HospitalInspections.org

Based on observations, the facility failed to maintain a 2 hours seperation between Powell and the Parking structure. This facility has a capacity of 674 residents and that time of the revisit had a census of 374.

Findings include:

Observations on 10/13/10, revealed there was a 20 minute door between Powell and the Parking structure. A 2 hour door is required.

Based on observations, it was determined the facility was composed of fire resistive and protected non-combustible construction (concrete and steel). The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with materials to limit the transfer of smoke. The facility has a capacity of 674 residents and that time of the revisit had a census of 374.

Findings include:

1. Observations on 10/12/10, revealed a hole (approximately 2 inches in size) in the ceiling tile in A Level - PACU - Room A 155.

2. Observations on 10/12/10, revealed missing ceiling tile in the north second floor NICU overflow in the Sprinkler Valve Shutoff ' 2 ' Room.

3. Observations on 10/13/10, revealed a gap around a sprinkler penetration in the Level - C Ultrasound Room.

4. Observations on 10/13/10, revealed the closet in the Northeast Radiology area, near the Radiology Classroom and Transcription Copier Room failed to be protected with 1 hour rated construction. Observations revealed there were large penetrations in the ceiling which had not been sealed.

5. Observations on 10/13/10, revealed a missing escutcheon ring around the sprinkler head in the North 6 West Nurses Station creating a gap (approximately ? inch to ? inch in size) at the ceiling.

6. Observations on 10/13/10, revealed a gap (approximately ? inch to ? inch in size) around a sprinkler head penetration in the NE 3 Electrical Closet at the ceiling.

7. Observations on 10/12/10, revealed a gap (approximately ? inch to ? inch in size) around a blue cable penetration in the wall and ceiling of the egress corridor next to the C-Store near the white IT box mounted on the wall.

8. Observations on 10/12/10, revealed a gap (approximately ? inch in size) around wires in Room 5101 at Methodist West.

9. Observations on 10/12/10, revealed a gap (approximately 3 inches in size) around a cable tray in Room 5049 at Methodist West.

10. Observations on 10/12/10, revealed a gap (approximately ? inch in size) around conduit in Room 4042 at Methodist West.

11. Observations on 10/12/10, revealed a gap (approximately ? inch in size) around conduit in Room 3039 at Methodist West.

12. Observations on 10/12/10, revealed a gap (approximately ? inch in size) around conduit in Room 3037 at Methodist West.

13. Observations on 10/13/10, revealed a gap (approximately ? inch to ? inch in size) in the ceiling in the PACS Office.

Based on observations, it was determined the facility was composed of fire resistive and protected non-combustible construction (concrete and steel). The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with materials to limit the transfer of smoke. The facility has a capacity of 674 residents and that time of the revisit had a census of 374.

Findings include:

1. Observations on 10/12/10, revealed a missing escutcheon ring in the IT repair room of the Younkers building.

Based on observations, it was determined the facility was composed of fire resistive and protected non-combustible construction (concrete and steel). The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with materials to limit the transfer of smoke. The facility has a capacity of 674 residents and that time of the revisit had a census of 374.

Findings include:

Observations on 10/13/10, revealed an area 1 foot by 2 foot that was missing the spray on fire proofing. This was locared in the Powell 7th Mechanical Room.

Based on observations, the facility failed to separate the corridors from other areas by partitions complying with 19.3.6.2 through 19.3.6.5 of the 2000 Life Safety Code. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Life Safety Code. This facility has a capacity of a 674 and had a census of a 374 residents.

Findings include:

Observations on 10/12/10, revealed the break room and lounge areas open to the corridor in the Emergency Room C - Store corridor on the North first floor. The compartment was equipped with sprinkler protection. Absent was smoke detection in the corridor and the rooms which open onto the corridor.

Based on observations, the facility is not ensuring that doors to resident rooms are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. Also, the facility failed to provide door hardware which required a single motion to unlatch and open the door from the frame. This deficient practice would not prevent the spread of fire and smoke. The facility has a capacity for 674 and at the time of the survey the census was 374 patients.

Findings include:

1. Observations on 10/13/10, revealed the corridor door to the C Level Laundry Chute Room did not latch properly when tested.

2. Observations on 10/13/10, revealed the corridor door to Room C - 23 did not close and latch properly when tested. Observations showed the sequencer did not operate properly to allow the door to close and latch into the frame.

3. Observations on 10/13/10, revealed carts obstructing the corridor door to the C Level - Dish Room from closing and latch properly.

4. Observations on 10/13/10, revealed the corridor door to the B Level - Environmental Room did not latch properly when tested.

5. Observations on 10/12/10, revealed the corridor door to the B Level - Environmental Closet across from the Kelly Dining Room did not latch properly when tested.

6. Observations on 10/12/10, revealed a brick had been used to clock open the corridor door to south fourth floor room S - 428.

7. Observations on 10/12/10, revealed the corridor doors to the following rooms were equipped with a doorknob and separate deadbolt lock: E - 316; E - 314; E - 312; E - 310; E - 304; and E - 332. Observations showed if the deadbolt was locked it required to motions to unlatch the door from the frame.

8. Observations on 10/12/10, revealed a plant had been used to block open the corridor door to the east third floor room E - 316.

9. Observations no 10/12/10, revealed the corridor door to north fourth Megavator did not latch properly when tested.

9. Observations on 10/12/10, revealed the corridor door to north 2 NICU overflow - Room N - 238 did not latch properly when tested.

10. Observations on 10/12/10, revealed the corridor door south 2 - Room S - 246 did not latch properly when tested.

Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keeps the doors shut tightly into their frames. This deficient practice would not prevent the spread of fire and smoke. The facility has a capacity for 374 and at the time of the survey the census was674 patients.

Findings include:

1. Observations on 10/13/10, revealed the corridor door to Room P568 did not latch properly when tested.

2. Observations on 10/13/10, revealed the corridor door to Room P565 did not latch properly when tested.

3. Observations on 10/13/10, revealed the corridor door to Room P463 did not latch properly when tested.

Based on observation, the facility is not assuring that stairway exit enclosures are enclosed at all times to impede the travel of smoke and fire gases. This deficient practice could potentially affect all occupants using the Younker Building West Stairway exit in the event of an emergency. This facility has a capacity of 674 with a census of 374.
Findings include:
Observation on 10/13/10 at approximately 1:05 p.m., revealed the Younker Building West Stairway tower 2nd floor stairway door failed to positively latch within the door frame. The door entering the enclosed stair tower failed to positively latch do to a missing latch plate on the door frame. Maintenance Staff A verified this observation.

Based on observation, the facility failed to maintain smoke doors to resist the passage of smoke. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Observations on 10/12/10, revealed the smoke doors by Room P201 failed to close properly.

