HospitalInspections.org

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the course of the survey on February 22 and 23, 2012, that corridor doors and their frames were not provided with hold open devices that release when the door is pushed or pulled in accordance with section 18.3.6.3.3 of the Life Safety Code. This was evidenced by the following:

Each door leaf of the corridor double door set was provided with an automatic self-closure device that was activated with an overhead push-button switch. The self-closure device did not release the doors when they were pushed or pulled upon. This was observed at:
a) the doors to ER Trauma Room #6
b) doors from the Same Day Surgery Suite.

Each of the corridor door deficiency items were discussed with the Director of Plant Operations during a tour of the facility and again during the exit conference.

This portion applies to Building AA, known as the Walk-in Clinic.

It was determined by observation during the survey that the facility failed to maintain and protect the vertical openings in accordance with the Life Safety Code. This was evidenced by:

The corridor door providing access to the basement of the facility failed to have the required self-closure device installed.

The vertical opening deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

It was determined by observation during the survey that the facility failed to maintain and protect the vertical openings in accordance with the Life Safety Code. This was evidenced by:

a) Two (2) of two (2) doors providing access to the basement of the facility failed to have the required self-closure device installed.

b) Two (2) of two (2) stairs providing access to the basement of the facility failed to have landings at the top of the stairway in accordance with NFPA 101, section 7.2.2.3.2.

The vertical opening deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the survey that the facility failed to maintain and protect the hazardous areas in accordance with the Life Safety Code. This was evidenced by:

It was observed that there was a large, unsealed hole from the corridor through the cinderblock wall into the boiler room, above the drop ceiling.

The hazardous area deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

It was determined by observation during the survey that the facility failed to maintain and protect the hazardous areas in accordance with the Life Safety Code. This was evidenced by:

Two (2) of two (2) doors providing access to the basement of the facility, which is considered a hazardous area based on size and amount and type of storage, failed to have a minimum fire resistance rating of 3/4-hour, as required.

The hazardous area deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

Based on observation during the survey, it was determined the facility failed to arrange the means of egress in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:

1) The cross-corridor doors serving the nursery suite were found to be locked at all times with magnetic locking devices, which have a push button override beside the door. When activated by the nursery security bracelets, the push button override function is inactive. Neither of these conditions meet the requirements set forth in 18.2.2.2.4.

2) Due to the above locking arrangement, the north corridor, outside the nursery unit becomes an approximately 40-foot dead end corridor.

3) The corridor door separating the hospital corridor from the remainder of the hospital was found to have a manual lock on the exit-side of the door and fails to meet the requirements of 18.2.2.2.4.

4) Due to the above locking arrangement, the corridor leading to the hospital corridor separation becomes an approximately 80-foot dead end corridor.

5) The exterior exit door serving the doctors hallway near the ORs was found to be locked at all times with magnetic locking device, which has a push button override beside the door. This condition does not meet the requirements set forth in 18.2.2.2.4.

6) The ramp serving the west exit failed to have compliant handrails on either side of the ramp run, as required by 7.2.5.4. Note: the ramp had an elevation change greater than six-inches.

The means of egress deficiency items were discussed during the course of the survey and again during the exit conference.

This portion applies to Building AA, known as the Walk-in Clinic.

Based on observation during the survey, it was determined the facility failed to arrange the means of egress in accordance with Life Safety Code Section 38.2 and Chapter 7. This was evidenced by the following:

All exterior exit doors were found to have a lock on the egress side of the door that, when locked, would not allow egress out of the building without first unlocking the door. The facility failed to provide the correct signage on these doors, as specified in 7.2.1.5.1, exception 2. Note: The building has an occupant load of greater than 50 people.

The means of egress deficiency items were discussed during the course of the survey and again during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

Based on observation during the survey, it was determined the facility failed to arrange the means of egress in accordance with Life Safety Code Section 38.2 and Chapter 7. This was evidenced by the following:

All exterior exit doors were found to have a lock on the egress side of the door that, when locked, would not allow egress out of the building without first unlocking the door. The facility failed to provide the correct signage on these doors, as specified in 7.2.1.5.1, exception 2. Note: The building has an occupant load of greater than 50 people.

The means of egress deficiency items were discussed during the course of the survey and again during the exit conference.

This portion applies to Building AA, known as the Walk-in Clinic.

