HospitalInspections.org

Based on observation and interview it was determined that the facility failed to maintain the construction type of the building.

Findings include:


On 05/08/2018 at approximately 1:28 pm it was observed through observation and inspection that the 2 hr fire barrier has unprotected penetrations by the old CTAC at the Lobby door.

The Facility Maintenance Director witnessed this evidence through observation and interview.

Based on observation and inspection the facility failed to maintain building construction type.

Findings include:

On 5-17-18 at approximately 8:47 am it was observed through observation and inspection that there are unprotected through penetrations to the 1 hr fire barrier wall of the ED Mechanical Room.

On 5-17-18 at approximately 8:48 am it was observed through observation and inspection that there is no spray on fire proofing to the back side of a steel beam in the ED Mechanical Room.\

On 5-17-18 at approximately 10:17 am it was observed through observation and inspection that there are unprotected through penetrations to the 1 hr fire barrier wall of the MOB- West second floor Mechanical Room.

On 5-17-18 at approximately 10:27 am it was observed through observation and inspection that there are unprotected through penetrations in the MOB- West electrical room.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain building construction.

Findings include:

On 5-14-18 at approximately 9:31 am it was observed through observation and inspection that drywall mud has been used to patch holes in the spray on fire proofing on the steel beams of Mechanical Penthouse #4 on the roof.

On 5-14-18 at approximately 9:32 am it was observed through observation and inspection that the fire proofing on the steel beams in Mechanical Penthouse #3 on the roof is not sprayed on, it appears to be tooled.

On 5-14-18 at approximately 9:24 am it was observed through observation and inspection that the fire proofing has not been reapplied around the beam clamps in Mechanical Penthouse #3 on the roof .

On 5-14-18 at approximately 9:44 am it was observed through observation and inspection that the roof for the elevator mechanical room for elevators 4 & 5 on the roof has exposed wooden beams.

On 5-14-18 at approximately 9:46 am it was observed through observation and inspection that spray on fire proofing on the steel beams of Mechanical Penthouse #1 on the roof is missing or improperly applied.

On 5-14-18 at approximately 10:34 am it was observed through observation and inspection that the spray on fire proofing is not complete above the ceiling outside of Room 642.

On 5-14-18 at approximately 11:17 am it was observed through observation and inspection that a steel column above the 5 East Clinical Coordinators Office is not completely enclosed in drywall.

On 5-14-18 at approximately 11:37 am it was observed through observation and inspection that there exposed areas to the steel beams where the spray on fire proofing is missing above the ceiling in the 5 East elevator Lobby.

On 5-14-18 at approximately 1:50 pm it wa

Based on observation and inspection the facility failed to maintain the building construction type.

Findings include:

On 05/08/2018 between approximately 8:30 am and 3:00 pm it was observed that the 2 hour fire separation between floors was modified from its original approved construction. Alterations to the ceiling include, fire rated tiles replaced with non-rated tiles, lighting not "tented", and utilizing the interstitial space as a return air plenum.

On 05/08/2018 at approximately 1:38 pm it was observed through observation and inspection that a speaker in the ceiling outside of the Admin. Offices is not tented as required by UL G202.

On 05/08/2018 at approximately 2:32 pm it was observed through observation and inspection that the ceiling tiles in the rated assembly are painted with pictures in the Respond call area. Also ceiling tiles have been replaced with with wood panels in the ceiling grid.

On 05/08/2018 at approximately 2:32 pm it was observed through observation and inspection that there is flex duct not connected to anything in the plenum ceiling in the Reception area.

On 05/08/2018 at approximately 2:20 pm it was observed through observation and inspection that there are unprotected through penetrations to the two hour fire barrier above the door going from the Respond area into the Lobby.

On 05/09/2018 at approximately 9:17 am it was observed through observation and inspection that the rated ceiling assembly is not being maintained around elevator #3.

On 05/09/2018 at approximately 9:28 am it was observed through observation and inspection that the smoke barriers are not being maintained on both side of the corridor between Valley Gastro and the Allergy Center.

On 05/09/2018 at approximately 9:28 am it was observed through observation a

Based on observation and interview it was determined that the facility failed to maintain the building construction type.

Findings include:

On 05/16/2018 between approximately 12:57 pm it was observed through observation and inspection that the spray on fire proofing has come off of the steel beams in the Oncology mechanical room.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain emergency egress.

Findings include:

On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that provided documentation indicated that the annual fire door inspection was completed in January of 2018 and all the doors failed. Documentation for corrections could only be provided for 3 floors of the main hospital.

On 05/09/2018 at approximately 10:15 am it was observed through observation and inspection that the egress corridor is used a storage area in the Allergy area.

On 05/09/2018 at approximately 2:05 pm it was observed through observation and inspection that the egress corridor is used a storage area in the Quad Lobby.

