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Based on observations of the Rumford Hospital Facility by surveyors 38667 and 05910 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

X-ray room G34 area was observed to be under construction without self-closing rated door separation

While surveying the facility on 6-11-2018 with surveyor 40403 and in the presence of maintenance personnel this surveyor did observe:

Ground Floor:

Near stairwell #4 and located above the acoustical ceiling conduit penetrating the 2-hour fire barrier not fire stopped.

Multiple 2-hour fire wall barrier penetrations on the corridor side of the Skip space as well as penetrations into the 2-hour fire barrier on the Skip space side.

Medical gas room door located within the 2-hour fire barrier wall requires an automatic closing device.

Closet located between the medical gas room and bathroom; the door is tabled as a 45 minute door located in a 2-hour fire barrier wall. The door is required to be fire rated for 90 minutes.

Penetrations through the floor located above the ceiling in the pharmacy corridor shall be fire stopped.

Penetrations through the floor located near the Day Surgery Door above the ceiling.

X-Ray corridor: The 2-hour fire barrier wall located in the corridor has been removed; fire barrier walls shall be continuous from exterior wall to exterior wall.


First Floor:

Physical Therapy area. The two hour fire barrier at this location has multiple penetrations; holes, wires, conduit and currently not fire stopped at the top of the ceiling/floor above all penetrations shall be fire stopped to a UL listed assembly.
This wall also required to be verified that it meets the two hour fire barrier requirement; it appears that this wall has only a single layer of sheetrock.

Physical Therapy -Back Corridor has a large basket ball size hole in the 2 hour fire barrier wall located above the ceiling.

The Maternity door located in the 2-hour fire barrier wall is required to be 90 minute fire rated and self-closing with positive latching.

The nurse managers office door requires a 90 minute fire rated door and self-closing with positive latching.

Med/Surge first set of double doors located in the 2-hour fire barrier wall shall be labeled 90 minute fire rated doors.

In the med/Surge area near nurses station and across from ICU several penetrations by wires and conduit along the 2-hour fire rated barrier wall.

Fire rated double doors located at Admin/Lab wing shall latch at the bottom.

90 minute fire rated double doors located in Physical Therapy wing shall latch at the bottom.

Above the 90 minute fire rated doors located at the physical therapy Wing penetrations were found in the 2 hour fire barrier; wiring not sealed with UL listed fire stopping material.

Second Floor:

Rehab area; fire barrier door located in the two hour fire barrier wall is not labeled as fire rated door, holes were found in the door and the lamination of the door has been chipped away.

Above the ceiling at the two hour fire barrier that separates the Rehab area from the rest of the hospital, the fire barrier is compromised by conduit, piping, wiring, etc. all penetrations shall be sealed with UL listed fire stopping material.

Rehab door #2 near room 212 and located in a two hour fire barrier wall is not labeled and penetrations through the fire barrier were discovered above the ceiling near this door.



Surveyor: Dion, Sue D

Based on observations of the Rumford Hospital Facility by surveyors 05910 and 38667 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

The 2 hour linen chute, in material management, was not properly terminated at the underside of the space above. Joint compound and taping, or improperly applied UL listed fire rated material, which appeared to be excessively thin, is not acceptable.

The fire rated separation wall, separating material management and the corridor was not properly terminated at the underside of the space above. Joint compound and taping, or improperly applied UL listed fire rated material, which appeared to be excessively thin, is not acceptable.

Kitchen storage space: multiple holes and penetrations observed in the 2 hour rated wall.

The maintenance shop door which showed a 2 hour requirement on the life safety floor plans was not marked and was also found to contain holes in.

Stairway 1 door at the ground floor by the lab (showed 2 hour requirement on the life safety floor plans) had holes both in the doorframe and in the door itself.

The 2 hour wall separating the Medical gases room through to the corridor was missing the layers of gypsum wallboard.






