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Based on observations and interview, the facility failed to provide the 2 hour fire resistance separation between 2 different building types. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observations and interview on 4/10/12 through 4/12/12, revealed the following:

1. The North Tower 2 hour wall between the North Tower 2 and the North Main Lobby revealed a conduit penetration (approximately 1/4 inch in size) located above the suspended ceiling.

2. The North Tower 1st Floor 2 hour wall by the Younker Connector revealed a pipe & communications line penetration (approximately 3/16 inch in size) located above the suspended ceiling.

3. The North Tower Level A 2 hour fire wall to Blank Hospital revealed a wire bundle penetration (approximately 1/4 inch in size) located above the suspended ceiling.

4. The North Tower Level B 2 hour fire wall between the North Wing and the South Wing revealed a pipe penetration (approximately 4 inches in size), a hole (approximately 1 inch in size) located above the suspended ceiling.

5. The North Tower Level C 2 hour Fire Wall in Radiology by the Men's Locker Room revealed a blue pipe penetration (approximately 1/4 inch in size) located above the suspended ceiling.

6. The Northeast Addition Middle Corridor 2 hour Fire Wall revealed a conduit penetration (approximately 1/4 inch in size) located above the suspended ceiling.

7. The Northeast Addition 2nd Floor 2 hour Fire Wall by the Pharmacy revealed a conduit penetration (approximately 3/16 inch in size) located above the suspended ceiling.

8. The Blank Hospital Level C 2 hour wall to the North Wing revealed a pipe penetration (approximately 1/4 inch in size).

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and staff interview, it was determined the facility was a 6 story building and consisted of fire resistant construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with one-hour fire rated materials to protect the adjacent floors. This deficient practice affects all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents at the time of inspection.

Findings include:

Observations and interview on 4/10/12, revealed the following;

1. The North Tower 6th Floor Room N669 revealed a vertical sprinkler head (1 of 2) penetration (approximately 1/2 inch in size) located in the ceiling lid above the Bed.

2. The North Tower 5th Floor Room N563 revealed a vertical sprinkler head penetration (approximately 1/2 inch in size) located in the ceiling lid above the Bed.

3. The North Tower 5th Floor by Room 565 revealed a vertical sprinkler head penetration (approximately 1/2 inch in size) due to a sprinkler escutcheon ring falling off the head.

4. The North Tower 4th Floor Room 460 revealed a vertical sprinkler head penetration (approximately 1/2 inch in size) located by the Chair.

5. The North Tower 4th Floor Nurse's Station revealed a vertical sprinkler head penetration (approximately 1/2 inch in size) located by the Medication Room N-424.

6. The North Tower 4th Floor by the Environmental Closet revealed a vertical gap (approximately 1/4 inch in size) located around the sprinkler head.

7. The North Tower 3rd Floor Room N377 revealed a vertical sprinkler penetration (approximately 1 inch in size) located above the Bed.

8. The North Tower Control Room 11 revealed a vertical sprinkler penetration (approximately 1/2 inch in size) located in the ceiling lid.

9. The North Tower 7th Floor Megavator Room revealed a missing piece of drywall (approximately 2 feet by 7 feet in size) off the wall. The absence of the drywall leaves the inner wall structure exposed. Maintenance Staff A indicated that the facility was in the process of repairing a leak in the roof of this area.

10. The North Tower 4th Floor revealed that the baseboard was missing from the bottom of all of the Corridor Walls throughout the floor.

11. The North Tower 3rd Floor Electrical Closet revealed an open pipe penetration (approximately 2 inches in size), extending through the wall of the North Tower.

12. The Microbiology Compressed Gas Storage Room revealed 4 penetrations (approximately 3/16 inch in size each) located around lines extending through the ceiling, a vertical insulated pipe penetration (approximately 3/16 inch in size) through the ceiling, and 2 vertical holes (approximately 1 inch in size each) located in the ceiling.

13. The Dietician's Office revealed a sprinkler pipe penetration (approximately 1/2 inch in size).

14. The Cooler #23 revealed a sprinkler pipe penetration (approximately 1/2 inch in size) into a resident's room.

15. The Level D EVS Break Room revealed 3 sprinkler pipe penetrations (approximately 1/2 inch in size each).

16. The MOB 1 Children's Health Center Cubicle Office Area revealed a vertical hole (approximately 1/2 inch in size) in the tile around the sprinkler head.