Based on observations, the facility failed to maintain fire doors to close and resist the passage of smoke. This facility has a capacity of 674 and a census of 374 residents.

Findings include:

1. Observations on 10/13/10, revealed the east fire door in the set of double doors in the corridor by the Biotech Engineering Office did not latch properly when tested.

2. Observations no 10/12/10, revealed the smoke barrier doors in the corridor on north sixth floor by the Clean Utility Room, N -675 did not latch properly when tested.

(A)
Based on observations, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. The doors shall be self-closing or automatic-closing. The facility has a capacity for 83 and at the time of the survey the census was 65 residents.

Findings include:

1. Observations on 10/12/10, revealed a center of a conduit penetration (approximately 1 inch in size) located in the corridor wall on the inside of Room #5049 had not been sealed.

2. Observations on 10/12/10, revealed gaps around multiple conduit penetrations located in Room #4100 had not been sealed.

3. Observations on 10/12/10, revealed a wire penetration (approximately ? inch in size) located in the suspended ceiling of Room #4049 had not been sealed.

4. Observations on 10/12/10, revealed a vent cover penetration (approximately ? inch in size) located in Room #3039 had not been sealed.

5. Observations on 10/12/10, revealed a center of a conduit penetration (approximately ? inch in size) located in the corridor wall on the inside of Room #2158 had not been sealed.

6. Observations on 10/12/10, revealed that there was mass storage on top of the air handlers in Room 1190.




The Safety Director confirmed these findings at the time of the survey process.

(B)
Based on observations, the facility is not ensuring that doors to hazardous rooms are provided with suitable hardware that keeps the doors shut tightly into their frames. This deficient would not prevent the spread of fire and smoke. The facility has a capacity for 674 and at the time of the survey the census was 374 residents.

Findings include:

1. Observations on 10/13/10, revealed the door to the Flammable Liquids Storage Room in Receiving did not latch properly when tested at the time of the survey.

2. Observations on 10/13/10, revealed the corridor door to the Old Print Shop on the C Level did not latch properly when tested.

3. Observations on 10/12/10, revealed the corridor door to the Northeast Addition Generator Room next to Room A - 184 did not latch properly when tested.

4. Observations on 10/12/10, revealed the corridor door to the north sixth storage room N - 600 did not latch properly when tested.

5. Observations on 10/12/10, revealed east fifth - E-515, Dark Room, was greater than 50 square feet and being used for storage. The corridor door was not equipped with a self closing device.

6. Observations on 10/12/10 at 10:06 a.m., revealed the North 5 Environmental Room had a hole (approximately 2 inches by 2 inches in size) in the wall next to the chemical dispenser.
7. Observations on 10/12/10 at 2:05 p.m., revealed the Cath. Lab Mechanical Room had a hole (approximately 2 inches around) in the wall along the steps at the ceiling.

8. Observations on 10/12/10 at 2:35 p.m., revealed the Floor (B) Mechanical Room had a gap (approximately 2 inches in size) around a 6 inch sprinkler pipe penetration in the north wall that enters above the ceiling tiles of the Cafeteria Conference Room.

9. Observations on 10/12/10 at 10:27 a.m., revealed the doors to the North (4) Oxygen Storage and Patent Storage room were not equipped with a self closing device for the nurses ' station door. The door was held open with a friction device located at the bottom of the door. This would affect approximately 23 residents, staff and visitors at the time of the survey.

Based on surveyor observation, the facility failed to separate hazardous areas from other compartments. This deficient practice affects all occupants of 1 of 1 smoke zones.
Findings include:
Observations on 10/14/10 revealed the following hazardous area deficiencies:
1. Three 1-inch penetrations around pipes & conduits through the ceiling of the boiler room of the Eye Surgery and Laser Eye Center.
2. Two 3-inch holes through the ceiling of the boiler room of the Eye Surgery and Laser Eye Center.

Based on observations, the facility is not providing unobstructed exit discharge pathways leading away from the building that provides a clear path of egress. This facility has a capacity of 674 with a census of 374.

Findings include:

1. Observations on 10/13/10, revealed the C Level exit discharge hard surface pathway leading through the construction area was obstructed by construction supplies. The exit sign above this door had also been covered at the time of the inspection.

2. Observations on 10/12/10 at 10:40 a.m, revealed the hinged charting stations in the North (4) patient corridor for rooms #475, 476, 477 and 478 did not retract when tested.

Based on observations, the facility is not providing unobstructed exit discharge pathways leading away from the building that provides a clear path of egress. This facility has a capacity of 674 with a census of 374.

Findings include:

1. Observations on 10/13/10, revealed the hinged charting station in the patient corridor on Younker 5 for room #522 would not retract when tested.

2. Observations on 10/13/10 at 1:00 p.m, revealed the facility was not maintaining clear and unobstructed corridor. The double doors MP0000051 next to Y219 contained a bolt lock. If the lock is used the doors would not open for occupant egress on the east end of the corridor.

Based on observations, the facility failed to maintain one of the battery operated emergency light units to operate properly. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

1. Observations on 10/13/10, revealed 2 of 3 emergency light units in C Level - Storage Room D did not operate properly when tested.

2. Observations on 10/13/10 revealed the 2 emergency light units located in the Molecular Lab failed to illuminate when tested. The Safety Director confirmed this finding.

3. Observations on 10/12/10 at 1:25 p.m., revealed the emergency light unit in the ETS Transfer Room # A177 did not operate properly when tested.
4. Observations on 10/12/10 at approximately 1:24 p.m, revealed the egress lighting in N.E. to Skilled had provide with on/off switches on each end of the corridor. When the switches were in the off position the corridor was absent of emergency egress lighting.
5. Observations on 10/13/10 revealed the 2 emergency light units located in the Central Supply Room failed to illuminate when tested.

(A)
Based on observations, the facility failed to maintain photoluminescent exit signs in accordance National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.10.7.2. The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the sign shall be in accordance with its listing. Photoluminescent signs need a specific minimum level of light on the face of the sign to ensure that the sign is charged for emergency operation and legibility in both the normal and emergency modes. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Observations on 10/12/10, revealed photoluminescent signs had been installed in the South One corridor. Observations showed a light source had not been installed near the signs.

(B)
Based on observations the facility failed to maintain Exit Signs in the facility. This deficient practice could affect all staff this location.
Findings include:
Observations on 10/13/10 at 9:21 a.m., revealed the Southeast Exit door of the Chiller Room had a non-functioning Exit Sign.

Based on observations, the facility failed to maintain photoluminescent exit signs in accordance National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.10.7.2. The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the sign shall be in accordance with its listing. Photoluminescent signs need a specific minimum level of light on the face of the sign to ensure that the sign is charged for emergency operation and legibility in both the normal and emergency modes. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Observations on 10/13/10, revealed signs had been installed in the Powell Crossover Corridor. However these exit signs were not visible due to I-beams being in the way.

