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Tag No.: E0007
Based on document review and interview, it was determined the facility failed to ensure policies and procedures were in place addressing patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans, affecting the entire facility.
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the Facility's Emergency Preparedness Plan did not include the following policies and procedures:
a. Persons at-risk;
b. Delegation of authority and succession plans.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the documentation was not available.
Tag No.: E0023
Based on document review and interview, it was determined the facility failed to develop
Emergency Plan (EP) policies and procedures including a system of medical documentation preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of records, affecting the entire facility.
Findings Include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the Emergency Preparedness plan did not include maintaining medical documentation preserving patient information and securing availability of records to support continuity of care during an emergency.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the EP plan did not include a policy for maintaining and securing resident records.
Tag No.: E0026
Based on document review and interview, it was determined the facility failed to provide policy and procedure documentation concerning the role of the Hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials, affecting the entire facility.
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the facility could not provide Emergency Preparedness plan policy and procedure documentation concerning the Roles under a Waiver Declared by the Secretary.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing documentation.
Tag No.: E0031
Based on document review and interview, it was determined the facility failed to ensure the Emergency Preparedness Plan included all Emergency Officials Contact information, including Federal, State, tribal, regional, and local emergency preparedness staff affecting the entire component.
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the Facility's Emergency Preparedness plan did not include federal and state contact information in the Emergency Officials Contact Information.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing documentation.
Tag No.: E0036
Based on document review and interview, it was determined the facility failed to develop
an Emergency Preparedness training program based on the facility's Emergency Preparedness plan, affecting the entire facility.
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the facility failed to develop an Emergency Preparedness training program.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing documentation.
Tag No.: E0037
Based on document review and interview, it was determined the facility failed to maintain a training program based on the facility's Emergency Preparedness plan, affecting the entire facility.
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the facility failed to perform training to the Emergency Preparedness plan including the following:
a. Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role;
b. Provide emergency preparedness training at least every two (2) years;
c. Maintain documentation of the training;
d. Demonstrate staff knowledge of emergency procedures.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on February 28, 2021, at 2:10 p.m., confirmed the missing documentation.
Tag No.: K0100
Based on observation, interview and document review, it was determined the facility failed to provide portable, accurate life safety floor plans as required, affecting the entire component (Building 10).
Findings include:
1. Observation, interview and document review on April, 27, 2021, between 8:00 a.m. and 3:00 p.m., revealed the facility failed to provide a set of accurate portable life safety floor plans. The Division of Safety Inspection requires all facilities under our jurisdiction have a portable, accurate life safety floor plan on site to be used during the course of the Life Safety Code Survey.
The Life Safety Code Floor Plans shall include the following:
a. Smoke Barrier Walls;
b. Fire Barrier Walls;
c. Horizontal Exits;
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted;
f. Shafts Walls.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed portable, accurate life safety floor plans were not available.
Tag No.: K0100
Based on observation, interview and document review, it was determined the facility failed to provide portable, accurate life safety floor plans, affecting the entire facility (Building 1).
Findings include:
1. Observation, interview and document review on April, 27, 2021, between 8:00 a.m. and 3:00 p.m., revealed the facility failed to provide a set of accurate portable life safety floor plans. The Division of Safety Inspection requires all facilities under our jurisdiction have a portable, accurate life safety floor plan on site to be used during the course of the Life Safety Code Survey.
The Life Safety Code Floor Plans shall include the following:
a. Smoke Barrier Walls;
b. Fire Barrier Walls;
c. Horizontal Exits;
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted;
f. Shafts Walls.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed portable, accurate life safety floor plans were not available.
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Tag No.: K0100
Based on observation, interview and document review, it was determined the facility failed to provide portable, accurate life safety floor plans, affecting the entire facility (Building 51).
Findings include:
1. Observation, interview and document review on April, 27, 2021, between 8:00 a.m. and 3:00 p.m., revealed the facility failed to provide a set of accurate portable life safety floor plans. The Division of Safety Inspection requires all facilities under our jurisdiction have a portable, accurate life safety floor plan on site to be used during the course of the Life Safety Code Survey.
The Life Safety Code Floor Plans shall include the following:
a. Smoke Barrier Walls;
b. Fire Barrier Walls;
c. Horizontal Exits;
d. Rated Rooms (Storage Rooms, Soiled Utility Rooms, designated Medical Gas Rooms) will be clearly designated. It is the facility's responsibility to have all Rated Rooms indicated on their Life Safety Code Floor Plan;
e. Required Exits should be clearly noted;
f. Shafts Walls.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed portable, accurate life safety floor plans were not available.
Tag No.: K0132
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating between non-health care buildings, affecting one of four levels within the facility.