On 05/09/2018 at approximately 2:58 pm it was observed through observation and inspection that the egress corridor is used a storage area in the back corridor.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain means of egress.

Findings include:

On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that provided documentation indicated that the annual fire door inspection was completed in January of 2018 and all the doors failed. Documentation for corrections could not be provided.

On 5-14-18 at approximately 10:05 am it was observed through observation and inspection that egress is obstructed out of the Clinical leaders office on the sixth floor.

On 5-14-18 at approximately 10:50 am it was observed through observation and inspection that beds are being stored in the sixth floor center stairwell alcove.

On 5-14-18 at approximately 1:43 pm it was observed through observation and inspection that there is furniture being stored in the 5 East corridor obstructing egress.

On 5-14-18 at approximately 3:03 pm it was observed through observation and inspection that a food tray cart is being stored in the egress corridor by Elevator #3 obstructing egress.

On 5-14-18 at approximately 2:32 pm it was observed through observation and inspection that the corridor door going out of the PT Office is obstructed by a homemade desk.

On 5-15-18 at approximately 9:00 am it was observed through observation and inspection that beds are being stored in the egress corridor outside of the CICU on the 3rd floor.

On 5-15-18 at approximately 12:36 pm it was observed through observation and inspection that beds are being stored in the exit corridor of the Cath Lab.

On 5-15-18 at approximately 1:35 pm it was observed through observation and inspection that the exit corridor outside of the bed storage area is being used to store beds and carts.

On

Based on observation and inspection the facility failed to maintain means of egress.

Findings include:

On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that provided documentation indicated that the annual fire door inspection was completed in January of 2018 and all the doors failed. Documentation for corrections could not be provided.

On 5/16/2018 at approximately 1:40 pm it was observed through observation and inspection that the egress corridor on the second floor of Oncology going into L&D 2 West is being used as a storage area for beds.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain means of egress.

Findings include:

On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that provided documentation indicated that the annual fire door inspection was completed in January of 2018 and all the doors failed. Documentation for corrections could not be provided.

The Facility Maintenance Director Witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain egress doors.

Findings include:

On 05/08/2018 at approximately 2:20 pm it was observed through observation and inspection that the egress door going from the Respond area into the Lobby has loose panic hardware.

On 05/09/2018 at approximately 3:04 pm it was observed through observation and inspection that the egress door exiting the Board Room requires more than 5 pounds of force to operate.


The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain exit doors.

Findings include:

On 5/16/2018 at approximately 1:16 pm it was observed through observation and inspection that the exit door by Accelerator #3 in Oncology requires more than 5 pounds of force to operate.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain Doors with Self-Closing Devices.

On 5-16-18 at approximately 9:05 am it was observed through observation and inspection that the rated doors in the 2 hour fire wall going into the Cancer Center do not close and latch automatically.

The Facility Maintenance Director witnessed this evidence through observation and interview.

Based on observation and interview it was determined that the facility failed to maintain smoke barrier doors.

Findings include:

On 05/16/2018 between approximately 12:57 pm it was observed through observation and inspection that the corridor door in the smoke barrier to the Oncology mechanical room is not maintained self closing.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain smokeproof enclosures.

Findings include:

On 5-14-18 at approximately 11:14 am it was observed through observation and inspection that stairwell #5 at 5 East has unprotected through penetrations.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain emergency lighting.

Findings include:

On 5-22-18 at approximately 5:50 am it was observed through observation and inspection that documentation could not be provided to show that the battery power emergency lighting in the Endo OR's is being inspected/ tested monthly and a 90 minute activation test is done annually.

The Facility Maintenance Director witnessed this evidence through observation and interview.

Based on observation and inspection the facility failed to maintain exit signage.

Findings include:

On 05/08/2018 at approximately 4:28 pm it was observed through observation and inspection that there is no exit sign in the old Admin. area.

On 05/09/2018 at approximately 11:24 am it was observed through observation and inspection that the second floor enclosed courtyard has no exit sign.

On 05/09/2018 at approximately 11:24 am it was observed through observation and inspection that the second floor enclosed courtyard doors going from the corridors do not have " NO EXIT" signs posted on them. ( NFPA 101 7.10.8.3)

On 05/09/2018 at approximately 1:30 pm it was observed through observation and inspection that the exit sign is not being maintained in Dr. Leggetts corridor.


The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain exit signs.

Findings include:

On 5-15-18 at approximately 10:48 am it was observed through observation and inspection that the exit sign by Nurse station A on 2 West L&D points you to a non exit area.

On 5-15-18 at approximately 12:37 pm it was observed through observation and inspection that the exit sign by the Cath Lab supply room points you to a non exit area.

On 5-16-18 at approximately 9:39 am it was observed through observation and inspection that the exit sign in the Discharge Lounge is not illuminated as designed.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain vertical openings.

Findings include:

On 05/08/2018 at approximately 1:59 pm it was observed through observation and inspection that there is wood blocking used as part of the elevator shaft construction on the first floor.