The Facility Safety Supervisor and Maintenance Staff B confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 corridor room wall properly separated from the corridor. This deficient practice could affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents at the time of inspection.

Findings include:

Observation and interview on 4/10/12, revealed a white wire penetration (approximately 1/4 inch in size) located in the corridor wall of the IT/Communications Room of the North Building 4th Floor. The Facility Safety Supervisor confirmed this finding on the date of inspection

Based on observation and interview, the facility failed to maintain 1 corridor room wall properly separated from the corridor. This deficient practice could affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observation and interview on 4/11/12, revealed a sprinkler pipe penetration (approximately 1/2 inch in size) in the Closet wall of the Exit Hall to the Park. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 2 doors in 1 smoke zone in proper working condition. This deficient practice would affect all st within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/10/12, revealed the following:

1. The North Tower Level C Supervisor of Radiology Office Door revealed a kick down device on the door to prevent the door from swinging closed.

2. The North Tower Level C PACS Office Door revealed a kick down device on the door to prevent the door from swinging closed.

3. The Blank Hospital 6th Floor Restroom by Room 503A revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

4. The Blank Hospital 6th Floor Door to the Laundry Room 516 revealed the door was obstructed from opening fully due to a cart blocking the door.

5. The Blank Hospital 6th Floor Physician's Lounge 555 revealed a garbage can propping open the door to the Sleep Room Hallway.

6. The Anna Blank Clinic Conference Room LL04 revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

The Facility Safety Supervisor confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain several corridor doors in proper working condition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The Younker 7th Floor IT Closet by Room 715 revealed the door failed to close and latch into the door frame with the swing of the door closer when tested.

2. The Younker 5th Floor Orthopaedic Technician Office revealed 3 holes in the door where the previous hardware had been replaced.

3. The Younker 5th Floor Staff Restroom by the Family Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

4. The Younker 3rd Floor CCU Supervisor's Office revealed the door was wedged in the open position.

5. The Younker 3rd Floor CCU Doors 305 A revealed the doors failed to close and latch properly into the door frame with the swing of the door closer.

6. The Younker 4th Floor "Powell 4 Medical Neurology" revealed the door closer for the door had been detached from the door.

7. The Younker 4th Floor "Powell 5 Unit Based Educator" revealed the door closer for the door had been detached from the door.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain proper 1 hour vertical fire separation in 1 location. This deficient practice could affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observation and interview on 4/11/12, revealed a center flexible conduit penetration (approximately 1/2 inch in size) located in the Corridor Wall to the Stairwell of Younker 3rd Floor by the Transition by Audiology. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the proper vertical separation between floors within the facility. This deficient practice would affect all staff and residents in the affected area. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observation and interview on 4/10/12, revealed the following:

1. The North Tower 4th Floor Elevator 2 Hour Fire Wall revealed a pipe penetration (approximately 1/4 inch in size).

2. The North Tower 4th Floor by Room 402 revealed the Stairwell door failed to close and latch properly into the door frame with the swing of the door closer.

3. The Methodist West Southwest Stairwell on Level 5 revealed a hole (approximately 1 inch in size) located in the East wall.

The Facility Safety Supervisor and Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects all residents and staff within the affected zones. This facility has a capacity of 674 and a census of 363 residents.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The Powell 4th Floor Smoke Barrier by Room P-438 revealed a pipe penetration (approximately 4 inches in size) located above the suspended ceiling.

2. The Powell 4th Floor Smoke Barrier by Room P439 revealed a pipe penetration (approximately 1/4 inch in size) located above the suspended ceiling.

3. The Powell 3rd Floor Smoke Barrier Wall #MP0000078 revealed a pipe penetration (approximately 4 inches in size) located above the suspended ceiling.

4. The Powell 3rd Floor Smoke Barrier Wall #MP0000077 revealed a pipe penetration (approximately 4 inches in size) located above the suspended ceiling.

The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects all residents and staff within the affected zones. This facility has a capacity of 674 and a census of 363 residents.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The Younker 7th Floor Smoke Barrier by Room 719 revealed a hole (approximately 1/2 inch in size) located above the suspended ceiling tiles.

2. The Younker 6th Floor Smoke Barrier by Room Y648 revealed a wire penetration (approximately 1/2 inch in size) and a conduit sleeve penetration (approximately 1 inch in size) located above the suspended ceiling tile.