Findings Include:
1. Observation on April 27, 2021, at 3:54 p.m., revealed the inactive leaf of Tunnel door 013, had a manual flush bolt installed in lieu of positive self-latching hardware, Ground Floor (Bldg 1).
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the appropriate fire door hardware was not installed.
Tag No.: K0132
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating between non-health care buildings, in two instances, affecting one of four levels within Building 51.
Findings Include:
1. Observation on April 28, 2021, at 10:14 a.m., revealed the following deficiencies of the Tunnel fire separation, Ground Floor, A Wing:
a. one leaf of the doors separating the tunnel was rusted shut and would not open;
b. the operable leaf of the tunnel doors lacked markings verifying the door and hardware ratings.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the fire separation was incomplete.
Tag No.: K0161
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of building components, in three instances, affecting two of four levels within Building 1.
Findings include:
1. Observation on April 27, 2021, at 1:22 p.m., revealed there was a white, cotton-like material laying on the acoustic pan ceiling, inside Bedroom 2099. It could not be determined if the material maintained fire resistance rated properties, Second Floor, E Wing, short dorm.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed there was an unknown material on the ceiling assembly.
2. Observation on April 27, 2021, at 2:11 p.m., revealed suspended ceiling tiles were bulging, within the assembly, at the end of the corridor, Second Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the ceiling integrity was compromised.
3. Observation on April 27, 2021, at 3:47 p.m., revealed, in the corridor, outside Little Theater 0116, there was blue rigid foam insulation secured to the deck, above the ceiling. It could not be determined if the material maintained fire resistance rated properties, Ground Floor.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed installation of an unknown material.
Tag No.: K0161
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of the building construction, in two instances, affecting two of four levels within Building 51.
Findings Include:
1. Observation on April 28, 2021, at 10:28 a.m., revealed there was exposed fiberglass insulation secured to the ceiling deck, inside the Gym Weight Room. It could not be determined if the material maintained fire resistive rated properties, Ground Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the unknown material secured to the ceiling.
2. Observation on April 28, 2021, at 11:00 a.m., revealed there was an unprotected steel beam, seen from the access panel, inside the Linen Chute Enclosure, Second Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the unprotected structural beam.
Tag No.: K0161
Based on observation and interview, it was determined the facility failed to maintain the fire resistive integrity of the building construction, in one instance, affecting one of four levels within Building 10.
Findings include:
1. Observation on April 27, 2021, at 9:47 a.m., revealed there was a block of CMU, at the exterior wall, which had been cut and was loose, above the ceiling, inside Linen Room 2104, Second Floor, E Wing, short dorm.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the unsecured portion of blocking.
Tag No.: K0225
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of stair enclosures, in three instances, affecting three of four levels, within Building 10.
Findings include:
1. Observation on April 27, 2021, at 9:40 a.m., revealed, on the Second Floor, Rated Door 2077 to the stairs accessing the Mechanical Penthouse, lacked fire rated door hardware.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the door lacked fire rated hardware.
2. Observation on April 27, 2021, at 10:56 a.m., revealed, on the First Floor, in the lobby area, above Stair Tower Door 1002, there was an unsealed opening of a conduit penetrating the rated stair tower wall.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the unsealed penetration.
3. Observation on April 28, 2021, at 11:55 a.m., revealed there were holes, in the stair wall, above the ceiling access panel, near the Sally Port, First Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed there were openings in the stair wall.
4. Observation on April 28, 2021, at 12:08 p.m., revealed exit discharge stair door 1031 was difficult to open, First Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the door required adjustment to open freely.
Tag No.: K0225
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of stair enclosures, in three instances, affecting two of four levels within Building 1.
Findings include:
1. Observation on April 27, 2021, between 2:56 p.m. and 3:00 p.m., revealed unsealed penetrations, above the ceiling, in rated stair enclosure walls, in the following locations:
a. 2:56 p.m., First Floor, A wing, short hall, above the stair enclosure door, there was a gap where the rated stair enclosure wall meets the deck slab;
b. 3:00 p.m., First Floor, A wing, above Stair Enclosure Door# 1044, there was an unsealed penetration around a data wire in the star enclosure wall.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the unsealed penetrations in the above named locations.
2. Observation on April 27, 2021, at 3:31 p.m., revealed stair door 085 self-closure was disconnected at the time of survey, ground floor.
Interview at the exit conference with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 pm, confirmed the stair enclosure was not maintained.
Tag No.: K0225
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of stair enclosures, in two instances, affecting one of four levels within Building 51.
Findings include:
1. Observation on April 28, 2021, at 10:22 a.m., revealed Stair Door 093 was offset and would not latch into its frame, Ground Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the stair door required adjustment.
2. Observation on April 28, 2021, at 1:45 p.m., revealed Stair B Exit Door 1032 required excessive force to open.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the door required excessive force to open.
