HospitalInspections.org

Based on observation, the facility failed to maintain fire resistive rated corridor walls in the following locations throughout the facility. This facility has a capacity of 278 patients and a census of 75.

Findings include:

1. Observations on 11/30/10, revealed that in the smoke doors outside of the "Old Purchasing Office" in the Sublevel above the lay-in ceiling tile there was a bundle of communication wires penetrating the wall leaving a 1 inch to 2 inch gap around the wires.
2. Observations on 11/30/10, revealed that above the ceiling at the Credit Union Door (1 hour rated wall) there was a 2 inch to 3 inch insulated waterline penetrating the wall. This left a 1 inch to 1 1/2 inch gap around the water line.
3. Observations on 11/30/10, revealed that above the ceiling at the fire doors across from Central Service Receiving there were the following penetrations:
a. 6 - 1/2 inch to 1 inch electrical conduits with 1/4 inch to 1/2 inch gaps
b. a gap of 1/2 inch to 1 inch in size along the top of the wall at the roof deck
c. 1/2 inch round hole in the wall under a sprinkler line in the center of the wall
4. Observations on 11/30/10, revealed two slots cut into the corridor wall of the Mailroom on the Sublevel used for mail drop-off.
5. Observations on 11/30/10, revealed a hole (approximately 5 inches by 5 inches in size) in the corridor wall of the Hot Water Tank Room on the Ground Floor.

Maintenance Staff verified these observations.

Based on surveyor observation, the facility is not ensuring that doors to patients rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames and resist the passage of smoke. This facility has a capacity of 278 patients and a census of 75.

Findings include:

1. Observation on 11/30/10, revealed that the resident room door of Room #338 contained a ? inch gap at the top of the door on the handle side.
2. Observation on 11/30/10 , revealed that the resident room door of Room #328 contained a one inch gap at the top of the door on the handle side.
3. Observations on 11/30/10, revealed numerous gaps around wires and pipes in the ceiling tiles located in the First Floor Electrical Closet next to MRI 1210.
4. Observations on 11/30/10, revealed a misplaced ceiling tile in the wheelchair storage area by the decon room located in ER.
5. Observations on 11/30/10, revealed a penetration near the ceiling on the north wall of Electrical Room #4107.
6. Observations on 11/30/10, revealed the corridor door to Room 219 would not close and latch properly when tested.
7. Observations on 11/30/10, revealed a penetration on the north wall above the door in T Closet-2nd Floor.

Maintenance Staff verified these observations.

Based on observation, the facility is not assuring that vertical openings between floors are enclosed with a fire resistance rating of at least two hour. This deficient practice affects all occupants that would use the East Stairwell of the building, including staff, visitors and residents, who may need to use this designated exit in the event of an emergency. This facility has a capacity of 278 with a census of 75 patients.

Findings include:

Observation on 11/30/10, the exit stairwell door by room #13 was placarded with a fire-rating label. The rating labels on the door and door frame were coated with paint. The rating of the door was not determined due to the label being unreadable.
Maintenance Staff confirmed this observation during the survey process.

Based on observations, the facility is not assuring that smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire into another smoke zone. This facility has a capacity of 278 and a census of 75 patients.

Findings include:

1. Observations on 11/30/10, revealed a duct penetration (approximately 1 inch by 2 inches in size) above the suspended ceiling tile above the Sublevel Fire Doors outside of the Quality Room.
2. Observations on 11/30/10, revealed a flexible conduit penetration (approximately 2 inches in size), a conduit penetration (approximately ? inch in size), a cable bundle penetration (approximately 4 inches in size), and a sprinkler pipe penetration (approximately 2 inches in size) located above the suspended ceiling in the Ground Level one-hour rated wall to the serving area above the southwest overhead door.
3. Observation on 11/30/10, revealed two cable bundle penetrations (approximately 1 inch in size each) and one cable bundle penetration (approximately 2 inches in size) located above the suspended ceiling above the Ground Level New Dock Doors.
4. Observation on 11/30/10, revealed two pipe penetrations (approximately 3 inches in size each) located above the suspended ceiling at the Emergency Room Barrier by exam room #13.
5. Observations on 11/30/10, revealed a conduit penetration (approximately 4 inches in size) located above the suspended ceiling at the Emergency Room Barrier by the ER Director's Office.

Maintenance Staff verified these observations.

Based on observation, the facility failed to maintain smoke doors to close and resist the passage of smoke. This facility has a capacity of 278 patients and a census of 75 at the time of the survey.

Findings include:

On 11/30/10, while testing the fire doors in the Adolescent Hallway on 1st Floor McDermott, it was observed that the doors did not latch closed. Maintenance Staff verified this observation.

Based on observations, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice was in numerous areas of the facility. The facility has a capacity of 278 and at the time of the survey the census was 75 patients.

Findings include:

1. Observations on 11/30/10, revealed the Craft Shop Storage room was not sealed from other compartments. There was a 3 inch waterline (copper) that went through the ceiling to the floor above. This had a 1/4 to 1/2 inch gap around the line.
2. Observations on 11/30/10, revealed the wall separating the Cafeteria (kitchen/serving) and Dining Area above the large rated roll-up door had the following penetrations:
a. a 1 inch sprinkler line with a 1/2 to 3/4 inch gap
b. numerous electrical conduits ranging in size from 1/2 to 1 inch with 1/4 to 1 inch gaps
c. communication wire bundles with 1/4 to 1/2 inch gaps
According to plans, this was a rated wall.
3. Observations on 11/30/10, revealed the Sublevel Oxygen Storage Room was not equipped with a self-closing device.
4. Observations on 11/30/10, revealed a gap (approximately 1 inch in size) around a cable bundle penetration in the corridor wall of the Ground Level IT Room by the elevator.
5. Observations on 11/30/10, revealed a conduit penetration (approximately 2 inches in size), a pipe penetration (approximately 3 inches in size), and 2 holes (approximately 1 inch in size each) with duct tape covering the sheet rock in the dirty side of the Ground Level Sterilization Room Hazardous Material.
6. Observations on 11/30/10, revealed the self-closing doors in the work areas in Same Day Surgery did not operate properly when tested.