On 05/08/2018 at approximately 2:10 pm it was observed through observation and inspection that there are unprotected through penetrations to stairwell #3 on the first floor.

On 05/08/2018 at approximately 2:12 pm it was observed through observation and inspection that the CMU block wall is not complete inside of stairwell #3 on the first floor.

On 05/08/2018 at approximately 2:15 pm it was observed through observation and inspection that there are unprotected through penetrations to the elevator shaft on the first floor.

On 05/08/2018 at approximately 2:16 pm it was observed through observation and inspection that there are unprotected steel beams inside of the elevator shaft on the first floor as part of the shaft construction.

On 05/09/2018 at approximately 2:04 pm it was observed through observation and inspection that there are unprotected through penetrations to the elevator shaft in the elevator lobby on the second floor.

Based on observation and inspection the facility failed to maintain vertical openings.

Findings include:

On 5-14-18 at approximately 2:59 pm it was observed through observation and inspection that there are unprotected through penetrations the 5 West elevator shaft #3.

On 5-14-18 at approximately 9:27 am it was observed through observation and inspection that there are unprotected through penetrations at the top of the elevator shaft in Mechanical Penthouse #4 on the roof.

On 5-14-18 at approximately 2:59 pm it was observed through observation and inspection that there are unprotected through penetrations the 5 West elevator shaft #3.

On 5-14-18 at approximately 2:43 pm it was observed through observation and inspection that there are unprotected through penetrations to the elevator 1 & 2 shafts on the 4th floor.

On 5-15-18 at approximately 11:07 am it was observed through observation and inspection that there are unprotected through penetrations to the 2 Center L&D elevator shaft above the ceiling.

On 5-15-18 at approximately 3:13 pm it was observed through observation and inspection that documentation could not be provided to show that the tube system is constructed within a fire rated barrier.

On 5-22-18 at approximately 10:22 am it was observed through observation and inspection that Elevator shafts 6 and 7 have unprotected through penetrations.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain vertical openings.

Findings include:

On 5-17-18 at approximately 9:35 am it was observed through observation and inspection that spray combustible foam is used to fill through penetrations inside the shaft of elevator #6.

On 5-17-18 at approximately 10:01 am it was observed through observation and inspection that the shafts for elevator #5 and elevator #6 do not appear to be constructed as required by the approved plans.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain hazardous areas.

Findings include:

On 5-14-18 at approximately 2:21 pm it was observed through observation and inspection that the corridor door for the Occupational Therapy Biohazard Room will not close and latch automatically.

On 5-14-18 at approximately 2:54 pm it was observed through observation and inspection that the corridor door to the 4 East combustible storage room is not self closing by Elevator #7 Lobby.

On 5-14-18 at approximately 3:14 pm it was observed through observation and inspection that the 3 East soiled utility electrical room is being used as a combustible storage area.

On 5-15-18 at approximately 1:38 pm it was observed through observation and inspection that there is a change of use to the bed storage room. This area used to be an office now its used as combustible storage.


The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain hazardous areas.

Findings include:

On 05/08/2018 at approximately 2:48 pm it was observed through observation and inspection that a office in the old Admin. area has been turned into a combustible storage room.

On 05/09/2018 at approximately 10:18 am it was observed through observation and inspection that the Allergy electrical room door is not self closing.

On 05/09/2018 at approximately 10:55 am it was observed through observation and inspection that the Unit 6 Laundry room door does not self close or latch.

On 05/09/2018 at approximately 3:16 pm it was observed through observation and inspection that there are unprotected through penetrations to the 1 hour rated wall of the soiled utility room.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and interview the facility failed to maintain Hazardous Areas.

Findings include:

On 5-17-18 at approximately 10:55 am it was observed through observation and inspection that an area in Jefferson surgical Urology has been converted into a combustible storage area.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain anesthetizing locations .

Findings include:

On 5-22-18 at approximately 5:11 am it was observed through observation and inspection that the anesthesia control valves in OR#7 are obstructed by storage.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and interview the facility failed to maintain anesthesia locations.

Findings include:


On 5-22-18 at approximately 5:41 am it was observed through observation and inspection that the anesthesia control valves are obstructed in Endo OR 32.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain cooking facilities.

Findings include:

On 5-16-18 at approximately 8:31 am it was observed through observation and inspection that there are gap between the vents in the Kitchen hood system.

On 5-16-18 at approximately 8:37 am it was observed through observation and inspection that the Kitchen hood vents have an accumulation of grease.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and interview the facility failed to maintain Alcohol Based Hand Rubs.

Findings include:

On 5-15-18 at approximately 11:00 am it was observed through observation and inspection that a ABHR dispenser is installed directly above a light switch. in the 2nd floor lactation room.