38667

Based on observations of the Rumford Hospital Facility by surveyors 38667 and 05910 with the maintenance supervisor of facilities that this standard is not met as evidenced by:


Multiple pipe penetrations through the ceiling to the floor above in the shop/sub-basement


Exit D-2 covered stair is non-conforming structure attached to the building; building required to meet minimum contruction type of II(111). Non-fire rated combustible materials are not allowed.

While surveying the facility on 6-11-2018 with surveyor 40403 and in the presence of maintenance personnel this surveyor did observe:

Dead bolt lock lock located on the double doors leading into the OR suite from the day surgery corridor. These doors are in a means of required egress from the OR.



37694

This standard is not met as evidenced by:

While inspecting this facility on June 11, 2018 with a Maintenance Technician and surveyor 34673, surveyor 37694 did observe:

The corridor to Delivery Rooms 32 and 33 in Maternity Department is not 8 ft wide.

The alcove across from Rooms 32 and 33 in Maternity Department shall not be used for storage. 4 unapproved wheeled items were found impeding egress from these 2 rooms.

Portable scale and nurses cart found stored in the Rumford Surgical Associates wing.

Office supplies found stored in large alcove next to the Reception desk in Rumford Surgical Associates wing.

Portable scale found stored outside the Clinic Waiting Room on the 2nd Floor.

Portable nurses station and 4 portable vital machines found stored in the Med Surg corridor.

Double door storage closets throughout Med Surg wing shall positively latch and resist the passage of smoke. These closets are currently being held closed with unapproved magnets and a loose chain.

Surveyor: Dion, Sue D

This standard not met as evidenced by:

Stairs and a chair stored in the corridor marked G-P on floor plans.

Based on observations of the Rumford Hospital Facility by surveyors 38667 and 05910 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

Stairwell 2 (SS) shaft opening to rated stairwell is not self-closing or positive latching

While surveying the facility on 6-11-2018 with surveyor 40403 and in the presence of maintenance personnel this surveyor did observe:

EXIT sign required from the OR suite to the Day Surgery corridor.


37694

This standard is not met as evidenced by:

While inspecting this facility on June 11, 2018 with a Maintenance Technician and surveyor 34673, surveyor 37694 did observe:

Exit sign shall be installed over the 2nd exit from Maternity towards Med Surg wing.

Based on observations of the Rumford Hospital Facility by surveyors 38667 and 05910 with the maintenance supervisor of facilities that this standard is not met as evidenced by:


Penetration in ceiling of the environmental services room G 54

Multiple pipe penetrations were observed in the sprinkler room

Multiple pipe penetrations in Electrical Room G-20 were observed through the rated wall to the corridor

Multiple electrical conduit and pipe penetrations in the electrical subbasement and universal storage space.

Multiple penetrations in the room G-70 (marked on floor plans) through the rated wall.

Multiple penetrations in the gypsum wallboard and electrical and pipe penetrations in material management to the corridor.

Multiple electrical conduit and pipe penetrations in the room G-45 (marked on the floor plans) through the rated wall.

While inspecting this facility on June 11, 2018 with a Maintenance Technician and surveyor 34673, surveyor 37694 did observe:

Resident Linen Closet in the OH/Employee Health wing has multiple holes in the ceiling sheetrock. The ceiling shall be sealed to meet the fire-rating of the ceiling.

Based on observations of the Rumford Hospital Facility by surveyors 05910 and 38667 with the maintenance supervisor of facilities that this standard is not met as evidenced by:


A grease cup was observed missing in the kitchen hood, and must be provided.

A broken baffle filter was observed installed in the kitchen hood.

Gaps between the baffle filters and between the filters and the frame of the kitchen hood was observed.

Based on observations of the Rumford Hospital Facility by surveyors 05910 and 38667 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

The room used as a biohazard collection room had painted rigid foam board covering the walls. Rigid foam board does not provide a class A, B or C interior wall finish.

The subbasement old storage room had the ceiling covered with rigid foam board insulation. Rigid foam board does not provide a class A, B or C interior ceiling finish.

This standard is not met as evidenced by:

Based on observations of the Rumford Hospital Facility by surveyors 05910 and 38667 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

A heat detector was observed hanging from its wires and lacking proper securement in the boiler room.

