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Based on observation of surveyor 16732 on 05/08/17

The two hour fire rated wall separating 1975/1954 construction has 90 minute rated fire doors and one leaf does not close and latch


The maintenance worker was present during this observation

Based on records review and interview with maintenance director surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:


1. No documentation could be provided to indicate that doors were being inspected in accordance with 2012 NFPA 101-7.2.1.15

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Medical surgical wing- near chapel/family room had three wheelchairs stored in the exit corridor.

2. Emergency department had storage in the corridor that could create an obstruction to egress.

3. OR-wing had storage located on both sides of the corridor that could cause an obstruction to egress and reduced corridor width to less than 4'

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Door to ASU has a dead bolt lock on one side and barrel bolts on the other. Doors are the second exit out of the department and can not contain such devices that require special knowledge to egress the space.

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Sliding exit doors located in the emergency department and main entrance did not have the required signage to instruct occupants to push to open in an emergency.

2. The above doors also required excessive force to activate the break-away feature for emergency egress.

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. The area near the ASU locker room does not have adequate exit signage to direct occupant to exit and one sign is not visible from the far end of the corridor

Based on observation of surveyor 16732 on 05/08/17:


1) Entry way (vestibule) at shipping and receiving has trash collection, garbage collection, bottle collection, storage of ceiling tiles and other combustible storage items that are not enclosed in a hazardous room.
2) Corridor neat maintenance shop has several bio medical equipment stored in hallway along with cardboard boxes and not enclosed in a hazardous room
3) Maintenance repair shop door does not have a self closer on door
4) Plant operations door does not have self closer on door
5) Dietary storage area in corridor has several combustibles stored in a cubical area and the area is open at the top leaving storage open to the exit corridor

The maintenance worker was present during this observation









35163

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Electrical room (2 hr rated) located near medical surgical wing stairwell had penetrations, missing ceiling tiles and gap where concrete wall meets metal roof decking with no fire stopping material present and that would not prevent the passage of smoke/fire.

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Laboratory did not have methanol in an approved/rated storage cabinet.

Based on records review surveyor 35163 on 05/08/17, in the presence of the maintenance director the following was not met:

1. No documentation could be provided to indicate that the following devices had been tested within the last twelve months.
-Duct detector-2nd outside x-ray
-Smoke detector 1st ER
-Smoke detector 1st outside elevator

The last/current fire alarm report documentation indicated the above devices were not tested.

2. Data room at 75 elevator has wires that were attached to sprinkler piping.

Based on observation of surveyor 16732 on 05/08/17:

Following sprinkler heads are missing escutcheon plates:

1) Air handler room room missing escutcheon plate
2) Mop closet is missing sprinkler coverage from sprinkler system in building. Room has a domestic sprinkler head in the room attached to copper piping with a shutoff valve.
3) Kitchen storage room missing escutcheon plate.

The maintainence worker was present during this observation



35163

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Alcove located near bathroom/behind medical surgical wing nursing station has no sprinkler protection.

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Storage room located in medical surgical conference room had storage within 18" of the sprinkler head and would not allow for proper sprinkler pattern development.

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Data room at 75 elevator had penetrations in the wall that would not prevent the passage of smoke.

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Medical surgical wing- doctors office door was held open with a rubber wedge and would not allow for proper closure.

2. Patient room # 211 had gap larger than 1/2" between the door and frame and would not properly prevent the passage of smoke.

3. ICU/SCU nursing station bathroom that has been converted to a storage room and did not have a self closing device on the door.
-missing ceiling tiles need to be replaced to prevent the passage of smoke

4. Patient room door # 216 would not properly close/latch. The door was hitting the frame prior to the latching mechanism meeting the receiver.

5. OB/GYN room located within the emergency department had a push down door hold open device which creates an obstruction to proper door closure during an emergency

6. Patient room door located next to ASU nursing station has a push down door hold open device that creates an obstruction to the proper closure of the door during an emergency.

7. PACU- Patient room door has a push down door hold open device that creates an obstruction to the proper closure of the door during an emergency.

8. OR-Clean utility has a push down door hold open device that creates an obstruction to the proper closure of the door during an emergency.