On 5-16-18 at approximately 9:11 am it was observed through observation and inspection that a ABHR dispenser is installed directly over a light switch in the Blue Ridge Cancer Care back office break room.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain the fire alarm system.

Findings include:

On 05/08/2018 at approximately 2:48 pm it was observed through observation and inspection that the smoke detector is installed too close to the wall in the old Admin. area.

On 05/09/2018 at approximately 2:26 pm it was observed through observation and inspection that a heat detector is not properly installed in the Dietary Office. It is loosely suspended by the wire.

The Facility Maintenance Director witnessed this evidence through observation and interview.

Based on observation and inspection the facility failed to maintain the fire alarm system.

Findings include:


On 5-22-18 at approximately 5:54 am it was observed through observation and inspection that there is a damaged heat detector in the Central Sterile Supply Room.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to install sprinklers properly.

Findings include:

On 05/09/2018 at approximately 10:54 am it was observed through observation and inspection that the unit 6 Electrical room has no sprinkler protection.

On 05/09/2018 at approximately 11:20 am it was observed through observation and inspection that the EVS Office /Electrical room has no sprinkler protection.

On 05/09/2018 at approximately 11:24 am it was observed through observation and inspection that the second floor enclosed courtyard has no sprinkler protection.


The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain monitoring of the sprinkler system.

Findings include:

On 05/09/2018 at approximately 10:11 am it was observed through observation and inspection that the sprinkler control valves are not chained or supervised in the Electrical/ Sprinkler room.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain the sprinkler system.

Findings include:

On 5-14-18 at approximately 9:24 am it was observed through observation and inspection that sprinklers above the air handler in Mechanical Penthouse #4 on the roof have an accumulation of dust.

On 5-14-18 at approximately 9:40 am it was observed through observation and inspection that the inspectors test valve is missing the smooth boar orifice outside of Mechanical Penthouse #3 on the roof.

On 5-14-18 at approximately 10:46 am it was observed through observation and inspection that wires are strapped to sprinkler piping above the ceiling by Elevator 1 & 2 on the sixth floor.

On 5-14-18 at approximately 2:58 pm it was observed through observation and inspection that there is a painted sprinkler in the corridor by Room 544.

On 5-14-18 at approximately 3:01 pm it was observed through observation and inspection that there is sprinkler piping that is not properly hung and that wiring is strapped to the spinkler piping on 5 West by the elevator shaft #3.

On 5-14-18 at approximately 3:00 pm it was observed through observation and inspection that ceiling tiles are missing in the 4th floor Lobby IT room.

On 5-15-18 at approximately 12:11 pm it was observed through observation and inspection that a sprinkler in the 2nd floor Janitors closet appears to have signs of corrosion.

On 5-15-18 at approximately 1:01 pm it was observed through observation and inspection that the concealed sprinkler head covers are painted over in the CVOR 1 area.

On 5-15-18 at approximately 1:29 pm it was observed through observation and inspection that sprinklers in the 2nd floor Biohazard room appear to be painted.

On 5-15-18 at approximately 1:32 pm it was

Based on observation and inspection the facility failed to maintain the sprinkler system.

Findings include:


On 05/09/2018 at approximately 10:12 am it was observed through observation and inspection that there are sprinkler piping hangers that have come loose in the Electrical / Sprinkler Room.

On 05/09/2018 at approximately 10:23 am it was observed through observation and inspection that a sprinkler escutcheon ring is missing in the Allergy supply closet.

On 05/09/2018 at approximately 10:48 am it was observed through observation and inspection that ceiling tiles are missing in Rooms 609, 608, 607, 606, 604, 602 and 601.

On 05/09/2018 at approximately 10:48 am it was observed through observation and inspection that there are holes in the hard ceiling in Rooms 609, 608, 607, 606, 604, 602 and 601.

On 05/09/2018 at approximately 10:48 am it was observed through observation and inspection that a non- listed trim ring is in use in Rooms 609, 608, 607, 606, 604, 602 and 601.

On 05/09/2018 at approximately 10:57 am it was observed through observation and inspection that the ceiling grid in the Staff locker room is falling down and that ceiling tiles are missing.

On 05/09/2018 at approximately 11:08 am it was observed through observation and inspection that the concealed covers for the sprinkler heads have been painted over in Unit 5 Room PAV 2-87, 88 and Room PAV 2-97, 98.

On 05/09/2018 at approximately 11:11 am it was observed through observation and inspection that a gap at the concealed sprinkler cover in Unit 5 Room PAV 2-87, 88 is using tissue to fill the gap.

On 05/09/2018 at approximately 1:13 pm it was observed through observation and inspection that escutcheon rings are missing in the Adolescent corridor.

On 05/09/2018 a

Based on observation and inspection the facility failed to maintain the sprinkler system.

Findings include:

On 5-17-18 at approximately between 8:30 am and 3:00 PM it was observed through observation and inspection that throughout the building sprinklers have an accumulation of dust.