Maintenance Staff verified these observations.

(A)
Based on observation and interview the facility is not providing an unobstructed corridor that provides a clear path of egress in the Emergency Room. This facility has a capacity of 278 with a census of 75.

Findings include:

Observations on 11/30/10, reveled the facility was not maintaining clear and unobstructed corridors in the Emergency Room Corridor. The Corridor form ER rooms 8-12 had hinged charting stations between Rooms #8-9 and #10-11. These devices did not retract when pressure was released to allow the gas struts to retract.
Maintenance Staff verified these findings.

(B)
Based on observations, the facility failed to maintain exits readily accessible at all times in accordance with 7.1. This deficient practice could affect staff utilizing the Administrator's Archives in the Sublevel.. This facility has a capacity of 278 residents and a census of 75.

Findings include:

Observations on 11/30/10, revealed a padlock on the door of the Administrator's Archives area. Exiting from inside this area could not be made without the use of a key for the padlock. Maintenance Staff verified this observation.

(C)
Based on observations, the facility failed to provide an approved exit discharge from one exit door by not having a paved path to a " Public Way " . This affects 1 of 4 smoke zones, affecting approximately 6 residents and 3 staff members.
Findings include:
Observations on 11-30-10 revealed the facility failed to provide a paved sidewalk that extends from the exit door located near Resident Room #8 to a " Public Way " at "PMIC" located on the Glenwood Resource Campus. This exit discharge simply terminates on a small concrete pad once outside the exit door. Facility Staff A confirmed this finding.

Based on observations, the facility failed to maintain one emergency light unit in proper working order. This affects one of one smoke zones, affecting approximately three patients and six staff members.

Findings include:

Observations on 11/30/10, revealed the emergency light unit located near the Receptionist Desk at the Mercy Hospital Clinic at 1203 Locust St., Glenwood, IA had on the two light bulbs burnt out. Medical Clinic Staff A confirmed this finding.

Based on observation, the facility is not providing the proper directional exit sign for means of egress in accordance with 7.10.1. This facility has a capacity of 278 patients and a census of 75.

Findings include:

Observations on 11/30/10, revealed Exam #1 Hallway by Exam #1 in the Ground Floor Heart and Vascular Area was not equipped with an exit sign to the corridor. Maintenance Staff verified this observation.

Based on observations, 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 failing to manually lock the electrical breaker that is dedicated to the buildings fire alarm system. This affects 4 of 4 smoke zones, affecting approximately 14 residents and 6 staff members.
Findings include:
Observations on 11/30/10, revealed the electrical breaker that is dedicated to the buildings fire alarm system at the "PMIC" located on the Glenwood Resource Campus failed to be mechanically locked in the " On " position. This lock is to prevent accidental or intentional disconnection of the fire alarm breaker. The Housekeeping Supervisor confirmed this finding.

Based on observation, this facility is not assuring that the fire alarm system is installed in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 278 and a census of 75 patients.

Findings include:

1. Observation on 11/30/10, revealed a smoke detector within 36 inches of an air diffuser in the corridor next to room #417.
2. Observation on 11/30/10, revealed a smoke detector within 36 inches of an air diffuser in the East End JRC room.
3. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 309.
4. Observation on 11/30/10, revealed a smoke detector within 36 inches of an air diffuser in the corridor next to room 252.
5. Observation on 11/30/10, revealed a smoke detector within 36 inches of an air diffuser in the Family Gathering Room #1522.
6. Observations on 11/30/10, revealed a smoke detector within 36 inches of an air vent in Room 305.
7. Observations on 11/30/10, revealed a smoke detector within 36 inches of an HVAC vent in Room 341.
8. Observations on 11/30/10, revealed a smoke detector within 36 inches of an HVAC vent in Room 339.
9. Observations on 11/30/10, revealed a smoke detector within 36 inches of an HVAC vent in Room 337.
10. Observations on 11/30/10, revealed a smoke detector within 36 inches of an HVAC vent in Room 333.
11. Observations on 11/30/10, revealed a smoke detector within 36 inches of an HVAC vent in Room 331.
12. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 314.
13. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 321.
14. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 330.
15. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 332.
16. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 340.

Maintenance Staff verified these observations.

(A)
Based on observation, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that sprinkler heads are free of corrosion, paint or other foreign material. This could affect the operation of the heads by obstructing the spray patterns and delaying the response time and causing the heads to be inoperable. This deficient practice was found in numerous areas of the facility and affects all occupants of the building. This facility has a census of 75 patients and a capacity of 278.