Tag No.: K0281
Based on observation and interview, it was determined the facility failed to maintain required illumination of the means of egress, in five instances, affecting one of four levels in Building 1.
Findings Include:
1. Observation on April 27, 2021, at 3:31 p.m., revealed Stair 5 lacked two forms of illumination at the exit discharge, in the event one bulb becomes inoperable, Ground Floor.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the the exit discharge required additional illumination.
2. Observation on April 27, 2021, between 3:40 p.m. and 3:45 p.m., revealed the following stair tower lights were blown:
a. 3:40 p.m., Stair 5 lowest landing, Ground Floor;
b. 3:45 p.m., at the Pool Side Exit Door 0107, Ground Floor;
c. 3:57 p.m., at Exit Discharge Door 017, Ground Floor.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed illumination was inoperable at the above locations.
3. Observation on April 27, 2021, at 3:45 p.m., revealed the corridor means of egress was in darkeners when the light switch was turned in the off position, near the pool side exit, Ground Floor.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed continuous illumination was not provided.
Tag No.: K0281
Based on observation and interview, it was determined the facility failed to maintain illumination in stair enclosures, in one instance, affecting one of four levels within Building 51.
Findings include:
1. Observation on April 28, 2021, at 10:26 a.m., revealed, on the Ground Floor, inside Stair Enclosure# 0111, the light was not functioning.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the lack of illumination, in the stair enclosure, on the Ground Floor.
Tag No.: K0293
Based on observation and interview, it was determined the facility failed ensure exit signs were installed and maintained, in three instances, affecting three of four levels within Building 1.
Findings include:
1. Observation on April 27, 2021, at 1:55 p.m., revealed the mechanical penthouse lacked exit signage.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the mechanical penthouse lacked exit signage.
2. Observation on April 27, 2021, at 2:15 p.m., revealed, in the Second Floor, A-Hall corridor, near Storage Room# 2065, an exit sign was dislodged from the ceiling.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the exit sign was dislodged from the ceiling.
3. Observation on April 27, 2021, at 3:57 p.m. revealed the corridor lacked a directional exit sign near Storage Room 016, Ground Floor.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed exit signage was incomplete.
Tag No.: K0293
Based on observation and interview, it was determined the facility failed to ensure exit directional signs were installed, in two instances, affecting two of four levels within Building 10.
Findings include:
1. Observation on April 27, 2021, between 9:22 a.m. and 9:40 a.m., revealed the following locations lacked exit signage:
a. 9:22 a.m., Mechanical Penthouse;
b. 9:40 a.m., Center Hall, E Wing, Second Floor.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the lack of exit signage.
Tag No.: K0293
Based on observation and interview, it was determined the facility failed to maintain exit directional signage, in three instances, affecting two of four levels within Building 51.
Findings include:
1. Observation on April 28, 2021, at 10:19 a.m., revealed an exit sign was installed above a locked door leading to the Tunnel, near the classrooms, Ground Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the improper location of the exit sign.
2. Observation on April 28, 2021, at 10:25 a.m., revealed the exit sign, on the Ground Floor, near the door to Stair Enclosure Door# 0111, was not illuminated.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the exit sign was not illuminated.
3. Observation made on April 28, 2021, at 10:53 am, revealed the exit sign in A-Wing, 1st floor, above door 135 did not have the chevron removed to indicate the direction to the exit.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the exit sign failed to indicate the direction to the exit.
Tag No.: K0311
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings, in one instance, affecting two of five smoke zones in Building 1.
Findings include:
1. Observation on April 27, 2021, at 2:55 p.m, revealed, inside Mechanical Shaft 1088, next to the Laundry Room, there was a large opening in the ceiling, and an unsealed duct penetration which lacked access to verify installation of a fire damper, First Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the unprotected vertical openings.
Tag No.: K0311
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings, in three instances, affecting three of four levels within Building 51.
Findings include:
1. Observation on April 28, 2021, at 10:52 a.m., revealed there were openings around pipe penetrations, through the ceiling inside fuse box closet 039, Ground Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed there were openings in the ceiling.
2. Observation on April 28, 2021, at 11:32 a.m., revealed the fire extinguisher cabinet was recessed into the shaft wall near electrical panel 1C DSGS-1985, First Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the integrity of the enclosure was compromised.
3. Observation on April 28, 2021, between 12:07 p.m. and 12:13 p.m., revealed combustible storage housed inside the mechanical Penthouse:
a. 12:07 p.m., Room 302, cardboard boxes;
b. 12:13 p.m., Room 304, old gasoline cans.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the combustible storage in the above named locations.
Tag No.: K0311
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of vertical openings between floors, in two instances, affecting two of four levels within Building 10.
Findings include:
1. Observation on April 27, 2021, at 11:20 a.m., revealed, on the First Floor, in the D-1 Nurses' Station Med Room, inside Pipe Chase Closet 1018, there were four (4) unsealed pipes penetrating the floor slab.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the unsealed vertical penetrations.
