1:05 pm, hole was not sealed at the top of the door frame of 90 minute FRD 41 door in the 68 Stairwell on Level 2.
f. At 1:08 pm, hole was not sealed in 90 minute fire-rated door FRD 30 in the 68 Stairwell on Level 1.
g. At 1:08 pm, screw missing from bottom hinge of 90 minute fire-rated door FRD 30 in the 68 Stairwell on Level 1.
h. At 1:08 pm, hole was not sealed in 90 minute fire-rated door FRD 30 in the 68 Stairwell on Level 1.
i. At 1:13 pm, top hinge-side of the 90 minute fire-rated FRD 42 is peeling away from the wood in the 62 East Stairwell on Level 2.

The surveyors confirmed these findings with the Engineering Supervisor at the time of the observation.




37694

Based on observations and interview, the critical access hospital failed to install emergency lighting in the new generator building.

Finding:
On 6/4/19 at 1:49 pm, surveyor, with the Engineering Supervisor present, observed the following:

Emergency lights were not installed in the new generator building.

The surveyor confirmed these observations with the Engineering Supervisor at the time of the observation.

Based on observations and interview, the Critical Access Hospital, failed to install exit signs in the third floor Mechanical Space.

Finding:

On 6/4/19 at 10:02 AM, surveyors, with the Maintenance Director present, observed the following:

No exit signs were present in the third floor mechanical space.

The surveyor confirmed these observations with the Engineering Supervisor at the time of the observation.

Based on observations, the critical access hospital failed to maintain hazardous area enclosures.

Findings:

On 06/04/2019, surveyors with the maintenance director present, observed the following:


a. 12:43 AM the soiled utility room door located in oncology would not latch upon closure.


b. 1:49 PM the boiler room had penetrations in the floor ceiling assembly with no fire stopping material present.


The surveyors confirmed these observations with the maintenance director at the time of the observations

Based on observations and interview, the critical access hospital failed to install a fire alarm system in generator building.

Findings:

On 6/4/19 at 1:49 PM, surveyor, with the Engineering Supervisor present, observed the following:

a. Pull station was not installed in the new generator building.
b. Horn strobe was not installed in the new generator building.

The surveyor confirmed these observations with the Engineering Supervisor at the time of the observation.

Based on observations, the critical access hospital failed to provide required smoke detection .

Finding:

On 06/04/2019, surveyors with the Maintenance Director present, observed the following:


1:29 PM the emergency department sleeping room provided for physician & staff did not have a smoke detection device.


The surveyors confirmed these observations with the Maintenance Director at the time of the observations

Based on observations, between 11:12 am and 12:54 pm, the critical access hospital failed to provide sprinkler coverage in accordance with NFPA 13.

Findings:

1. On 06/04/2019, surveyors with the Maintenance Director present, observed the following:


a. 11:12 AM the CSR storage room located on the third floor does not have sprinkler protection.


b. 11:14 AM the medical gas bulk tank room located on the third floor does not have sprinkler protection.


The surveyors confirmed these observations with the Maintenance Director at the time of the observations



37695



2. On 06/04/2019, surveyors with the maintenance director present, observed the following:

a. 11:14 AM, the entrance way into Oncology/Hematology does not have sprinkler coverage.


b. 12:47 PM, Mechanical room number 3 does not have sprinkler coverage.


c. 12:54 PM, Mechanical room number 4 does not have sprinkler coverage.


d. 1:17 PM, the Sterilizer room located outside of Clean Sterile does not have sprinkler coverage.


The surveyors confirmed these observations with the maintenance director at the time of the observations

35163

Based on observations, record review and interview, the critical access hospital failed to maintain the fire sprinkler system by ensuring that the 3 year Full trip test was completed, sprinkler piping was free of attached items on the piping system and heads were not obstructed,. in accordance with NFPA 25.



Findings:


1. On June 4, 2019 between 11:00 AM and 12:00 PM surveyors observed the following:

A. The dry sprinkler riser was not tagged indicating when the last 3 year full trip test was completed. Upon review of the sprinkler records from 2016 through may of 2019 there was no record of a full trip test being completed.
This surveyor confirmed with the facility Engineering Supervisor that the 3 year full trip test was over due.