(A)
Based on observations and interview the facility failed to provide a properly maintained fire alarm system. The deficient practice could affect all smoke compartments in the building, the basement level and all residents, visitors and staff. .

Findings include:

Observations and interview with Maintenance Staff A on 10/13/10 at 11:10 a.m., revealed the Fire Alarm Booster power Supply in the Younker 3 Sleep Room batteries were not dated. On interviewing Staff they were unable to provide the date in which they were installed.
(B)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The facility has 674 certified beds and at the time of the survey the census was 374.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the facility was in the process of having the fire alarm system tested and inspected. At the time of the survey the facility was unable to provide additional documentation showing semi-annual inspection of the fire alarm system.

(A)
Based on observations the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, 7-4.2, by ensuring the fire alarm system is maintained in normal operating condition. The building has 674 certified beds and at the time of the revisit the census was 374.

Findings include:

Observations on 10/13/10, revealed a missing cover on the water flow switch attached the sprinkler riser in the Powell 1 Mechanical Room. Observations also showed the abandoned water flow switch on the sprinkler riser had been disconnected from the fire alarm system but had not been removed.
(B)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The facility has 674 certified beds and at the time of the survey the census was 374.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the facility was in the process of having the fire alarm system tested and inspected. At the time of the survey the facility was unable to provide additional documentation showing semi-annual inspection of the fire alarm system.

(A)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The facility has 674 certified beds and at the time of the survey the census was 374.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the facility was in the process of having the fire alarm system tested and inspected. At the time of the survey the facility was unable to provide additional documentation showing semi-annual inspection of the fire alarm system.
(B)
Based on record review, the facility failed to maintain a complete automatic fire alarm system in accordance with National Fire Protection Association (NFPA) 72, 1999. The facility has a capacity of 674 and at the time of the survey had a census of 374.
Findings include:
Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
Blank
? C - Level main control tamper switch did not trip module

(A)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The facility has 83 certified beds and at the time of the survey the census was 65.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the fire alarm system was last tested and inspected by Siemens on 9/25/10. At the time of the survey the facility was unable to provide additional documentation showing the system had been inspected or tested semi-annually.
(B)
Based on record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 72, 1999. The facility has a capacity of 674 and at the time of the survey had a census of 374.
Findings include:
Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
North Wing Mechanical Room
? North 3 Tamper did not trip module
? Cath Lab panel in trouble, check smoke head
2. Observations on 10/12/10 at 10:45 a.m., revealed the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the South (4) electrical panel breaker #16 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off.

(C)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The facility has 674 certified beds and at the time of the survey the census was 374.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the facility was in the process of having the fire alarm system tested and inspected. At the time of the survey the facility was unable to provide additional documentation showing semi-annual inspection of the fire alarm system.

Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the building.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the fire alarm system was last inspected in August of 2009. At the time of the survey the facility was unable to provide additional documentation showing semi-annual inspection of the fire alarm system.

Based on observations, the facility failed to supervise valves to the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, and NFPA 101 the Life Safety Code, 2000 edition, 9.7.2.1. The facility has a capacity of 674 with a census of 374.

Findings include:

1. Observations on 10/13/10, revealed a control valve for the sprinkler piping in the Kitchen Storage Room. The valve was not equipped with a tamper switch that was electrically supervised to sound an alarm. In the event that the water supply was turned off at the valve, an alarm would not notify the building occupants or the fire alarm monitoring company of the trouble.
2. Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
North Wing Mechanical Room
? OS&Y fire pump test header needs tamper switch
? OS&Y for hose cabinet, standpipe, A - stairs needs tamper switch
? OS&Y for hose cabinet, standpipe north 7 sprinklers needs tamper switch
? OS&Y for hose cabinet, standpipe C - Level stairwell and School of Nursing tunnel needs tamper switch
? OS&Y for hose cabinet, Center North wing needs tamper switch
South Wing
? C - level CD room needs tamper switch wired
? OS&Y for Mechanical room high sprinklers, South C needs tamper switch
? Tamper above Surgery in Cat Walk needs tamper switch wired

(A)
Based on observations and record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. Also, the facility failed to maintain a complete automatic sprinkler system in accordance with NFPA 25, 1998 edition, 2-2.1.1. Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation. Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. The facility has a capacity of 674 with a census of 374 patients.
Findings include:
1. Observations on 10/13/10, revealed a fluorescent light had been hung from a sprinkler pipe in the south C Level Kitchen Storage Room.
2. Observations on 10/13/10, revealed 2 fluorescent light fixtures were attached to the sprinkler piping in the C Level - Storage Room B.
3. Observations on 10/13/10, revealed dirt/foreign debris on the sprinkler head in the C Level - Elevator Equipment Room.
4. Observations on 10/13/10, revealed combustible storage that was located closer than 18 inches from the bottom of the sprinkler deflector located in the Radiology Film Storage Room. The Safety Director confirmed this finding.

5. Observations on 10/12/10, revealed a missing escutcheon ring around the sprinkler head in the A Level - Cath Lab Soiled Utility Room and Phlebotomy Room.
6. Observations on 10/12/10, revealed dirt/foreign debris on the sprinkler head on north sixth in the south stairway on the sixth level.
7. Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
South Wing
? Painted sprinkler heads in D - level hallway
? Environmental office and Equipment Storage needs sprinklers
? Caged area containing steam pipe needs sprinklers
? Remove tested to 200 psi from South dry standpipe connection
? Floor drain will not take full flow
Boiler Room
? Flow switch above boiler paddle sticks in pipe, needs repaired
8. Observations on 10/12/10 at 1:23 p.m., revealed that the Laundry Chute Room (A-176) had dirty or obstructed sprinkler heads. The sprinkler heads had dirt/lint and plastic hanging on the diffuser/ arms and link.

9. Observations on 10/12/10 at 2:44 p.m., revealed that in the Kitchen in the Pizza Making area five (5) of five 95) sprinkler heads were coated in dirt and had a green corrosion on the arms/link and diffuser.

10. Observations on 10/13/10 at 8:40 a.m., revealed that the South (D) Wire Cage room above the electrical panels next to the north wall had white paint on the sprinkler head.
11. Observations on 10/12/10 at 8:45 a.m., revealed that the South (D) basement Walk-in Freezer had an obstructed sprinkler head. The sprinkler head was covered with ice build-up.
12. Observations on 10/12/10, revealed 2, missing escutcheon rings around sprinkler heads in the hallway outside the Kitchen Supervisor ' s Office.
13. Record review of the sprinkler system maintenance records on 10/14/10, revealed the facility was unable to provide documentation showing the sprinkler system in Methodist West had been been provided with an annual test and inspection.
14. Observations on 10/13/10, revealed there were mixed types of sprinkler heads in the Radiology Core Area.