2. Observation on April 27, 2021, at 11:12 a.m., revealed there was an opening, above the sleeve, where the duct penetrates the shaft wall, inside the Cafeteria, First Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the vertical opening.
Tag No.: K0345
Based on observation and interview, it was determined the facility failed to maintain fire alarm system components in operable condition, in one instances, affecting one of four levels within Building 10.
Findings include:
1. Observation on April 27, 2021, at 10:30 a.m., revealed, in the Second Floor, D-2 short hall corridor, a fire alarm strobe was dislodged from the wall.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed a fire alarm strobe was dislodged from the wall.
Tag No.: K0345
Based on observation and interview, it was determined the facility failed to maintain fire alarm system components in operable condition, in two instances, affecting two of five smoke zones within Building 51.
Findings include:
1. Observation on April 28, 2021, between 10:02 a.m. and 10:27 a.m., revealed fire alarm pull stations were dislodged from the wall, in the following locations:
a. 10:02 a.m., Ground Floor, in the C side corridor, near Occupational Therapy Room 060;
b. 10:27 a.m., Ground Floor, near the door to Stair Enclosure Door 0111.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the fire alarm pull stations were dislodged from the wall in the above named locations.
Tag No.: K0345
Based on observation and interview, it was determined the facility failed to maintain fire alarm system components inoperable condition, in one instance, affecting the entire facility (Building 1).
Findings include:
1. Observation on April 27, 2021, at 2:10 p.m., revealed, in the Second Floor, A-Hall corridor, near Room# 2066, a fire alarm pull station was dislodged from the wall.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed a fire alarm pull station was dislodged from the wall.
Tag No.: K0347
Based on observation and interview, it was determined the facility failed to maintain smoke detectors in a smoke resistive ceiling assembly, in four instances, affecting two of four levels within Building 1.
Findings include:
1. Observation on April 27, 2021, between 2:15 p.m. and 2:55 p.m., revealed holes, gaps, and missing ceiling tiles near smoke detectors, at the following locations:
a. 2:15 p.m., Second Floor, A-Hall corridor, near Storage Room# 2065, there was a hole in a ceiling tile around an exit sign;
b. 2:31 p.m., Second Floor, lobby area, above the door to the penthouse stairs, there was a missing ceiling tile;
c. 2:32 p.m., Second Floor, lobby area, above the door to Room# 2145, there was a hole in a ceiling tile;
d. 2:55 p.m., First Floor, A-wing, short hall, inside the mechanical room, there were missing ceiling tiles.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the facility did not maintain a smoke resistive ceiling assembly, at the above named locations.
Tag No.: K0347
Based on observation and interview, it was determined the facility failed to maintain smoke detectors in a smoke resistive ceiling assembly, in six instances, affecting three of four levels within Building 10.
Findings include:
1. Observation on April 27, 2021, between 9:55 a.m. and 12:28 p.m., revealed holes, gaps, and missing ceiling tiles near smoke detectors, in the following locations:
a. 9:55 a.m., Second Floor, Room 2070 chow hall, two (2) missing ceiling tiles;
b. 10:00 a.m., Second Floor, Room 2007 visitor's room, missing ceiling tile;
c. 10:25 a.m., Second Floor, D-2 short hall, above Stair Tower Door 2048, a hole in the ceiling;
d. 10:28 a.m., Second Floor, D-2 short hall, above the smoke barrier door, a hole in the ceiling;
e. 11:25 a.m., First Floor, D-1 short hall, inside the Mechanical Room, missing ceiling tile;
f. 12:28 p.m., Ground Floor, inside the Barber Shop, missing ceiling tile.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the facility did not maintain a smoke resistive ceiling assembly, in the above named locations.
Tag No.: K0353
Based on observation and interview, it was determined the facility failed to maintain a smoke tight ceiling assembly for sprinkler system components, in one instance, affecting one of four levels within Building 10.
Findings include:
1. Observation on April 27, 2021, at 10:29 a.m., revealed there was a hole. in the ceiling, inside Recreation Room Closet 2076, which could impede activation of the sprinkler system, Second Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the opening in the ceiling.
Tag No.: K0353
Based on observation and interview, it was determined the facility failed to maintain sprinklers within a smoke tight assembly, in one instance, affecting one of five smoke zones within Building 1.
Findings Include:
1. Observation on April 27, 2021, at 1:22 p.m., revealed there were missing and broken ceiling tiles, inside the Dental office storage room, Ground floor.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the ceiling assembly was not smoke tight.
Tag No.: K0353
Based on observation and interview, it was determined the facility failed to maintain sprinkler system components without obstructions, in one instance, affecting one of four levels within Building 51.