3. The Younkers 3rd Floor Smoke Barrier to Younker Elevator revealed a conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling tile.

4. The Younkers 3rd Floor Northeast Addition Smoke Barrier by the Staff Lounge 353 revealed a wire bundle penetration (approximately 1/2 inch in size) located above the suspended ceiling.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain smoke barriers within the facility in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects all residents and staff within the facility. This facility has a capacity of 674 and a census of 363 residents.

Findings include:

Observations and interview on 4/10/12, revealed the following:

1. The North Tower 4th Floor Smoke Barrier by Room 454 revealed a conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling.

2. The North Tower 3rd Floor by Room N376 revealed a pipe penetration (approximately 1/2 inch in size) located above the suspended ceiling.

3. The North Tower 2nd Floor Smoke Barrier by Storage Room N220 revealed a conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling.

4. The North Tower Emergency Department Smoke Barrier to the Megavator revealed an IT wire bundle penetration (approximately 1/2 inch in size) located above the suspended ceiling.

5. The Emergency Department East Hallway Exit Smoke Barrier revealed a conduit penetration (approximately 1/2 inch in size).

6. The North Tower 3rd Floor Smoke Barrier Wall by Room N356 revealed 2 conduit penetrations (approximately 3/16 inch in size) located above the suspended ceilng.

7. The North Tower 3rd Floor Smoke Barrier by Room N362 revealed a conduit penetration (approximately 3/16 inch in size) located above the suspended ceiling.

8. The Northeast Addition on the 3rd Floor revealed a conduit penetration (approximately 3/16 inch in in the Smoke Barrier Wall in Pod A next to Room 311, located above the suspended ceiling.

9. The Northeast Addition on the 3rd Floor revealed a flexible conduit penetration (approximately 3/16 inch in size) located above the suspended ceiling tile in the Smoke Barrier Wall in Pod A next to Room 311.

10. The Methodist West 5th Floor Smoke Barrier by Room 5001 revealed 3 center conduit penetrations (approximately 1/2 inch in size each) located above the suspended ceiling tile.

The Facility Safety Supervisor and Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain smoke barrier doors in proper working condition. This deficient practice would affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observation and interview on 4/11/12, revealed the Younker 5th Floor Smoke Barrier Doors by Room 515 failed to close and latch properly into the door frame with the swing of the door closers. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 8 sets of smoke barrier doors in proper working condition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observations and interview on 4/10/12, revealed the following:

1. The North Tower 6th Floor Fire Doors by Room N675 revealed the doors failed to close and latch properly into the door frame with the swing of the door closers.

2. The North Tower 3rd Floor Smoke Barrier by the Employees Break Room revealed the Doors failed to close and latch properly into the door frame with the swing of the door closers.

3. The North Tower 2nd Floor Neonatal Overflow Area Smoke Barrier by Room N220 revealed a gap (approximately 1 1/2 inches in size) located between the bottom of the doors and the floor.

4. The North Tower 2nd Floor Neonatal Overflow Area Smoke Barrier by Room N236 revealed a gap (approximately 1 1/2 inches in size) located between the bottom of the doors and the floor.

5. The North Tower Level C Fire Doors to Radiology revealed the doors failed to close and latch properly into the door frame with the swing of the door closers.

6. The North Tower Level C Smoke Barrier Doors to to the Radiology Adult Holding Area revealed the doors failed to close and latch properly into the door frame with the swing of the door closers.

7. The North Tower Smoke Barrier Doors by Room N62 revealed the doors failed to close and latch properly into the door frame with the swing of the door closers.

8. The Methodist West Smoke Barrier Doors near Room 3125 revealed the doors failed to cloe and latch properly into the door frame with the swing of the door closers.

10. The MOB1 Children's Health Center West Lobby door to the Patient Area revealed the door failed to close and latch properly into the door frame with eh swing of the door closer.

The Facility Safety Supervisor and the Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. This deficient practice would affect allresidents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents.


Findings include:

Observation and interview on 4/11/12, revealed the Younkers 7th Floor Equipment Room by Room 717 door failed to close and latch properly into the door frame with the swing of the door closer. The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. This deficient practice would affect all residents and staff within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents.