15. Observations on 10/13/10, revealed there were dirty heads in the Radiology Core Area.

16. Observations on 10/13/10, revealed there were mixed type sprinkler heads in the CT Waiting Area.

Based on observations and record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998. The facility has a capacity of 674 and at the time of the survey had a census of 374.
Findings include:
Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
Powell
? Main drain won ' t take full flow
? Flow switch on Powell standpipe riser needs replaced (6 " )
? Powell 4 needs new gauge

Based on observations and record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998. The facility has a capacity of 674 and at the time of the survey had a census of 374.
Findings include:
Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
Younkers
? Younkers 7 needs new gauge
? Younkers 8 needs new gauge
? Younkers B - Level Maintenance area sprinkler head coverage is inadequate and not all rooms are sprinklered
? Younkers Level 2 Room Y219 sprinklers are too close together, needs one sprinkler removed

Based on observations, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. The facility has a capacity of 674 and at the time of the survey process the census was 374 residents.

Findings include:

Observations on 10/13/10, revealed a cart was obstructing access to the fire extinguisher cabinet in the C - Level corridor outside of the Dish Room.

Based on record review and observations, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. This deficient practice affects occupants in one of six zones. The facility has a capacity of 83 and at the time of the survey had a census of 65.

Findings include:

Observations and record review on 10/12/10, revealed the facility was unable to provide documentation to show the wet chemical extinguishing system in the hood in the Kitchen had been provided with a monthly owners inspection. The Safety Director confirmed these findings.

(A)
Based on observations the facility failed to maintain the standpipe and hose system in accordance with National Fire Protection Association (NFPA) Standard 25 and NFPA 1962. Fire hoses shall be inspected annually. In-service hose designed for occupant use only shall be removed and service-tested at intervals not exceeding 5 years after the date of manufacturer and every 3 years thereafter. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Observations on 10/12/10 through 10/13/10, revealed a fire hose within the standpipe cabinets in the following locations: corridor across from the C Level Wash Room; corridor outside of the Dish Room on the C Level; corridor by the Old Print Shop on the C Level; the south third floor corridor across from Room 336; in the south 2 corridor across from Room S - 236; in the east fifth corridor by the Life Flight Sleep Study Room; and in the east fourth corridor by E - 101. Maintenance Staff reported the fire hoses are not inspected as required.

(B)
Based on observations, the facility failed to provide doors to storage areas with means of unlatching the door/gate from the egress side. All doors/gates in the facility shall be able to be opened from the inside without the use of a key, tool, or special knowledge. The facility has a capacity of 674 and at the time the census was 374.

Findings include:

Observations on 10/13/10, revealed the gate to the C Level - Kitchen Storage Area had been locked with a padlock.

(C)
Based on observations, the facility failed to maintain the suppression system located in the Cath Lab in accordance with applicable NFPA standards. Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Observations on 10/12/10, revealed components of a suppression system such as the discharge nozzle and manual actuator had been left installed in the Cath Lab Soiled Utility Room. Facility Staff reported the tanks containing the suppressing agent had been removed and they did not believe the system was left in service.

(D)
Based on record review the facility failed to maintain the clean agent fire extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 2001, Standard on Clean Agent Fire Extinguishing Systems. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Record review on 10/14/10, revealed the FM 200 system in MRI had last been inspected on 11/2/09. At the time of the survey the facility was unable to provide additional documentation showing the system had been inspected semi-annually.


(E)
Based on observations, the facility failed to maintain storage of flammable liquids at Methodist West. The facility has a capacity of 83 and at the time of the survey had a census of 40.

Findings include:

Observations on 10/12/10, revealed there was 100 gallons of used oil being stored in the Main Mechanical Room at Methodist West.

Based on observation, the facility failed to provide emergency task illumination at the emergency generator transfer switch location. The emergency generator would affect all smoke compartments and all of the facility residents and staff.
Findings include:
Observation on 10/14/10, revealed a battery emergency light unit was not provided at the emergency generator transfer switch location serving the Hand Therapy and Outpatient Therapy West facilities to provide task illumination.

Based on observation, the facility failed to provide emergency task illumination at the emergency generator transfer switch location. The emergency generator would affect all smoke compartments and all of the facility residents and staff.
Findings include:
Observation on 10/14/10, revealed a battery emergency light unit was not provided at the emergency generator transfer switch location serving the Merle Hay Family Physicians facility to provide task illumination.

Based on observations, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility has a capacity of 674 and a census of 374 residents.

Findings include:

1. Observations on 10/12/10, revealed an extension cord used for the microwave in the Emergency Room C-Store corridor in the North first floor.

2. Observations no 10/12/10, revealed a surge protector had been plugged into another surge protector north fourth - E - 419.

3. Observations on 10/12/10 at 1:38 p.m., revealed yellow extension cords with an outlet in use in numerous surgery suites. These extension cords were plugged in to wall outlets and were used to power surgery equipment. These ranged in size from 10 feet to 25 feet in length.

4. Observations on 10/12/10 at 2:10 p.m., revealed the facility failed to maintain the electrical wiring in the Cath. Lab Mechanical Room. Observations revealed an open junction box with exposed electrical wiring.

5. Observations on 10/13/10 at 8:56 a.m., revealed the facility failed to maintain the electrical wiring in the Wire Cage area of Level D in the Main Building. Electrical Panel 3-1-1-3-D3-5-D4 had a 1 ? inch knock out missing on the right side of the box.

6. Observations on 10/13/10 at 8:50 a.m., revealed the facility failed to maintain the electrical wiring in the South (D) Break Room. Electrical Panel 9-1-7-L-D3 contained breakers that did not indicate their designations. The following breakers: 2, 4 and 8 were not labeled.

7. Observations on 10/12/10, revealed there was a powerstrip plugged in to the wall in Room 1064 at Methodist West.

Based on surveyor observation, the facility failed to maintain the electrical system in accordance with National Fire Protection Association (NFPA) 70. This deficient practice affects all occupants of 1 of 1 smoke zones.
Findings include:
Observations on 10/14/10 at 8:26 a.m. revealed storage obstructing access to the electrical panels in the emergency generator transfer switch room serving Hand Therapy and Outpatient Therapy West.

Based on observations, the facility failed to maintain a 2 hours seperation between Powell and the Parking structure. This facility has a capacity of 674 residents and that time of the revisit had a census of 374.

Findings include:

Observations on 10/13/10, revealed there was a 20 minute door between Powell and the Parking structure. A 2 hour door is required.

