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Based on observation the facility failed to ensure egress doors were were not equipped with a locking mechanism that could not be defeated from the egress side as required.

Findings:

On 4/13/17 at 12:40 am during a tour of the facility, with the director of maintenance, a door to the men's dressing room located near the delivery room was observed to have a barrel latch.

Based on record review, observation and interview the facility failed to ensure heating, cooling and ventilation were in accordance with ASHRAE 170.

Findings:

On 04/12/17 at 1:57 pm during record review of the the test & balance documentation reports for 2015 and 2016 showed that not all areas needing HVAC testing were included on the report. The reports included the two operating rooms and an isolation room. The decontamination room in the surgical suite was not included as were soiled linen/biohazardous waste rooms were omitted from facilitys' test & balance reports.

On 04/12/17 at 1:57 pm during an interview the director of maintenance stated he believed the required rooms were included on the testing reports but will advise the vendor to include the additional areas required.

On 04/13/17 at 10:37 am the surveyor performed the tissue test to the bottom of the decontamination room door that was located in the sugical suite. The tissue test showed the room was positively ventilated and not negatively ventilated as required per ASHRAE 170.
On 04/13/17 at 10:37 am the director of maintenance stated they will get the ventilation corrected.

Based on observation and interview the facility failed to ensure fire walls were free of penetrations as required.

Findings:

On 04/13/17 at 10:45 am the surveyor observed six penetrations in the fire wall near patient room 219 and four penetrations in the mechanical room.

On 04/13/17 at 10:45 am the director of maintenance stated they will get the penetrations fixed.

Based on observation and interview the facility failed to ensure electrical receptacles within six feet of a countertop water source were equipped with ground fault circuit interrupter receptacles (GFCI) as required.

Findings:

On 04/12/17 at 12:02 pm the surveyor observed a non-GFCI eletrical receptacle on the counter top service area within six feet of the countertop water source.

On 04/12/17 at 12:02 pm the director of maintenance stated he did not know how that one was missed.

Based on record review and interview the facility failed to ensure fire drills were conducted each quarter for each shift as required.

On 04/12/17 at 11:15 am record review of facility fire drills showed there was no documentation of fire drills conducted or completed for the 1st, 2nd and 3rd quarters of 2015 for each facility shift.

On 04/12/17 at 11:15 am during an interview, the director of maintenance said they had staff turnover during that time and the fire drills were overlooked.

Based on record review and interview the facility failed to ensure building systems risk assessments were completed as required.

On 04/12/17 at 11:05 am during record review the director of maintenance failed to provide the facility building systems risk assessments.

On 04/12/17 at 11:05 am the director of maintenance stated they did not have the building system risk assessments.

Based on record review and interview the facility failed to ensure building systems risk assessments for their medical gas systems were completed as required.

On 04/12/17 at 11:04 am during record review the director of maintenance failed to provide the facility building systems risk assessments.

On 04/12/17 at 11:04 am the director of maintenance stated they did not have the medical gas system risk assessment.

Based on record review and interview the facility failed to ensure building systems risk assessments for their essential eletrical systems were completed as required.

On 4/12/17 at 11:03 am during record review the director of maintenance failed to provide the building systems risk assessment.

On 04/12/17 at 11:03 am during an interview the director of maintenance stated they did not have the eletrical risk assessments.