Findings include:
1. Observation on April 28, 2021, at 11:50 a.m., revealed a copper pipe blocking the sprinkler, at the top of the Soiled Linen Chute, in A-wing, Second Floor.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the blocked sprinkler.
Tag No.: K0355
Based on document review and interview, it was determined the facility failed to ensure fire extinguishers were maintained and inspected properly, affecting the entire facility (Building 51).
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the facility could not provide documentation showing an annual maintenance was performed on the fire extinguishers.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing documentation.
2. Document review on April 27, 2021, at 9:45 a.m., revealed the facility could not provide certification documentation for the inspector who performed the facility's annual portable fire extinguisher inspection, in August 2020.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing documentation.
Tag No.: K0355
Based on document review and interview, it was determined the facility failed to ensure portable fire extinguisher inspectors were certified, affecting the entire facility (Building 1).
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the facility could not provide certification documentation for the inspector who performed the facility's annual portable fire extinguisher inspection, in August 2020.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing documentation.
Tag No.: K0355
Based on observation, document review and interview, it was determined the facility failed to ensure fire extinguishers were maintained and inspected properly, affecting the entire facility (Building 10).
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the facility could not provide certification documentation for the inspector who performed the facility's annual portable fire extinguisher inspection, in August 2020.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing documentation.
2. Observation on April 27, 2021, at 10:10 a.m., revealed, in the Second Floor, D-2 short hall, near Room 2011, there was a damaged fire extinguisher locator light, above the extinguisher.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the locator light was damaged.
3. Observation on April 27, 2021, at 12:12 p.m., revealed, in the Ground Floor corridor, near Nursing Supply Storage Room 066, a fire extinguisher's access was obstructed by multiple large bins stored in front of it.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed access to the fire extinguisher was obstructed.
Tag No.: K0363
Based on observation and interview, it was determined the facility failed to maintain positive self-latching and smoke tight resistance of corridor doors, in one instance, affecting one of four levels within Building 10.
Findings include:
1. Observation on April 27, 2021, at 9:40 a.m., revealed the Med room top half of the dutch door had manual slide bolts impeding latching/closing of the door when engaged, each Resident Floor Level, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the impediment to closing the corridor door.
Tag No.: K0363
Based on observation and interview, it was determined the facility failed to ensure corridor doors were smoke tight, and positively latched into the door frame, in four instances, affecting four of four floor levels within Building 1.
Findings include:
1. Observation on April 27, 2021, at 1:07 p.m., revealed the top half of the Med room corridor dutch door had manual slide bolts, impeding closing/latching of the door when engaged, each resident sleeping Floor Level, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the impediment to closing the corridor doors.
2. Observation on April 27, 2021, at 1:29 p.m., revealed Laundry Room Door 2082 latch was stuck in place when the door was opened, Second Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the corridor door latch required adjustment.
3. Observation on April 27, 2021, at 2:21 p.m., revealed, on the Second Floor, A short hall corridor, the door to Mechanical Room# 2044 failed to positively latch.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the door failed to latch.
4. Observation on April 27, 2021, at 3:05 p.m., there was a gap along the side of Bathroom Corridor Door 1125. The bathroom opens into the day hall, where the door separating the rooms was in the open position at the time of inspection, First Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the corridor door was not smoke tight in its frame.
5. Observation on April 27, 2021, at 3:56 p.m., revealed the Men's Toggery room had a hold-open device built into the self-closing hardware, Ground Floor.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the corridor door was held open by an unauthorized means.
Tag No.: K0363
Based on observation and interview, it was determined the facility failed to ensure corridor doors resisted the passage of smoke and positively latched into their frames, at non sprinklered locations, in fourteen instances, affecting two of four levels within Building 51.
Findings include:
1. Observation on April 28, 2021, between 11:17 a.m. and 12:35 p.m., revealed corridor doors with the following deficiencies:
a. 11:17 a.m., C-wing, First Floor, Door 1033, holes in the door and frame;
b. 11:30 a.m., C-wing, First Floor, Door 1012, impediment to closing;
c. 11:43 a.m., A-wing, Second Floor, Door 232, holes in door;
d. 11:45 a.m., A-wing, Second Floor, Door 225, excessive gap between the door and frame, on the latch side;
e. 11:47 a.m., A-wing, Second Floor, Door 236, excessive gap between the door and frame on the latch side;
f. 11:55 a.m., A-wing, Second Floor, Door 241, holes in frame;
g. 11:56 a.m., A-wing, Second Floor, Door 218, impediment to closing;
h. 12:01 p.m., A-wing, Second Floor, Door 248, window assembly not fire rated glass;
i. 12:05 p.m., B-wing, Second Floor, Door 250, not positively latching into frame;
j. 12:24 p.m., C-wing, Second Floor, Door 285, holes in door near doorknob;
k. 12:26 p.m., C-wing, Second Floor, Door 2021, impediment to closing;
l. 12:29 p.m., C-wing, Second Floor, Door 299, excessive gap between the door and frame on the latch side;
m. 12:34 p.m., C-wing, Second Floor, Door 2003, impediment to closing;
n. 12:35 p.m., C-wing, Second Floor, Door 2005, window assembly not fire rated glass.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the corridor door deficiencies in the above named locations.