2. On 6/4/19 at 11:35 AM, surveyors, with the Engineering Supervisor and Master Electrician present, observed the following:

A. Cables were attached to sprinkler pipe wall penetration above the ceiling at fire barrier FRD 39/FRD 40 doors on Level 2.

The surveyors confirmed these observations with the Engineering Supervisor at the time of the observation.


3. On 06/04/2019 between 12:23 PM, and 1:24 PM, surveyors with the maintenance director present, observed the following:


A. The housekeeping closet located in the second floor breast health wing was missing a sprinkler escutcheon plate/ring.


B. The storage closet located in the stress test room had storage within 18" of the sprinkler head.

C. A sprinkler head located in the stress test room is not properly seated to the escutcheon rings and there were visible gaps between the sprinkler and escutcheon rings.

D. The laundry storage room located on the first floor had storage within 18" of the sprinkler head.


The surveyors confirmed these observations with the maintenance director at the time of the observations



37694

Based on observations, the Critical Access Hospital failed to maintain hazardous room open to the corridor.

Finding:

On 06/04/2019, surveyors with the Maintenance Director present, observed the following:


At 11:03 AM, the linen closet's located on the third floor containing medical supplies were not positively latching.


The surveyors confirmed these observations with the Maintenance Director at the time of the observations

Based on observations and records review, the Critical Access Hospital failed to ensure portable space heaters regulations were followed.

Findings:

On 06/04/2019, surveyors with the Maintenance Director present, observed the following:


a. 11:36 AM, the OB supply room located on the third floor had a portable space heater. The device did not have a tip over shutoff safety switch, and no documentation was provided that it could not exceed 212 degrees Fahrenheit.


b. 1:57 PM, the staff break room located on the first floor had a portable space heater. The device did not have a tip over shutoff safety switch, did not have the required 3' clearance around it per manufacturers requirements, and no documentation was provided that it did not exceed 212 degrees Fahrenheit.




The surveyors confirmed these observations with the Maintenance Director at the time of the observations

Based on document review, the Critical Access Hospital failed to ensure the Medical Gas system is properly maintained.

Findings:

On 6/4/19 between 12:30 pm and 2:30pm, surveyors observed the following from facility documentation:

1. Medical Surgical
a. Room 3207 - 2nd vacuum inlet leaks and has a low flow of 2.0 scfm.
b. Room 3207 - 2nd vacuum inlet needs a new faceplate and needs back assembly to be rebuilt.

2. Emergency Department
a. Zone valves located at the nurse's station have no wall intervening between the valves and the outlets/inlets they control. NFPA 99, 2012 edition paragraph 5.1.4.8 (1)

3. Medical Imaging
a. Vacuum zone valve located left of CT scan is ½" and not minimum ¾". NFPA 99, 2012 edition paragraph 5.1.10.11.1.3

5. Master Alarms and Sources
a. Oxygen Supply System:
I. Final line gauge is not readable from a standing position. NFPA 99, 2012 edition paragraph 5.1.8.2.1
II. Supply line outside the fence is unprotected. NFPA 99, 2012 edition paragraph 5.1.10.11.2
III. Supply line to the facility is painted. NFPA 99, 2012 edition paragraph 5.1.11.1.3


b. Nitrous Oxide Manifold:
I. Mechanical ventilation runs to the attic and not outside. NFPA 99, 2012 edition paragraph 9.3.7.5.3
II. Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300mm (1 ft.) of the floor and adjacent to the cylinder or containers. NFPA 99, 2012 edition paragraph 9.3.7.5.3.3
III. The manifold room door does not have a minimum one-hour fire resistance rating. NFPA 99, 2012 edition paragraph 5.1.3.3.2 (4)
IV. Pressure relief vent line does not vent to the outside of the building. NFPA 99, 2012 edition paragraph 5.1.3.5.6.1 (4)
V. There is currently asbestos tile finished floor in the manifold room. Hospital is required to make sure the floor is constructed to non-combustible materials. NFPA 99, 2012 edition paragraph 5.1.3.3.2 (4)

c. Vacuum Pump:
I. Source valve does not consist of three pieces permitting in-line serviceability. NFPA 99, 2012 edition paragraph 5.1.4.3 (5)
II. All turns, offsets, and other changes in direction to the vacuum piping are soft soldered and not brazed. NFPA 99, 2012 edition paragraph 5.1.10.3.1 and 5.1.10.4
III. There are currently pro-press fittings on sections of the vacuum pipeline. NFPA 99, 2012 edition paragraph 5.1.10.10
IV. There are current sections of the vacuum pipeline that are piped with black iron. NFPA 99, 2012 edition paragraph 5.1.10.2.1
V. The vacuum exhaust is piped with black iron. NFPA 99, 2012 edition paragraph 5.1.10.2.1
VI. Vacuum exhaust needs to be screened to protect against the entry of vermin, debris, or precipitation. NFPA 99, 2012 edition paragraph 5.1.3.7.7.3

The surveyors confirmed these observations at the time of document review.

