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Based on observation and interview, the facility failed to maintain emergency light used for egress lighting. This deficient practice could effect all occupants in the St Luke's Children's Day Treatment building. The facility is a Treatment Center.

Findings include:

Observation and interview on 10/31/18 at 3:47 p.m., revealed the west corridor of the Clinic did not have battery back-up emergency lighting to be used for emergency exiting. Administrative Staff A verified this finding.

Based on observation and interview, the facility failed to maintain one emergency light used for emergency exiting. This deficient practice could effect all occupants in the St Luke's Children's Day Treatment building. The facility is a Treatment Clinic.

Findings include:

Observation and interview on 10/31/18 at 3:42 p.m., revealed the emergency light by the Southeast Office did not illuminate when tested. Administrative Staff A verified this finding.

Based on observation and interview the facility failed to maintain the fire rating on one stairwell shaft. This deficient practice affects eight smoke zones and residents and staff off of stairwell G. The facility has a certified capacity of 350 residents with the current census of 147 residents.

Findings include:

Observation and interview on 10/30/18 at 10:34 a.m., revealed an 1/2 inch penetration above the door inside of Stairwell G on the Fourth floor. Administrative Staff A and Maintenance Staff A verified these findings.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected one of twenty-six smoke zones in the Main Hospital and four area in the Out Patient Clinics. This facility has a capacity of 350 and a current census of 147 residents.

Findings include:

Observation and interview on 10/30/18 from 9:45 a.m. to 1:29 p.m. and 10/31/18 from 8:32 a.m. to 9:16 a.m., revealed the following areas did not have self-closing devices on the Hazardous rooms:

1. Main Hospital 6th floor North Wing Storage Room by Room #665.
2. Imaging Service (Marion) Soiled Linen Room.
3. Therapy Plus (Marion) Soiled Linen Room.
4. Therapy Plus & Mammography (4325 Williams SW, CR) Soiled Linen Room.
5. Wound Healing & Hyperbaric Center (Hiawatha) Soiled Linen Room.

Administrative Staff A and Maintenance Staff A confirmed these observations.



Hazardous area with Sprinkler
NFPA standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have closers and positive latches.

Based on observation and interview, the facility failed to maintain the smoke detectors in accordance with the National Fire Protection Association 72. This deficient practice effects two hazardous areas and could effect all residents and staff on the first floor in the Women's and Children's Center. The facility has a certified capacity of 350 with the current census of 147 residents.

Finding include:

Observation and interview on 10/30/18 from 10:59 a.m. to 11:15 a.m., revealed two Soiled Linen Rooms (#1132 and #1159) in the Women's and Children's Center had smoke detectors that were too close to ceiling diffusers (within 3 feet). Administrative Staff A and Maintenance Staff A verified these findings.

Based on observation and interview, the facility failed to maintain all components of the sprinkler system in accordance with the National Fire Protection Association 25. This deficient practice effects all occupants in the 1st floor Kitchen/Dining Room and one of twenty-six smoke zones. The facility has a certified capacity of 350 with the current census of 147 residents.

Findings include:

Observation and interview on 10/30/18 at 8:59 a.m., revealed numerous sprinkler escutcheon plates hanging away from the ceiling in the Main Kitchen by the walk in freezer area. Administrative Staff A and Maintenance Staff A verified this finding.

Based on observation and interview, the facility failed to provide a Ground Fault Circuit Interrupter (GFCI) outlet for one area in the building. This deficient practice effects all occupants in the Kitchen area on the 5th floor. The facility has a certified capacity of 350 with the current census of 147 residents.

Findings include:

Observation and interview on 10/30/18 at 10:27 a.m., revealed the outlet next to the sink on the 5th floor Center Kitchen was not a GFCI outlet. Administrative Staff A and Maintenance Staff A verified this finding.

Based on observation and staff interview, the facility is not storing oxygen tanks in accordance with National Fire Protection Association (NFPA) Standard 99, including to maintain full and empty containers physically separate from each other to prevent staff from accidentally grabbing an empty bottle in the event of an emergency. This deficient practice occurred in one of six oxygen storage areas and effects all staff and visitors in one of twenty-six smoke zones. This facility has a capacity of 350 and a census of 147 residents.

Findings include:

Observation and interview on 10/29/18 at 2:09 p.m., revealed the Bulk Oxygen Small Cylinder Storage Room did not have the empty or full oxygen cylinders clearly marked or separated from one another. Administrative Staff A and Maintenance Staff A confirmed this finding.