This standard is not met as evidenced by:

While inspecting this facility on June 11, 2018 with a Maintenance Technician and surveyor 34673, surveyor 37694 did observe:

Smoke detection shall be provided in On Call sleeping room in OH/Employee Health wing.

Smoke detection shall be provided in the sleeping room labeled "Showers" in OH/Employee Health wing.



38667

Based on observations of the Rumford Hospital Facility by surveyors 38667 and 05910 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

Smoke detection shall be provided in On Call sleeping room in ASU lockers for doctors sleeping area

Smoke detection shall be provided in Sleeping Room G-52 for doctors sleeping area

This standard is not met as evidenced by:

While inspecting this facility on June 11, 2018 with a Maintenance Technician and surveyor 34673, surveyor 37694 did observe:

On Call Sleeping Room in OH/Employee Health wing lacks required sprinkler coverage.

Clean Supply Closet in OH/Employee Health wing lacks required sprinkler coverage.

Resident Linen Closet in OH/Employee Health wing lacks required sprinkler coverage.




38667

Based on observations of the Rumford Hospital Facility by surveyors 38667 and 05910 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

Covered exit at Ground D-2 exit stair exceeds 48" and lacks sprinkler coverage

Operating Room staff lounge lacks sprinkler coverage


Surveyor: Dion, Susan
This standard is not met as evidenced by:

Based on observations by surveyor 0590 with a OR Nurse,

Operating Room #2 lack sprinkler head coverage.

Operation Room #3 lack sprinkler head coverage.


In the hospital laboratory duct work was observed approximately 18" wide by 12" in depth that had no sprinkler coverage beneath it to provide coverage.

In storage room marked G 71 on floor plans, an L shaped section of the room approximately 7 feet in depth had no sprinkler head coverage.

Dirty Utility by ASU lack sprinkler head coverage.

This standard is not met as evidenced by:

During record review of this facility on June 11, 2018, surveyor 37694 did observe:

Documentation could not be provided to indicate that the 5 year hydrostatic testing of the Fire Department Connection has been completed.



While inspecting this facility on June 11, 2018 with a Maintenance Technician and surveyor 34673, surveyor 37694 did observe:

Escutcheon cap is missing in the Medical Supplies Closet by the 1st Floor elevator.



38667

Based on observations of the Rumford Hospital Facility by surveyors 38667 and 05910 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

Missing escutcheon plate on sprinkler head in vegetable cooler in kitchen

Sprinkler pipe in laundry room area by door to corridor has a hanger that is not attached

Standpipe OS&Y valve inspection tag labeled as February 2017 and does not appear to have been properly inspected and tested


Surveyor: Dion, Susan
Based on observations by surveyor 05910 and 38667 with the maintenance supervisor, this standard is not met as evidences by:

Clean storage in ASU was missing a escutcheon plate on the sprinkler head.

Dirty sprinkler heads were observed in the hospital main dining room.

A dirty sprinkler head directly under a vent in the kitchen dishing area.

A dirty sprinkler head in the main kitchen meat freezer.

Various styles of sprinkler heads without replace sprinkler heads in a spare sprinkler head box. Examples of different sprinkler heads without replaces include: Cart Storage, Kitchen, X-Ray changing room, Linen room marked on floor plans G 42.

This standard is not met as evidenced by:

While inspecting this facility on June 11, 2018 with a Maintenance Technician and surveyor 34673, surveyor 37694 did observe:

2nd Floor corridor door to the Rumford Surgical Associates wing shall positively latch.

EVS door in OH/Employee Health wing shall be equipped with self-closing hardware.

Clean Supply Room door in OH/Employee Health wing shall positively latch.

2nd Floor Wax Room shall positively latch.

The 2 storage rooms next to 1st Floor Soiled Utility shall positively latch.