It was determined by observation and staff interview during the survey that the facility failed to maintain emergency backup lighting as required by NFPA 101. This was evidenced by the following:

A) At the time of the survey, the facility failed to provide documentation that the battery backed-up emergency lighting throughout the building had been annually tested for 90 minutes during the past one-year time period.

B) At the time of the survey, the facility failed to provide documentation that the battery backed-up emergency lighting throughout the building had been tested monthly for 30 seconds during the past one-year time period.

The emergency lighting deficiency item was discussed during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

It was determined by observation and staff interview during the survey that the facility failed to maintain emergency back-up lighting as required by NFPA 101. This was evidenced by the following:

a) At the time of the survey, the facility failed to provide documentation that the battery backed-up emergency lighting throughout the building had been annually tested for 90 minutes during the past one-year time period.

b) At the time of the survey, the facility failed to provide documentation that the battery backed-up emergency lighting throughout the building had been tested monthly for 30 seconds during the past one-year time period.

c) The exit light serving the west exit door was found to be broken at the time of the survey.

The emergency lighting deficiency item was discussed during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by documentation review and staff interview during the survey on February 22 and 23, 2012, that the facility failed to hold a quarterly fire drill on each shift, as a minimum, in accordance with Life Safety Code section 18.7.1. This was evidenced by the following:

Staff stated that the facility operates using two 12 hour shifts per day from 7:00 to 7:00.
Fire drill records were not available for:
a) the overnight shift in the 1st calendar quarter of 2011 and
b) the overnight shift in the 4th calendar quarter of 2011.

Each of the fire drill deficiency items were discussed with the Director of Plant Operations during a review of the facility's required documentation and again during the exit conference.

This portion applies to Building AA, known as the Walk-in Clinic.

It was determined by observation and through record review during the course of the survey that the facility failed to perform fire drills in accordance with Life Safety Code. This was evidenced by the following:

At the time of the survey, the building failed to provide documentation for having completed any fire drills in a one year period.

The fire drill deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

It was determined by observation and through record review during the course of the survey that the facility failed to perform fire drills in accordance with Life Safety Code. This was evidenced by the following:

At the time of the survey, the building failed to provide documentation for having completed any fire drills in a one year period.

The fire drill deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to install the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

The visual and audible annunciation provided in the Operating Room Suite was not adequate to provide the required notification throughout the suite. Upon activation of the Fire Alarm System, the audible alarms could not be heard over the average ambient noise found in four (4) of four (4) operating rooms. Further, the visual notification of the fire alarm system could not be seen in four (4) of four (4) operating rooms.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

It was determined by observation during the course of the survey that the facility failed to maintain the automatic smoke detection system in accordance with the Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

At the time of the survey, the facility failed to provide documentation that the smoke detection system had been inspected annually, as required.

The smoke detection system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the survey on February 22 and 23, 2012, that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with NFPA Standard 13, Installation of Sprinkler Systems for all portions of the facility. This was evidenced by the following:

a) A portion of the Hospital Phone Room was obstructed at ceiling height by a 22" deep by 12" wide concrete beam. Sprinkler protection was not provided to an area approximately 6' wide by 18' long for the IT data instrumentation located within the room.

b) The lower side of the ductwork located within the South Fan Room was observed to be greater than four feet wide and was not protected by the fire sprinkler system in accordance with (1999) NFPA 13, section 5-5.5.3.1.

c) The facility failed to extend the sprinkler coverage to the enclosed clean room located within the south pharmacy room.

d) The walkway on the southwest side of the building that serves as an exit discharge for the exit near the cafeteria and the exit near the administrative offices on the west side of the building was found to have a combustible overhang extending for approximately eighty to ninety feet, none of which was found to be protected by automatic fire sprinkler system, as required by NFPA 13.

The sprinkler protection deficiency items were discussed with the Director of Plant Operations during a tour of the facility.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the course of the survey on February 22 and 23, 2012, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems. This was evidenced by the following:

a) Three pendant style sprinkler heads located within the corridor near the Lower Fan Room were observed with foreign matter/paint on the frangible element link area.
Note: Foreign matter/paint/over spray on the automatic sprinkler heads could effect the proper thermal response of the frangible element and the operation of the water release mechanism.
NOTE: These sprinkler heads cannot be cleaned and must be replaced per 1999 NFPA 13, section 3-2.6.3.

b) The required escutcheons were missing in the following locations:
(i) above the desk location in Physical Therapy Treatment Room #7,
(ii) two (2) in the Alamo IT Room,
(iii) in the back room for Office #30, and
(iv) in the back room for Office #31.

c) There was a ceiling tile missing in the Alamo IT Room, exposing the unsprinklered space between the drop ceiling and the floor/ceiling assembly of the building.