Based on observations, it was determined the facility was composed of fire resistive and protected non-combustible construction (concrete and steel). The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with materials to limit the transfer of smoke. The facility has a capacity of 674 residents and that time of the revisit had a census of 374.

Findings include:

1. Observations on 10/12/10, revealed a hole (approximately 2 inches in size) in the ceiling tile in A Level - PACU - Room A 155.

2. Observations on 10/12/10, revealed missing ceiling tile in the north second floor NICU overflow in the Sprinkler Valve Shutoff ' 2 ' Room.

3. Observations on 10/13/10, revealed a gap around a sprinkler penetration in the Level - C Ultrasound Room.

4. Observations on 10/13/10, revealed the closet in the Northeast Radiology area, near the Radiology Classroom and Transcription Copier Room failed to be protected with 1 hour rated construction. Observations revealed there were large penetrations in the ceiling which had not been sealed.

5. Observations on 10/13/10, revealed a missing escutcheon ring around the sprinkler head in the North 6 West Nurses Station creating a gap (approximately ? inch to ? inch in size) at the ceiling.

6. Observations on 10/13/10, revealed a gap (approximately ? inch to ? inch in size) around a sprinkler head penetration in the NE 3 Electrical Closet at the ceiling.

7. Observations on 10/12/10, revealed a gap (approximately ? inch to ? inch in size) around a blue cable penetration in the wall and ceiling of the egress corridor next to the C-Store near the white IT box mounted on the wall.

8. Observations on 10/12/10, revealed a gap (approximately ? inch in size) around wires in Room 5101 at Methodist West.

9. Observations on 10/12/10, revealed a gap (approximately 3 inches in size) around a cable tray in Room 5049 at Methodist West.

10. Observations on 10/12/10, revealed a gap (approximately ? inch in size) around conduit in Room 4042 at Methodist West.

11. Observations on 10/12/10, revealed a gap (approximately ? inch in size) around conduit in Room 3039 at Methodist West.

12. Observations on 10/12/10, revealed a gap (approximately ? inch in size) around conduit in Room 3037 at Methodist West.

13. Observations on 10/13/10, revealed a gap (approximately ? inch to ? inch in size) in the ceiling in the PACS Office.

Based on observations, it was determined the facility was composed of fire resistive and protected non-combustible construction (concrete and steel). The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with materials to limit the transfer of smoke. The facility has a capacity of 674 residents and that time of the revisit had a census of 374.

Findings include:

1. Observations on 10/12/10, revealed a missing escutcheon ring in the IT repair room of the Younkers building.

Based on observations, it was determined the facility was composed of fire resistive and protected non-combustible construction (concrete and steel). The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with materials to limit the transfer of smoke. The facility has a capacity of 674 residents and that time of the revisit had a census of 374.

Findings include:

Observations on 10/13/10, revealed an area 1 foot by 2 foot that was missing the spray on fire proofing. This was locared in the Powell 7th Mechanical Room.

Based on observations, the facility failed to separate the corridors from other areas by partitions complying with 19.3.6.2 through 19.3.6.5 of the 2000 Life Safety Code. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Life Safety Code. This facility has a capacity of a 674 and had a census of a 374 residents.

Findings include:

Observations on 10/12/10, revealed the break room and lounge areas open to the corridor in the Emergency Room C - Store corridor on the North first floor. The compartment was equipped with sprinkler protection. Absent was smoke detection in the corridor and the rooms which open onto the corridor.

Based on observations, the facility is not ensuring that doors to resident rooms are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames. Also, the facility failed to provide door hardware which required a single motion to unlatch and open the door from the frame. This deficient practice would not prevent the spread of fire and smoke. The facility has a capacity for 674 and at the time of the survey the census was 374 patients.

Findings include:

1. Observations on 10/13/10, revealed the corridor door to the C Level Laundry Chute Room did not latch properly when tested.

2. Observations on 10/13/10, revealed the corridor door to Room C - 23 did not close and latch properly when tested. Observations showed the sequencer did not operate properly to allow the door to close and latch into the frame.

3. Observations on 10/13/10, revealed carts obstructing the corridor door to the C Level - Dish Room from closing and latch properly.

4. Observations on 10/13/10, revealed the corridor door to the B Level - Environmental Room did not latch properly when tested.

5. Observations on 10/12/10, revealed the corridor door to the B Level - Environmental Closet across from the Kelly Dining Room did not latch properly when tested.

6. Observations on 10/12/10, revealed a brick had been used to clock open the corridor door to south fourth floor room S - 428.

7. Observations on 10/12/10, revealed the corridor doors to the following rooms were equipped with a doorknob and separate deadbolt lock: E - 316; E - 314; E - 312; E - 310; E - 304; and E - 332. Observations showed if the deadbolt was locked it required to motions to unlatch the door from the frame.

8. Observations on 10/12/10, revealed a plant had been used to block open the corridor door to the east third floor room E - 316.

9. Observations no 10/12/10, revealed the corridor door to north fourth Megavator did not latch properly when tested.

9. Observations on 10/12/10, revealed the corridor door to north 2 NICU overflow - Room N - 238 did not latch properly when tested.

10. Observations on 10/12/10, revealed the corridor door south 2 - Room S - 246 did not latch properly when tested.

Based on observations, the facility is not ensuring that doors to rooms are provided with suitable hardware that keeps the doors shut tightly into their frames. This deficient practice would not prevent the spread of fire and smoke. The facility has a capacity for 374 and at the time of the survey the census was674 patients.

Findings include:

1. Observations on 10/13/10, revealed the corridor door to Room P568 did not latch properly when tested.

2. Observations on 10/13/10, revealed the corridor door to Room P565 did not latch properly when tested.

3. Observations on 10/13/10, revealed the corridor door to Room P463 did not latch properly when tested.

Based on observation, the facility is not assuring that stairway exit enclosures are enclosed at all times to impede the travel of smoke and fire gases. This deficient practice could potentially affect all occupants using the Younker Building West Stairway exit in the event of an emergency. This facility has a capacity of 674 with a census of 374.
Findings include:
Observation on 10/13/10 at approximately 1:05 p.m., revealed the Younker Building West Stairway tower 2nd floor stairway door failed to positively latch within the door frame. The door entering the enclosed stair tower failed to positively latch do to a missing latch plate on the door frame. Maintenance Staff A verified this observation.

Based on observation, the facility failed to maintain smoke doors to resist the passage of smoke. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Observations on 10/12/10, revealed the smoke doors by Room P201 failed to close properly.

Based on observations, the facility failed to maintain fire doors to close and resist the passage of smoke. This facility has a capacity of 674 and a census of 374 residents.

Findings include:

1. Observations on 10/13/10, revealed the east fire door in the set of double doors in the corridor by the Biotech Engineering Office did not latch properly when tested.

