HospitalInspections.org

Building construction type and height meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/20/2014 between approximately 1300 and 1530 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1) Floor 1 IT Storage room has multiple ceiling tiles missing; exposing the combustible components of the area above the ceiling and an open junction box containing " live parts " (see K0147).

The above was discussed and acknowledged by the Maintenance Supervisor.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 18.3.6.3.6 are permitted. 18.3.6.3.6

Roller latches are prohibited by CMS regulations in all health care facilities.

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to maintain the fire rated doors in the building capable of closing and latching tight to the frame, this could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
1. In the Rainier Tower the door to the PICU closet next to patient room's 4-331 & 4-340 have no latching hardware installed.
2. In the Phillips center the door to the soiled linen room next to patient room 707 failed to close and latch.

The above was discussed and acknowledged by the facilities director.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3

Roller latches are prohibited by CMS regulations in all health care facilities.

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
1. The door to the elevator lobby #17 failed to close and latch (this deficiency was corrected at the time of the survey)

The above was discussed and acknowledged by the facilities director.

Smoke barriers are provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients. 18.3.7.1, 18.3.7.2

This requirement is not met as evidenced by: Surveyor 19192

Based upon record review and observation on 3/18 thru 21/ 2014 between approximately 0830 and 1600 hours the facility has failed to maintain the fire separation doors in the building. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.
The findings include, but are not limited to:
1. In the Rainier Tower the double fire doors next to patient room 4-520 failed to close and latch. (this deficiency was corrected at the time of the survey)

The above was discussed and acknowledged by the facilities director.

Smoke barriers are provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients. 19.3.7.1, 19.3.7.2

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to maintain the fire separation doors in the building. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion
The findings include, but are not limited to:
1. At Allenmore Hospital the fire door in the corridor by the Emergency department north failed to close and latch when the coordinator was used. (this deficiency was corrected at the time of the survey)

The above was discussed and acknowledged by the facilities director.

Exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 18.2.10.1

This requirement is not met as evidenced by:

Based upon record review and observation on 3/18 thru 21/ 2014 between approximately 0830 and 1600 hours the facility has failed to maintain proper exit signage. This could potentially misdirect residents, staff and/or visitors during an emergency.

The findings include, but are not limited to:
1. In the Phillips center in the seventh floor recovery there is an exit sign that is not properly illuminated.

The above was discussed and acknowledged by the facilities director.

A fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4

This requirement is not met as evidenced by: Surveyor 19192

Based upon record review and observation on 3/18 thru 21/ 2014 between approximately 0830 and 1600 hours the facility has failed to have appropriate testing of the fire alarm system which could result in the failure of notification to staff and emergency forces.

The findings include, but are not limited to:
1. At Allenmore Hospital the fire alarm control panel is in trouble mode indicating a main lobby elevator fault.

The above was discussed and acknowledged by the facilities director.

If there is an automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 18.3.5

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
1. In the Rainier Tower the sixth floor conference room closet has no sprinkler coverage.

The above was discussed and acknowledged by the facilities director.

If there is an automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 19.3.5

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
1. In the Baker Center the dry pendant sprinkler heads in the walk in coolers and freezers are more than 10 years old and shall be replaced or sample tested.

The above was discussed and acknowledged by the facilities director.

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. In the Phillips center there is a CVAR cart in the alcove that is to tall and is obstructing the sprinkler head.
2. In the Phillips center there is a linen cart in the alcove by patient room 706 that is to tall and is obstructing the sprinkler head.

The above was discussed and acknowledged by the facilities director.

Portable fire extinguishers are provided in all health care occupancies in accordance with 9.7.4.1. 19.3.5.6, NFPA 10

This requirement is not met as evidenced by: Surveyor 19192

Based upon record review and observation on 3/18 thru 21/ 2014 between approximately 0830 and 1600 hours the has failed to assure proper maintenance of the facilities portable fire extinguishers. This potentially delays a quick response to contain a fire from spreading which could expose and endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1. In the Rainier Pavilion across from 4-535 there is a portable fire extinguisher in the overcharged zone. (this deficiency was corrected at the time of the survey)
2. Floor 1 Administration offices, (South door) one portable fire extinguisher is mounted too high (this deficiency was corrected at time of survey).

The above was discussed and acknowledged by the facilities director.

Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities.
(a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation.
(b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. NFPA 99 4.3.1.1.2, 19.3.2.4

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to properly maintain the storage of medical gas in the facility. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. At Allenmore Hospital in the surgery department there are med gas cylinders unsecured from tipping over. (this deficiency was corrected at the time of the survey)

The above was discussed and acknowledged by the facilities director.

Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/20/2014 between approximately 0830 and 1300 hours The facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

Exposed electrical wires " Live Parts " are not allowed to be accessible to building occupants.

The findings include, but are not limited to:
1) Floor 4 Olympic classroom three center rows each had two multi-plug devices daisy chained.
2) Floor 2 Olympic Clinical Educator Office, un-approved extension cord installed.
3) Floor 4 Pharmacy store room 6 exposed " live parts " from a removed wall clock.
4) Floor 4 Pharmacy store room office 1 exposed " live parts " from a removed wall clock.


The above was discussed and acknowledged by the Maintenance Supervisor.

Building construction type and height meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/20/2014 between approximately 1300 and 1530 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1) Floor 1 IT Storage room has multiple ceiling tiles missing; exposing the combustible components of the area above the ceiling and an open junction box containing " live parts " (see K0147).