Tag No.: K0372
Based on observation and interview, it was determined the facility failed to maintain smoke barriers with a fire resistance rating, in one instance, affecting one of four levels within Building 51.
Findings include:
1. Observation on April 28, 2021, at 11:03 a.m., revealed the following deficiencies above the ceiling, in the smoke barrier partition, outside the Nurses' Station, First Floor, A Wing:
a. a small hole;
b. 12 x 12" inch non rated metal panel;
c. an exposed metal stud.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed there were openings in the smoke barrier.
Tag No.: K0372
Based on observation and interview, it was determined the facility failed to maintain the fire resistive integrity of smoke barrier partitions, affecting two of five smoke zones inside Building 1.
Findings include:
1. Observation on April 27, 2021, at 1:13 p.m., revealed there was a gap in the smoke barrier at the exterior block wall, inside Linen Room 1107, First Floor, E Wing, short dorm.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed there was an opening in the smoke barrier partition.
Tag No.: K0372
Based on observation and interview, it was determined the facility failed to ensure smoke barrier walls were free of unsealed penetrations, in two instances, affecting four of five smoke zones within Building 10.
Findings include:
1. Observation on April 27, 2021, at 9:47 a.m., revealed an opening, along the deck of the smoke barrier wall, above the ceiling, inside Linen Room 2104, Second Floor, E Wing short dorm.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the opening in the smoke barrier wall.
2. Observation on April 27, 2021, at 11:08 a.m., revealed, on the First Floor, near Visitation Room 1011, above Smoke Barrier Door 1012, there was a section of the smoke barrier wall missing, near the deck slab, where pipes passed through the smoke barrier.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing section of the smoke barrier wall.
Tag No.: K0379
Based on observation and interview, it was determined the facility failed to ensure window assemblies in smoke barrier doors were fire rated, in one instance, affecting one of four levels within Building 51.
Findings include:
1. Observation on April 28, 2021, at 11:58 a.m., revealed the window assembly, in the smoke barrier door, between A-wing and B-wing, on the Second Floor, was not fire rated glass.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the window assembly was not fire rated glass.
Tag No.: K0511
Based on observation and interview, it was determined the facility failed ensure electrical components were protected, in six instances, affecting three of four levels within Building 10.
Findings include:
1. Observation on April 27, 2021, between 9:08 a.m. and 10:55 a.m., revealed unprotected electrical wiring, in the following locations:
a. 9:08 a.m., in the Mechanical Penthouse, inside the old elevator machine room, there was an open electrical panel with exposed wiring;
b. 9:45 a.m., on the Second Floor, there was an open junction box with exposed wiring, above Stair Tower Door 2000;
c. 10:29 a.m., Second Floor, short hall D-2, there was an open junction box, above the smoke barrier doors;
d. 10:45 a.m., inside First Floor, IT Room 1074, there was an open electrical panel with
exposed wiring;
e. 10:55 a.m., First Floor, Lobby, above Stair Tower Door 1002, there was an open junction box.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the unprotected electrical wiring in the above named locations.
2. Observation on April 27, 2021, at 9:43 a.m., revealed a fixed electric baseboard heater with a manual control, installed inside Seclusion Room 2110. A means to disconnect the heater from ungrounded conductors could not be verified at the time of inspection, Second Floor, E Wing.
Refer to NFPA 70 National Electrical Code, 2011 edition, Chapter 424.19.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the protection feature could not be verified.
Tag No.: K0511
Based on observation and interview, it was determined the facility failed ensure electrical wiring was protected, in four instances, affecting one of four levels within Building 1.
Findings include:
1. Observations on April 27, 2021, between 9:08 a.m. and 10:55 a.m., revealed unprotected electrical wiring, in the following locations:
a. 1:57 p.m., in the Mechanical Penthouse, there were open electrical panels with exposed wiring on two air handler units.
b. 1:59 p.m., in the Mechanical Penthouse, there was a cut-off MC electrical cable with exposed wiring under an air handler unit.
c. 2:03 p.m., in the Mechanical Penthouse, there was an open wall mounted electrical panel with exposed wiring.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the unprotected electrical wiring in the above named locations.
Tag No.: K0511
Based on observation and interview, it was determined the facility failed to ensure electrical wiring was protected, in two instances, affecting two of four levels within Building 51.