Findings include:

1. Observations on 11/30/10, revealed a sprinkler head in the Sublevel Men's Restroom was corroded.
2. Observations on 11/30/10, revealed that 2 of 6 heads in the Old Vacuum Pump Room were corroded.
3. Observations on 11/30/10, revealed that the sprinkler heads in the Central Supply Decon Room were covered with lint/dust.
4. Observations on 11/30/10, revealed that the sprinkler heads in Radiology Room #4 were covered with lint/dust.
5. Observation on 11/30/10, revealed that the 3 East Nurses Station sprinkler head was covered with dust.
6. Observation on 11/30/10, revealed that the 3rd floor Waiting Room sprinkler head next to the air diffuser was covered with dust.
7. Observation on 11/30/10, revealed that the 3rd floor Main Nurses Station sprinkler head located next to the air diffuser was covered with dust.
8. Observation on 11/30/10, revealed that the 2nd floor corridor next to room #224 sprinkler head was covered with dust.
9. Observation on 11/30/10, revealed that the 2nd floor Post Intensive Care 2 West 1 of 3 sprinkler heads was covered with dust.
10. Observation on 11/30/10, revealed that the 2nd floor Elevator Lobby sprinkler head was covered with dust.
11. Observation on 11/30/10, revealed that the 1st floor behind the copier in the Nurses Station the sprinkler head was covered with dust.
12. Observation on 11/30/10, revealed a corroded sprinkler head in the Sublevel Fire Exit Corridor behind the laundry room.
13. Observation on 11/30/10, revealed the sprinkler head in the laundry chute located in the Ground Floor Laundry Chute Room was obstructed with a torn laundry bag.
14. Observations on 11/30/10, revealed a missing escutcheon ring in the Quality Manager's Server Room next to the mailroom on the Sublevel.
15. Observations on 11/30/10, revealed a dust/lint covered sprinkler head by the fryer in the Kitchen.
16. Observations on 11/30/10, revealed a loose escutcheon ring in the Central Service Decon Area on the Ground Level.
17. Observations on 11/30/10, revealed a dust/lint covered sprinkler head in the ER Dr's Office.
18. Observations on 11/30/10, revealed a dust/lint covered sprinkler head in the EMS Office located in ER.
19. Observations on 11/30/10, revealed a foreign substance on the sprinkler head near the corridor door in Room 404.
20. Observations on 11/30/10, revealed dust/lint on the sprinkler head above patient bed in Room 303.
21. Observations on 11/30/10, revealed dust/lint on the sprinkler heads in Room 305.
22. Observations on 11/30/10, revealed dust/lint on the sprinkler heads in Room 307.
23. Observations on 11/30/10, revealed dust/lint on the sprinkler heads in Room 309.
24. Observations on 11/30/10, revealed dust/lint on the sprinkler heads in Room 311.
25. Observations on 11/30/10, revealed dust/lint on the sprinkler head above the patient bed in Room 313.
26. Observations on 11/30/10, revealed the escutcheon ring in Room 201 above the "Sharps container" was loose.

Maintenance Staff verified these observations.

(B)
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 not documenting quarterly sprinkler inspections. This affects 4 of 4 smoke zones, affecting all occupants throughout the facility.

Findings include:

Observations on 11-30-10 revealed the facility failed to properly document quarterly inspections of the facilities automatic sprinkler system. The facility is contracting semi-annual inspections of the sprinkler system and are conducting "In House" inspections 2 more times a year at "PMIC" located on the Glenwood Resource Campus . The only documentation that the facility provided was an inspection report from Ahern dated in July and September of 2010. Facility Staff A confirmed this finding.

Based on observation, the facility failed to maintain the fire extinguishers as required by National Fire Protection Association (NFPA) Standard 10. This facility has a capacity of 278 patients and at the time of the survey the census was 75.

Findings include:

1. Observations on 11/30/10, revealed laundry carts obstructing the fire extinguisher in the Sublevel Laundry Room by the alarmed exit.
2. Observations on 11/30/10, revealed the fire extinguisher located in the 1st Floor OR #2 was not properly mounted.
3. Observations on 11/30/10, revealed missing monthly inspections (April-July) on the fire extinguisher by the door leading to the Materials Management Office on the Sublevel.
4. Observations on 11/30/10, revealed a fire extinguisher in Mechanical Room G317 on Ground Level was last annually inspected by a certified technician in Sept. '09.
5. Observations on 11/30/10, revealed the fire extinguisher in Mechanical Room G317 on Ground Level was not properly mounted.

Maintenance Staff verified these observations.

Based on observation, record review and staff interview, the facility is not providing a range hood suppression system that is in compliance with National Fire Protection Association (NFPA) 96, 3-1 and 2-1.2 and with the standard UL 300. This deficient practice affects all occupants of the building. This facility has a census of 75 patients and a capacity of 278.

Findings include:

Observations, record review and interview on 11/30/10, revealed that the electrical appliances under the hood suppression system are not tied into the system and would not shut down should the system be activated. Maintenance Staff indicated that the facility is in the process of correcting this issue. This deficiency was noted on an inspection report by General Fire and Safety on 9/20/10.

Based on observation and interview, the facility failed to provide curtains that are flame resistant in accordance with provisions of National Fire Protection Association (NFPA) 101, 10.3. This facility has a capacity of 278 patients and a census of 75.

Findings include:

Observations on 11/30/10, revealed the curtains in the Materials Management Office were not tagged as being flame retardant. Maintenance Staff verified this observation.

(A)
Based on observation, the facility is not adequately securing carbon dioxide cylinders to prevent them from accidental damage or dislocation. This facility has a capacity of 278 patients and a census of 75.

Findings include:

Observations on 11/30/10, revealed two compressed carbon dioxide cylinders were not properly secured in the Sublevel Oxygen Storage Room. Maintenance Staff verified this observation.