The fire sprinkler system deficiency items were discussed with the Director of Plant Operations during a tour of the facility and again during the exit conference.

This portion applies to Building AB, known as Cortez Primary Care.

It was determined by observation during the course of the survey that the facility failed to maintain the automatic fire sprinkler system in accordance with the Life Safety Code, NFPA 13D, and NFPA 25. This was evidenced by the following:

a) Two (2) of two (2) control valves located on the sprinkler system's supply line failed to be supervised or locked as required by NFPA 13D. At the time of the survey, the indicating handles for these control valves were removed; further, the door to the room housing the sprinkler supply and control equipment would not lock. Note: Removing the indicating handles for sprinkler system control valves is not an acceptable practice for meeting the requirements of NFPA 13D.

b) The facility failed to provide a hydraulic placard at the main system riser, as required.

The sprinkler system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the survey on February 22 and 23, 2012, that the facility failed to provide a piped-in medical gas system meeting the requirements of (1999) NFPA 99, Health Care Facilities. This was evidenced by the following:

A review of the medical gas system's annual inspection, test and maintenance records, provided by an independent medical gas system contractor to the facility, and dated April 27, 2011, documented deficiency items that had not yet been corrected at the time of this survey, to include:
1) There was no intervening wall between the zone valve box and outlets served, in accordance with NFPA 99, section 4-3.1.2.3(d), and located in:
(a) the 2nd floor ICU area.
2) The zone valve box was missing a pressure/VAC indicator, in accordance with NFPA 99, section 4-3.1.2.3(d), and located on:
(a) the 2nd floor for Rooms 201- 210,
(b) the 2nd floor for Rooms 212 - 224,
(c) the 2nd floor for Rooms 225 - 229.

These medical gas system deficiency items were discussed with the Director of Plant Operations during a review of the facility's documentation and confirmed during the survey.

This portion applies to Building A1, known as the Main Hospital.

It was determined by staff interview during the survey on February 22 and 23, 2012, that the facility failed to provide protection to anesthetizing locations in accordance with Life Safety Code section 18.3.2 and NFPA 99, Standard for Health Care Facilities. This was evidenced by the following:

Based upon document review of hand written once-a-day daily recordings on monthly charts provided by the facility during the on-site evaluation, it was determined that three of three anesthetizing locations were not maintained with minimum humidity levels of 35% prior to the date of February 15, 2012. Daily humidity levels were commonly recorded in the mid-20% level for the months of December 2011 and January 2012 with an occasional recording at 35% RH or greater.
Staff stated that an adjustment was made to temperature and humidity levels within the three anesthetizing locations on February 13, 2012, that resulted in humidity levels at or above 35% RH.

NFPA 99, Chapter 5, section 5-4.1 states "The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater."

This humidity level deficiency item regarding anesthetizing locations was discussed with the Director of Plant Operations during a review of the facility's required documentation.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the course of the survey on February 22 and 23, 2012, that the facility failed to properly provide handrails within the stair enclosure in accordance with Life Safety Code section 18.2.2.3 and referenced section 7.2.2.4.5. This was evidenced by the following:

Wooden handrails were observed on each side of the stairs in the following stair enclosure locations:
a) in the ER/Room 217 stairs,
b) in the Laboratory/Room 208 stairs and
c) in the Pharmacy stairs.
These handrails were approximately 1?" by 7?" and exceeded the maximum allowed perimeter dimension.

Life Safety Code section 7.2.2.4.5. (3) * states: Handrails shall have a circular cross section with an outside diameter of not less than 1? inch and not more than 2 inches.
Exception: Any other shape with a perimeter dimension of not less than 4 inches but not more than 6? inches and with the largest cross-sectional dimension not more than 2? inches shall be permitted, provided that edges are rounded so as to provide a radius of not less than 1/8 inch.

The handrail deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation, staff interview, and document review that the facility failed to install and maintain the essential electrical system in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

Although the facility has designated each transfer switch and the associated main distribution panels as belonging to one of the three required branches, the subsequent distribution panels throughout the essential electrical system failed to be divided in accordance with NFPA 99, having items belonging on particular branches intermingled throughout the system and items not allowed to be on the Life Safety and Critical branches found thereon.

