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Based on observation and interview the facility failed to ensure doors in a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress as required in accordance with NFPA 101, 2012 Edition, Chapter 19.2.2.2.6.

Findings:

On 07/17/17 at 10:34 am deadbolt locks were seen on the recovery room door and surgical area break room both located in the surgery area. The clean chemical storage room located on the dietary hall corridor had a swing-latch deadbolt installed on it. The safety nurse stated she would get maintenance to uninstall the deadbolts and swing-latch deadbolt.

Based on observation and interview the facility failed to ensure doors were equipped with self-closing hardware or by a release device complying with NFPA 101, 2012 Edition, Chapter 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: required manual fire alarm system; and local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and automatic sprinkler system, if installed and loss of power in accordance with NFPA 101, 2012 Edition, Chapter 19.2.2.2.7, and 19.2.2.2.8.

On 07/17/17 at 10:42 am a dirty utility closet located by the private rooms were and the housekeeping closet in the surgical area were observed to not have self-closing hardware installed on their doors.

On 07/17/17 at 10:51 am a clean chemical storage closet located on the dietary hall corridor was observed to have a latching padlock and roller latch hardware without self-closing hardware. The safety nurse stated they would correct the issues with the door.

Based on observation and interview the facility failed to ensure illumination of means of egress to include exit discharge is arranged in accordance with NFPA 101, 2012 Edition, Chapter 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention in accordance to NFPA 101, 2012 Edition Chapter 19.2.8.

Findings:

On 07/18/17 at 1:20 pm each of the designated exit discharges from the facility were observed to have lighting fixtures on normal power. The safety nurse was asked if the exit discharge lighting would always illuminate when the emergency generator came on and there was no normal electrical power. She stated she did not know and could not confirm which lights would illuminate under generator power. The maintenance staff person was asked and she stated she knew lights did come on when the generator came on but does not have any documentation indicating how many or which ones.

Based on observation and interview the facility failed to ensure their hazardous areas were protected as required in NFPA 101, 2012 Edition, Chapter 8.7.1 and Chapter 19.3.2.1.

Findings:

On 07/17/17 at 10:51 am a clean chemical storage closet located on the dietary hall corridor was observed to be without self-closing and positive latching hardware. The safety nurse stated they would correct the issues with the door.

Based on record review, observation and interview the facility failed to ensure ventilation within the surgical suite were in accordance with ASHRAE 170 as required.

Findings:

On 07/17/17 at 1:56 pm record review showed the facility test and balance report dated 07/07/17 was reviewed and did not include testing of the endoscopy procedure room located in the surgery area. The assistant surgical manager was asked if the endoscopy procedure room was included in the test/balance and she stated no. She stated they just called the vendor to come and complete the test and balance testing/inspection.

On 07/19/17 at 10:05 am the surveyor and safety nurse inspected the roof top HVAC unit that serves the surgical area. The HVAC unit was observed to have a manometer that was not working and the viewing line of the manometer indicating pressure level was not readable. The surveyor asked the safety nurse how the filters serving the surgery area were changed and she stated we would have to ask maintenance or surgical staff personnel. The surgical assistant manager was asked how they change their HVAC filters that serve the operating rooms and area. She said they would have to find out by talking to their maintenance staff. The maintenance person said the HVAC vendor changes the filters when they come to the facility to provide preventative maintenance. She was asked if they change the filters based on manometer reading per ASHRAE 170 and she said she did not believe so. The maintenance person was asked for the air quality/manometer reading documentation and she failed to provide it.

Based on observation and interview the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed over or within one inch of an ignition source as required.

Findings:

On 07/17/17 at 2:28 pm two ABHR's were observed to be installed over ignition sources. One ABHR was located in the recovery room and the other located in the clean processing room within the surgery area.

On 07/17/17 at 2:28 pm the safety nurse asked where the ABHR's should be installed. The surveyor stated not installed within 1 inch of an ignition source or over an ignition source.

Based on record review and interview the facility failed to ensure the automatic sprinkler metallic piping was internally inspected in accordance with NFPA 25, 2011 Edition, Chapter 14.2.1, 14.2.1.1, and 14.2.1.4.

