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ENDLESS MOUNTAINS HEALTH SYSTEMS
Exit Signage
Tag No.: K0293
Based on observation and interview, it was determined the facility failed to install exit signage in four locations, affecting one of two floors.
Findings include:
1. Observation on July 29, 2022, at 10:22 a.m., revealed exit signage was lacking in four locations, above smoke barrier separation doors.
Exit interview with the Facilities Manager on July 29, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the exit signage deficiencies.
Vertical Openings - Enclosure
Tag No.: K0311
Based on observation and interview, it was determined the facility failed to maintain one vertical opening, affecting one of two floors.
Findings include:
1. Observation on July 29, 2022, at 10:27 a.m., revealed three penetrations of the A elevator shaft enclosure, located at the basement level.
Exit interview with the Facilities Manager on July 29, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the vertical openings deficiency.
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of two floors.
Findings include:
1. Observation on July 29, 2022, at 10:57 a.m., revealed the first floor, Activities Storage Room door required adjustment to fully latch.
Exit interview with the Facilities Manager on July 29, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the hazardous area enclosure deficiency.
Fire Alarm System - Testing and Maintenance
Tag No.: K0345
Based on documentation review and interview, it was determined the facility failed to maintain the building fire alarm system, affecting two of two floors.
Findings include:
1. Observation on July 29, 2022, at 11:15 a.m., revealed the facility lacked current, semi-annual, visual fire alarm inspection data.
Exit interview with the Facilities Manager on July 29, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the building fire alarm deficiency.
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and interview, as well as documentation review, it was determined the facility failed to maintain the automatic sprinkler system in two locations, affecting two of two floors.
Findings include:
1. Observation on July 29, 2022, between 10:02 a.m., and 10:31 a.m., revealed storage items were located within eighteen inches of an adjacent sprinkler head assembly within the following areas:
a. 10:02 a.m., Kitchen Storage.
b. 10:31 a.m., ED closet.
2. Observation of building automatic sprinkler system documentation between 11:22 a.m., and 11:33 a.m., revealed the facility lacked five year, internal valve internal pipe, and sprinkler gauge change documentation.
Exit interview with the Facilities Manager on July 29, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the automatic sprinkler system deficiencies.
Corridor - Doors
Tag No.: K0363
Based on observation and interview, it was determined the facility failed to maintain corridor openings in one location, affecting one of two floors.
Findings include:
1. Observation on July 29, 2022, at 9:59 a.m., revealed the Central Kitchen door required adjustment to fully latch.
Exit interview with the Facilities Manager on July 29, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the corridor opening deficiency.
HVAC
Tag No.: K0521
Based on documentation review and interview, it was determined the facility failed to maintain the HVAC systems, affecting two of two floors.
Findings include:
1. Observation on July 29, 2022, at 11:11 a.m., revealed the facility lacked 6 year, fire damper preventative maintenance documentation.
Exit interview with the Facilities Manager on July 29, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the HVAC deficiency.
Rubbish Chutes, Incinerators, and Laundry Chu
Tag No.: K0541
Based on observation and interview, it was determined the facility failed to maintain one soiled linen chute, affecting one of three floors.
Findings include:
1. Observation on July 29, 2022, at 10:37 a.m., revealed neither the soiled linen chute room entrance door, nor the soiled linen chute access door were locked (one must be locked).
Exit interview with the Facilities Manager on July 29, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the soiled linen chute deficiency.
Gas and Vacuum Piped Systems - Inspection and
Tag No.: K0908
Based on observation and interview, it was determined the facility failed to maintain the medical gas system in one location, affecting one of two floors.
Findings include:
1. Observation on July 29, 2022, at 10:06 a.m., revealed an oxygen line, located within the basement-level, Boiler Room, was residing on dissimilar metal.
Exit interview with the Facilities Manager on July 29, 2022, between 11:50 a.m., and 12:00 p.m., confirmed the medical gas system deficiency.