2. Observations no 10/12/10, revealed the smoke barrier doors in the corridor on north sixth floor by the Clean Utility Room, N -675 did not latch properly when tested.

(A)
Based on observations, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. The doors shall be self-closing or automatic-closing. The facility has a capacity for 83 and at the time of the survey the census was 65 residents.

Findings include:

1. Observations on 10/12/10, revealed a center of a conduit penetration (approximately 1 inch in size) located in the corridor wall on the inside of Room #5049 had not been sealed.

2. Observations on 10/12/10, revealed gaps around multiple conduit penetrations located in Room #4100 had not been sealed.

3. Observations on 10/12/10, revealed a wire penetration (approximately ? inch in size) located in the suspended ceiling of Room #4049 had not been sealed.

4. Observations on 10/12/10, revealed a vent cover penetration (approximately ? inch in size) located in Room #3039 had not been sealed.

5. Observations on 10/12/10, revealed a center of a conduit penetration (approximately ? inch in size) located in the corridor wall on the inside of Room #2158 had not been sealed.

6. Observations on 10/12/10, revealed that there was mass storage on top of the air handlers in Room 1190.




The Safety Director confirmed these findings at the time of the survey process.

(B)
Based on observations, the facility is not ensuring that doors to hazardous rooms are provided with suitable hardware that keeps the doors shut tightly into their frames. This deficient would not prevent the spread of fire and smoke. The facility has a capacity for 674 and at the time of the survey the census was 374 residents.

Findings include:

1. Observations on 10/13/10, revealed the door to the Flammable Liquids Storage Room in Receiving did not latch properly when tested at the time of the survey.

2. Observations on 10/13/10, revealed the corridor door to the Old Print Shop on the C Level did not latch properly when tested.

3. Observations on 10/12/10, revealed the corridor door to the Northeast Addition Generator Room next to Room A - 184 did not latch properly when tested.

4. Observations on 10/12/10, revealed the corridor door to the north sixth storage room N - 600 did not latch properly when tested.

5. Observations on 10/12/10, revealed east fifth - E-515, Dark Room, was greater than 50 square feet and being used for storage. The corridor door was not equipped with a self closing device.

6. Observations on 10/12/10 at 10:06 a.m., revealed the North 5 Environmental Room had a hole (approximately 2 inches by 2 inches in size) in the wall next to the chemical dispenser.
7. Observations on 10/12/10 at 2:05 p.m., revealed the Cath. Lab Mechanical Room had a hole (approximately 2 inches around) in the wall along the steps at the ceiling.

8. Observations on 10/12/10 at 2:35 p.m., revealed the Floor (B) Mechanical Room had a gap (approximately 2 inches in size) around a 6 inch sprinkler pipe penetration in the north wall that enters above the ceiling tiles of the Cafeteria Conference Room.

9. Observations on 10/12/10 at 10:27 a.m., revealed the doors to the North (4) Oxygen Storage and Patent Storage room were not equipped with a self closing device for the nurses ' station door. The door was held open with a friction device located at the bottom of the door. This would affect approximately 23 residents, staff and visitors at the time of the survey.

Based on surveyor observation, the facility failed to separate hazardous areas from other compartments. This deficient practice affects all occupants of 1 of 1 smoke zones.
Findings include:
Observations on 10/14/10 revealed the following hazardous area deficiencies:
1. Three 1-inch penetrations around pipes & conduits through the ceiling of the boiler room of the Eye Surgery and Laser Eye Center.
2. Two 3-inch holes through the ceiling of the boiler room of the Eye Surgery and Laser Eye Center.

Based on observations, the facility is not providing unobstructed exit discharge pathways leading away from the building that provides a clear path of egress. This facility has a capacity of 674 with a census of 374.

Findings include:

1. Observations on 10/13/10, revealed the C Level exit discharge hard surface pathway leading through the construction area was obstructed by construction supplies. The exit sign above this door had also been covered at the time of the inspection.

2. Observations on 10/12/10 at 10:40 a.m, revealed the hinged charting stations in the North (4) patient corridor for rooms #475, 476, 477 and 478 did not retract when tested.

Based on observations, the facility is not providing unobstructed exit discharge pathways leading away from the building that provides a clear path of egress. This facility has a capacity of 674 with a census of 374.

Findings include:

1. Observations on 10/13/10, revealed the hinged charting station in the patient corridor on Younker 5 for room #522 would not retract when tested.

2. Observations on 10/13/10 at 1:00 p.m, revealed the facility was not maintaining clear and unobstructed corridor. The double doors MP0000051 next to Y219 contained a bolt lock. If the lock is used the doors would not open for occupant egress on the east end of the corridor.

Based on observations, the facility failed to maintain one of the battery operated emergency light units to operate properly. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

1. Observations on 10/13/10, revealed 2 of 3 emergency light units in C Level - Storage Room D did not operate properly when tested.

2. Observations on 10/13/10 revealed the 2 emergency light units located in the Molecular Lab failed to illuminate when tested. The Safety Director confirmed this finding.

3. Observations on 10/12/10 at 1:25 p.m., revealed the emergency light unit in the ETS Transfer Room # A177 did not operate properly when tested.
4. Observations on 10/12/10 at approximately 1:24 p.m, revealed the egress lighting in N.E. to Skilled had provide with on/off switches on each end of the corridor. When the switches were in the off position the corridor was absent of emergency egress lighting.
5. Observations on 10/13/10 revealed the 2 emergency light units located in the Central Supply Room failed to illuminate when tested.

(A)
Based on observations, the facility failed to maintain photoluminescent exit signs in accordance National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.10.7.2. The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the sign shall be in accordance with its listing. Photoluminescent signs need a specific minimum level of light on the face of the sign to ensure that the sign is charged for emergency operation and legibility in both the normal and emergency modes. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Observations on 10/12/10, revealed photoluminescent signs had been installed in the South One corridor. Observations showed a light source had not been installed near the signs.

(B)
Based on observations the facility failed to maintain Exit Signs in the facility. This deficient practice could affect all staff this location.
Findings include:
Observations on 10/13/10 at 9:21 a.m., revealed the Southeast Exit door of the Chiller Room had a non-functioning Exit Sign.

Based on observations, the facility failed to maintain photoluminescent exit signs in accordance National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 7.10.7.2. The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the sign shall be in accordance with its listing. Photoluminescent signs need a specific minimum level of light on the face of the sign to ensure that the sign is charged for emergency operation and legibility in both the normal and emergency modes. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Observations on 10/13/10, revealed signs had been installed in the Powell Crossover Corridor. However these exit signs were not visible due to I-beams being in the way.

(A)
Based on observations and interview the facility failed to provide a properly maintained fire alarm system. The deficient practice could affect all smoke compartments in the building, the basement level and all residents, visitors and staff. .