Findings include:
1. Observation on April 28, 2021, between 11:03 a.m. and 11:05 am, revealed there were open junction boxes with exposed inner wiring, at the following locations:
a. 11:30 a.m., above the ceiling, near the smoke barrier partition, outside the Nurses' Station, First Floor, A Wing;
b. 11:05 a.m., Ground Floor, C wing, above the smoke barrier door.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the unprotected electrical wiring.
Tag No.: K0521
Based on observation and interview, it was determined the facility failed to maintain protection of Heating, Ventilation, and Air Conditioning (HVAC) systems, free of debris, in two instances, affecting one of four levels within Building 10.
Findings include:
1. Observation on April 27, 2021, at 10:22 a.m., revealed there was excessive dust/lint build-up in the exhaust duct of staff bathroom 2084, Second Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the ductwork required cleaning.
2. Observation on April 27, 2021, at 10:47 a.m., revealed there was limited accessibility, above the ceiling, to verify the fire damper, which was approximately one foot from the shaft wall. This was one of three ducts in the passage corridor outside the visitor's lobby, Second Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the location of the fire damper.
Tag No.: K0521
Based on observation and interview, it was determined the facility failed to maintain protection of heating, air conditioning and ventilation systems, free of debris, in five instances, affecting two of four levels in Building 1.
Findings include:
1. Observation on April 27, 2021, between 2:21 p.m. and 3:01 p.m., revealed there was excessive dust/lint build-up inside the following exhaust vents:
a. 2:21 p.m., inside Room 2092, Second Floor, E Wing;
b. 3:01 p.m., inside Room 1096, First Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the ductwork required cleaning.
2. Observation on April 27, 2021, at 2:35 p.m., revealed the dryer exhaust vent was partially disconnected inside Laundry Room 2082, Second Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed ventilation was obstructed..
3. Observation on April 27, 2021, at 2:42 p.m, revealed there were two ducts penetrating the shaft wall, in the exit passage corridor, outside the visitor's lobby. The fire dampers inside the ducts had been activated. The dampers were held open by an unauthorized means (wood 2 x 4's), First Floor, E Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the ductwork lacked appropriate protection.
Tag No.: K0521
Based on observation and interview, it was determined the facility failed to install and maintain Heating, Ventilating, and Air Conditioning (HVAC) system components, affecting the entire facility (Building 51).
Findings include:
1. Observation on April 28, 2021, between 8:00 a.m. and 2:30 p.m., revealed a heavy build up of dust and lint on HVAC diffusers throughout the building.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed there was a heavy build up of dust and lint on HVAC diffusers throughout the component.
2. Observation on April 28, 2021, at 12:11 p.m., revealed the fire damper, inside the duct penetrating the shaft wall, above the ceiling, was in the closed position, by door 224, Second Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshall on April 28, 2021, at 2:10 p.m., confirmed the fire damper had been activated.
3. Observation on April 28, 2021, at 12:27 p.m., revealed the installation of fire dampers could not be determined at the wall mounted return air grill, inside Room 216, Second Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshall on April 28, 2021, at 2:10 p.m., confirmed protection of the duct penetration could not be determined.
Tag No.: K0541
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of linen chute enclosures, in one instance, affecting one of four levels within Building 51.
Findings Include:
1. Observation on April 28, 2021, at 11:00 a.m., revealed there was an opening, in the linen chute wall, behind the corridor door. There was also partially exposed insulation and a wire blocking closure of the access door, Second Floor, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the linen chute enclosure was incomplete.
Tag No.: K0541
Based on observation and interview, it was determined the facility failed to maintain the fire resistance rating of soiled linen chute discharge rooms, in two instances, affecting one of five levels within Building 10.
Findings include:
1. Observation on April 27, 2021, between 12:28 p.m. and 12:52 p.m., revealed, in the Ground Floor, the door and frame assemblies, on the two (2) soiled linen chute discharge rooms were not fire rated.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the door and frame assemblies were not fire rated.
Tag No.: K0754
Based on observation and interview, it was determined the facility failed to maintain protection of trash receptacles within hazardous areas, in one instance, affecting one of four levels in Building 1.
Findings Include:
1. Observation on April 27, 2021, at 3:58 p.m., revealed there were unattended 32 gallon trash receptacles, in the corridor means of egress, in the area of Cedar Room 005. Trash receptacles 32 gallons or more shall be located in a room protected as a hazardous area, Ground Floor.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the location of the trash receptacles.
Tag No.: K0912
Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility (Building 1).
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:
a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the facility could not provide documentation the receptacles were tested.
Tag No.: K0912
Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility (Building 10).
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:
a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the facility could not provide documentation receptacles were tested.
Tag No.: K0912
Based on document review and interview, it was determined the facility failed to ensure electrical receptacles were tested in patient care rooms and at deep sedation bed locations, affecting the entire facility (Building 51).