The essential electrical system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the course of the survey on February 22 and 23, 2012, that corridor doors and their frames were not provided with hold open devices that release when the door is pushed or pulled in accordance with section 18.3.6.3.3 of the Life Safety Code. This was evidenced by the following:

Each door leaf of the corridor double door set was provided with an automatic self-closure device that was activated with an overhead push-button switch. The self-closure device did not release the doors when they were pushed or pulled upon. This was observed at:
a) the doors to ER Trauma Room #6
b) doors from the Same Day Surgery Suite.

Each of the corridor door deficiency items were discussed with the Director of Plant Operations during a tour of the facility and again during the exit conference.

This portion applies to Building AA, known as the Walk-in Clinic.

It was determined by observation during the survey that the facility failed to maintain and protect the vertical openings in accordance with the Life Safety Code. This was evidenced by:

The corridor door providing access to the basement of the facility failed to have the required self-closure device installed.

The vertical opening deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

It was determined by observation during the survey that the facility failed to maintain and protect the vertical openings in accordance with the Life Safety Code. This was evidenced by:

a) Two (2) of two (2) doors providing access to the basement of the facility failed to have the required self-closure device installed.

b) Two (2) of two (2) stairs providing access to the basement of the facility failed to have landings at the top of the stairway in accordance with NFPA 101, section 7.2.2.3.2.

The vertical opening deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the survey that the facility failed to maintain and protect the hazardous areas in accordance with the Life Safety Code. This was evidenced by:

It was observed that there was a large, unsealed hole from the corridor through the cinderblock wall into the boiler room, above the drop ceiling.

The hazardous area deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

It was determined by observation during the survey that the facility failed to maintain and protect the hazardous areas in accordance with the Life Safety Code. This was evidenced by:

Two (2) of two (2) doors providing access to the basement of the facility, which is considered a hazardous area based on size and amount and type of storage, failed to have a minimum fire resistance rating of 3/4-hour, as required.

The hazardous area deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

Based on observation during the survey, it was determined the facility failed to arrange the means of egress in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:

1) The cross-corridor doors serving the nursery suite were found to be locked at all times with magnetic locking devices, which have a push button override beside the door. When activated by the nursery security bracelets, the push button override function is inactive. Neither of these conditions meet the requirements set forth in 18.2.2.2.4.

2) Due to the above locking arrangement, the north corridor, outside the nursery unit becomes an approximately 40-foot dead end corridor.

3) The corridor door separating the hospital corridor from the remainder of the hospital was found to have a manual lock on the exit-side of the door and fails to meet the requirements of 18.2.2.2.4.

4) Due to the above locking arrangement, the corridor leading to the hospital corridor separation becomes an approximately 80-foot dead end corridor.

5) The exterior exit door serving the doctors hallway near the ORs was found to be locked at all times with magnetic locking device, which has a push button override beside the door. This condition does not meet the requirements set forth in 18.2.2.2.4.

6) The ramp serving the west exit failed to have compliant handrails on either side of the ramp run, as required by 7.2.5.4. Note: the ramp had an elevation change greater than six-inches.

The means of egress deficiency items were discussed during the course of the survey and again during the exit conference.

This portion applies to Building AA, known as the Walk-in Clinic.

Based on observation during the survey, it was determined the facility failed to arrange the means of egress in accordance with Life Safety Code Section 38.2 and Chapter 7. This was evidenced by the following:

All exterior exit doors were found to have a lock on the egress side of the door that, when locked, would not allow egress out of the building without first unlocking the door. The facility failed to provide the correct signage on these doors, as specified in 7.2.1.5.1, exception 2. Note: The building has an occupant load of greater than 50 people.

The means of egress deficiency items were discussed during the course of the survey and again during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

Based on observation during the survey, it was determined the facility failed to arrange the means of egress in accordance with Life Safety Code Section 38.2 and Chapter 7. This was evidenced by the following:

All exterior exit doors were found to have a lock on the egress side of the door that, when locked, would not allow egress out of the building without first unlocking the door. The facility failed to provide the correct signage on these doors, as specified in 7.2.1.5.1, exception 2. Note: The building has an occupant load of greater than 50 people.

The means of egress deficiency items were discussed during the course of the survey and again during the exit conference.

This portion applies to Building AA, known as the Walk-in Clinic.

It was determined by observation and staff interview during the survey that the facility failed to maintain emergency backup lighting as required by NFPA 101. This was evidenced by the following:

A) At the time of the survey, the facility failed to provide documentation that the battery backed-up emergency lighting throughout the building had been annually tested for 90 minutes during the past one-year time period.

