HospitalInspections.org

(A)
Based on observations and staff interview, the facility failed to maintain and/or provide ceiling smoke tiles. This affects 12 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Observations between 07/19/11 and 08/02/11, revealed the following:

Main Building
1. The 5th Floor South Hall Soiled Hold Room revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid.
2. The 3rd Floor Server Room revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid.
3. The 2nd Floor Audiology Testing Room revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid.
4. The Level A Old MRI Room revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid.
5. The Level B Maintenance Shop revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid. At the time of inspection, these missing tiles revealed support chains and pulleys were located where the tiles should have been.
6. The Level B Welding Shop revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid.
7. There was a ceiling tile missing above the television in Room 341.


(B)
Based on observations, the facility failed to maintain appropriate construction standards as required by the Life Safety Code. Corridor walls and ceilings must be rated to protect the corridor. This affects 13 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:
Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed that there was a penetration (approximately 1 inch), around communications cables extending through the wall.
2. Observations between 7/19/2011 and 8/2/2011, revealed that there was a penetration (approximately 3/16 inch) around utilities extending through the wall.
3. Observations between 7/19/2011 and 8/2/2011, revealed that there was a penetration (approximately ½ " ) around utilities extending through the wall.
4. Observations between 7/19/2011 and 8/2/2011, revealed that there was an escutcheon missing from a sprinkler head above the door to the bathroom in Room 779.
5. Observations between 7/19/2011 and 8/2/2011, revealed that there was an escutcheon that was not flush with the wall in Room 782.
6. Observations between 7/19/2011 and 8/2/2011, revealed that there was an escutcheon that was not flush with the ceiling by the elevator in the 7th Floor Soiled Hold Room.
7. Observations between 7/19/2011 and 8/2/2011, revealed that there was a hole (approximately ½ inch) in the smoke barrier wall by the 7th Floor South NCS desk.
8. Observations between 7/19/2011 and 8/2/2011, revealed that there was a penetration (approximately ½ inch), around communication lines extending through the smoke barrier wall by Room 734 on the 7th Floor.
9. Observations between 7/19/2011 and 8/2/2011, revealed an escutcheon that was not flush with the wall in Room 743.
10. Observations between 7/19/2011 and 8/2/2011, revealed that there was an escutcheon missing from a sprinkler head above the bathroom door in Room 740.
11. Observations between 7/19/2011 and 8/2/2011, revealed that there was foam that was not fire rated filling penetrations in the 6th Floor Smoke Barrier Wall by Room 673.
12. Observations between 7/19/2011 and 8/2/2011, revealed that there was an escutcheon ring that was not flush with the wall in Room 645/647- (Double Room.)
13. Observations between 7/19/2011 and 8/2/2011, revealed that the sprinkler escutcheon was not flush with the wall on the south wall of Room 896.
14. Observations between 7/19/2011 and 8/2/2011, revealed that there was a missing ceiling tile in Room 635/637- Double Room.
15. Observations between 7/19/2011 and 8/2/2011, revealed that there was a penetration (approximately ¼ inch), around communication cables extending through the 5th Floor Smoke Barrier Wall by the South Unit NCS Desk.
16. Observations between 7/19/2011 and 8/2/2011, revealed that there was a missing escutcheon in the Nuclear Medicine Dual Head Room.


Mercy West
1. Observations between 7/19/2011 and 8/2/2011, revealed that there was a gap (approximately ¼ inch) around a penetration located above the smoke doors by room 2558.
2. Observations between 7/19/2011 and 8/2/2011, revealed that the 1st Floor Mechanical Room had multiple gaps in the fire retardant spray coating on the I-Beams in locations where electrical junction boxes and pipe supports had been attached to the I-Beams.
3. Observations between 7/19/2011 and 8/2/2011, revealed that the 1st Floor Fountain Pump Room 1106 had multiple gaps in the fire retardant spray coating on the I-Beams in locations where electrical junction boxes and pipe supports had been attached to the I-Beams.

Based on observations, the facility failed to maintain corridor doors within proper standards. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed that the 4th Floor Janitor Closet by Exam Room had 2 vents/louvers installed in the corridor door.
2. Observations between 7/19/2011 and 8/2/2011, revealed that the 4th Floor IDEC Corridor by the North Stairwell had a book shelf blocking the Exam Room Corridor Door from fully opening.
3. Observations between 7/19/2011 and 8/2/2011, revealed that the Level A UPS Room Back Door failed to close and latch properly into the door frame with the swing of the door closer when tested.
4. Observations between 7/19/2011 and 8/2/2011, revealed that the Level B Locksmith Door had a kick-down device located on the door to keep the door from closing with the swing of the door closer.
5. Observations between 7/19/2011 and 8/2/2011, revealed that the Level B Women's Locker Room Corridor Door failed to close and latch properly into the door frame with the swing of the door closer when tested.
6. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 4000 did not close and latch.
7. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 3058 has a door wedge.
8. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 929 did not latch.
9. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 919 - did not latch.
10. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 820 did not latch.
11. Observations between 7/19/2011 and 8/2/2011, revealed that the strike plate on the door to Room 869 was broken, preventing the door from latching.
12. Observations between 7/19/2011 and 8/2/2011, revealed that the door to the 8th Floor Clean Hold Room did not latch.
13. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 333 did not latch.
14. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 349 did not latch.
15. Observations between 7/19/2011 and 8/2/2011, revealed that there were door props in use on two doors in the Administration Waiting Area on the 2nd Floor.
16. Observations between 7/19/2011 and 8/2/2011, revealed that there was a bolt lock on the north double exit doors in the Hines Board Room.
17. Observations between 7/19/2011 and 8/2/2011, revealed that the the door to Room 681 did not latch.
18. Observations between 7/19/2011 and 8/2/2011, revealed that the the Level A Catacombs showed13 of 13 Storage Room Doors were locked using a hasp and padlock device that would hinder exiting from the areas when the hasp and padlock were engaged on the door.
19. Observations between 7/19/2011 and 8/2/2011, revealed that the the Level B Welding Shop Door had a hasp and padlock device on the door that would hinder exiting from the room when the hasp and padlock was engaged on the door.
20. Observations between 7/19/2011 and 8/2/2011, revealed that the door closer on 9th Floor Clean Hold Storage Room was in need of repair. It failed to function properly when tested during this survey.
21. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Echo Tech Room did not close and latch upon test.
22. Observations between 7/19/2011 and 8/2/2011, revealed a padlock and chain located on the door to the gated storage area on the 10th floor.
23. Observations between 7/19/2011 and 8/2/2011, revealed that the 2nd Floor Surgery Storage Room 2745 door latching hardware strike plate grinded against the latching hardware and caused the door latching hardware to fail to open.

Mercy Franklin
1. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Resident Room #6 in the Children ' s Area failed to close and latch when tested.
2. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Resident Room #7 in the Children ' s Area failed to close and latch when tested.
3. Observations between 7/19/2011 and 8/2/2011, revealed the door to Resident Room #10 in the Children ' s Area failed to close and latch when tested.


Mercy West
1. Observations between 7/19/2011 and 8/2/2011, revealed the use of a metal wedge holding the door open located at the 8th Floor Electrical Room.
2. Observations between 7/19/2011 and 8/2/2011, revealed a broken closer for the door to Room 5375, 5th Floor Janitors Closet.
3. Observations between 7/19/2011 and 8/2/2011, revealed that the 5th Floor Rehabilitation Gym Door (5470) was wedged open with a door wedge.
4. Observations between 7/19/2011 and 8/2/2011, revealed that the 2nd Floor Chapel Door failed to close and latch properly into the door frame with the swing of the door closer.
5. Observations between 7/19/2011 and 8/2/2011, revealed that the 2nd Floor Emergency Room 7 (2507) door to the Central Nurse ' s Station was propped open with furniture.
6. Observations between 7/19/2011 and 8/2/2011, revealed that the 2nd Floor Emergency Room 8 (2528) door to the Central Nurse's Station was propped open with furniture.

Based on observations and staff interview, the facility failed to maintain some exit doors and exit enclosures within proper standards. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.



Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor South Fire Doors to the Elevator Bank doors failed to close and latch properly into the door frame with the swing of the door closers.
2. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Room by W408 had a vertical hole (approximately 6 inches by 6 inches in size) located in the ceiling. At the time of inspection, this hole was covered with duct tape.
3. Observations between 7/19/2011 and 8/2/2011, revealed the 8th Floor Stairwell Door by Room 853 did not close and latch.
4. Observations between 7/19/2011 and 8/2/2011, revealed 8th Floor Stairwell Door by Room 803 did not latch.
5. Observations between 7/19/2011 and 8/2/2011, revealed the 8th Floor Stairwell Door by Room 849 did not latch.
6. Observations between 7/19/2011 and 8/2/2011, revealed the 7th Floor Stairwell Door by Room 749 did not latch.


Mercy West
1. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Double Fire Doors to the Passenger Elevator doors failed to close and latch properly into the door frame with the swing of the door closers.
2. Observations between 7/19/2011 and 8/2/2011, The 4th Floor Double Fire Doors to the Passenger Elevator doors failed to close and latch properly into the door frame with the swing of the door closers.

Based on observations, the facility failed to provide and maintain some exit signs for required locations within proper standards. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed there was not an exit sign installed to indicate the direction of travel to an exit above the South Doors at the 5th Floor Elevator Bank.
2. Observations between 7/19/2011 and 8/2/2011, revealed there was not an exit sign in the middle of the corridor to indicate the direction of travel to an exit through either of the Suites (Transplant Center Suite 500 and Transplant Unit).
3. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Corridor Door by Room W410 was not equipped with an exit sign to indicate the direction of travel to an exit.