Based on document review, the Critical Access Hospital failed to ensure the Medical Gas system is properly maintained.

Findings:

On 6/4/19 between 12:30 PM and 2:30 PM, surveyors observed the following from facility documentation:

4. Surgical Services

a. Operating room 1 - there are no dedicated WAGD inlets installed in this Anesthetizing location.
b. Operating room 2 - there are no dedicated WAGD inlets installed in this Anesthetizing location.
c. Minor Procedure (OR3) - there are no dedicated WAGD inlets installed in this Anesthetizing location.

The surveyors confirmed these observations at the time of document review.

Based on document review, the Hospital failed to ensure the Medical Gas system is properly maintained.

Findings:

On 6/4/19 between 12:30 pm and 2:30pm, surveyors observed the following from facility documentation:

1. Emergency Department

a. Area alarm located at the Nurses station does not have separate visual indicators for each condition monitored.

2. Surgical Services

a. Area alarm located across from Minor Procedure does not have separate visual indicators for each condition monitored.

The surveyors confirmed these observations at the time of document review.

Based on observations, the Critical Access Hospital failed to maintain 1 of 3 medical gas rooms in accordance with NFPA 99.

Findings:

1. On 06/04/2019, surveyors with the Maintenance Director present, observed the following:

a. 11:14 AM, the Nitrous oxide and oxygen supply room located on the third floor had combustible material on the walls and floors.
b. There is no fire stopping material present where the pipe penetrates the wall to prevent the passage of smoke/fire.

The surveyors confirmed these observations with the maintenance director at the time of the observations

Based on observations, the Critical Access Hospital failed to maintain medical gas piping in accordance with NFPA 99.

Findings:

On 06/04/2019, surveyors with the Maintenance Director present, observed the following:


1. 10:42 AM, medical air piping located in the attic space near the medical air compressor was not properly labeled. a section of the medical air piping is labeled as medical vacuum


1. 12:41 PM, the zone valve box located across from the pharmacy directors office did not have a visible label that indicated the areas in which it served.


The surveyors confirmed these observations with the Maintenance Director at the time of the observations



39983

Based on document review, the Hospital failed to ensure the Medical Gas system is properly maintained.

Findings:

On 6/4/19 between 12:30 pm and 2:30pm, surveyors observed the following from facility documentation:

1. Master Alarms and Sources

a. Oxygen Supply System: Exterior supply line outside the fence is not properly labeled.


The surveyors confirmed these observations at the time of document review.

Based on observations and interview, the hospital failed to ensure the installation of junction box covers on 1 of 3 Levels.

Findings:

On 6/4/19 at 11:34 AM, surveyors, with the Engineering Supervisor and Master Electrician present, observed the following:

a. Junction box was not covered above the ceiling at fire barrier door FRD 40 on Level 2.

The surveyors confirmed these observations with the Engineering Supervisor and Master Electrician at the time of the observation.

Based on observations, the Critical Access Hospital failed to use fixed wiring to power equipment.

Findings:

On 06/04/2019, surveyors with the Maintenance Director present, observed the following:


1. 10:42 AM, a extension cord located in the attic space was being used as a substitute for fixed wiring, to power a device attached to the medical air compressor.


2. 11:20 AM, the Director of Surgery office located on the third floor has a multi outlet power strip interconnected with another multi outlet power strip, used to power office equipment, and an extension cord being used to power a AM/FM radio.

3. 11:43 AM, a multi-use power strip was located in the nutritional office, supplying power to a small refrigerator.

4. 1:57 PM, the staff break room had a multi outlet power strip being used as a substitute for fixed wiring, to power a portable space heater and microwave oven.

The surveyors confirmed these observations with the Maintenance Director at the time of the observations



37695