9. Storage closet door located next to the cashiers office had gap larger than 1/2" between door and frame and room is missing ceiling tile. Both items would not prevent the passage of smoke

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Data room at 75 elevator has a metal grill located at the bottom of the door and would not prevent the passage of smoke.

2. Sterile supply room had area behind the autoclaves that had penetrations in walls/ceiling that would not prevent the passage of smoke.

Based on observation of surveyor 16732 on 05/08/17

The following areas have penetrations in walls and ceilings that do not resist the passage of smoke:

1) Ceiling tiles missing in air handler room
2) Sprinkler pipe in back of medical records room going through wall
3) Shredding paper room has ceiling tiles missing.
4) Penetrations in ceiling of entry way of shipping and receiving. There is spray foam in one penetration that leads to the operating room above.
5) Kitchen storage room has discontinued piping that has been cut off and no firestopping.
6) Landry Room has penetrations in walls and ceilings.
7) Central supply room has large orange IT cable going through wall

The maintenance worker was present during this observation

Based on observation of surveyor 16732 on 05/08/17


Control box on boiler in boiler room missing cover


The maintenance worker was present during this observation

Based on records review surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. The emergency plan was requested upon inspection but was not provided, no written copies are kept at nursing station locations (only electronic/computer accessed) and when asked to have the plan emailed for review it was not provided.

Based on interview with maintenance director surveyors 35163 and 37695 on 05/08/17, following was not met:

1. Drills that were conducted at night when patients were sleeping consisted of maintenance director conducting a question and answer period with the staff and not having staff actively participate in a drill using the procedures in the emergency plan.

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Medical gas zone valve box located in OR wing was not visible or accessible due to items being stored in front of the box.

Based on observation and interview with maintenance director on 05/11/2017:

1) There is no documented maintenance programs for Medical Gas, vacuum, Waste Anesthetic Gas Disposal
2) There is no program that included inventory of all source systems, control valves, alarms and manufactures assemblies and outlets.
3) There are no inspection and maintenance schedules established through risk assement considering manufacturer recommendations.
4) There are no inspection procedures and resting methods established through risk assement.
5) There is no persons at the facility that is working on the gas system that has demonstrated training and certification or credentialing to the requirements of AASE 6030 or 6040.

Based on observation of surveyor 16732 and interview with maintenance director on 05/08/17

There is no documentation that the gas and vacuum systems are being inspected and tested as part of maintenance program.

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Medical gas/vacuum zone valve box located outside of ASU was not properly labeled to indicate which rooms it serves.

2. Medical gas/vacuum zone valve box located outside in PACU was not properly labeled to indicate which rooms it serves

3. Medical gas/vacuum zone valve box located outside in OR wing was not properly labeled to indicate which rooms it serves

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. There was a electrical receptacle missing a cover in pharmacy.

2. The swingbed activity room located above the TV hanging on the wall had an open junction box with low voltage wires exposed, box needs to be covered.

Based on observations and records review surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. No documentation could be provided to indicate the operating rooms electrical system meets requirements for wet locations.
-no risk assessment had been completed/documented at time of inspection.

Based on observation of surveyor 16732 on 05/08/17

Electrical cover missing ceiling junction box in central supply.

The maintenance worker was present during this observation


35163

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Electrical circuit breaker box/panel located in sterile supply had item stored in front of it, which obstructed access to panel.

2. Storage closet located next to the cashiers office containing electrical panels, items stored in front of electrical panels obstruct access.

Based on observation of surveyor 16732 on 05/08/17

Gold Star Microwave and coffee pot plugged into powerstrip. Manufacture of microwave says shall be plugged in directly into outlet

The maintenance director was present during this observation




35163

Based on observations surveyors 35163 and 37695 on 05/08/17, in the presence of the maintenance director the following was not met:

1. Medical surgical wing conference room had a power strip/multi outlet device that was powering coffee pot and toaster oven-manufacturer recommends devices be plugged direct into wall receptacle.

2. In the corridor across from patient room # 212 , there was a power strip/multi outlet device that was powering a refrigeration appliance. this appliance needs to be plugged directly into a receptacle per manufacturers recommendations.

3. ASU-nursing station had power strip/multi outlet device that was being use to power microwave and toaster, these appliances need to be plugged directly into a electrical receptacle per manufacturers recommendations.