Based on observations, the facility failed to maintain appropriate construction standards for smoke barrier walls as required by the Life Safety Code. Corridor walls and ceilings must be rated to protect the corridor from the spread of smoke. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:
Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed there was an opening (approximately 3/16 inch),in the smoke barrier wall on the 8th Floor by Room 833.
2. Observations between 7/19/2011 and 8/2/2011, revealed there was an open pipe penetration,( approximately 1 inch), extending through the smoke barrier wall on the 8th Floor by Room 833.
3. Observations between 7/19/2011 and 8/2/2011, revealed the 7th Floor Smoke Barrier wall penetrations by Room 784:
4. Observations between 7/19/2011 and 8/2/2011, revealed there was a penetration (approximately 3/16 inch), around a cable extending through the 2 hour fire wall between the Main Building and West Building at the ER West Entrance.
5. Observations between 7/19/2011 and 8/2/2011, revealed there was a hole (approximately ½ inch), in the 2 hour fire wall between the Main Building and the West Building at the ER West Entrance.
6. Observations between 7/19/2011 and 8/2/2011, revealed there was a hole (approximately ¼ inch), in the 2 hour fire wall between the Main Building and the West Building at the ER West Entrance.
7. Observations between 7/19/2011 and 8/2/2011, revealed there was a penetration (approximately ¼ inch) around a conduit extending through the smoke barrier by the Starbucks.

Based on observations, the facility failed to maintain some smoke barrier doors in the facility. This deficient practice would not prevent the spread of smoke, This affects 10 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:


Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Transport Headquarters Smoke Barrier doors failed to close and latch properly into the door frames with the swing of the door closers when tested.

2. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Smoke Barrier Doors to the Transport Headquarters middle beam between the doors was missing which did not allow the doors to properly close and latch into the door frame with the swing of the door closers.

3. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor East Entrance Door to the New Cath Lab was missing a latching bracket at the top of the door which did not allow this door to close and latch properly into the door frame with the swing of the door closer when tested.

4. Observations between 7/19/2011 and 8/2/2011, revealed the entrance to Maternity Triage Unit Smoke Doors not close and latch.


Mercy Franklin
Observations between 7/19/2011 and 8/2/2011, revealed the set of smoke barrier doors that are located near the Nurses Station to 1st Step failed to close and latch when tested.

Mercy West
Observations between 7/19/2011 and 8/2/2011, revealed that the smoke doors by the Staff Elevators failed to close and latch properly when tested.

Based on observations, the facility failed to maintain some hazardous rooms in safe and required conditions. This affects 10 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed the 6th Floor Penthouse Elevator Equipment Room had a penetration (approximately 1 foot by 6 feet in size) located in the East Wall that was filled with fire caulking.
2. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Dialysis Soiled Utility Hold door failed to close and latch properly into the door frame with the swing of the door closer.
3. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor South Soiled Hold Room door failed to close and latch properly into the door frame with the swing of the door closer.
4. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Soiled Hold Room W412 had a large pipe penetration (approximately 4 feet by 2 feet in size) into the Elevator Equipment Shaft.
5. Observations between 7/19/2011 and 8/2/2011, revealed the Level B Maintenance Supply Room had an unprotected louver in the corridor door.
6. Observations between 7/19/2011 and 8/2/2011, revealed the Level B I.T. Room revealed an unprotected louver in the corridor door.
7. Observations between 7/19/2011 and 8/2/2011, revealed the door to Room 308 - Soiled Hold did not close and latch. The door is on a closure.
8. Observations between 7/19/2011 and 8/2/2011, revealed the Door to the Soiled Hold Room on the 9th floor did not close and latch properly when tested.

Mercy Franklin
1. Observations between 7/19/2011 and 8/2/2011, revealed 2 pipe penetrations (approximately ¾ inches in size and 1 inch in size) located in the ceiling of the Children ' s Area Laundry Room.
2. Observations between 7/19/2011 and 8/2/2011, revealed a vent pipe penetration (approximately ¾ inches in size) located in the ceiling of the Adult Area Laundry Room.

Mercy West
1. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor MRI Equipment Room 2665 had a penetration (approximately 1 inch in size) located in the west wall of the room.
2. Observations between 7/19/2011 and 8/2/2011, revealed the 7th Floor Electrical Equipment Room 7121 had a pipe penetrations (approximately ¼ inch in size) located in the corridor wall.
3. Observations between 7/19/2011 and 8/2/2011, revealed the 1st Floor Loading Dock had a center conduit penetration (approximately ½ inch in size) located above the Corridor Door.
4. Observations between 7/19/2011 and 8/2/2011, revealed the 1st Floor Medical Gas Storage Room had a center conduit penetration (approximately ½ inch size) located above the Carbon Dioxide System.
5. Observations between 7/19/2011 and 8/2/2011, revealed the 1st Floor Electrical Equipment Room 1021 had a conduit penetration (approximately ½ inch size) located in the 2 hour fire resistant wall.

Based on observations, the facility failed to maintain some exit areas in safe and required conditions. This affects 8 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Corridor by the North Stairwell had multiple storage cabinets in the hallway that obstruct the width of the corridor.
2. Observations between 7/19/2011 and 8/2/2011, revealed the 3rd Floor Cardiac-Vascular Hallways revealed hinged charting stations that were not equipped with self-closing devices to allow the charting station to return to a closed position when pressure was released from the station.
3. Observations between 7/19/2011 and 8/2/2011, revealed the storage of beds in the means of egress by the exit doors located on the 10th Floor.

Mercy Franklin
Observations between 7/19/2011 and 8/2/2011, revealed the door to the Seclusion/Restraint Room was equipped with a dead bolt style locking device.

Mercy West
Observations between 7/19/2011 and 8/2/2011, revealed files blocking the path of egress in the Surgery Waiting Area by Room 2411.

Based on record review, the facility failed to provide documentation of monthly (30 second) and annual (90 minute) tests of the battery emergency lights. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Mercy West Endoscopy
Record review on 07/20/11 at 10:25 a.m., revealed the facility failed to provide documentation of monthly (30 second) and annual (90 minute) tests of the battery emergency lights.

Based on observations, the facility failed to maintain the emergency lighting in the building to verify that it is in proper working condition as required by 7.9. This affects 4 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:


Main Building
Observations between 7/19/2011 and 8/2/2011, revealed that the emergency light located in the East Building A Level switch gear room had a bulb out.


Mercy West Endoscopy
1. Observations between 7/19/2011 and 8/2/2011, revealed that the exit sign located near dressing room 7 in mammography failed to function properly.
2. Observations between 7/19/2011 and 8/2/2011, revealed that the exit sign located near dressing room 3 in mammography failed to function properly

Mercy Riverside Rehabilitation Center
Observations between 7/19/2011 and 8/2/2011, revealed the exit sign located near the main exit failed to function properly.

Based on record review, the facility failed to ensure fire drills are being held at varying times. This affects 9 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.



Findings include:


Mercy Franklin
Record review between 7/19/2011 and 8/2/2011, revealed that the facility failed to vary the times of fire drills conducted on the 1st and 3rd nursing shifts during the first 2 quarters of 2011. Of the 4 documented fire drills, the times were only 5 minutes apart. (1-18-11 at 0705. 1-19-11 at 0700. 3-23-11 at 0630 and 6-7-11 at 0630).

Based on observations and interview, the facility failed to maintain the facility fire alarm system in accordance with National Fire Protection Association (NFPA) standard 72, National Fire Alarm Code 1999 edition. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed the 6th Floor Penthouse Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
2. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Stairwell to the West Building Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
3. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Dialysis East Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
4. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Transplant Suite by the East Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
5. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Transplant Suite by the Suite Entry Door Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
6. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Center Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
7. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Corridor by the north Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
8. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Stairwell by Room W401 Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
9. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Stairwell by Room W425 Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
10. Observations between 7/19/2011 and 8/2/2011, revealed the 3rd Floor West Stairwell in Cardiovascular Care Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
11. Observations between 7/19/2011 and 8/2/2011, revealed the 3rd Floor East Stairwell revealed a Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
12. Observations between 7/19/2011 and 8/2/2011, revealed the 3rd Floor North Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
13. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor East Stairwell in Endoscopy Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
14. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor West Stairwell in Endoscopy Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
15. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor North Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
16. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Central Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
17. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Hallway by the A/V Coordinator ' s Office Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
18. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor by the Scheduling Office and North Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
19. Observations between 7/19/2011 and 8/2/2011, revealed the Level A Wellness Center Door to the Stairwell revealed a Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
20. Observations between 7/19/2011 and 8/2/2011, revealed the Level A Center Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
21. Observations between 7/19/2011 and 8/2/2011, revealed the Level A East Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
22. Observations between 7/19/2011 and 8/2/2011, revealed the Level A West Stairwell revealed a Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
23. Observations between 7/19/2011 and 8/2/2011, revealed the Level B Hallway by the Paint Shop Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
24. Observations between 7/19/2011 and 8/2/2011, revealed the Level B West Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
25. Observations between 7/19/2011 and 8/2/2011, revealed the Level B Center Stairwell revealed a Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
26. Observations between 7/19/2011 and 8/2/2011, revealed the Level B East Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
27. Observations between 7/19/2011 and 8/2/2011, revealed the Main Fire Alarm Panel was in Trouble Status. The system indicated a dirty smoke detector in the Recovery Waiting Room.
28. Observations between 7/19/2011 and 8/2/2011, revealed the 3rd Floor W3CC Office had a smoke detector located within 3 feet of an air diffuser.
29. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Endoscopy Supply Room had a smoke detector located within 3 feet of an air diffuser.
30. Observations and interview between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Fire Alarm Control Panel Enunciator revealed a message stating " Communication lost with the System ' s Master. " Interview with the Facility Assistant Maintenance Director revealed the facility was working on the fire alarm system during the inspection.
31. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Corridor by the Room W242 had a smoke detector within 3 feet of an air diffuser.
32. Observations and interview between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Fire Alarm Enunciator Panel located by the Elevators revealed the panel was not illuminated. Interview with the Facility Assistant Maintenance Director revealed the Fire Alarm Enunciator Panel was not connected at the time of inspection.
33. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor New Cath Lab by the South Recovery Desk had a smoke detector within 3 feet of an air diffuser.
34. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor New Cath Lab Soiled Hold Room had a smoke detector within 3 feet of an air diffuser.
35. Observations between 7/19/2011 and 8/2/2011, revealed the Level A Former MRI Prep Room had a smoke detector within 3 feet of an air diffuser.
36. Observations between 7/19/2011 and 8/2/2011, revealed the Level B Telecom Room had a smoke detector within 3 feet of an air diffuser.
37. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Nursery/Pediatrics Unit Secretary ' s Office 2051 had a smoke detector that was installed within 3 feet of an air diffuser.
38. Observations between 7/19/2011 and 8/2/2011, revealed the smoke detector located in the Telemetry Room was within 36 inches of air moving equipment.