On 5-17-18 at approximately 10:24 am it was observed through observation and inspection that ceiling tiles and sprinkler escutcheon rings are missing in the old Roanoke Orthopedic Area.

On 5-17-18 at approximately 10:40 am it was observed through observation and inspection that the ceiling grid has been removed in the sprinklered Jefferson Surgical Communications Room.

On 5-22-18 at approximately 5:03 am it was observed through observation and inspection that several of the covers for the concealed sprinkler heads have been painted and that a non approved plastic collar has been installed in OR#1.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and interview it was determined that the facility failed to maintain the sprinkler system.

Findings include:

On 05/16/2018 between approximately 12:51 pm it was observed through observation and inspection that wire is suspended from the sprinkler piping in the Oncology IT Room.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain portable fire extinguishers.

Findings include:

On 5-14-18 at approximately 9:21 am it was observed through observation and inspection that the portable fire extinguisher in Mechanical Penthouse #4 on the roof is not mounted.

On 5-14-18 at approximately 2:53 pm it was observed through observation and inspection that the portable fire extinguisher in the 4 East Nurse Station is obstructed by medical equipment.

On 5-15-18 at approximately 1:28 pm it was observed through observation and inspection that a portable fire extinguisher is missing in the 2nd floor Biohazard room.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain corridor doors.

Findings include:

On 05/09/2018 at approximately 9:40 am it was observed through observation and inspection that there are unprotected through penetrations to the corridor door going into the Hearing Clinic.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain smoke barriers.

Findings include:

On 5-14-18 at approximately 11:08 am it was observed through observation and inspection that there are unprotected through penetrations to the smoke barrier wall above the ceiling above the smoke doors by the 6 East soiled utility room.

On 5-14-18 at approximately 11:17 am it was observed through observation and inspection that the smoke barrier wall does not go completely to the above decking above the 5 East Clinical Coordinators Office.

On 5-14-18 at approximately 2:48 pm it was observed through observation and inspection that there are unprotected through penetrations to the smoke barrier wall above the 4 Center smoke doors by Room 400.

On 5-15-18 at approximately 9:15 am it was observed through observation and inspection that there are unprotected through penetrations to the smoke barrier above the CICU entrance doors.

On 5-15-18 at approximately 12:05 pm it was observed through observation and inspection that there is an unprotected through penetration to the smoke barrier above the 2nd floor double corridor doors going into the OR on 2 East.

On 5-15-18 at approximately 12:13 pm it was observed through observation and inspection that there is an unprotected through penetration to the smoke barrier above the ceiling at the Director of Surgical Services Office on 2 East.

On 5-15-18 at approximately 12:25 pm it was observed through observation and inspection that there are unprotected through penetrations above the ceiling to the smoke barrier wall of the SICU Mechanical room.

On 5-15-18 at approximately 12:48 pm it was observed through observation and inspection that there are unprotected through penetrations to the smoke partition wall above the ce

Based on observation and inspection the facility failed to maintain smoke barriers.

Findings include:

On 5-17-18 at approximately 10:01 am it was observed through observation and inspection that there are unprotected through penetrations to the smoke barrier wall of the TV storage room on the Second floor.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain smoke barriers.

Findings include:

On 5/16/2018 at approximately 1:03 pm it was observed through observation and inspection that there are unprotected through penetrations to the one hour smoke barrier above the double corridor doors by the soiled holding room in Oncology.

On 5/16/2018 at approximately 1:03 pm it was observed through observation and inspection that the double smoke doors in the Oncology corridor by the soiled holding room has a center gap that exceeds the allowable limit.

On 5/16/2018 at approximately 1:10 pm it was observed through observation and inspection that there are unprotected through penetrations to the one hour smoke barrier wall above the ceiling in Oncology by Accelerator #2.

On 5/16/2018 at approximately 1:47 pm it was observed through observation and inspection that there are unprotected through penetrations to the one hour smoke barrier wall in the Oncology second floor shell space.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and interview the facility failed to maintain the construction of smoke barriers.

Findings include:

On 05/09/2018 at approximately 9:28 am it was observed through observation and inspection that the smoke barriers are not being maintained on both side of the corridor between Valley Gastro and the Allergy Center

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain smoke barrier doors.

Findings include:

On 5-17-18 at approximately 10:01 am it was observed through observation and inspection that there are the corridor door to the TV storage room on the Second floor is not self closing.

On 5-17-18 at approximately 1:07 PM it was observed through observation and inspection that the double corridor smoke doors do not close completely to reduce the passage of smoke by the OR stairwell.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain smoke barrier doors.

Findings include:

On 05/09/2018 at approximately 9:51 am it was observed through observation and inspection that the self closing devices have been removed from the smoke barrier corridor doors in the ENT patient care corridor.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain smoke doors.

Findings include:

On 5-14-18 at approximately 10:23 am it was observed through observation and inspection that the double corridor smoke doors do not completely close at the 6 West staff lounge.