(B)
Based on observations, the facility is not providing the proper signs to indicate where oxygen is being stored in accordance with National Fire Protection Association (NFPA) Standard 99.; This facility has a census of 75 and a capacity of 278 patients.

Findings include:
Observations on 11/30/10, revealed the absence of signs to indicated oxygen storage in Utility Room 1629.

(A)
Based on observation, the facility failed to test all fire hose located in hose cabinets throughout the building. This affects the entrie facility. This facility has a capacity of 278 patients and a census of 75.

Findingd include:

Observations on 11-30-10, revealed the hose in the hose cabinets had not been tested since 2006. Per National Fire Protection Association (NFPA) 1962 section 4.3.2, fire hose shall be tested 5 years after being put in service and every 3 years after that.

(B)
Based on observation, the facility failed to maintain elevator equipment in proper working order. This affects the entrie facility. This facility has a capacity of 278 patients and a census of 75.

Findingd include:

Observations on 11-30-10, revealed the hydrulic line for the elevator was pinched between the lid and the housing. It also had a rag wrapped around it for padding.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff, patients, and visitors of the facility at risk in the event of a fire. The facility had a capacity of 278 and a census of 75 at the time of the survey.

Findings Include:

1. Observations on 11/30/10, revealed the facility failed to maintain the electrical system in the Electrical Closet #1613. The following breakers in panel CLA-C were not properly labeled to indicate there designations: 14, 16 and 18.
2. Observations on 11/30/10, revealed the facility failed to maintain the electrical system in the Electrical Closet #1434. The Electrical Panel LT31-72 contained an open knock-out in breaker location #65.
3. Observations on 11/30/10, revealed the facility failed to maintain the electrical system in the 3rd floor Supply Room across from Patent Room #311. This room contained a sink on the east wall. The facility failed to provide a ground fault circuit interrupter electrical outlet next to the sink.
4. Observations on 11/30/10, revealed the facility failed to maintain the electrical system in the 3rd floor Elevator Lobby. The Lobby contained a water fountain and the facility failed to provide a ground fault circuit interrupter electrical outlet next to the water fountain.
5. Observations on 11/30/10, revealed the facility failed to maintain the electrical system on the 2nd floor connection with the Professional Center. Above the ceiling tiles over the fire doors there was Prox Reading wires penetrating the 2 hour fire wall. These wires are a new install and not encapsulated in electrical conduit.
6. Observations on 11/30/10, revealed the facility failed to maintain the electrical system on the 2nd floor corridor next to Patent Room #216 and #207. Above the ceiling tiles.
7. Observation on 11/30/10, revealed 8 of 8 florescent ceiling lights were not properly hardwired in the Sublevel Housekeeping Closet.
8. Observations on 11/30/10, revealed exposed electrical wiring in one of two ceiling lighting devices in the Ground Level Housekeeping Closet.
9. Observations on 11/30/10, revealed two missing junction box covers above the suspended ceiling at the Ground Level Serving Area Southwest Overhead.
10. Observations on 11/30/10, revealed Electrical Panel LB located in the Ground Level Heart and Vascular Area was not completely labeled. Breakers 4, 6, 8, 10, 12, 14, and 16 were not labeled.
11. Observations on 11/30/10, revealed Electrical Panel CL1 in the ER was not completely labeled. Breakers 26, 29, 31, 34, and 40 were not labeled.
12. Observations on 11/30/10, revealed an obstructed electrical panel ("Central Supply KP-B") in the Kitchen.
13. Observations on 11/30/10, revealed two separate temporary lighting devices that contained spliced wires, taped wires and bare wires located in the Main Mechanical Room in the Ground Level.
14. Observations on 11/30/10, revealed partially labeled electrical panels in the 1st Floor Diagnostics/MRI Hallway. These were panels: EL, HF, LG, and LG.

Maintenance Staff verified these observations.

Based on observation, record review and staff interview, the facility did not indicate the appropriate Authorities Having Jurisdiction (AHJ), nor the phone numbers of those agencies for the sprinkler system outage policy . This deficient practice affects all occupants of the building. This facility has a capacity of 278 and a census of 75 patients.

Findings include:

Observations, record review and staff interview on 11/30/10, revealed the facility failed to name the following as AHJ: State Fire Marshal's Office and the Department of Inspections and Appeals. The policy also failed to contain the phone numbers for these agencies. The Facility Maintenance Director indicated that he was not aware of this requirement.

Based on observation, record review and staff interview, the facility did not indicate the appropriate Authorities Having Jurisdiction (AHJ), nor the phone numbers of those agencies for the fire alarm system outage policy . This deficient practice affects all occupants of the building. This facility has a capacity of 278 and a census of 75 patients.

Findings include:

Observations, record review and staff interview on 11/30/10, revealed the facility failed to name the following as AHJ: State Fire Marshal's Office and the Department of Inspections and Appeals. The policy also failed to contain the phone numbers for these agencies. The Facility Maintenance Director indicated that he was not aware of this requirement.

Based on observations, the facility failed to have Alcohol Based Hand Rub dispensers properly located. This affects one of one smoke zones.

Findings include:

1. Observations on 11/30/10, revealed Alcohol Based Hand Rub dispensers located above an electrical source (electrical outlet) near Patient Room #4 in the main therapy room on the west wall in Physical Therapy at 1702 West Broadway. Therapy Staff A confirmed this observation.
2. Observations on 11/30/10, revealed Alcohol Based Hand Rub dispensers located above an electrical source (electrical outlet) in the following locations at Mercy Hospital Clinic at 1203 Locust St., Glenwood, IA: hallway near Exam Room #3,
Exam Room #2, Exam Room #4, and Exam Room #5. Medical clinic Staff A confirmed these findings.