(A)
Based on observations, the facility failed to maintain one overhead rolling fire door. This affects 2 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:
Observations between 07/19/11 and 08/02/11, revealed the 4th Floor 4 West Exam Room revealed a fire resistant rated overhead rolling fire door that as not maintained in proper working condition. At the time of inspection, this overhead rolling door was not in use and was unable to be lowered.


(B)
Based on observations and record review, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by not documenting or conducting the required sensitivity test of the buildings fire alarm system. This affects 7 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:


Mercy Franklin

Record review on 07/20/11, revealed the facility failed to provide documentation of the required sensitivity test of the buildings fire alarm system.

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Mercy Sleep Center
Record review on 07/20/11 at 9:00 a.m. revealed the facility failed to provide documentation of semi-annual testing of the fire alarm system.

Mercy West Endoscopy
Record review on 07/20/11 at 10:00 a.m. revealed the fire alarm system was last tested in September of 2010 instead of semi-annually as required.

Mercy Riverside Rehabilitation Center
Record review on 07/20/11 at 2:15 p.m., revealed the fire alarm system was last inspected in August of 2009 instead of semi-annual as required.

Mercy Outpatient Cardiac Testing
1. Record review on 07/20/11 at 2:15 p.m., revealed the fire alarm system was last inspected in June of 2010 instead of semi-annually as required.
2. Record review on 07/20/11 at 2:15 p.m., revealed no documentation of sensitivity testing of the smoke detectors.

Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition. This affects 37 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Observations between 07/19/11 and 8/2/11, revealed the following:

Main Building
1. The 5th Floor Dialysis Waiting Room 2 revealed the Atrium was not equipped with sprinkler heads to provide proper sprinkler coverage for the affected area.
2. The 5th Floor Transplant Center Suite 500 Private Room by the Waiting Room revealed the Closet was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
3. The 4th Floor North Stairwell revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
4. The 3rd Floor Cardiac-Vascular West Stairwell revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
5. The 3rd Floor Cardiac-Vascular East Stairwell revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
6. The 2nd Floor East Stairwell in Endoscopy revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
7. The 2nd Floor North Stairwell revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
8. The 2nd Floor Central Stairwell revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
9. The Level A Catacombs Plumbers Area revealed the Sticker Storage Area was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
10. The Level A Catacombs Plumbers Area revealed a mixture of ordinary fusible link sprinkler heads (no color) and high heat fusible link sprinkler heads (white) by the Sticker Storage Area.
11. The Level A Catacombs revealed the Old Elevator Pit was not equipped with sprinkler heads to provide proper sprinkler coverage for the affected area.
12. The Level A Catacombs Plumbers Area revealed the Old Stairs Area was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
13. The Level A Catacombs North Stairwell revealed the Stairwell was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
14. The Level A West Lobby by the South Doors revealed the Vestibule and directly inside the Lobby Door were not provided with sprinkler heads to provide proper sprinkler coverage for the areas.
15. The Level A Mammography Waiting Room Closet revealed the areas was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
16. The Level A Old Spiral Stairway revealed the area was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
17. The Level B Wood Shop revealed 2 of 4 sprinkler heads that were located over 4 feet below the ceiling deck.
18. The 6th Floor Penthouse revealed 2 of approximately 20 sprinkler heads located above the Air Handler Unit 71 on the North Side of the room that were filled with lint and dust.
19. The 5th Floor Dialysis Locker Room revealed a missing escutcheon ring on 1 of 1 sprinkler head.
20. The 5th Floor Dialysis Work Room revealed a sprinkler head (1 of 4) located above the Sink with a paint-like substance on it and a missing escutcheon ring. This room also revealed a sprinkler head (1 of 4) in the Northwest corner of the room that had a foreign material on the head.
21. The 5th Floor Dialysis East Stairwell revealed a paint-like substance on 1 of 1 sprinkler head in the area.
22. The 5th Floor Transplant Center Suite 500 Private Room/Office by the Waiting Room revealed a paint-like substance on the sprinkler head (1 of 2) located over the Dinner Table in the room.
23. The 4th Floor IDEC Exam Room revealed an IT Wireless System installed within 1 inch of the sprinkler head (1 of 1) in this room.
24. The 4th Floor Office W406 revealed a light fixture installed within 2 inches of the sprinkler head (1 of 1) in this room.
25. The 4th Floor Office 407 revealed a sprinkler head (1 of 3) missing the escutcheon ring.
26. The 4th Floor Office 409 revealed a sprinkler head (1 of 3) missing the escutcheon ring.
27. The 2nd Floor Corridor by Room W242 revealed the sprinkler head (1 of approximately 8) was missing the escutcheon ring.
28. The 2nd Floor Bacteriology Lab W249 revealed 3 of 12 sprinkler heads that were missing escutcheon rings.
29. The 2nd Floor Soiled Hold Room revealed a paint-like substance on 1 of 2 sprinkler heads.
30. The 2nd Floor Performance Improvement Offices Stairwell to the Wellness Center revealed a paint-like substance on 1 of 1 sprinkler heads in this area.
31. The Level A Wellness Storage Room by the Whirlpool revealed a sprinkler head (1 of 2) with a missing escutcheon ring.
32. The Level A Pool revealed 12 of 12 sprinkler heads with a corrosive material on the heads.
33. The Level A by the Old Spiral Staircase revealed a sprinkler head (1 of 6) was missing the escutcheon ring.

Mercy West
The 2nd Floor Room 2533B revealed that it was unable to be determined to be properly covered with a sprinkler system.

Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to conduct the required quarterly testing of the system. This affects 3 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Mercy Franklin

Record review on 7-19-11, revealed the facility failed to provide and document a quarterly inspection of the buildings automatic sprinkler system during the first quarter year of 2011.



Mercy North ASC
Record review on 7-19-11, revealed the facility failed to provide documentation of quarterly flow tests of the sprinkler system.

Mercy Sleep Center
Record review on 7-19-11, revealed the facility failed to provide documentation of annual service and quarterly flow tests of the sprinkler system.

Mercy Radiology Center
Record review on 7-19-11, revealed no documentation of quarterly flow tests of the sprinkler system.

Based on observations and staff interview, 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. This affects 8 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:
Observations between 07/19/11 and 08/02/11 revealed the following:
Main Building
1. The 5th Floor Dialysis Store Room revealed the room was missing the fire extinguisher. The support and hanger for the fire extinguisher was furnished but the fire extinguisher was not located in the room.
2. The 4th Floor Corridor by the North Stairwell revealed that the area was missing a fire extinguisher. The support and hanger for the fire extinguisher was located but the fire extinguisher was not found.
3. The 4th Floor IDEC Room W416 revealed a fire extinguisher that was installed behind a door. When the door was in the fully open position, this fire extinguisher was not accessible or visible.
4. The 2nd Floor Microbiology Micro Storage Room W243 revealed the fire extinguisher was installed behind the corridor door and when the door was fully open, the fire extinguisher was not accessible or visible.
5. The Level B Welding Shop revealed the fire extinguisher was missing the monthly visual inspection for June 2011.
6. The Level B Morgue Cooler Room revealed the fire extinguisher in was blocked by a cart.
7. The Level B Clinical Engineering Room revealed the fire extinguisher was being blocked by a cart.

Mercy West
Observations revealed that the 1st Floor Lab revealed the South Fire Extinguisher was being obstructed by service equipment.

Based on observations, the facility failed to maintain approved decorative materials in the facility in accordance with National Fire Protection Association (NFPA), Life Safety Code. This affects 4 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings revealed:
Observations between 07/19/11 and 08/02/11, revealed the following:
Main Building
1. The Level B Maintenance Coordinator's Office revealed a vinyl mini-blind located on the window of the door.
2. The 2nd Floor Vascular Ultrasound Corridor Door revealed a vinyl mini-blind on the door window.