Findings:

On 07/18/17 at 11:01 am record review showed the fire sprinkler system inspection did not include the five year internal inspection of metallic sprinkler piping and branch line conditions for the purpose of inspecting for the presence of foreign organic and inorganic material. The safety nurse stated they called their vendor to have it added to their inspection list.

Based on observation and interview the facility failed to ensure there were no penetrations to the smoke barrier walls and fire barrier walls as required.

Findings:

On 07/18/17 at 12:58 pm two penetrations were observed to be in the smoke barrier wall in the plenum space located above the emergency room receptionist's desk. The safety nurse stated they will get the holes fixed.

On 07/19/17 at 1:02 pm two penetrations were observed in the firewall barrier located above the entrance to the facility's laboratory. The safety nurse stated they will get the holes fixed.

Based on observation and interview the facility failed to ensure corridor doors were provided with a means of suitable for keeping the door closed and did not have roller latches installed as required.

Findings:

On 07/17/17 at 3:01 pm a row of three double doors with roller latches were observed to have no positive latching hardware installed.

On 07/17/17 at 3:01 pm the safety nurse stated the area is the dietary hallway clean linen storage.

On 07/17/17 at 3:05 pm a roller latch was observed to be installed on the recovery room door located near the surgery area entrance.

On 07/18/17 at 10:01 am a barrel latch was observed to be installed on the corridor doors leading into the surgical area semi-restricted area.

Based on observation and interview the facility failed to ensure electrical wiring and equipment complied with NFPA 70, National Electric Code as required.

Findings:

On 07/17/17 at 2:25 pm a multiplug was observed to be daisy chained into a power tap along with a microwave being plugged into a power tap located in the accounting office. The safety nurse stated it would be corrected.

On 07/17/17 at 3:09 pm a microwave was observed to be plugged into a power tap in the surgical area breakroom. The safety nurse stated it would be corrected.

Based on record review and interview the facility failed to ensure fire drills conducted included the transmission of a fire alarm signal as required in NFPA 101, 2012 Edition, Chapter 19.7.1.4 through 19.7.1.7.

Findings:

On 07/17/17 at 10:25 am the facility's fire drill documentation was reviewed and each fire drill did not include there was a transmission of a fire alarm signal. The maintenance person was asked how they conduct their fire drills. She stated the process and it did not include transmission of a fire alarm signal.

Based on observation and interview the facility failed to ensure space heaters used in nonsleeping staff areas had heating elements which did not exceed 212 degrees Fahrenheit as required in NFPA 101, 2012 Edition, Chapter 19.7.8.

Findings:

On 07/17/17 at 3:09 pm a space heater was observed in the accounting office and laboratory manager's office. The safety nurse was asked for the manufacturer's documentation which indicates the heating elements do not exceed 212 degrees Fahrenheit and failed to provide the documentation.

Based on record review and interview the facility failed to ensure completion of their building systems medical gas system risk assessment as required.

Findings:

On 07/17/17 at 10:20 am during record review the safety nurse was asked for the building systems medical gas systems risk assessment documentation and the nurse failed to provide the documentation.

Based on observation and interview the facility failed to ensure wet procedure locations were protected by either isolated power or ground-fault circuit interrupters (GFCI) and to maintain written records of inspection, performance, exercising period, and repairs in accordance with NFPA 99, 2012 Edition, Chapters 6.3.2.2.8.4, 6.3.2.2.8.7, and 6.4.4.2.

Findings:

On 07/18/17 at 10:31 am the electrical receptacles in the operating room and endoscopy procedure room were observed to not be GFCI. The maintenance person stated that she believed the plugs were potentially GFCI but was but provided no documentation to verify they were GFCI receptacles. The maintenance person was asked for documentation of the testing and maintenance of the GFCI. The maintenance person stated she would have to contact their electrical vendor to ascertain if they have those documents. The maintenance person failed to provide the documentation.

Based on record review and interview the facility failed to ensure their building system risk assessment for their essential electrical systems was completed as required.

Findings:

On 07/17/17 at 10:20 am during record review the safety nurse was asked for the building systems essential electric system risk assessment documentation and the safety nurse failed to provide the documentation.