B) At the time of the survey, the facility failed to provide documentation that the battery backed-up emergency lighting throughout the building had been tested monthly for 30 seconds during the past one-year time period.

The emergency lighting deficiency item was discussed during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

It was determined by observation and staff interview during the survey that the facility failed to maintain emergency back-up lighting as required by NFPA 101. This was evidenced by the following:

a) At the time of the survey, the facility failed to provide documentation that the battery backed-up emergency lighting throughout the building had been annually tested for 90 minutes during the past one-year time period.

b) At the time of the survey, the facility failed to provide documentation that the battery backed-up emergency lighting throughout the building had been tested monthly for 30 seconds during the past one-year time period.

c) The exit light serving the west exit door was found to be broken at the time of the survey.

The emergency lighting deficiency item was discussed during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by documentation review and staff interview during the survey on February 22 and 23, 2012, that the facility failed to hold a quarterly fire drill on each shift, as a minimum, in accordance with Life Safety Code section 18.7.1. This was evidenced by the following:

Staff stated that the facility operates using two 12 hour shifts per day from 7:00 to 7:00.
Fire drill records were not available for:
a) the overnight shift in the 1st calendar quarter of 2011 and
b) the overnight shift in the 4th calendar quarter of 2011.

Each of the fire drill deficiency items were discussed with the Director of Plant Operations during a review of the facility's required documentation and again during the exit conference.

This portion applies to Building AA, known as the Walk-in Clinic.

It was determined by observation and through record review during the course of the survey that the facility failed to perform fire drills in accordance with Life Safety Code. This was evidenced by the following:

At the time of the survey, the building failed to provide documentation for having completed any fire drills in a one year period.

The fire drill deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

It was determined by observation and through record review during the course of the survey that the facility failed to perform fire drills in accordance with Life Safety Code. This was evidenced by the following:

At the time of the survey, the building failed to provide documentation for having completed any fire drills in a one year period.

The fire drill deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to install the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

The visual and audible annunciation provided in the Operating Room Suite was not adequate to provide the required notification throughout the suite. Upon activation of the Fire Alarm System, the audible alarms could not be heard over the average ambient noise found in four (4) of four (4) operating rooms. Further, the visual notification of the fire alarm system could not be seen in four (4) of four (4) operating rooms.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building AC, known as the Blood Draw Station.

It was determined by observation during the course of the survey that the facility failed to maintain the automatic smoke detection system in accordance with the Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

At the time of the survey, the facility failed to provide documentation that the smoke detection system had been inspected annually, as required.

The smoke detection system deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the survey on February 22 and 23, 2012, that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with NFPA Standard 13, Installation of Sprinkler Systems for all portions of the facility. This was evidenced by the following:

a) A portion of the Hospital Phone Room was obstructed at ceiling height by a 22" deep by 12" wide concrete beam. Sprinkler protection was not provided to an area approximately 6' wide by 18' long for the IT data instrumentation located within the room.

b) The lower side of the ductwork located within the South Fan Room was observed to be greater than four feet wide and was not protected by the fire sprinkler system in accordance with (1999) NFPA 13, section 5-5.5.3.1.

c) The facility failed to extend the sprinkler coverage to the enclosed clean room located within the south pharmacy room.

d) The walkway on the southwest side of the building that serves as an exit discharge for the exit near the cafeteria and the exit near the administrative offices on the west side of the building was found to have a combustible overhang extending for approximately eighty to ninety feet, none of which was found to be protected by automatic fire sprinkler system, as required by NFPA 13.

The sprinkler protection deficiency items were discussed with the Director of Plant Operations during a tour of the facility.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the course of the survey on February 22 and 23, 2012, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems. This was evidenced by the following:

a) Three pendant style sprinkler heads located within the corridor near the Lower Fan Room were observed with foreign matter/paint on the frangible element link area.
Note: Foreign matter/paint/over spray on the automatic sprinkler heads could effect the proper thermal response of the frangible element and the operation of the water release mechanism.
NOTE: These sprinkler heads cannot be cleaned and must be replaced per 1999 NFPA 13, section 3-2.6.3.

b) The required escutcheons were missing in the following locations:
(i) above the desk location in Physical Therapy Treatment Room #7,
(ii) two (2) in the Alamo IT Room,
(iii) in the back room for Office #30, and
(iv) in the back room for Office #31.

c) There was a ceiling tile missing in the Alamo IT Room, exposing the unsprinklered space between the drop ceiling and the floor/ceiling assembly of the building.