Mercy Franklin
Observations revealed a vinyl mini-blind window covering in the Adult Area Medical Records Office.



Mercy West
Observations in the 1st Floor Dietary Office 1316 revealed a vinyl mini-blind located on the window inside the office.

Based on observations, the facility failed to maintain oxygen tanks in accordance with NFPA 99, by ensuring that tanks were adequately secured to prevent them from accidental damage or dislocation. This affects 3 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.



Findings include:

Observations between 07/19/11 and 08/02/11, revealed the following:

Main Building
There were 12 large compressed gas cylinders that were not secured in the Level A Medical Gas Storage Room.


Mercy West
1. The oxygen bottle located in Room 1742, Cath Room was not secured as required.
2. The 1st Floor Medical Gas Storage Room revealed 6 oxygen tanks that were not properly secured from falling.

(A)
Based on observations and staff interview, the facility failed to safely maintain several compressed gas containers. This affects 3 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
Observations between 7/19/2011 and 8/2/2011, revealed an Argon Compressed Gas Cylinder was not properly secured from falling. This tank was located in the Level B Welding Shop.

Mercy West
1. Observations between 7/19/2011 and 8/2/2011, revealed in the 1st Floor Pop Storage Room 1220 a carbon dioxide compressed gas bottle that was not properly secured from falling.
2. Observations between 7/19/2011 and 8/2/2011, revealed in the 2nd Floor Ambulance Garage a carbon dioxide compressed gas bottle that was not properly secured from falling.


(B)
Main Building
Based on observations, the facility failed to safely maintain one metal storage container. This affects 1 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Observations between 7/19/2011 and 8/2/2011, revealed the use of a metal container that was full of oil rags. This was located in the 3rd Floor Emergency Flight Deck.
(C)
Mercy Riverside Rehabilitation Center
Based on observation, the facility failed to properly separate combustible storage from heating equipment. This affects 1 of 144 smoke zones in the event of a fire related emergency. The facility has is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:
Observations between 7/19/2011 and 8/2/2011, revealed boxes located next to the water heater in the Mechanical Room.

Based on observations and staff interview, the facility failed to provide oxygen signs at locations where oxygen is stored in accordance with NFPA 99. This affects 1 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Mercy West

The 1st Floor Oxygen Storage Room 1616 revealed there was not a " No-Smoking/Oxygen Storage " sign on the door to indicate the room was being used for multiple oxygen tank storage.


Main Building

Room 3064 did not have an oxygen sign as required.

Based on record review, the facility failed to provide proper documentation of testing of the emergency generator. This affects 1 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:

Mercy West Radiology and Endoscopy
Record review on 07/20/11 at 10:20 a.m., revealed the generator test log failed to indicate whether or not the generator was tested under a minimum load of 30-percent of the nameplate output of the generator.

Based on observations, the facility failed to maintain the facility's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This affects 21 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011 in the 5th Floor Dialysis Treatment Room by the Northeast Nurse ' s Station revealed an electrical outlet box that was unsecured from the wall.
2. Observations between 7/19/2011 and 8/2/2011 in the 5th Floor Dialysis Waiting Room 2 revealed a plastic surge protector with an aquarium, a lamp, and an extension cord plugged into it. This surge protector was plugged into a plastic electrical timer device and an electrical adapter.
3. Observations between 7/19/2011 and 8/2/2011 in the 4th Floor IDEC Office Desk revealed several lamps and heater devices that were plugged into plastic surge protectors.
4. Observations between 7/19/2011 and 8/2/2011 in the 4th Floor IDEC Reception Area revealed 2 heater devices plugged into plastic surge protectors.
5. Observations between 7/19/2011 and 8/2/2011 in the 2nd Floor Performance Improvement Conference Room revealed 2 electrical drop cords in use with computer equipment.
6. Observations between 7/19/2011 and 8/2/2011 in the 2nd Floor Scheduling Room revealed multiple fans on plastic surge protectors.
7. Observations between 7/19/2011 and 8/2/2011 in the Level A Wellness Center revealed Treadmills and Staff Lockers located within 3 feet of electrical panels.
8. Observations between 7/19/2011 and 8/2/2011 in the Level A Catacombs Corridor revealed 2 fans plugged into electrical drop cords.
9. Observations between 7/19/2011 and 8/2/2011 in the Level A Catacombs Plumbers Area revealed exposed electrical wires in the suspended lighting unit by the Sticker Storage Room.
10. Observations between 7/19/2011 and 8/2/2011 in the Level A Catacombs Plumbers Area revealed the Fluorescent Lighting unit in the Old Elevator Pit was not hardwired.
11. Observations between 7/19/2011 and 8/2/2011 in the Level A Catacombs Contract Electricians Storage Room revealed 2 fans plugged into electrical drop cords.
12. Observations between 7/19/2011 and 8/2/2011 in the Level B Telephone Room revealed 2 open electrical junction boxes located on the ceiling.
13. Observations between 7/19/2011 and 8/2/2011 in the Level B East Stairwell in the Corridor revealed 2 open electrical junction boxes.
14. Observations between 7/19/2011 and 8/2/2011 revealed an open gap in Electrical Panel 9BN- in the 9th Floor 9B Galley Room.
15. Observations between 7/19/2011 and 8/2/2011 revealed an electrical outlet within 6 feet of a sink in the corridor outside Rooms 919 that is not a ground fault circuit interrupter type. Floors 6 through 9 had this issue on all electrical outlets within 6 feet of sinks in the corridors by Patient Rooms.
16. Observations between 7/19/2011 and 8/2/2011 in the 8th Floor Patient and Visitor Lounge revealed a surge protector supplying power to a lamp.
17. Observations between 7/19/2011 and 8/2/2011 in the revealed an open gap in Electrical Panel 8AN.
18. Observations between 7/19/2011 and 8/2/2011 in the revealed a surge protector supplying power to another surge protector in the Ruan Neurology Clinic Lobby. One of the surge protectors was supplying power to fish tank equipment.
19. Observations between 7/19/2011 and 8/2/2011 revealed that there was a surge protector supplying power to a coffee maker and espresso machine in Room 421.
20. Observations between 7/19/2011 and 8/2/2011 revealed an electrical Panel LN2 in Mechanical Room #2936 that was not properly lableled.
21. Observations between 7/19/2011 and 8/2/2011 revealed no circuit schedule on electrical panels AHU-68 and AHU-67.
22. Observations between 7/19/2011 and 8/2/2011 revealed an open gap in Electrical Panel PH-2 in the 11th Floor Elevator Control Room.
23. Observations between 7/19/2011 and 8/2/2011 revealed that there was an electrical panel that was not properly labeled by the Laundry Dock.
24. Observations between 7/19/2011 and 8/2/2011 revealed that there was a circuit breaker for the Fire Alarm that was not mechanically protected. The breaker is located in Panel C-3 in the East #2 Chapel Closet.
25. Observations between 7/19/2011 and 8/2/2011 revealed that the circuit breaker location for the Fire Alarm was not indicated at the Main Fire Alarm Panel.
26. Observations between 7/19/2011 and 8/2/2011 revealed that there was an open gap in Electrical Panel RC in the Print Shop Mechanical Room on the A-Level.
27. Observations between 7/19/2011 and 8/2/2011 revealed a surge protector supplying power to a power bed. 10th Floor Biological Medical repair.
28. Observations between 7/19/2011 and 8/2/2011 revealed unapproved electrical devices plugged into surge protectors (Doppler Ultrasound) located in th e9th Floor Director's Office.
29. Observations between 7/19/2011 and 8/2/2011 revealed a damaged electrical junction box cover located above the East Smoke Door on the 9th Floor.
30. Observations between 7/19/2011 and 8/2/2011 revealed a need for plug knockouts on the electric panel in 9 North Soils Hold Room.
31. Observations between 7/19/2011 and 8/2/2011 revealed a ventilation machine plugged into a surge protector in Room 2180.
32. Observations between 7/19/2011 and 8/2/2011 revealed a refrigerator plugged into a surge protector in Room 2180.
33. Observations between 7/19/2011 and 8/2/2011 revealed unlabeled breakers in the kitchen Panel pnl1b breakers 78 and 80.
34. Observations between 7/19/2011 and 8/2/2011 revealed the absence of a GFCI outlet for the outlet numbered N3a circuit 49.

Mercy Franklin
Observations and staff interview between 7/19/2011 and 8/2/2011 revealed a T.V. and VCR were plugged into an electrical extension cord in the Children ' s Area Classroom.

Mercy West
1. Observations and staff interview between 7/19/2011 and 8/2/2011 revealed the 1st Floor IT Training Room revealed 9 surge protectors that were plugged into other surge protectors within the room. This room also revealed a fan plugged into a plastic surge protector.
2. Observations and staff interview between 7/19/2011 and 8/2/2011 revealed the 1st Floor Linen Room revealed an electrical extension cord to the electronic scale.

Based on observations, the facility failed to have Alcohol Based Hand Rub dispensers properly located. This affects 2 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:

Main Building
Observations between 7/19/2011 and 8/2/2011, revealed an alcohol-based hand sanitizer located directly above an electrical outlet by door to Room 933.

Mercy Franklin
Observations and interview between 7/19/2011 and 8/2/2011, revealed an Alcohol Based Hand Rub dispenser was located over an electrical source in the Adult Partial Nurses Station.