Findings include:

Observations and interview on 4/10/12, revealed the following:

1. The North Tower 5th Floor Environmental Room N555 revealed a vertical sprinkler penetration (approximately 1/2 inch in size) located in the ceiling lid.

2. The North Tower Laboratory Wash Room revealed a vertical duct penetration (approximately 1/4 inch in size) located in the ceiling lid.

3. The North Tower Level B Megavotor Chair Storage Room revealed the Corridor Door failed to close and latch properly into the door frame with the swing of the door closer.

4. The North Tower Level C Housekeeping Closet by Room 13 revealed the door closer had been detached from the door.

5. The North Tower Level C Housekeeping Closet by Room 13 revealed a vertical pipe penetration (approximately 1/2 inch in size) located in the ceiling lid.

6. The Blank Hospital 3rd Floor Equipment Room 361A revealed the door failed to close and latch properly into the door frame with the swing of the door closer when tested.

7. The MOB1 Children's Health Center West Electrical Closet revealed a conduit sleeve penetration (approximately 1/2 inch in size) located in the corridor wall.

8. The Ankeny Blank Pediatric Therapy Garage Storage Area revealed the door was not equipped with a self-closing device on the door.

9. The Ankeny Blank Pediatric Therapy East Storage Rooms (4 rooms) failed to stay tightly latched whenin the door frames when tested. These doors were equipped with magnetic type latches instead of positive latches. This building was inspected on 4/17/12.

10. The West Des Moines Blank Pediatric Therapy 4 Closet Doors across from the Staff Restroom revealed that the doors did not stay tightly latched within the door frames. These doors were equipped with positive latching devices. This building was inspected on 4/17/12.

11. The West Des Moines Blank Pediatric Therapy 4 Closet Doors located in the Main Therapy Area revealed that the doors were not provided with positive latching devices. This building was inspected on 4/17/12.



The Facility Maintenance Director and the Facility Safety Supervisor confirmed these findings on the date of inspection.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. This deficient practice would affect all residents within the affected zones.


Findings include:

Observations and interview on 4/17/12, revealed the following:

1. The Holding & Breakdown Room revealed a vertical pipe penetration (approximately 1 inch in size) located in the ceiling lid.

2. The Mechanical Room revealed a pipe penetration (approximately 2 inches in size) located above the corridor door.

3. The The OR3/Autoclave Room revealed 8 vertical conduit and pipe penetrations (approximately 1/4 inch in size) located in the ceiling lid.

The Facility Maintenance Staff C confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain exit pathways that were clear, unobstructed, and easily accessible at all times. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/10/12, revealed the following:

1. The 5th Floor of the North Building revealed Hinged Nursing Charting Stations attached to the walls that failed to be self-closing when pressure was released.

2. The North Building 3rd Floor Corridor revealed Hinged Charting Stations attached to the walls that failed to be self-closing when pressure was released.

3. The MOB1 Children's Health Center Doctor's Office Hallway revealed a chair in the Hallway.

4. The Anna Blank Clinic Basement Mechanical Door revealed the door failed to open when tested.

5. The Ankeny Blank Pediatrics Therapy revealed the 2 Northeast Mechanical Room Doors were closed and latched with slide locks that would not allow for access to an exit from the interior of the room. This building was inspected on 4/17/12.

The Facility Safety Supervisor confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain several emergency lighting units within the facility in proper working condition. This deficient practice would affect all residents and staff members within the affected zones. The facility had a capacity of 674 residents and census of 363 residents.

Findings include:

Observations and interview on 4/12/12, revealed the following:

1. The Blank Infusion Center Corridor by the Front Desk revealed the emergency lighting unit failed to illuminate when tested.

2. The Blank Infusion Center Corridor by Room 3 revealed the emergency lighting unit failed to illuminate when tested.

3. The Blank Infusion Center Corridor by Room 5 revealed the emergency lighting unit failed to illuminate when tested.

4. The Store Room "D" revealed the emergency lighting unit on the west side of the concrete pillar failed to illuminate when tested.

5. The Outpatient Therapy South revealed the emergency lighting unit located next to the Restroom failed to illuminate when tested. This building was inspected on 4/17/12.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to assure exit signs were properly displayed and visible throughout the facility in 2 locations. This deficient practice affects 1 smoke zone. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The facility failed to provide visible illuminated exit signs to indicate the path of egress in the middle of the East Hall, on the West Side of the smoke barriers on the 2nd, 3rd, 4th, and 5th Floors.