The fire sprinkler system deficiency items were discussed with the Director of Plant Operations during a tour of the facility and again during the exit conference.

This portion applies to Building AB, known as Cortez Primary Care.

It was determined by observation during the course of the survey that the facility failed to maintain the automatic fire sprinkler system in accordance with the Life Safety Code, NFPA 13D, and NFPA 25. This was evidenced by the following:

a) Two (2) of two (2) control valves located on the sprinkler system's supply line failed to be supervised or locked as required by NFPA 13D. At the time of the survey, the indicating handles for these control valves were removed; further, the door to the room housing the sprinkler supply and control equipment would not lock. Note: Removing the indicating handles for sprinkler system control valves is not an acceptable practice for meeting the requirements of NFPA 13D.

b) The facility failed to provide a hydraulic placard at the main system riser, as required.

The sprinkler system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the survey on February 22 and 23, 2012, that the facility failed to provide a piped-in medical gas system meeting the requirements of (1999) NFPA 99, Health Care Facilities. This was evidenced by the following:

A review of the medical gas system's annual inspection, test and maintenance records, provided by an independent medical gas system contractor to the facility, and dated April 27, 2011, documented deficiency items that had not yet been corrected at the time of this survey, to include:
1) There was no intervening wall between the zone valve box and outlets served, in accordance with NFPA 99, section 4-3.1.2.3(d), and located in:
(a) the 2nd floor ICU area.
2) The zone valve box was missing a pressure/VAC indicator, in accordance with NFPA 99, section 4-3.1.2.3(d), and located on:
(a) the 2nd floor for Rooms 201- 210,
(b) the 2nd floor for Rooms 212 - 224,
(c) the 2nd floor for Rooms 225 - 229.

These medical gas system deficiency items were discussed with the Director of Plant Operations during a review of the facility's documentation and confirmed during the survey.

This portion applies to Building A1, known as the Main Hospital.

It was determined by staff interview during the survey on February 22 and 23, 2012, that the facility failed to provide protection to anesthetizing locations in accordance with Life Safety Code section 18.3.2 and NFPA 99, Standard for Health Care Facilities. This was evidenced by the following:

Based upon document review of hand written once-a-day daily recordings on monthly charts provided by the facility during the on-site evaluation, it was determined that three of three anesthetizing locations were not maintained with minimum humidity levels of 35% prior to the date of February 15, 2012. Daily humidity levels were commonly recorded in the mid-20% level for the months of December 2011 and January 2012 with an occasional recording at 35% RH or greater.
Staff stated that an adjustment was made to temperature and humidity levels within the three anesthetizing locations on February 13, 2012, that resulted in humidity levels at or above 35% RH.

NFPA 99, Chapter 5, section 5-4.1 states "The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater."

This humidity level deficiency item regarding anesthetizing locations was discussed with the Director of Plant Operations during a review of the facility's required documentation.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the course of the survey on February 22 and 23, 2012, that the facility failed to properly provide handrails within the stair enclosure in accordance with Life Safety Code section 18.2.2.3 and referenced section 7.2.2.4.5. This was evidenced by the following:

Wooden handrails were observed on each side of the stairs in the following stair enclosure locations:
a) in the ER/Room 217 stairs,
b) in the Laboratory/Room 208 stairs and
c) in the Pharmacy stairs.
These handrails were approximately 1?" by 7?" and exceeded the maximum allowed perimeter dimension.

Life Safety Code section 7.2.2.4.5. (3) * states: Handrails shall have a circular cross section with an outside diameter of not less than 1? inch and not more than 2 inches.
Exception: Any other shape with a perimeter dimension of not less than 4 inches but not more than 6? inches and with the largest cross-sectional dimension not more than 2? inches shall be permitted, provided that edges are rounded so as to provide a radius of not less than 1/8 inch.

The handrail deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation, staff interview, and document review that the facility failed to install and maintain the essential electrical system in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

Although the facility has designated each transfer switch and the associated main distribution panels as belonging to one of the three required branches, the subsequent distribution panels throughout the essential electrical system failed to be divided in accordance with NFPA 99, having items belonging on particular branches intermingled throughout the system and items not allowed to be on the Life Safety and Critical branches found thereon.

The essential electrical system deficiency items were discussed during the survey and again during the exit conference.