(A)
Based on observations and staff interview, the facility failed to maintain and/or provide ceiling smoke tiles. This affects 12 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Observations between 07/19/11 and 08/02/11, revealed the following:

Main Building
1. The 5th Floor South Hall Soiled Hold Room revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid.
2. The 3rd Floor Server Room revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid.
3. The 2nd Floor Audiology Testing Room revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid.
4. The Level A Old MRI Room revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid.
5. The Level B Maintenance Shop revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid. At the time of inspection, these missing tiles revealed support chains and pulleys were located where the tiles should have been.
6. The Level B Welding Shop revealed several ceiling smoke tiles that were removed from the proper location in the ceiling tile grid.
7. There was a ceiling tile missing above the television in Room 341.


(B)
Based on observations, the facility failed to maintain appropriate construction standards as required by the Life Safety Code. Corridor walls and ceilings must be rated to protect the corridor. This affects 13 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:
Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed that there was a penetration (approximately 1 inch), around communications cables extending through the wall.
2. Observations between 7/19/2011 and 8/2/2011, revealed that there was a penetration (approximately 3/16 inch) around utilities extending through the wall.
3. Observations between 7/19/2011 and 8/2/2011, revealed that there was a penetration (approximately ½ " ) around utilities extending through the wall.
4. Observations between 7/19/2011 and 8/2/2011, revealed that there was an escutcheon missing from a sprinkler head above the door to the bathroom in Room 779.
5. Observations between 7/19/2011 and 8/2/2011, revealed that there was an escutcheon that was not flush with the wall in Room 782.
6. Observations between 7/19/2011 and 8/2/2011, revealed that there was an escutcheon that was not flush with the ceiling by the elevator in the 7th Floor Soiled Hold Room.
7. Observations between 7/19/2011 and 8/2/2011, revealed that there was a hole (approximately ½ inch) in the smoke barrier wall by the 7th Floor South NCS desk.
8. Observations between 7/19/2011 and 8/2/2011, revealed that there was a penetration (approximately ½ inch), around communication lines extending through the smoke barrier wall by Room 734 on the 7th Floor.
9. Observations between 7/19/2011 and 8/2/2011, revealed an escutcheon that was not flush with the wall in Room 743.
10. Observations between 7/19/2011 and 8/2/2011, revealed that there was an escutcheon missing from a sprinkler head above the bathroom door in Room 740.
11. Observations between 7/19/2011 and 8/2/2011, revealed that there was foam that was not fire rated filling penetrations in the 6th Floor Smoke Barrier Wall by Room 673.
12. Observations between 7/19/2011 and 8/2/2011, revealed that there was an escutcheon ring that was not flush with the wall in Room 645/647- (Double Room.)
13. Observations between 7/19/2011 and 8/2/2011, revealed that the sprinkler escutcheon was not flush with the wall on the south wall of Room 896.
14. Observations between 7/19/2011 and 8/2/2011, revealed that there was a missing ceiling tile in Room 635/637- Double Room.
15. Observations between 7/19/2011 and 8/2/2011, revealed that there was a penetration (approximately ¼ inch), around communication cables extending through the 5th Floor Smoke Barrier Wall by the South Unit NCS Desk.
16. Observations between 7/19/2011 and 8/2/2011, revealed that there was a missing escutcheon in the Nuclear Medicine Dual Head Room.


Mercy West
1. Observations between 7/19/2011 and 8/2/2011, revealed that there was a gap (approximately ¼ inch) around a penetration located above the smoke doors by room 2558.
2. Observations between 7/19/2011 and 8/2/2011, revealed that the 1st Floor Mechanical Room had multiple gaps in the fire retardant spray coating on the I-Beams in locations where electrical junction boxes and pipe supports had been attached to the I-Beams.
3. Observations between 7/19/2011 and 8/2/2011, revealed that the 1st Floor Fountain Pump Room 1106 had multiple gaps in the fire retardant spray coating on the I-Beams in locations where electrical junction boxes and pipe supports had been attached to the I-Beams.

Based on observations, the facility failed to maintain corridor doors within proper standards. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed that the 4th Floor Janitor Closet by Exam Room had 2 vents/louvers installed in the corridor door.
2. Observations between 7/19/2011 and 8/2/2011, revealed that the 4th Floor IDEC Corridor by the North Stairwell had a book shelf blocking the Exam Room Corridor Door from fully opening.
3. Observations between 7/19/2011 and 8/2/2011, revealed that the Level A UPS Room Back Door failed to close and latch properly into the door frame with the swing of the door closer when tested.
4. Observations between 7/19/2011 and 8/2/2011, revealed that the Level B Locksmith Door had a kick-down device located on the door to keep the door from closing with the swing of the door closer.
5. Observations between 7/19/2011 and 8/2/2011, revealed that the Level B Women's Locker Room Corridor Door failed to close and latch properly into the door frame with the swing of the door closer when tested.
6. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 4000 did not close and latch.
7. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 3058 has a door wedge.
8. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 929 did not latch.
9. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 919 - did not latch.
10. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 820 did not latch.
11. Observations between 7/19/2011 and 8/2/2011, revealed that the strike plate on the door to Room 869 was broken, preventing the door from latching.
12. Observations between 7/19/2011 and 8/2/2011, revealed that the door to the 8th Floor Clean Hold Room did not latch.
13. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 333 did not latch.
14. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Room 349 did not latch.
15. Observations between 7/19/2011 and 8/2/2011, revealed that there were door props in use on two doors in the Administration Waiting Area on the 2nd Floor.
16. Observations between 7/19/2011 and 8/2/2011, revealed that there was a bolt lock on the north double exit doors in the Hines Board Room.
17. Observations between 7/19/2011 and 8/2/2011, revealed that the the door to Room 681 did not latch.
18. Observations between 7/19/2011 and 8/2/2011, revealed that the the Level A Catacombs showed13 of 13 Storage Room Doors were locked using a hasp and padlock device that would hinder exiting from the areas when the hasp and padlock were engaged on the door.
19. Observations between 7/19/2011 and 8/2/2011, revealed that the the Level B Welding Shop Door had a hasp and padlock device on the door that would hinder exiting from the room when the hasp and padlock was engaged on the door.
20. Observations between 7/19/2011 and 8/2/2011, revealed that the door closer on 9th Floor Clean Hold Storage Room was in need of repair. It failed to function properly when tested during this survey.
21. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Echo Tech Room did not close and latch upon test.
22. Observations between 7/19/2011 and 8/2/2011, revealed a padlock and chain located on the door to the gated storage area on the 10th floor.
23. Observations between 7/19/2011 and 8/2/2011, revealed that the 2nd Floor Surgery Storage Room 2745 door latching hardware strike plate grinded against the latching hardware and caused the door latching hardware to fail to open.

Mercy Franklin
1. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Resident Room #6 in the Children ' s Area failed to close and latch when tested.
2. Observations between 7/19/2011 and 8/2/2011, revealed that the door to Resident Room #7 in the Children ' s Area failed to close and latch when tested.
3. Observations between 7/19/2011 and 8/2/2011, revealed the door to Resident Room #10 in the Children ' s Area failed to close and latch when tested.


Mercy West
1. Observations between 7/19/2011 and 8/2/2011, revealed the use of a metal wedge holding the door open located at the 8th Floor Electrical Room.
2. Observations between 7/19/2011 and 8/2/2011, revealed a broken closer for the door to Room 5375, 5th Floor Janitors Closet.
3. Observations between 7/19/2011 and 8/2/2011, revealed that the 5th Floor Rehabilitation Gym Door (5470) was wedged open with a door wedge.
4. Observations between 7/19/2011 and 8/2/2011, revealed that the 2nd Floor Chapel Door failed to close and latch properly into the door frame with the swing of the door closer.
5. Observations between 7/19/2011 and 8/2/2011, revealed that the 2nd Floor Emergency Room 7 (2507) door to the Central Nurse ' s Station was propped open with furniture.
6. Observations between 7/19/2011 and 8/2/2011, revealed that the 2nd Floor Emergency Room 8 (2528) door to the Central Nurse's Station was propped open with furniture.

Based on observations and staff interview, the facility failed to maintain some exit doors and exit enclosures within proper standards. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.



Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor South Fire Doors to the Elevator Bank doors failed to close and latch properly into the door frame with the swing of the door closers.
2. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Room by W408 had a vertical hole (approximately 6 inches by 6 inches in size) located in the ceiling. At the time of inspection, this hole was covered with duct tape.
3. Observations between 7/19/2011 and 8/2/2011, revealed the 8th Floor Stairwell Door by Room 853 did not close and latch.
4. Observations between 7/19/2011 and 8/2/2011, revealed 8th Floor Stairwell Door by Room 803 did not latch.
5. Observations between 7/19/2011 and 8/2/2011, revealed the 8th Floor Stairwell Door by Room 849 did not latch.
6. Observations between 7/19/2011 and 8/2/2011, revealed the 7th Floor Stairwell Door by Room 749 did not latch.


Mercy West
1. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Double Fire Doors to the Passenger Elevator doors failed to close and latch properly into the door frame with the swing of the door closers.
2. Observations between 7/19/2011 and 8/2/2011, The 4th Floor Double Fire Doors to the Passenger Elevator doors failed to close and latch properly into the door frame with the swing of the door closers.

Based on observations, the facility failed to provide and maintain some exit signs for required locations within proper standards. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed there was not an exit sign installed to indicate the direction of travel to an exit above the South Doors at the 5th Floor Elevator Bank.
2. Observations between 7/19/2011 and 8/2/2011, revealed there was not an exit sign in the middle of the corridor to indicate the direction of travel to an exit through either of the Suites (Transplant Center Suite 500 and Transplant Unit).
3. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Corridor Door by Room W410 was not equipped with an exit sign to indicate the direction of travel to an exit.