Based on observation, the facility failed to maintain fire resistive rated corridor walls in the following locations throughout the facility. This facility has a capacity of 278 patients and a census of 75.

Findings include:

1. Observations on 11/30/10, revealed that in the smoke doors outside of the "Old Purchasing Office" in the Sublevel above the lay-in ceiling tile there was a bundle of communication wires penetrating the wall leaving a 1 inch to 2 inch gap around the wires.
2. Observations on 11/30/10, revealed that above the ceiling at the Credit Union Door (1 hour rated wall) there was a 2 inch to 3 inch insulated waterline penetrating the wall. This left a 1 inch to 1 1/2 inch gap around the water line.
3. Observations on 11/30/10, revealed that above the ceiling at the fire doors across from Central Service Receiving there were the following penetrations:
a. 6 - 1/2 inch to 1 inch electrical conduits with 1/4 inch to 1/2 inch gaps
b. a gap of 1/2 inch to 1 inch in size along the top of the wall at the roof deck
c. 1/2 inch round hole in the wall under a sprinkler line in the center of the wall
4. Observations on 11/30/10, revealed two slots cut into the corridor wall of the Mailroom on the Sublevel used for mail drop-off.
5. Observations on 11/30/10, revealed a hole (approximately 5 inches by 5 inches in size) in the corridor wall of the Hot Water Tank Room on the Ground Floor.

Maintenance Staff verified these observations.

Based on surveyor observation, the facility is not ensuring that doors to patients rooms, offices and other ancillary areas are free of impediments that would prevent the doors from being closed or that the doors are provided with suitable hardware that keep the doors shut tightly into their frames and resist the passage of smoke. This facility has a capacity of 278 patients and a census of 75.

Findings include:

1. Observation on 11/30/10, revealed that the resident room door of Room #338 contained a ? inch gap at the top of the door on the handle side.
2. Observation on 11/30/10 , revealed that the resident room door of Room #328 contained a one inch gap at the top of the door on the handle side.
3. Observations on 11/30/10, revealed numerous gaps around wires and pipes in the ceiling tiles located in the First Floor Electrical Closet next to MRI 1210.
4. Observations on 11/30/10, revealed a misplaced ceiling tile in the wheelchair storage area by the decon room located in ER.
5. Observations on 11/30/10, revealed a penetration near the ceiling on the north wall of Electrical Room #4107.
6. Observations on 11/30/10, revealed the corridor door to Room 219 would not close and latch properly when tested.
7. Observations on 11/30/10, revealed a penetration on the north wall above the door in T Closet-2nd Floor.

Maintenance Staff verified these observations.

Based on observation, the facility is not assuring that vertical openings between floors are enclosed with a fire resistance rating of at least two hour. This deficient practice affects all occupants that would use the East Stairwell of the building, including staff, visitors and residents, who may need to use this designated exit in the event of an emergency. This facility has a capacity of 278 with a census of 75 patients.

Findings include:

Observation on 11/30/10, the exit stairwell door by room #13 was placarded with a fire-rating label. The rating labels on the door and door frame were coated with paint. The rating of the door was not determined due to the label being unreadable.
Maintenance Staff confirmed this observation during the survey process.

Based on observations, the facility is not assuring that smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire into another smoke zone. This facility has a capacity of 278 and a census of 75 patients.

Findings include:

1. Observations on 11/30/10, revealed a duct penetration (approximately 1 inch by 2 inches in size) above the suspended ceiling tile above the Sublevel Fire Doors outside of the Quality Room.
2. Observations on 11/30/10, revealed a flexible conduit penetration (approximately 2 inches in size), a conduit penetration (approximately ? inch in size), a cable bundle penetration (approximately 4 inches in size), and a sprinkler pipe penetration (approximately 2 inches in size) located above the suspended ceiling in the Ground Level one-hour rated wall to the serving area above the southwest overhead door.
3. Observation on 11/30/10, revealed two cable bundle penetrations (approximately 1 inch in size each) and one cable bundle penetration (approximately 2 inches in size) located above the suspended ceiling above the Ground Level New Dock Doors.
4. Observation on 11/30/10, revealed two pipe penetrations (approximately 3 inches in size each) located above the suspended ceiling at the Emergency Room Barrier by exam room #13.
5. Observations on 11/30/10, revealed a conduit penetration (approximately 4 inches in size) located above the suspended ceiling at the Emergency Room Barrier by the ER Director's Office.

Maintenance Staff verified these observations.

Based on observation, the facility failed to maintain smoke doors to close and resist the passage of smoke. This facility has a capacity of 278 patients and a census of 75 at the time of the survey.

Findings include:

On 11/30/10, while testing the fire doors in the Adolescent Hallway on 1st Floor McDermott, it was observed that the doors did not latch closed. Maintenance Staff verified this observation.

Based on observations, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice was in numerous areas of the facility. The facility has a capacity of 278 and at the time of the survey the census was 75 patients.