On 5-14-18 at approximately 1:42 pm it was observed through observation and inspection that the door in the 1 hour rated smoke barrier is held open by a bungee cord in the 5 Center Dialysis supply Room.

On 5-14-18 at approximately 2:20 pm it was observed through observation and inspection that there are unprotected through penetrations to the smoke barrier corridor door going into Physical Therapy.

On 5-14-18 at approximately 2:33 pm it was observed through observation and inspection that the door sequencer device has been removed off of the double corridor smoke doors by Room 433.

On 5-15-18 at approximately 10:21 am it was observed through observation and inspection that the door sequencer device has been removed off of the double corridor smoke doors by Room 334.

On 5-15-18 at approximately 12:15 pm it was observed through observation and inspection that the 2 East double smoke corridor doors do not completely close.

On 5-15-18 at approximately 12:49 pm it was observed through observation and inspection that the door sequencer device does not operate on the 2 East double corridor doors by the soiled utility room.

On 5-16-18 at approximately 9:19 am it was observed through observation and inspection that the door sequencer device has been removed off of the smoke corridor doors by Stairwell #1.

On 5-16-18 at approximately 9:36 am it was observed through observation and inspection that the smoke door on the left side of the Lobby does not close completely.

T

Based on observation and inspection the facility failed to maintain rubbish chutes.

Findings include:

On 5-15-18 at approximately 10:34 am it was observed through observation and inspection that the Trash chute door in the 3 East Biohazard room is not self closing and latching.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain clearance of combustibles.

Findings include:

On 05/09/2018 at approximately 2:41 pm it was observed through observation and inspection that combustibles are stored within 3 feet of the Kiln in the Art Room.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to provide an approved evacuation and relocation plan.

Findings include:

On 05/09/2018 at approximately 1:06 pm it was observed through observation and inspection that documentation could not be provided to show that Unit 1 has an approved evacuation and relocation plan.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to conduct fire drills.

Findings include:

On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that fire drills were held as required.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to conduct fire drills.

Findings include:

On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that fire drills were held for the months of March 2017, April 2017, September 2017, October 2017, and March 2016 thru October 2016.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to conduct fire drills.

Findings include:

On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that fire drills were held as required.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain combustible decorations.

Findings include:

On 05/09/2018 at approximately 2:40 pm it was observed through observation and inspection that documentation could not be provided to show that the combustible decorations suspended from the ceiling in the Art Room meet the following:

Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product.
o Decorations meet NFPA 701.
o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289.
o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4).
o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present.
19.7.5.6

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain combustible decorations.

Findings include:

On 5-15-18 at approximately 2:02 pm it was observed through observation and inspection that documentation could not be provided to show that the combustible decorations suspended from the ceiling in the 11-7 Lab Supervisors Office meet NFPA 701 requirements or are non-combustible.

On 5-16-18 at approximately 10:51 am it was observed through observation and inspection that documentation could not be provided to show that the combustible curtains suspended from the wall in the Radiology Associates Office in MRI meet NFPA 701 requirements or are non-combustible.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain portable space heaters.

Findings include:

On 5-15-18 at approximately 10:35 am it was observed through observation and inspection that a portable space heater is in use within 3 feet of combustible materials in the 3 East Case Managers Office.

On 5-15-18 at approximately 11:01 am it was observed through observation and inspection that a portable space heater is plugged into a power strip in the 2nd floor lactation room.

On 5-15-18 at approximately 2:03 pm it was observed through observation and inspection that a portable space heater is in use within 3 feet of combustible materials in the Lab Managers Office.

On 5-15-18 at approximately 3:09 pm it was observed through observation and inspection that a portable space heater is in use within 3 feet of combustible materials in the Admin. Office on the 1st floor.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain a risk assessment.

Findings include:

On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that a formal and documented risk assessment procedure performed by qualified personnel could not be produced.

On 5-14-18 at approximately 10:19 am it was observed through observation and inspection that a documented risk assessment or policy could not be provided for the toaster ovens, crockpots, griddles and toasters all listed for household use in the 6 West staff lounge.

On 5-14-18 at approximately 1:37 PM it was observed through observation and inspection that a documented risk assessment or policy could not be provided for the electric griddle in the 5 East Nurse breakroom.

On 5-14-18 at approximately 1:51 PM it was observed through observation and inspection that a documented risk assessment or policy could not be provided for the toaster oven, microwave, electric flat top griddle, and coffee pot in the 5 West conference room.

On 5-15-18 at approximately 1:51 PM it was observed through observation and inspection that a documented risk assessment or policy could not be provided for the toaster oven in the MICU clean utility room.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain a risk assessment.

Findings include:

On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that a formal and documented risk assessment procedure performed by qualified personnel could not be produced.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain gas and vacuum piped systems.