Based on observations, the facility failed to maintain appropriate construction standards for smoke barrier walls as required by the Life Safety Code. Corridor walls and ceilings must be rated to protect the corridor from the spread of smoke. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:
Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed there was an opening (approximately 3/16 inch),in the smoke barrier wall on the 8th Floor by Room 833.
2. Observations between 7/19/2011 and 8/2/2011, revealed there was an open pipe penetration,( approximately 1 inch), extending through the smoke barrier wall on the 8th Floor by Room 833.
3. Observations between 7/19/2011 and 8/2/2011, revealed the 7th Floor Smoke Barrier wall penetrations by Room 784:
4. Observations between 7/19/2011 and 8/2/2011, revealed there was a penetration (approximately 3/16 inch), around a cable extending through the 2 hour fire wall between the Main Building and West Building at the ER West Entrance.
5. Observations between 7/19/2011 and 8/2/2011, revealed there was a hole (approximately ½ inch), in the 2 hour fire wall between the Main Building and the West Building at the ER West Entrance.
6. Observations between 7/19/2011 and 8/2/2011, revealed there was a hole (approximately ¼ inch), in the 2 hour fire wall between the Main Building and the West Building at the ER West Entrance.
7. Observations between 7/19/2011 and 8/2/2011, revealed there was a penetration (approximately ¼ inch) around a conduit extending through the smoke barrier by the Starbucks.

Based on observations, the facility failed to maintain some smoke barrier doors in the facility. This deficient practice would not prevent the spread of smoke, This affects 10 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:


Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Transport Headquarters Smoke Barrier doors failed to close and latch properly into the door frames with the swing of the door closers when tested.

2. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Smoke Barrier Doors to the Transport Headquarters middle beam between the doors was missing which did not allow the doors to properly close and latch into the door frame with the swing of the door closers.

3. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor East Entrance Door to the New Cath Lab was missing a latching bracket at the top of the door which did not allow this door to close and latch properly into the door frame with the swing of the door closer when tested.

4. Observations between 7/19/2011 and 8/2/2011, revealed the entrance to Maternity Triage Unit Smoke Doors not close and latch.


Mercy Franklin
Observations between 7/19/2011 and 8/2/2011, revealed the set of smoke barrier doors that are located near the Nurses Station to 1st Step failed to close and latch when tested.

Mercy West
Observations between 7/19/2011 and 8/2/2011, revealed that the smoke doors by the Staff Elevators failed to close and latch properly when tested.

Based on observations, the facility failed to maintain some hazardous rooms in safe and required conditions. This affects 10 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed the 6th Floor Penthouse Elevator Equipment Room had a penetration (approximately 1 foot by 6 feet in size) located in the East Wall that was filled with fire caulking.
2. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Dialysis Soiled Utility Hold door failed to close and latch properly into the door frame with the swing of the door closer.
3. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor South Soiled Hold Room door failed to close and latch properly into the door frame with the swing of the door closer.
4. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Soiled Hold Room W412 had a large pipe penetration (approximately 4 feet by 2 feet in size) into the Elevator Equipment Shaft.
5. Observations between 7/19/2011 and 8/2/2011, revealed the Level B Maintenance Supply Room had an unprotected louver in the corridor door.
6. Observations between 7/19/2011 and 8/2/2011, revealed the Level B I.T. Room revealed an unprotected louver in the corridor door.
7. Observations between 7/19/2011 and 8/2/2011, revealed the door to Room 308 - Soiled Hold did not close and latch. The door is on a closure.
8. Observations between 7/19/2011 and 8/2/2011, revealed the Door to the Soiled Hold Room on the 9th floor did not close and latch properly when tested.

Mercy Franklin
1. Observations between 7/19/2011 and 8/2/2011, revealed 2 pipe penetrations (approximately ¾ inches in size and 1 inch in size) located in the ceiling of the Children ' s Area Laundry Room.
2. Observations between 7/19/2011 and 8/2/2011, revealed a vent pipe penetration (approximately ¾ inches in size) located in the ceiling of the Adult Area Laundry Room.

Mercy West
1. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor MRI Equipment Room 2665 had a penetration (approximately 1 inch in size) located in the west wall of the room.
2. Observations between 7/19/2011 and 8/2/2011, revealed the 7th Floor Electrical Equipment Room 7121 had a pipe penetrations (approximately ¼ inch in size) located in the corridor wall.
3. Observations between 7/19/2011 and 8/2/2011, revealed the 1st Floor Loading Dock had a center conduit penetration (approximately ½ inch in size) located above the Corridor Door.
4. Observations between 7/19/2011 and 8/2/2011, revealed the 1st Floor Medical Gas Storage Room had a center conduit penetration (approximately ½ inch size) located above the Carbon Dioxide System.
5. Observations between 7/19/2011 and 8/2/2011, revealed the 1st Floor Electrical Equipment Room 1021 had a conduit penetration (approximately ½ inch size) located in the 2 hour fire resistant wall.

Based on observations, the facility failed to maintain some exit areas in safe and required conditions. This affects 8 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Corridor by the North Stairwell had multiple storage cabinets in the hallway that obstruct the width of the corridor.
2. Observations between 7/19/2011 and 8/2/2011, revealed the 3rd Floor Cardiac-Vascular Hallways revealed hinged charting stations that were not equipped with self-closing devices to allow the charting station to return to a closed position when pressure was released from the station.
3. Observations between 7/19/2011 and 8/2/2011, revealed the storage of beds in the means of egress by the exit doors located on the 10th Floor.

Mercy Franklin
Observations between 7/19/2011 and 8/2/2011, revealed the door to the Seclusion/Restraint Room was equipped with a dead bolt style locking device.

Mercy West
Observations between 7/19/2011 and 8/2/2011, revealed files blocking the path of egress in the Surgery Waiting Area by Room 2411.

Based on record review, the facility failed to provide documentation of monthly (30 second) and annual (90 minute) tests of the battery emergency lights. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Mercy West Endoscopy
Record review on 07/20/11 at 10:25 a.m., revealed the facility failed to provide documentation of monthly (30 second) and annual (90 minute) tests of the battery emergency lights.

Based on observations, the facility failed to maintain the emergency lighting in the building to verify that it is in proper working condition as required by 7.9. This affects 4 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:


Main Building
Observations between 7/19/2011 and 8/2/2011, revealed that the emergency light located in the East Building A Level switch gear room had a bulb out.


Mercy West Endoscopy
1. Observations between 7/19/2011 and 8/2/2011, revealed that the exit sign located near dressing room 7 in mammography failed to function properly.
2. Observations between 7/19/2011 and 8/2/2011, revealed that the exit sign located near dressing room 3 in mammography failed to function properly

Mercy Riverside Rehabilitation Center
Observations between 7/19/2011 and 8/2/2011, revealed the exit sign located near the main exit failed to function properly.

Based on record review, the facility failed to ensure fire drills are being held at varying times. This affects 9 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.



Findings include:


Mercy Franklin
Record review between 7/19/2011 and 8/2/2011, revealed that the facility failed to vary the times of fire drills conducted on the 1st and 3rd nursing shifts during the first 2 quarters of 2011. Of the 4 documented fire drills, the times were only 5 minutes apart. (1-18-11 at 0705. 1-19-11 at 0700. 3-23-11 at 0630 and 6-7-11 at 0630).

Based on observations and interview, the facility failed to maintain the facility fire alarm system in accordance with National Fire Protection Association (NFPA) standard 72, National Fire Alarm Code 1999 edition. This affects 27 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011, revealed the 6th Floor Penthouse Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
2. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Stairwell to the West Building Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
3. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Dialysis East Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
4. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Transplant Suite by the East Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
5. Observations between 7/19/2011 and 8/2/2011, revealed the 5th Floor Transplant Suite by the Suite Entry Door Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
6. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Center Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
7. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Corridor by the north Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
8. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Stairwell by Room W401 Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
9. Observations between 7/19/2011 and 8/2/2011, revealed the 4th Floor Stairwell by Room W425 Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
10. Observations between 7/19/2011 and 8/2/2011, revealed the 3rd Floor West Stairwell in Cardiovascular Care Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
11. Observations between 7/19/2011 and 8/2/2011, revealed the 3rd Floor East Stairwell revealed a Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
12. Observations between 7/19/2011 and 8/2/2011, revealed the 3rd Floor North Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
13. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor East Stairwell in Endoscopy Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
14. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor West Stairwell in Endoscopy Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
15. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor North Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
16. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Central Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
17. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Hallway by the A/V Coordinator ' s Office Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
18. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor by the Scheduling Office and North Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
19. Observations between 7/19/2011 and 8/2/2011, revealed the Level A Wellness Center Door to the Stairwell revealed a Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
20. Observations between 7/19/2011 and 8/2/2011, revealed the Level A Center Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
21. Observations between 7/19/2011 and 8/2/2011, revealed the Level A East Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
22. Observations between 7/19/2011 and 8/2/2011, revealed the Level A West Stairwell revealed a Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
23. Observations between 7/19/2011 and 8/2/2011, revealed the Level B Hallway by the Paint Shop Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
24. Observations between 7/19/2011 and 8/2/2011, revealed the Level B West Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
25. Observations between 7/19/2011 and 8/2/2011, revealed the Level B Center Stairwell revealed a Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
26. Observations between 7/19/2011 and 8/2/2011, revealed the Level B East Stairwell Fire Alarm Pull Station located by the Stairwell that was installed over 5 feet off the ground.
27. Observations between 7/19/2011 and 8/2/2011, revealed the Main Fire Alarm Panel was in Trouble Status. The system indicated a dirty smoke detector in the Recovery Waiting Room.
28. Observations between 7/19/2011 and 8/2/2011, revealed the 3rd Floor W3CC Office had a smoke detector located within 3 feet of an air diffuser.
29. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Endoscopy Supply Room had a smoke detector located within 3 feet of an air diffuser.
30. Observations and interview between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Fire Alarm Control Panel Enunciator revealed a message stating " Communication lost with the System ' s Master. " Interview with the Facility Assistant Maintenance Director revealed the facility was working on the fire alarm system during the inspection.
31. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Corridor by the Room W242 had a smoke detector within 3 feet of an air diffuser.
32. Observations and interview between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Fire Alarm Enunciator Panel located by the Elevators revealed the panel was not illuminated. Interview with the Facility Assistant Maintenance Director revealed the Fire Alarm Enunciator Panel was not connected at the time of inspection.
33. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor New Cath Lab by the South Recovery Desk had a smoke detector within 3 feet of an air diffuser.
34. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor New Cath Lab Soiled Hold Room had a smoke detector within 3 feet of an air diffuser.
35. Observations between 7/19/2011 and 8/2/2011, revealed the Level A Former MRI Prep Room had a smoke detector within 3 feet of an air diffuser.
36. Observations between 7/19/2011 and 8/2/2011, revealed the Level B Telecom Room had a smoke detector within 3 feet of an air diffuser.
37. Observations between 7/19/2011 and 8/2/2011, revealed the 2nd Floor Nursery/Pediatrics Unit Secretary ' s Office 2051 had a smoke detector that was installed within 3 feet of an air diffuser.
38. Observations between 7/19/2011 and 8/2/2011, revealed the smoke detector located in the Telemetry Room was within 36 inches of air moving equipment.