Findings include:

1. Observations on 11/30/10, revealed the Craft Shop Storage room was not sealed from other compartments. There was a 3 inch waterline (copper) that went through the ceiling to the floor above. This had a 1/4 to 1/2 inch gap around the line.
2. Observations on 11/30/10, revealed the wall separating the Cafeteria (kitchen/serving) and Dining Area above the large rated roll-up door had the following penetrations:
a. a 1 inch sprinkler line with a 1/2 to 3/4 inch gap
b. numerous electrical conduits ranging in size from 1/2 to 1 inch with 1/4 to 1 inch gaps
c. communication wire bundles with 1/4 to 1/2 inch gaps
According to plans, this was a rated wall.
3. Observations on 11/30/10, revealed the Sublevel Oxygen Storage Room was not equipped with a self-closing device.
4. Observations on 11/30/10, revealed a gap (approximately 1 inch in size) around a cable bundle penetration in the corridor wall of the Ground Level IT Room by the elevator.
5. Observations on 11/30/10, revealed a conduit penetration (approximately 2 inches in size), a pipe penetration (approximately 3 inches in size), and 2 holes (approximately 1 inch in size each) with duct tape covering the sheet rock in the dirty side of the Ground Level Sterilization Room Hazardous Material.
6. Observations on 11/30/10, revealed the self-closing doors in the work areas in Same Day Surgery did not operate properly when tested.

Maintenance Staff verified these observations.

(A)
Based on observation and interview the facility is not providing an unobstructed corridor that provides a clear path of egress in the Emergency Room. This facility has a capacity of 278 with a census of 75.

Findings include:

Observations on 11/30/10, reveled the facility was not maintaining clear and unobstructed corridors in the Emergency Room Corridor. The Corridor form ER rooms 8-12 had hinged charting stations between Rooms #8-9 and #10-11. These devices did not retract when pressure was released to allow the gas struts to retract.
Maintenance Staff verified these findings.

(B)
Based on observations, the facility failed to maintain exits readily accessible at all times in accordance with 7.1. This deficient practice could affect staff utilizing the Administrator's Archives in the Sublevel.. This facility has a capacity of 278 residents and a census of 75.

Findings include:

Observations on 11/30/10, revealed a padlock on the door of the Administrator's Archives area. Exiting from inside this area could not be made without the use of a key for the padlock. Maintenance Staff verified this observation.

(C)
Based on observations, the facility failed to provide an approved exit discharge from one exit door by not having a paved path to a " Public Way " . This affects 1 of 4 smoke zones, affecting approximately 6 residents and 3 staff members.
Findings include:
Observations on 11-30-10 revealed the facility failed to provide a paved sidewalk that extends from the exit door located near Resident Room #8 to a " Public Way " at "PMIC" located on the Glenwood Resource Campus. This exit discharge simply terminates on a small concrete pad once outside the exit door. Facility Staff A confirmed this finding.

Based on observations, the facility failed to maintain one emergency light unit in proper working order. This affects one of one smoke zones, affecting approximately three patients and six staff members.

Findings include:

Observations on 11/30/10, revealed the emergency light unit located near the Receptionist Desk at the Mercy Hospital Clinic at 1203 Locust St., Glenwood, IA had on the two light bulbs burnt out. Medical Clinic Staff A confirmed this finding.

Based on observation, the facility is not providing the proper directional exit sign for means of egress in accordance with 7.10.1. This facility has a capacity of 278 patients and a census of 75.

Findings include:

Observations on 11/30/10, revealed Exam #1 Hallway by Exam #1 in the Ground Floor Heart and Vascular Area was not equipped with an exit sign to the corridor. Maintenance Staff verified this observation.

Based on observations, 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 failing to manually lock the electrical breaker that is dedicated to the buildings fire alarm system. This affects 4 of 4 smoke zones, affecting approximately 14 residents and 6 staff members.
Findings include:
Observations on 11/30/10, revealed the electrical breaker that is dedicated to the buildings fire alarm system at the "PMIC" located on the Glenwood Resource Campus failed to be mechanically locked in the " On " position. This lock is to prevent accidental or intentional disconnection of the fire alarm breaker. The Housekeeping Supervisor confirmed this finding.

Based on observation, this facility is not assuring that the fire alarm system is installed in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer that three feet to air supply or air return. Installation of a smoke detector close to a ceiling fan or air diffusers can impede the operation of the smoke detector and can affect all occupants of the building. This facility has a capacity of 278 and a census of 75 patients.

Findings include:

1. Observation on 11/30/10, revealed a smoke detector within 36 inches of an air diffuser in the corridor next to room #417.
2. Observation on 11/30/10, revealed a smoke detector within 36 inches of an air diffuser in the East End JRC room.
3. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 309.
4. Observation on 11/30/10, revealed a smoke detector within 36 inches of an air diffuser in the corridor next to room 252.
5. Observation on 11/30/10, revealed a smoke detector within 36 inches of an air diffuser in the Family Gathering Room #1522.
6. Observations on 11/30/10, revealed a smoke detector within 36 inches of an air vent in Room 305.
7. Observations on 11/30/10, revealed a smoke detector within 36 inches of an HVAC vent in Room 341.
8. Observations on 11/30/10, revealed a smoke detector within 36 inches of an HVAC vent in Room 339.
9. Observations on 11/30/10, revealed a smoke detector within 36 inches of an HVAC vent in Room 337.
10. Observations on 11/30/10, revealed a smoke detector within 36 inches of an HVAC vent in Room 333.
11. Observations on 11/30/10, revealed a smoke detector within 36 inches of an HVAC vent in Room 331.
12. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 314.
13. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 321.
14. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 330.
15. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 332.
16. Observation on 11/30/10, revealed smoke detectors within 36 inches of an air diffuser in Room 340.

Maintenance Staff verified these observations.