Findings include:

On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the roof construction of the "Tank Farm" outside enclosure is of combustible materials. (NFPA 99 2012 5.1.3.3.2 #3)

On 5-8-18 at approximately 11:24 am it was observed through observation and inspection that the "Tank Farm" outside enclosure has only one means of entry/exit. (NFPA 99 2012 5.1.3.3.2 #3)

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain gas and vacuum piped systems.

Findings include:

On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the roof construction of the "Tank Farm" outside enclosure is of combustible materials. (NFPA 99 2012 5.1.3.3.2 #3)

On 5-8-18 at approximately 11:24 am it was observed through observation and inspection that the "Tank Farm" outside enclosure has only one means of entry/exit. (NFPA 99 2012 5.1.3.3.2 #3)

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain gas and vacuum piped systems categories.

Findings include:

On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show what category of gas and vacuum piped systems is utilized by the facility.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain gas and vacuum piped systems categories.

Findings include:

On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show what category of gas and vacuum piped systems is utilized by the facility.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain gas and vacuum piped systems.

Findings include:

On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the entry door to the "Tank Farm" outside enclosure does not have a sign containing the minimum verbiage.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain gas and vacuum piped systems.

Findings include:

On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the entry door to the "Tank Farm" outside enclosure does not have a sign containing the minimum verbiage.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain gas and vacuum piped systems.

Findings include:

On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation for the Medical gas, vacuum, WAGD, or support gas systems indicates the systems were tested on 12/27-28/2017. The testing documents report deficiencies, and documentation could not be produced to show that they have been corrected

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain the electrical system.

Findings include

On 5-17-18 at approximately 10:38 am it was observed through observation and inspection that there are extension cords being used as permanent wiring in the MOB wing OB/GYN second floor office. ( NFPA 70 2011 590.1)

On 5-17-18 at approximately 10:39 am it was observed through observation and inspection that there are power strips plugged into other power strips in the MOB wing OB/GYN second floor office.

On 5-17-18 at approximately 10:40 am it was observed through observation and inspection that an extension cord is being used as permanent wiring above the ceiling in the MOB wing OB/GYN second floor office lobby. ( NFPA 70 2011 590.1)

On 5-17-18 at approximately 1:05 PM it was observed through observation and inspection that a junction box is missing the approved cover above the ceiling of the Electrical room MOB - West second floor OR. ( NFPA 70 2011 314.25)

On 5-22-18 at approximately 5:02 am it was observed through observation and inspection that medical grade power strips are plugged one into another in OR#1.

On 5-22-18 at approximately 5:05 am it was observed through observation and inspection that an electrical service panel is obstructed by an Anesthesia cart in OR#5 and OR#11. ( NFPA 70 2011 110.26)

On 5-22-18 at approximately 5:05 am it was observed through observation and inspection that an electrical service panel is obstructed by the Da Vinci Surgical System in OR#8. ( NFPA 70 2011 110.26)

On 5-22-18 at approximately 5:17 am it was observed through observation and inspection that the breakers in electrical service panel IPL are not labeled in OR#11. ( NFPA 70 2011 230.2 (E) )

On 5-22-18 at approximately 5:21 am it was obse

Based on observation and inspection the facility failed to maintain the electrical system.

Findings include:

On 05/08/2018 at approximately 1:44 pm it was observed through observation and inspection that there is a junction box above the ceiling that is missing the approved cover in the Lobby.

On 05/08/2018 at approximately 2:10 pm it was observed through observation and inspection that there is a junction box above the ceiling that is missing the approved cover by the first floor stairwell.

On 05/09/2018 at approximately 9:17 am it was observed through observation and inspection that there is a junction box above the ceiling that is missing the approved cover by elevator #3.

On 05/09/2018 at approximately 9:40 pm it was observed through observation and inspection that an extension cord is being used as permanent wiring in the Hearing Clinic Office.

On 05/09/2018 at approximately 9:56 am it was observed through observation and inspection that there is a junction box above the ceiling that is missing the approved cover above the water fountain.

On 05/09/2018 at approximately 3:00 pm it was observed through observation and inspection that there is a junction box missing the approved cover in the EVS Office by the Dryers.

On 05/09/2018 at approximately 10:40 am it was observed through observation and inspection there are electrical connections not inside a junction box above the ceiling on the second floor unit 6.

On 05/09/2018 at approximately 1:45 pm it was observed through observation and inspection that the electrical panel in the Unit 3 supply room is obstructed by storage.

On 05/09/2018 at approximately 2:29 pm it was observed through observation and inspection that a junction box is missing a knockout in the Dietary Office.

Based on observation and inspection the facility failed to maintain the electrical system.

Findings include:

On 5-14-18 at approximately 9:36 am it was observed through observation and inspection that side knock outs are missing from electrical panels H-084 & H-028 in Mechanical Penthouse #2 on the roof.