Findings include:

Observations and interview with Maintenance Staff A on 10/13/10 at 11:10 a.m., revealed the Fire Alarm Booster power Supply in the Younker 3 Sleep Room batteries were not dated. On interviewing Staff they were unable to provide the date in which they were installed.
(B)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The facility has 674 certified beds and at the time of the survey the census was 374.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the facility was in the process of having the fire alarm system tested and inspected. At the time of the survey the facility was unable to provide additional documentation showing semi-annual inspection of the fire alarm system.

(A)
Based on observations the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, 7-4.2, by ensuring the fire alarm system is maintained in normal operating condition. The building has 674 certified beds and at the time of the revisit the census was 374.

Findings include:

Observations on 10/13/10, revealed a missing cover on the water flow switch attached the sprinkler riser in the Powell 1 Mechanical Room. Observations also showed the abandoned water flow switch on the sprinkler riser had been disconnected from the fire alarm system but had not been removed.
(B)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The facility has 674 certified beds and at the time of the survey the census was 374.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the facility was in the process of having the fire alarm system tested and inspected. At the time of the survey the facility was unable to provide additional documentation showing semi-annual inspection of the fire alarm system.

(A)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The facility has 674 certified beds and at the time of the survey the census was 374.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the facility was in the process of having the fire alarm system tested and inspected. At the time of the survey the facility was unable to provide additional documentation showing semi-annual inspection of the fire alarm system.
(B)
Based on record review, the facility failed to maintain a complete automatic fire alarm system in accordance with National Fire Protection Association (NFPA) 72, 1999. The facility has a capacity of 674 and at the time of the survey had a census of 374.
Findings include:
Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
Blank
? C - Level main control tamper switch did not trip module

(A)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The facility has 83 certified beds and at the time of the survey the census was 65.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the fire alarm system was last tested and inspected by Siemens on 9/25/10. At the time of the survey the facility was unable to provide additional documentation showing the system had been inspected or tested semi-annually.
(B)
Based on record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 72, 1999. The facility has a capacity of 674 and at the time of the survey had a census of 374.
Findings include:
Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
North Wing Mechanical Room
? North 3 Tamper did not trip module
? Cath Lab panel in trouble, check smoke head
2. Observations on 10/12/10 at 10:45 a.m., revealed the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the South (4) electrical panel breaker #16 was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off.

(C)
Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the campus. The facility has 674 certified beds and at the time of the survey the census was 374.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the facility was in the process of having the fire alarm system tested and inspected. At the time of the survey the facility was unable to provide additional documentation showing semi-annual inspection of the fire alarm system.

Based on record review the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the building.

Findings include:

Record review of the fire alarm test records on 10/14/10, revealed the fire alarm system was last inspected in August of 2009. At the time of the survey the facility was unable to provide additional documentation showing semi-annual inspection of the fire alarm system.

Based on observations, the facility failed to supervise valves to the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA), Standard 72, 1999 edition, and NFPA 101 the Life Safety Code, 2000 edition, 9.7.2.1. The facility has a capacity of 674 with a census of 374.

Findings include:

1. Observations on 10/13/10, revealed a control valve for the sprinkler piping in the Kitchen Storage Room. The valve was not equipped with a tamper switch that was electrically supervised to sound an alarm. In the event that the water supply was turned off at the valve, an alarm would not notify the building occupants or the fire alarm monitoring company of the trouble.
2. Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
North Wing Mechanical Room
? OS&Y fire pump test header needs tamper switch
? OS&Y for hose cabinet, standpipe, A - stairs needs tamper switch
? OS&Y for hose cabinet, standpipe north 7 sprinklers needs tamper switch
? OS&Y for hose cabinet, standpipe C - Level stairwell and School of Nursing tunnel needs tamper switch
? OS&Y for hose cabinet, Center North wing needs tamper switch
South Wing
? C - level CD room needs tamper switch wired
? OS&Y for Mechanical room high sprinklers, South C needs tamper switch
? Tamper above Surgery in Cat Walk needs tamper switch wired

(A)
Based on observations and record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. Also, the facility failed to maintain a complete automatic sprinkler system in accordance with NFPA 25, 1998 edition, 2-2.1.1. Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation. Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. The facility has a capacity of 674 with a census of 374 patients.
Findings include:
1. Observations on 10/13/10, revealed a fluorescent light had been hung from a sprinkler pipe in the south C Level Kitchen Storage Room.
2. Observations on 10/13/10, revealed 2 fluorescent light fixtures were attached to the sprinkler piping in the C Level - Storage Room B.
3. Observations on 10/13/10, revealed dirt/foreign debris on the sprinkler head in the C Level - Elevator Equipment Room.
4. Observations on 10/13/10, revealed combustible storage that was located closer than 18 inches from the bottom of the sprinkler deflector located in the Radiology Film Storage Room. The Safety Director confirmed this finding.

5. Observations on 10/12/10, revealed a missing escutcheon ring around the sprinkler head in the A Level - Cath Lab Soiled Utility Room and Phlebotomy Room.
6. Observations on 10/12/10, revealed dirt/foreign debris on the sprinkler head on north sixth in the south stairway on the sixth level.
7. Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
South Wing
? Painted sprinkler heads in D - level hallway
? Environmental office and Equipment Storage needs sprinklers
? Caged area containing steam pipe needs sprinklers
? Remove tested to 200 psi from South dry standpipe connection
? Floor drain will not take full flow
Boiler Room
? Flow switch above boiler paddle sticks in pipe, needs repaired
8. Observations on 10/12/10 at 1:23 p.m., revealed that the Laundry Chute Room (A-176) had dirty or obstructed sprinkler heads. The sprinkler heads had dirt/lint and plastic hanging on the diffuser/ arms and link.

9. Observations on 10/12/10 at 2:44 p.m., revealed that in the Kitchen in the Pizza Making area five (5) of five 95) sprinkler heads were coated in dirt and had a green corrosion on the arms/link and diffuser.

10. Observations on 10/13/10 at 8:40 a.m., revealed that the South (D) Wire Cage room above the electrical panels next to the north wall had white paint on the sprinkler head.
11. Observations on 10/12/10 at 8:45 a.m., revealed that the South (D) basement Walk-in Freezer had an obstructed sprinkler head. The sprinkler head was covered with ice build-up.
12. Observations on 10/12/10, revealed 2, missing escutcheon rings around sprinkler heads in the hallway outside the Kitchen Supervisor ' s Office.
13. Record review of the sprinkler system maintenance records on 10/14/10, revealed the facility was unable to provide documentation showing the sprinkler system in Methodist West had been been provided with an annual test and inspection.
14. Observations on 10/13/10, revealed there were mixed types of sprinkler heads in the Radiology Core Area.