38667

Based on observations of the Rumford Hospital Facility by surveyors 38667 and 05910 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

Purchasing storage room door to the corridor shall not be propped open with a fan

Door to kitchen near G81 Exit does not self-close and not positive latching due to damaged hinges

This standard is not met as evidenced by:

While inspecting this facility on June 11, 2018 with a Maintenance Technician and surveyor 34673, surveyor 37694 did observe:

The following corridor doors are shall resist the passage of smoke. They are currently equipped with unapproved louvers.

1. Storage room to the right of the 1st floor Soiled Utility closet near PT.
2. Storage room across from Room 226 on the 2nd Floor.

While surveying the facility on 6-11-2018 with surveyor 40403 and in the presence of maintenance personnel this surveyor did observe:


Penetrations found above ceiling through the smoke barrier wall located above the double doors in Day Surgery Corridor.

Penetrations found above ceiling through the smoke barrier wall located above the double doors near the OR suite.

Double doors located in the smoke barrier in the X-Ray corridor; penetrations found in the smoke barrier above the ceiling.

Penetrations above the ceiling in several areas of the smoke barrier wall at the Emergency Department.

Based on observations of the Rumford Hospital Facility by surveyors 38667 and 05910 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

Laundry chutes in both areas lack sprinkler coverage

This standard is not met as evidenced by:

During record review of this facility and interview with the Maintenance Director on June 11, 2018, surveyor 37694 did observe:

Where drills are conducted between 9pm and 6am, a coded announcement may be used instead of audible alarms.

3rd shift drills have been conducted between 6am and 7am.

This standard is not met as evidenced by:

During record review of this facility and interview with the Maintenance Director on June 11, 2018, surveyor 37694 did observe:

The fire door inspection report from April 25, 2018 indicates 33 doors are out of compliance. Documentation could not be provided to indicate that these doors are scheduled for repair or replacement.

This standard is not met as evidenced by:

During record review and interview with the Maintenance Director on June 11, 2018, surveyor 37694 did observe:

The Medical Gas Inspection Report from August 2, 2017 indicates that there are 16 Maintenance Discrepancies and 40 Compliance Discrepancies at this facility. 42 of the 56 total discrepancies were listed in the Discrepancy List of the Inspection Report from August 15, 2016. Documentation could not be provided to indicate that these items have been scheduled for repair or replacement.

This standard is not met as evidenced by:

While inspecting this facility on June 11, 2018 with a Maintenance Technician and surveyor 34673, surveyor 37694 did observe:

Computer Lab in the OH/Employee Health wing has 3 relocatable power taps plugged into one another. These shall be mounted and plugged directly into an outlet.

Relocatable power taps found on the floor throughout the Med Surg wing. These shall be mounted.

Relocatable power tap found in Office across from Room 31 in the Med Surg wing. These shall be mounted.




38667

Based on observations of the Rumford Hospital Facility by surveyors 38667 and 05910 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

Relocatable power strips were found in the Purchasing office for the fan and the water cooler. These items shall be plugged directly into an outlet


Surveyor: Dion, Susan

Based on observations of the Rumford Hospital Facility by surveyors 05910 and 38667 with the maintenance supervisor of facilities that this standard is not met as evidenced by:

A missing protective plate over a open electrical fixture box behind the linen dryers.

A missing protective plate over an open junction box in the kitchen storage room.

Relocatable power strip in the pharmacy. These shall be secured.

A relocatable power strip was found in room G-44 powering a microwave oven, a toaster and a coffee maker. These items shall be plugged directly into an outlet.

A relocatable power strip under a dest in the Rad Tech room G-43. This shall be secured.

A relocatable power strip in the Triage room. This shall be secured.

This standard is not met as evidenced by:

During record review and interview of this facility with the Maintenance Director on June 11, 2018, surveyor 37694 did observe:

Overhead Door Inspection Report from December 14, 2017 indicated that the Kitchen door #20687 shall be replaced due to age and fire link setup. Documentation could not be provided to indicate that this work has been scheduled for replacement.

Fire Damper Inspection Report on March 14, 2017 indicated that there are 4 deficiencies that shall be remedied. Documentation could not be provided to indicate that this work has been scheduled for repair or replacement.