(A)
Based on observation, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that sprinkler heads are free of corrosion, paint or other foreign material. This could affect the operation of the heads by obstructing the spray patterns and delaying the response time and causing the heads to be inoperable. This deficient practice was found in numerous areas of the facility and affects all occupants of the building. This facility has a census of 75 patients and a capacity of 278.

Findings include:

1. Observations on 11/30/10, revealed a sprinkler head in the Sublevel Men's Restroom was corroded.
2. Observations on 11/30/10, revealed that 2 of 6 heads in the Old Vacuum Pump Room were corroded.
3. Observations on 11/30/10, revealed that the sprinkler heads in the Central Supply Decon Room were covered with lint/dust.
4. Observations on 11/30/10, revealed that the sprinkler heads in Radiology Room #4 were covered with lint/dust.
5. Observation on 11/30/10, revealed that the 3 East Nurses Station sprinkler head was covered with dust.
6. Observation on 11/30/10, revealed that the 3rd floor Waiting Room sprinkler head next to the air diffuser was covered with dust.
7. Observation on 11/30/10, revealed that the 3rd floor Main Nurses Station sprinkler head located next to the air diffuser was covered with dust.
8. Observation on 11/30/10, revealed that the 2nd floor corridor next to room #224 sprinkler head was covered with dust.
9. Observation on 11/30/10, revealed that the 2nd floor Post Intensive Care 2 West 1 of 3 sprinkler heads was covered with dust.
10. Observation on 11/30/10, revealed that the 2nd floor Elevator Lobby sprinkler head was covered with dust.
11. Observation on 11/30/10, revealed that the 1st floor behind the copier in the Nurses Station the sprinkler head was covered with dust.
12. Observation on 11/30/10, revealed a corroded sprinkler head in the Sublevel Fire Exit Corridor behind the laundry room.
13. Observation on 11/30/10, revealed the sprinkler head in the laundry chute located in the Ground Floor Laundry Chute Room was obstructed with a torn laundry bag.
14. Observations on 11/30/10, revealed a missing escutcheon ring in the Quality Manager's Server Room next to the mailroom on the Sublevel.
15. Observations on 11/30/10, revealed a dust/lint covered sprinkler head by the fryer in the Kitchen.
16. Observations on 11/30/10, revealed a loose escutcheon ring in the Central Service Decon Area on the Ground Level.
17. Observations on 11/30/10, revealed a dust/lint covered sprinkler head in the ER Dr's Office.
18. Observations on 11/30/10, revealed a dust/lint covered sprinkler head in the EMS Office located in ER.
19. Observations on 11/30/10, revealed a foreign substance on the sprinkler head near the corridor door in Room 404.
20. Observations on 11/30/10, revealed dust/lint on the sprinkler head above patient bed in Room 303.
21. Observations on 11/30/10, revealed dust/lint on the sprinkler heads in Room 305.
22. Observations on 11/30/10, revealed dust/lint on the sprinkler heads in Room 307.
23. Observations on 11/30/10, revealed dust/lint on the sprinkler heads in Room 309.
24. Observations on 11/30/10, revealed dust/lint on the sprinkler heads in Room 311.
25. Observations on 11/30/10, revealed dust/lint on the sprinkler head above the patient bed in Room 313.
26. Observations on 11/30/10, revealed the escutcheon ring in Room 201 above the "Sharps container" was loose.

Maintenance Staff verified these observations.

(B)
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 not documenting quarterly sprinkler inspections. This affects 4 of 4 smoke zones, affecting all occupants throughout the facility.

Findings include:

Observations on 11-30-10 revealed the facility failed to properly document quarterly inspections of the facilities automatic sprinkler system. The facility is contracting semi-annual inspections of the sprinkler system and are conducting "In House" inspections 2 more times a year at "PMIC" located on the Glenwood Resource Campus . The only documentation that the facility provided was an inspection report from Ahern dated in July and September of 2010. Facility Staff A confirmed this finding.

Based on observation, the facility failed to maintain the fire extinguishers as required by National Fire Protection Association (NFPA) Standard 10. This facility has a capacity of 278 patients and at the time of the survey the census was 75.

Findings include:

1. Observations on 11/30/10, revealed laundry carts obstructing the fire extinguisher in the Sublevel Laundry Room by the alarmed exit.
2. Observations on 11/30/10, revealed the fire extinguisher located in the 1st Floor OR #2 was not properly mounted.
3. Observations on 11/30/10, revealed missing monthly inspections (April-July) on the fire extinguisher by the door leading to the Materials Management Office on the Sublevel.
4. Observations on 11/30/10, revealed a fire extinguisher in Mechanical Room G317 on Ground Level was last annually inspected by a certified technician in Sept. '09.
5. Observations on 11/30/10, revealed the fire extinguisher in Mechanical Room G317 on Ground Level was not properly mounted.

Maintenance Staff verified these observations.

Based on observation, record review and staff interview, the facility is not providing a range hood suppression system that is in compliance with National Fire Protection Association (NFPA) 96, 3-1 and 2-1.2 and with the standard UL 300. This deficient practice affects all occupants of the building. This facility has a census of 75 patients and a capacity of 278.

Findings include:

Observations, record review and interview on 11/30/10, revealed that the electrical appliances under the hood suppression system are not tied into the system and would not shut down should the system be activated. Maintenance Staff indicated that the facility is in the process of correcting this issue. This deficiency was noted on an inspection report by General Fire and Safety on 9/20/10.

Based on observation and interview, the facility failed to provide curtains that are flame resistant in accordance with provisions of National Fire Protection Association (NFPA) 101, 10.3. This facility has a capacity of 278 patients and a census of 75.