(A)
Based on observations, the facility failed to maintain one overhead rolling fire door. This affects 2 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:
Observations between 07/19/11 and 08/02/11, revealed the 4th Floor 4 West Exam Room revealed a fire resistant rated overhead rolling fire door that as not maintained in proper working condition. At the time of inspection, this overhead rolling door was not in use and was unable to be lowered.


(B)
Based on observations and record review, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code 1999 edition by not documenting or conducting the required sensitivity test of the buildings fire alarm system. This affects 7 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:


Mercy Franklin

Record review on 07/20/11, revealed the facility failed to provide documentation of the required sensitivity test of the buildings fire alarm system.

.


Mercy Sleep Center
Record review on 07/20/11 at 9:00 a.m. revealed the facility failed to provide documentation of semi-annual testing of the fire alarm system.

Mercy West Endoscopy
Record review on 07/20/11 at 10:00 a.m. revealed the fire alarm system was last tested in September of 2010 instead of semi-annually as required.

Mercy Riverside Rehabilitation Center
Record review on 07/20/11 at 2:15 p.m., revealed the fire alarm system was last inspected in August of 2009 instead of semi-annual as required.

Mercy Outpatient Cardiac Testing
1. Record review on 07/20/11 at 2:15 p.m., revealed the fire alarm system was last inspected in June of 2010 instead of semi-annually as required.
2. Record review on 07/20/11 at 2:15 p.m., revealed no documentation of sensitivity testing of the smoke detectors.

Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition. This affects 37 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Observations between 07/19/11 and 8/2/11, revealed the following:

Main Building
1. The 5th Floor Dialysis Waiting Room 2 revealed the Atrium was not equipped with sprinkler heads to provide proper sprinkler coverage for the affected area.
2. The 5th Floor Transplant Center Suite 500 Private Room by the Waiting Room revealed the Closet was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
3. The 4th Floor North Stairwell revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
4. The 3rd Floor Cardiac-Vascular West Stairwell revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
5. The 3rd Floor Cardiac-Vascular East Stairwell revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
6. The 2nd Floor East Stairwell in Endoscopy revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
7. The 2nd Floor North Stairwell revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
8. The 2nd Floor Central Stairwell revealed the Stairwell Landing was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
9. The Level A Catacombs Plumbers Area revealed the Sticker Storage Area was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
10. The Level A Catacombs Plumbers Area revealed a mixture of ordinary fusible link sprinkler heads (no color) and high heat fusible link sprinkler heads (white) by the Sticker Storage Area.
11. The Level A Catacombs revealed the Old Elevator Pit was not equipped with sprinkler heads to provide proper sprinkler coverage for the affected area.
12. The Level A Catacombs Plumbers Area revealed the Old Stairs Area was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
13. The Level A Catacombs North Stairwell revealed the Stairwell was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
14. The Level A West Lobby by the South Doors revealed the Vestibule and directly inside the Lobby Door were not provided with sprinkler heads to provide proper sprinkler coverage for the areas.
15. The Level A Mammography Waiting Room Closet revealed the areas was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
16. The Level A Old Spiral Stairway revealed the area was not equipped with a sprinkler head to provide proper sprinkler coverage for the affected area.
17. The Level B Wood Shop revealed 2 of 4 sprinkler heads that were located over 4 feet below the ceiling deck.
18. The 6th Floor Penthouse revealed 2 of approximately 20 sprinkler heads located above the Air Handler Unit 71 on the North Side of the room that were filled with lint and dust.
19. The 5th Floor Dialysis Locker Room revealed a missing escutcheon ring on 1 of 1 sprinkler head.
20. The 5th Floor Dialysis Work Room revealed a sprinkler head (1 of 4) located above the Sink with a paint-like substance on it and a missing escutcheon ring. This room also revealed a sprinkler head (1 of 4) in the Northwest corner of the room that had a foreign material on the head.
21. The 5th Floor Dialysis East Stairwell revealed a paint-like substance on 1 of 1 sprinkler head in the area.
22. The 5th Floor Transplant Center Suite 500 Private Room/Office by the Waiting Room revealed a paint-like substance on the sprinkler head (1 of 2) located over the Dinner Table in the room.
23. The 4th Floor IDEC Exam Room revealed an IT Wireless System installed within 1 inch of the sprinkler head (1 of 1) in this room.
24. The 4th Floor Office W406 revealed a light fixture installed within 2 inches of the sprinkler head (1 of 1) in this room.
25. The 4th Floor Office 407 revealed a sprinkler head (1 of 3) missing the escutcheon ring.
26. The 4th Floor Office 409 revealed a sprinkler head (1 of 3) missing the escutcheon ring.
27. The 2nd Floor Corridor by Room W242 revealed the sprinkler head (1 of approximately 8) was missing the escutcheon ring.
28. The 2nd Floor Bacteriology Lab W249 revealed 3 of 12 sprinkler heads that were missing escutcheon rings.
29. The 2nd Floor Soiled Hold Room revealed a paint-like substance on 1 of 2 sprinkler heads.
30. The 2nd Floor Performance Improvement Offices Stairwell to the Wellness Center revealed a paint-like substance on 1 of 1 sprinkler heads in this area.
31. The Level A Wellness Storage Room by the Whirlpool revealed a sprinkler head (1 of 2) with a missing escutcheon ring.
32. The Level A Pool revealed 12 of 12 sprinkler heads with a corrosive material on the heads.
33. The Level A by the Old Spiral Staircase revealed a sprinkler head (1 of 6) was missing the escutcheon ring.

Mercy West
The 2nd Floor Room 2533B revealed that it was unable to be determined to be properly covered with a sprinkler system.

Based on observations, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition by failing to conduct the required quarterly testing of the system. This affects 3 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Mercy Franklin

Record review on 7-19-11, revealed the facility failed to provide and document a quarterly inspection of the buildings automatic sprinkler system during the first quarter year of 2011.



Mercy North ASC
Record review on 7-19-11, revealed the facility failed to provide documentation of quarterly flow tests of the sprinkler system.

Mercy Sleep Center
Record review on 7-19-11, revealed the facility failed to provide documentation of annual service and quarterly flow tests of the sprinkler system.

Mercy Radiology Center
Record review on 7-19-11, revealed no documentation of quarterly flow tests of the sprinkler system.

Based on observations and staff interview, 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. This affects 8 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:
Observations between 07/19/11 and 08/02/11 revealed the following:
Main Building
1. The 5th Floor Dialysis Store Room revealed the room was missing the fire extinguisher. The support and hanger for the fire extinguisher was furnished but the fire extinguisher was not located in the room.
2. The 4th Floor Corridor by the North Stairwell revealed that the area was missing a fire extinguisher. The support and hanger for the fire extinguisher was located but the fire extinguisher was not found.
3. The 4th Floor IDEC Room W416 revealed a fire extinguisher that was installed behind a door. When the door was in the fully open position, this fire extinguisher was not accessible or visible.
4. The 2nd Floor Microbiology Micro Storage Room W243 revealed the fire extinguisher was installed behind the corridor door and when the door was fully open, the fire extinguisher was not accessible or visible.
5. The Level B Welding Shop revealed the fire extinguisher was missing the monthly visual inspection for June 2011.
6. The Level B Morgue Cooler Room revealed the fire extinguisher in was blocked by a cart.
7. The Level B Clinical Engineering Room revealed the fire extinguisher was being blocked by a cart.

Mercy West
Observations revealed that the 1st Floor Lab revealed the South Fire Extinguisher was being obstructed by service equipment.