On 5-14-18 at approximately 9:48 am it was observed through observation and inspection that a side knock out is missing from the air handler in the Elevator #7 control room on the roof.

On 5-14-18 at approximately 9:49 am it was observed through observation and inspection that a junction box is missing the approved cover in the Elevator #7 control room on the roof.

On 5-14-18 at approximately 10:12 am it was observed through observation and inspection that side knock out is missing from electrical panel H-081by Room 660.

On 5-14-18 at approximately 10:26 am it was observed through observation and inspection that the electrical service panel located at the 6 West nursing station is obstructed.

On 5-14-18 at approximately 2:21 pm it was observed through observation and inspection that there is a junction box that is missing the side knockouts above the ceiling by the OT smoke doors.

On 5-14-18 at approximately 3:13 pm it was observed through observation and inspection that there is a junction box that is missing the approved cover above the ceiling by Room 315.

On 5-14-18 at approximately 3:30 pm it was observed through observation and inspection that there is a junction box that is missing the approved cover above the ceiling by smoke door FD-33.

On 5-15-18 at approximately 9:05 am it was observed through observation and inspection that there are power strips plugged one into another in the CICU med/supply room.

On 5-15-18 at appro

Based on observation and inspection the facility failed to maintain the electrical system.

Findings include:

On 5/16/2018 at approximately 1:24 pm it was observed through observation and inspection that there is a junction box that is missing the approved cover above the ceiling in the Oncology waiting room by the elevator.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain electrical systems.

Findings include:

On 5-22-18 at approximately 5:00 am it was observed through observation and inspection that a written record of the risk assessment is not being maintained and available for inspection.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain electrical systems.

On 5-22-18 at approximately 5:33 am it was observed through observation and inspection that a written record of the risk assessment is not being maintained and available for inspection.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to test receptacles.

Findings include:

On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that receptacles have been tested after initial installation, replacement or servicing.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to test receptacles.

Findings include:

On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that receptacles have been tested after initial installation, replacement or servicing.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and interview it was determined that the facility failed to maintain the generator system.

Findings include:

On 05/07/2018 between approximately 8:30 am and 3:00 pm it was observed through observation and inspection that the facility could not provide documentation to show that the main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are not being maintained and readily available.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and interview it was determined that the facility failed to maintain the generator system.

Findings include:

On 05/07/2018 between approximately 8:30 am and 3:00 pm it was observed through observation and inspection that the facility could not provide documentation to show that the main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are not being maintained and readily available.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and interview it was determined that the facility failed to maintain the generator system.

Findings include:

On 05/07/2018 between approximately 8:30 am and 3:00 pm it was observed through observation and inspection that the facility could not provide documentation to show that the main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are not being maintained and readily available.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain electrical equipment.

Findings include:

On 05/09/2018 at approximately 2:18 pm it was observed through observation and inspection that a chest freezer in the Kitchen has a broken ground plug.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain electrical equipment.

Findings include:

On 5-17-18 at approximately 10:38 am it was observed through observation and inspection that there is patient-care-related electrical equipment plugged directly into a power strip within the patient care vicinity in the MOB wing OB/GYN second floor office.

On 5-17-18 at approximately 10:53 am it was observed through observation and inspection that there is patient-care-related electrical equipment plugged directly into a power strip in the patient care vicinity in the Jefferson Surgical Urology Exam room 10.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain patient-care-related electrical equipment.

Findings include:

On 5-15-18 at approximately 9:05 am it was observed through observation and inspection that there is medical equipment not plugged into a medical grade power strips in the CICU med/supply room.


On 5-22-18 at approximately 5:44 am it was observed through observation and inspection that there is a non medical grade power strip in use by the computer in the patient care vicinity in Endo OR #31

On 5-22-18 at approximately 6:17 am it was observed through observation and inspection that the communication equipment for the hyperbaric chamber closest to the desk, is plugged into a power strip.


The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain gas equipment.

Findings include:

On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the "Tank Farm" outside enclosure is within 20 feet of other combustible structures.

On 5-8-18 at approximately 11:23 am it was observed through observation and inspection that the "Tank Farm" outside enclosure contains an accumulation of combustible dead leaves.

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain gas equipment.

Findings include:

On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the "Tank Farm" outside enclosure is within 20 feet of other combustible structures. (NFPA 99 2012 11.3.2.3)

On 5-8-18 at approximately 11:23 am it was observed through observation and inspection that the "Tank Farm" outside enclosure contains an accumulation of combustible dead leaves. (NFPA 99 2012 11.3.2.3)

The Facility Maintenance Director witnessed this evidence by observation and interview.

Based on observation and inspection the facility failed to maintain hyperbaric facilities.

Findings include:

On 5-22-18 at approximately 6:09 am it was observed through observation and inspection that there is not appropriate required signage. ( NFPA 99 14.2.6.1)

The Facility Maintenance Director witnessed this evidence by observation and interview.