Findings include:

Observations on 11/30/10, revealed the curtains in the Materials Management Office were not tagged as being flame retardant. Maintenance Staff verified this observation.

(A)
Based on observation, the facility is not adequately securing carbon dioxide cylinders to prevent them from accidental damage or dislocation. This facility has a capacity of 278 patients and a census of 75.

Findings include:

Observations on 11/30/10, revealed two compressed carbon dioxide cylinders were not properly secured in the Sublevel Oxygen Storage Room. Maintenance Staff verified this observation.

(B)
Based on observations, the facility is not providing the proper signs to indicate where oxygen is being stored in accordance with National Fire Protection Association (NFPA) Standard 99.; This facility has a census of 75 and a capacity of 278 patients.

Findings include:
Observations on 11/30/10, revealed the absence of signs to indicated oxygen storage in Utility Room 1629.

(A)
Based on observation, the facility failed to test all fire hose located in hose cabinets throughout the building. This affects the entrie facility. This facility has a capacity of 278 patients and a census of 75.

Findingd include:

Observations on 11-30-10, revealed the hose in the hose cabinets had not been tested since 2006. Per National Fire Protection Association (NFPA) 1962 section 4.3.2, fire hose shall be tested 5 years after being put in service and every 3 years after that.

(B)
Based on observation, the facility failed to maintain elevator equipment in proper working order. This affects the entrie facility. This facility has a capacity of 278 patients and a census of 75.

Findingd include:

Observations on 11-30-10, revealed the hydrulic line for the elevator was pinched between the lid and the housing. It also had a rag wrapped around it for padding.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff, patients, and visitors of the facility at risk in the event of a fire. The facility had a capacity of 278 and a census of 75 at the time of the survey.

Findings Include:

1. Observations on 11/30/10, revealed the facility failed to maintain the electrical system in the Electrical Closet #1613. The following breakers in panel CLA-C were not properly labeled to indicate there designations: 14, 16 and 18.
2. Observations on 11/30/10, revealed the facility failed to maintain the electrical system in the Electrical Closet #1434. The Electrical Panel LT31-72 contained an open knock-out in breaker location #65.
3. Observations on 11/30/10, revealed the facility failed to maintain the electrical system in the 3rd floor Supply Room across from Patent Room #311. This room contained a sink on the east wall. The facility failed to provide a ground fault circuit interrupter electrical outlet next to the sink.
4. Observations on 11/30/10, revealed the facility failed to maintain the electrical system in the 3rd floor Elevator Lobby. The Lobby contained a water fountain and the facility failed to provide a ground fault circuit interrupter electrical outlet next to the water fountain.
5. Observations on 11/30/10, revealed the facility failed to maintain the electrical system on the 2nd floor connection with the Professional Center. Above the ceiling tiles over the fire doors there was Prox Reading wires penetrating the 2 hour fire wall. These wires are a new install and not encapsulated in electrical conduit.
6. Observations on 11/30/10, revealed the facility failed to maintain the electrical system on the 2nd floor corridor next to Patent Room #216 and #207. Above the ceiling tiles.
7. Observation on 11/30/10, revealed 8 of 8 florescent ceiling lights were not properly hardwired in the Sublevel Housekeeping Closet.
8. Observations on 11/30/10, revealed exposed electrical wiring in one of two ceiling lighting devices in the Ground Level Housekeeping Closet.
9. Observations on 11/30/10, revealed two missing junction box covers above the suspended ceiling at the Ground Level Serving Area Southwest Overhead.
10. Observations on 11/30/10, revealed Electrical Panel LB located in the Ground Level Heart and Vascular Area was not completely labeled. Breakers 4, 6, 8, 10, 12, 14, and 16 were not labeled.
11. Observations on 11/30/10, revealed Electrical Panel CL1 in the ER was not completely labeled. Breakers 26, 29, 31, 34, and 40 were not labeled.
12. Observations on 11/30/10, revealed an obstructed electrical panel ("Central Supply KP-B") in the Kitchen.
13. Observations on 11/30/10, revealed two separate temporary lighting devices that contained spliced wires, taped wires and bare wires located in the Main Mechanical Room in the Ground Level.
14. Observations on 11/30/10, revealed partially labeled electrical panels in the 1st Floor Diagnostics/MRI Hallway. These were panels: EL, HF, LG, and LG.

Maintenance Staff verified these observations.

Based on observation, record review and staff interview, the facility did not indicate the appropriate Authorities Having Jurisdiction (AHJ), nor the phone numbers of those agencies for the sprinkler system outage policy . This deficient practice affects all occupants of the building. This facility has a capacity of 278 and a census of 75 patients.

Findings include:

Observations, record review and staff interview on 11/30/10, revealed the facility failed to name the following as AHJ: State Fire Marshal's Office and the Department of Inspections and Appeals. The policy also failed to contain the phone numbers for these agencies. The Facility Maintenance Director indicated that he was not aware of this requirement.

Based on observation, record review and staff interview, the facility did not indicate the appropriate Authorities Having Jurisdiction (AHJ), nor the phone numbers of those agencies for the fire alarm system outage policy . This deficient practice affects all occupants of the building. This facility has a capacity of 278 and a census of 75 patients.

Findings include:

Observations, record review and staff interview on 11/30/10, revealed the facility failed to name the following as AHJ: State Fire Marshal's Office and the Department of Inspections and Appeals. The policy also failed to contain the phone numbers for these agencies. The Facility Maintenance Director indicated that he was not aware of this requirement.