Based on observations, the facility failed to maintain approved decorative materials in the facility in accordance with National Fire Protection Association (NFPA), Life Safety Code. This affects 4 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings revealed:
Observations between 07/19/11 and 08/02/11, revealed the following:
Main Building
1. The Level B Maintenance Coordinator's Office revealed a vinyl mini-blind located on the window of the door.
2. The 2nd Floor Vascular Ultrasound Corridor Door revealed a vinyl mini-blind on the door window.

Mercy Franklin
Observations revealed a vinyl mini-blind window covering in the Adult Area Medical Records Office.



Mercy West
Observations in the 1st Floor Dietary Office 1316 revealed a vinyl mini-blind located on the window inside the office.

Based on observations, the facility failed to maintain oxygen tanks in accordance with NFPA 99, by ensuring that tanks were adequately secured to prevent them from accidental damage or dislocation. This affects 3 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.



Findings include:

Observations between 07/19/11 and 08/02/11, revealed the following:

Main Building
There were 12 large compressed gas cylinders that were not secured in the Level A Medical Gas Storage Room.


Mercy West
1. The oxygen bottle located in Room 1742, Cath Room was not secured as required.
2. The 1st Floor Medical Gas Storage Room revealed 6 oxygen tanks that were not properly secured from falling.

(A)
Based on observations and staff interview, the facility failed to safely maintain several compressed gas containers. This affects 3 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
Observations between 7/19/2011 and 8/2/2011, revealed an Argon Compressed Gas Cylinder was not properly secured from falling. This tank was located in the Level B Welding Shop.

Mercy West
1. Observations between 7/19/2011 and 8/2/2011, revealed in the 1st Floor Pop Storage Room 1220 a carbon dioxide compressed gas bottle that was not properly secured from falling.
2. Observations between 7/19/2011 and 8/2/2011, revealed in the 2nd Floor Ambulance Garage a carbon dioxide compressed gas bottle that was not properly secured from falling.


(B)
Main Building
Based on observations, the facility failed to safely maintain one metal storage container. This affects 1 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Observations between 7/19/2011 and 8/2/2011, revealed the use of a metal container that was full of oil rags. This was located in the 3rd Floor Emergency Flight Deck.
(C)
Mercy Riverside Rehabilitation Center
Based on observation, the facility failed to properly separate combustible storage from heating equipment. This affects 1 of 144 smoke zones in the event of a fire related emergency. The facility has is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:
Observations between 7/19/2011 and 8/2/2011, revealed boxes located next to the water heater in the Mechanical Room.

Based on observations and staff interview, the facility failed to provide oxygen signs at locations where oxygen is stored in accordance with NFPA 99. This affects 1 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Mercy West

The 1st Floor Oxygen Storage Room 1616 revealed there was not a " No-Smoking/Oxygen Storage " sign on the door to indicate the room was being used for multiple oxygen tank storage.


Main Building

Room 3064 did not have an oxygen sign as required.

Based on record review, the facility failed to provide proper documentation of testing of the emergency generator. This affects 1 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.

Findings include:

Mercy West Radiology and Endoscopy
Record review on 07/20/11 at 10:20 a.m., revealed the generator test log failed to indicate whether or not the generator was tested under a minimum load of 30-percent of the nameplate output of the generator.

Based on observations, the facility failed to maintain the facility's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This affects 21 of 144 smoke zones in the event of a fire related emergency. The facility is licensed for 834 residents and the census at the time of the survey was 520 residents.


Findings include:

Main Building
1. Observations between 7/19/2011 and 8/2/2011 in the 5th Floor Dialysis Treatment Room by the Northeast Nurse ' s Station revealed an electrical outlet box that was unsecured from the wall.
2. Observations between 7/19/2011 and 8/2/2011 in the 5th Floor Dialysis Waiting Room 2 revealed a plastic surge protector with an aquarium, a lamp, and an extension cord plugged into it. This surge protector was plugged into a plastic electrical timer device and an electrical adapter.
3. Observations between 7/19/2011 and 8/2/2011 in the 4th Floor IDEC Office Desk revealed several lamps and heater devices that were plugged into plastic surge protectors.
4. Observations between 7/19/2011 and 8/2/2011 in the 4th Floor IDEC Reception Area revealed 2 heater devices plugged into plastic surge protectors.
5. Observations between 7/19/2011 and 8/2/2011 in the 2nd Floor Performance Improvement Conference Room revealed 2 electrical drop cords in use with computer equipment.
6. Observations between 7/19/2011 and 8/2/2011 in the 2nd Floor Scheduling Room revealed multiple fans on plastic surge protectors.
7. Observations between 7/19/2011 and 8/2/2011 in the Level A Wellness Center revealed Treadmills and Staff Lockers located within 3 feet of electrical panels.
8. Observations between 7/19/2011 and 8/2/2011 in the Level A Catacombs Corridor revealed 2 fans plugged into electrical drop cords.
9. Observations between 7/19/2011 and 8/2/2011 in the Level A Catacombs Plumbers Area revealed exposed electrical wires in the suspended lighting unit by the Sticker Storage Room.
10. Observations between 7/19/2011 and 8/2/2011 in the Level A Catacombs Plumbers Area revealed the Fluorescent Lighting unit in the Old Elevator Pit was not hardwired.
11. Observations between 7/19/2011 and 8/2/2011 in the Level A Catacombs Contract Electricians Storage Room revealed 2 fans plugged into electrical drop cords.
12. Observations between 7/19/2011 and 8/2/2011 in the Level B Telephone Room revealed 2 open electrical junction boxes located on the ceiling.
13. Observations between 7/19/2011 and 8/2/2011 in the Level B East Stairwell in the Corridor revealed 2 open electrical junction boxes.
14. Observations between 7/19/2011 and 8/2/2011 revealed an open gap in Electrical Panel 9BN- in the 9th Floor 9B Galley Room.
15. Observations between 7/19/2011 and 8/2/2011 revealed an electrical outlet within 6 feet of a sink in the corridor outside Rooms 919 that is not a ground fault circuit interrupter type. Floors 6 through 9 had this issue on all electrical outlets within 6 feet of sinks in the corridors by Patient Rooms.
16. Observations between 7/19/2011 and 8/2/2011 in the 8th Floor Patient and Visitor Lounge revealed a surge protector supplying power to a lamp.
17. Observations between 7/19/2011 and 8/2/2011 in the revealed an open gap in Electrical Panel 8AN.
18. Observations between 7/19/2011 and 8/2/2011 in the revealed a surge protector supplying power to another surge protector in the Ruan Neurology Clinic Lobby. One of the surge protectors was supplying power to fish tank equipment.
19. Observations between 7/19/2011 and 8/2/2011 revealed that there was a surge protector supplying power to a coffee maker and espresso machine in Room 421.
20. Observations between 7/19/2011 and 8/2/2011 revealed an electrical Panel LN2 in Mechanical Room #2936 that was not properly lableled.
21. Observations between 7/19/2011 and 8/2/2011 revealed no circuit schedule on electrical panels AHU-68 and AHU-67.
22. Observations between 7/19/2011 and 8/2/2011 revealed an open gap in Electrical Panel PH-2 in the 11th Floor Elevator Control Room.
23. Observations between 7/19/2011 and 8/2/2011 revealed that there was an electrical panel that was not properly labeled by the Laundry Dock.
24. Observations between 7/19/2011 and 8/2/2011 revealed that there was a circuit breaker for the Fire Alarm that was not mechanically protected. The breaker is located in Panel C-3 in the East #2 Chapel Closet.
25. Observations between 7/19/2011 and 8/2/2011 revealed that the circuit breaker location for the Fire Alarm was not indicated at the Main Fire Alarm Panel.
26. Observations between 7/19/2011 and 8/2/2011 revealed that there was an open gap in Electrical Panel RC in the Print Shop Mechanical Room on the A-Level.
27. Observations between 7/19/2011 and 8/2/2011 revealed a surge protector supplying power to a power bed. 10th Floor Biological Medical repair.
28. Observations between 7/19/2011 and 8/2/2011 revealed unapproved electrical devices plugged into surge protectors (Doppler Ultrasound) located in th e9th Floor Director's Office.
29. Observations between 7/19/2011 and 8/2/2011 revealed a damaged electrical junction box cover located above the East Smoke Door on the 9th Floor.
30. Observations between 7/19/2011 and 8/2/2011 revealed a need for plug knockouts on the electric panel in 9 North Soils Hold Room.
31. Observations between 7/19/2011 and 8/2/2011 revealed a ventilation machine plugged into a surge protector in Room 2180.
32. Observations between 7/19/2011 and 8/2/2011 revealed a refrigerator plugged into a surge protector in Room 2180.
33. Observations between 7/19/2011 and 8/2/2011 revealed unlabeled breakers in the kitchen Panel pnl1b breakers 78 and 80.
34. Observations between 7/19/2011 and 8/2/2011 revealed the absence of a GFCI outlet for the outlet numbered N3a circuit 49.

Mercy Franklin
Observations and staff interview between 7/19/2011 and 8/2/2011 revealed a T.V. and VCR were plugged into an electrical extension cord in the Children ' s Area Classroom.

Mercy West
1. Observations and staff interview between 7/19/2011 and 8/2/2011 revealed the 1st Floor IT Training Room revealed 9 surge protectors that were plugged into other surge protectors within the room. This room also revealed a fan plugged into a plastic surge protector.
2. Observations and staff interview between 7/19/2011 and 8/2/2011 revealed the 1st Floor Linen Room revealed an electrical extension cord to the electronic scale.