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed electrical receptacles in patient care rooms and at deep sedation bed locations were not tested for non-hospital grade receptacles at intervals not exceeding 12 months, and hospital grade receptacles based on documented performance data, minimally not exceeding 12 months. Receptacle testing should include the following:
a. patient care rooms;
b. visual inspection of physical integrity;
c. correct polarity of the hot and neutral connections;
d. retention force of the grounding blade (except locking-type receptacles) shall not be less than 115g (4 oz).
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the facility could not provide documentation the receptacles were tested.
Tag No.: K0915
Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator, in two instances, affecting two of two generators for Building 1.
Findings include:
1. Observation on April 28, 2021, at 1:20 p.m., revealed there was no emergency generator remote manual stop station located outside of the generator enclosures.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed there was not a remote manual stop switch located outside of the generator enclosures.
Tag No.: K0915
Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator, in two instances, affecting two of two generators for Building 10.
Findings include:
1. Observation on April 28, 2021, at 1:50 p.m., revealed there were no manual stop stations for the emergency generators, located outside of the generator enclosures.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed there was not a remote manual stop switch located outside of the generator enclosures.
Tag No.: K0915
Based on observation and interview, it was determined the facility failed to install a remote emergency stop switch for the emergency generator, in two instances, affecting two of two generators for Building 51.
Findings include:
1. Observation on April 28, 2021, at 1:35 p.m., revealed there was no emergency generator remote manual stop station located outside of the generator enclosures.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed there was not a remote manual stop switch located outside of the generator enclosures.
Tag No.: K0918
Based on document review and interview, it was determined the facility failed to conduct required testing of emergency generators, affecting two of two generators for Building 1.
Findings include:
1. Document review performed on April 27, 2021, at 9:45 a.m., revealed the facility could not produce documentation of the following required testing and inspections for the emergency generator:
a. Weekly visual inspection of the generator for April 9, 2021;
b. Monthly battery conductance testing;
c. Annual 90 minute Load Bank testing:
d. No evidence of wet-stacking;
e. three (3) year, four (4) hour load test;
f. Annual fuel quality test.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing documentation.
Tag No.: K0918
Based on document review and interview, it was determined the facility failed to maintain required testing of emergency generators, affecting two of two generators for Building 51.
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the facility could not produce documentation of the following required testing and inspections:
a. Weekly visual inspection of the generator for April 9, 2021;
b. Monthly battery conductance testing;
c. Annual 90 minute Load Bank testing:
d. No evidence of wet-stacking;
e. three (3) year, four (4) hour load test;
f. Annual fuel quality test.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing documentation.
Tag No.: K0918
Based on observation, document review and interview, it was determined the facility failed to maintain required inspections of emergency generator components, in operable condition, affecting the entire facility (Building 10).
Findings include:
1. Document review on April 27, 2021, at 9:45 a.m., revealed the facility could not produce documentation of the following required testing and inspections:
a. Weekly visual inspection of the generator for June 12, 2020 and April 9, 2021;
b. Monthly battery conductance testing;
c. Annual 90 minute Load Bank testing:
d. No evidence of wet-stacking;
e. 3 year, 4-hour load test;
f. Annual fuel quality test.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the missing documentation.
2. Observation on April 28, 2021, at 12:30 p.m., revealed, inside the 280 KW emergency generator enclosure, there was a warning light illuminated on the generator's main panel, indicating a Low Coolant Level.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the Low Coolant Level warning light was illuminated.
Tag No.: K0920
Based on observation and interview, it was determined the facility failed to prevent the unauthorized use of electrical devices, in two instances, affecting one of four levels within Building 10.
Findings include:
1. Observation on April 27, 2021, at 9:40 a.m., revealed, on the Second Floor, an outlet multiplier was in use, inside Doctor's Office 2144.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the prohibited use of an outlet multiplier.
2. Observation on April 27, 2021, at 12:00 p.m., revealed, inside Ground Floor, Escort Office 065, a coffee maker was plugged into a powerstrip.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed the improper use of a powerstrip.
Tag No.: K0920
Based on observation and interview, it was determined the facility failed to prevent the unauthorized use of electrical equipment, in two instances, affecting two of four levels within Building 51.
Findings include:
1. Observation on April 28, 2021, between 10:54 a.m. and 12:15 p.m., revealed unauthorized electrical devices were used, at the following locations:
a. 10:54 a.m., Ground Floor, inside Housekeeping Break Room 019, there was an extension cord in use;
b. 12:15 p.m., Second Floor, inside the Nurses' Station, a power tap was used for the printer, A Wing.
Exit Interview with the Chief Operating Officer, Institutional Safety Manager, Facilities Manager and Fire Marshal on April 28, 2021, at 2:10 p.m., confirmed extension cords were in use.