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The inspector observed, while accompanied by the CEO, CNO, Director of the Risk Management, Director of performance Improvement, Director of Plant Operation, Infection Control Manager, and Safety Officer, on 09/19/2019 that there were the following issues. They were the following issues:

A.) There was a door stop provided at the dietary storage room. This door shall be remained closed except for entering and receiving. The door closer shall be provided at this door.

The inspector observed, while accompanied by the CEO, CNO, Director of the Risk Management, Director of performance Improvement, Director of Plant Operation, Infection Control Manager, and Safety Officer, on 09/19/2019 that there were the following issues. They were the following issues:

A) The fire drills log on the first quarter of 2019 was not performed.

The inspector observed, while accompanied by the CEO, CNO, Director of the Risk Management, Director of performance Improvement, Director of Plant Operation, Infection Control Manager, and Safety Officer, on 09/19/2019 that there were the following issues. They were the following issues:

A) The sprinkler head located the Telephone room at unit 5 is less than 4" from the wall. Please adjust the location of eth sprinkler head to a place more than 4" from any wall in that room.

The inspector observed, while accompanied by the CEO, CNO, Director of the Risk Management, Director of performance Improvement, Director of Plant Operation, Infection Control Manager, and Safety Officer, on 09/19/2019 that there were the following issues. They were the following issues:

(A) There was a missing receptacle powered from life safety branch at the automatic transfer switch location.


(B) The electrical directory was not updated in accordance to the new or modified receptacles.


(C) Emergency panels were not distinctively marked so that they are readily identifiable as a component of the essential electrical system."


(D) The labels provided for the electrical panels and the essential transfer switches were not readily identifiable to identify life safety, critical and equipment branch.



(E) Please verify that there is a bonding wire provided between the normal and essential branch-circuits panelboards. Please reference NFPA 70, 2002: 517-14. - Panelboard bonding requires the equipment grounding terminal buses of the normal and essential branch-circuits panelboards serving the same individual patient vicinity be bonded together with an insulated continuous copper conductor not smaller than # 10 AWG.



(F) The fire alarm booster panel shown to be powered from the normal power. The Main fire alarm control panel and the remote fire alarm annunciator need to be verified that it is powered from the life safety branch. Once the correction is done please provide correct panel and circuit number on the face of the FACP.


(G) There was not an electrical panel and circuit number labeling on the face of the FACP



(H) Since there were numerous fire alarm booster panel and fire alarm related component were not powered from the life safety branch. Please verify all the fire alarm component will be corrected to the life safety branch.



(I) There were two the electrical panels' (2EAM, 2ECM) labels shown to be labeled as normal power however the panel directory shown nurse call system, auto doors, and exterior light at exits which shall be powered from the critical branch (nurse call system) and life safety branch (auto door and exterior exit lights).. Please very either correct the labeling or correct those item to the correct branches.



(J) There were flexible utilized from emergency life safety electrical panel (2EAM, 2ECM). This wiring system shall be a nonflexible metal raceway.

The inspector observed, while accompanied by the CEO, CNO, Director of the Risk Management, Director of performance Improvement, Director of Plant Operation, Infection Control Manager, and Safety Officer, on 09/19/2019 that there were the following issues. They were the following issues:

A) The policy and logs of the feature of fire protection - fire loss prevention in operating rooms was not available. Please provide updated policy for the fire loss prevention in operating room in accordance with NFPA 99, 2012, 15.13