15. Observations on 10/13/10, revealed there were dirty heads in the Radiology Core Area.

16. Observations on 10/13/10, revealed there were mixed type sprinkler heads in the CT Waiting Area.

Based on observations and record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998. The facility has a capacity of 674 and at the time of the survey had a census of 374.
Findings include:
Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
Powell
? Main drain won ' t take full flow
? Flow switch on Powell standpipe riser needs replaced (6 " )
? Powell 4 needs new gauge

Based on observations and record review, the facility failed to maintain a complete automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25, 1998. The facility has a capacity of 674 and at the time of the survey had a census of 374.
Findings include:
Record review of the sprinkler system maintenance records on 10/14/10, revealed the following deficiencies had been noted. Maintenance Staff reported many of them have been completed but at the time of the survey the facility was unable to provide documentation showing these deficiencies have been corrected.
Younkers
? Younkers 7 needs new gauge
? Younkers 8 needs new gauge
? Younkers B - Level Maintenance area sprinkler head coverage is inadequate and not all rooms are sprinklered
? Younkers Level 2 Room Y219 sprinklers are too close together, needs one sprinkler removed

Based on observations, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 1998 edition. Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. The facility has a capacity of 674 and at the time of the survey process the census was 374 residents.

Findings include:

Observations on 10/13/10, revealed a cart was obstructing access to the fire extinguisher cabinet in the C - Level corridor outside of the Dish Room.

Based on record review and observations, the facility failed to maintain the wet chemical extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 17A, the standard for Wet Chemical Extinguishing Systems, 5-2.1. A monthly inspection of the system shall be conducted. This deficient practice affects occupants in one of six zones. The facility has a capacity of 83 and at the time of the survey had a census of 65.

Findings include:

Observations and record review on 10/12/10, revealed the facility was unable to provide documentation to show the wet chemical extinguishing system in the hood in the Kitchen had been provided with a monthly owners inspection. The Safety Director confirmed these findings.

(A)
Based on observations the facility failed to maintain the standpipe and hose system in accordance with National Fire Protection Association (NFPA) Standard 25 and NFPA 1962. Fire hoses shall be inspected annually. In-service hose designed for occupant use only shall be removed and service-tested at intervals not exceeding 5 years after the date of manufacturer and every 3 years thereafter. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Observations on 10/12/10 through 10/13/10, revealed a fire hose within the standpipe cabinets in the following locations: corridor across from the C Level Wash Room; corridor outside of the Dish Room on the C Level; corridor by the Old Print Shop on the C Level; the south third floor corridor across from Room 336; in the south 2 corridor across from Room S - 236; in the east fifth corridor by the Life Flight Sleep Study Room; and in the east fourth corridor by E - 101. Maintenance Staff reported the fire hoses are not inspected as required.

(B)
Based on observations, the facility failed to provide doors to storage areas with means of unlatching the door/gate from the egress side. All doors/gates in the facility shall be able to be opened from the inside without the use of a key, tool, or special knowledge. The facility has a capacity of 674 and at the time the census was 374.

Findings include:

Observations on 10/13/10, revealed the gate to the C Level - Kitchen Storage Area had been locked with a padlock.

(C)
Based on observations, the facility failed to maintain the suppression system located in the Cath Lab in accordance with applicable NFPA standards. Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Observations on 10/12/10, revealed components of a suppression system such as the discharge nozzle and manual actuator had been left installed in the Cath Lab Soiled Utility Room. Facility Staff reported the tanks containing the suppressing agent had been removed and they did not believe the system was left in service.

(D)
Based on record review the facility failed to maintain the clean agent fire extinguishing system in accordance with National Fire Protection Association (NFPA) Standard 2001, Standard on Clean Agent Fire Extinguishing Systems. The facility has a capacity of 674 and at the time of the survey had a census of 374.

Findings include:

Record review on 10/14/10, revealed the FM 200 system in MRI had last been inspected on 11/2/09. At the time of the survey the facility was unable to provide additional documentation showing the system had been inspected semi-annually.


(E)
Based on observations, the facility failed to maintain storage of flammable liquids at Methodist West. The facility has a capacity of 83 and at the time of the survey had a census of 40.

Findings include:

Observations on 10/12/10, revealed there was 100 gallons of used oil being stored in the Main Mechanical Room at Methodist West.

Based on observation, the facility failed to provide emergency task illumination at the emergency generator transfer switch location. The emergency generator would affect all smoke compartments and all of the facility residents and staff.
Findings include:
Observation on 10/14/10, revealed a battery emergency light unit was not provided at the emergency generator transfer switch location serving the Hand Therapy and Outpatient Therapy West facilities to provide task illumination.

Based on observation, the facility failed to provide emergency task illumination at the emergency generator transfer switch location. The emergency generator would affect all smoke compartments and all of the facility residents and staff.
Findings include:
Observation on 10/14/10, revealed a battery emergency light unit was not provided at the emergency generator transfer switch location serving the Merle Hay Family Physicians facility to provide task illumination.

Based on observations, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility has a capacity of 674 and a census of 374 residents.

Findings include:

1. Observations on 10/12/10, revealed an extension cord used for the microwave in the Emergency Room C-Store corridor in the North first floor.

2. Observations no 10/12/10, revealed a surge protector had been plugged into another surge protector north fourth - E - 419.

3. Observations on 10/12/10 at 1:38 p.m., revealed yellow extension cords with an outlet in use in numerous surgery suites. These extension cords were plugged in to wall outlets and were used to power surgery equipment. These ranged in size from 10 feet to 25 feet in length.

4. Observations on 10/12/10 at 2:10 p.m., revealed the facility failed to maintain the electrical wiring in the Cath. Lab Mechanical Room. Observations revealed an open junction box with exposed electrical wiring.

5. Observations on 10/13/10 at 8:56 a.m., revealed the facility failed to maintain the electrical wiring in the Wire Cage area of Level D in the Main Building. Electrical Panel 3-1-1-3-D3-5-D4 had a 1 ? inch knock out missing on the right side of the box.

6. Observations on 10/13/10 at 8:50 a.m., revealed the facility failed to maintain the electrical wiring in the South (D) Break Room. Electrical Panel 9-1-7-L-D3 contained breakers that did not indicate their designations. The following breakers: 2, 4 and 8 were not labeled.

7. Observations on 10/12/10, revealed there was a powerstrip plugged in to the wall in Room 1064 at Methodist West.

Based on surveyor observation, the facility failed to maintain the electrical system in accordance with National Fire Protection Association (NFPA) 70. This deficient practice affects all occupants of 1 of 1 smoke zones.
Findings include:
Observations on 10/14/10 at 8:26 a.m. revealed storage obstructing access to the electrical panels in the emergency generator transfer switch room serving Hand Therapy and Outpatient Therapy West.