The above was discussed and acknowledged by the Maintenance Supervisor.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 18.3.6.3.6 are permitted. 18.3.6.3.6

Roller latches are prohibited by CMS regulations in all health care facilities.

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to maintain the fire rated doors in the building capable of closing and latching tight to the frame, this could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
1. In the Rainier Tower the door to the PICU closet next to patient room's 4-331 & 4-340 have no latching hardware installed.
2. In the Phillips center the door to the soiled linen room next to patient room 707 failed to close and latch.

The above was discussed and acknowledged by the facilities director.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3

Roller latches are prohibited by CMS regulations in all health care facilities.

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:
1. The door to the elevator lobby #17 failed to close and latch (this deficiency was corrected at the time of the survey)

The above was discussed and acknowledged by the facilities director.

Smoke barriers are provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients. 18.3.7.1, 18.3.7.2

This requirement is not met as evidenced by: Surveyor 19192

Based upon record review and observation on 3/18 thru 21/ 2014 between approximately 0830 and 1600 hours the facility has failed to maintain the fire separation doors in the building. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.
The findings include, but are not limited to:
1. In the Rainier Tower the double fire doors next to patient room 4-520 failed to close and latch. (this deficiency was corrected at the time of the survey)

The above was discussed and acknowledged by the facilities director.

Smoke barriers are provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients. 19.3.7.1, 19.3.7.2

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to maintain the fire separation doors in the building. This could result in the passage of smoke from one smoke compartment into another smoke compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion
The findings include, but are not limited to:
1. At Allenmore Hospital the fire door in the corridor by the Emergency department north failed to close and latch when the coordinator was used. (this deficiency was corrected at the time of the survey)

The above was discussed and acknowledged by the facilities director.

Exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 18.2.10.1

This requirement is not met as evidenced by:

Based upon record review and observation on 3/18 thru 21/ 2014 between approximately 0830 and 1600 hours the facility has failed to maintain proper exit signage. This could potentially misdirect residents, staff and/or visitors during an emergency.

The findings include, but are not limited to:
1. In the Phillips center in the seventh floor recovery there is an exit sign that is not properly illuminated.

The above was discussed and acknowledged by the facilities director.

A fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4

This requirement is not met as evidenced by: Surveyor 19192

Based upon record review and observation on 3/18 thru 21/ 2014 between approximately 0830 and 1600 hours the facility has failed to have appropriate testing of the fire alarm system which could result in the failure of notification to staff and emergency forces.

The findings include, but are not limited to:
1. At Allenmore Hospital the fire alarm control panel is in trouble mode indicating a main lobby elevator fault.

The above was discussed and acknowledged by the facilities director.

If there is an automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 18.3.5

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
1. In the Rainier Tower the sixth floor conference room closet has no sprinkler coverage.

The above was discussed and acknowledged by the facilities director.

If there is an automatic sprinkler system, it is installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. The system is properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully supervised. There is a reliable, adequate water supply for the system. Required sprinkler systems are equipped with water flow and tamper switches, which are electrically connected to the building fire alarm system. 19.3.5

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:
1. In the Baker Center the dry pendant sprinkler heads in the walk in coolers and freezers are more than 10 years old and shall be replaced or sample tested.

The above was discussed and acknowledged by the facilities director.

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. In the Phillips center there is a CVAR cart in the alcove that is to tall and is obstructing the sprinkler head.
2. In the Phillips center there is a linen cart in the alcove by patient room 706 that is to tall and is obstructing the sprinkler head.

The above was discussed and acknowledged by the facilities director.

Portable fire extinguishers are provided in all health care occupancies in accordance with 9.7.4.1. 19.3.5.6, NFPA 10

This requirement is not met as evidenced by: Surveyor 19192

Based upon record review and observation on 3/18 thru 21/ 2014 between approximately 0830 and 1600 hours the has failed to assure proper maintenance of the facilities portable fire extinguishers. This potentially delays a quick response to contain a fire from spreading which could expose and endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1. In the Rainier Pavilion across from 4-535 there is a portable fire extinguisher in the overcharged zone. (this deficiency was corrected at the time of the survey)
2. Floor 1 Administration offices, (South door) one portable fire extinguisher is mounted too high (this deficiency was corrected at time of survey).

The above was discussed and acknowledged by the facilities director.

Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities.
(a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation.
(b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. NFPA 99 4.3.1.1.2, 19.3.2.4

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/18 thru 21/2014 between approximately 0830 and 1600 hours the facility has failed to properly maintain the storage of medical gas in the facility. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1. At Allenmore Hospital in the surgery department there are med gas cylinders unsecured from tipping over. (this deficiency was corrected at the time of the survey)

The above was discussed and acknowledged by the facilities director.

Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

This requirement is not met as evidenced by: Surveyor 19192

Based upon observations and staff interviews on 3/20/2014 between approximately 0830 and 1300 hours The facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

Exposed electrical wires " Live Parts " are not allowed to be accessible to building occupants.

The findings include, but are not limited to:
1) Floor 4 Olympic classroom three center rows each had two multi-plug devices daisy chained.
2) Floor 2 Olympic Clinical Educator Office, un-approved extension cord installed.
3) Floor 4 Pharmacy store room 6 exposed " live parts " from a removed wall clock.
4) Floor 4 Pharmacy store room office 1 exposed " live parts " from a removed wall clock.


The above was discussed and acknowledged by the Maintenance Supervisor.