2. The West Des Moines Blank Pediatric Therapy revealed the exit sign by the Soiled Utility Room did not indicate egress to the West Exit Door due to the arrowed chevron not being removed.

Maintenance Staff A confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to provide fire drills of varied times of the day for 4 of 4 quarters review. This deficient practice would affect all residents within the facility. The facility had a capacity of 83 residents and a census of 23 residents on the date of inspection.

Findings include:

Record review and interview on 4/10/12, revealed the facility Fire Drill documentation for the Methodist West Hospital showed that 4 of the 3rd Shift drills were conducted at approximately the same time. The Third Shifts were conducted as follows: 3/6/11 at 10:51 p.m., on 6/7/11 at 1043 p.m., on 9/9/11 at 10:50 p.m., and on 12/18/11 at 10:53 p.m. The Facility Maintenance Staff A confirmed this finding.

Based on observations, record review, and interview, the facility failed to maintain the building's fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observations, record review, and interview on 4/10/12, revealed

1. The North Building 2nd Floor Intern's Lounge revealed a smoke detector that was installed within 3 feet of an air diffuser.

2. The Fire Alarm Panel located in the North Tower 3rd Floor Electrical Closet indicated that the system was in trouble. Maintenance Staff A indicated that the problem was a bad smoke detector.

3. The North Tower 4th Floor revealed a smoke detector covered with blue painter's tape in Room 479.

4. The Outpatient Infusion Area revealed a smoke detector that was installed within 3 feet of an air diffuser in the Corridor.

5. The Wound Healing Center by Exam Room 1 revealed a smoke detector that was installed within 3 feet of an air diffuser.

6. The North Tower Level A Mechanical Room revealed the Fire Alarm Control Panel circuit breaker located in Electrical Panel ELSA 120 B01 was not properly locked out.

7. The Blank Hospital 1st Floor across from the Physician's Neonatal Locker Room revealed a smoke detector that was installed within 3 feet of an air diffuser.

8. The MOB1 Children's Health Center Southwest Doctor's Office Corridor revealed a smoke detector installed within 3 feet of an air diffuser.

9. The MOB1 Children's Health Center Nurse's Station revealed a smoke detector installed within 3 feet of an air diffuser.

10. The MOB1 Children's Health Center East Weight Room Hallway revealed a smoke detector that was installed within 3 feet of an air diffuser.

11. The MOB1 Children's Health Center East Waiting Room Area revealed a smoke detector that was installed within 3 feet of an air diffuser.

12. The Methodist West Hospital 5th Floor Corridor by Room 5057 revealed a smoke detector that was installed within 3 feet of an air diffuser. This facility had a capacity of 83 residents and a census of 23 residents.

13. The West Des Moines Blank Pediatrics Therapy revealed the facility provided only an annual inspection of the building's Fire Alarm System.

The Facility Maintenance Staff A and B confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to provide proper sprinkler protection in 1 location within the facility in accordance with the National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler System, 1999 edition. This deficient practice would affect all residents and staff in the affected zone. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observation and interview on 4/11/12, revealed a mixture of a quick response sprinkler head and standard response sprinkler head in the Younkers 4th Floor EVS Closet on the East end of the West Hall. This room also revealed the two sprinkler heads were installed within 6 feet of each other. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to provide proper sprinkler protection in 4 locations within the facility in accordance with the National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler System, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observation and interview on 4/10/12, revealed the following:

1. The Laboratory Walk-in Cooler failed to be provided with any sprinkler coverage.

2. The Nuclear Medicine Room 5 revealed the room was not protected with any sprinkler coverage.

3. The Kitchen revealed the Walk-in Cooler failed to be provided with any sprinkler coverage.

4. The Kitchen revealed the Walk-in Freezer failed to be provided with any sprinkler coverage.

The Facility Maintenance Staff A and B confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspections, Testing, and Maintenance for Sprinkler Systems, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The Younkers 4th Floor Younkerville revealed a gap between the sprinkler head and the ceiling tile located above the East Therapy Mat by the "Smiley Face" ceiling tile.

2. The Younkers 4th Floor Younkerville revealed "branches" off the fake tree were within 18 inches of sprinkler heads located in the center of the room.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations, record review, and interview, the facility failed to maintain the building's sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspections, Testing, and Maintenance for Sprinkler Systems, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 4/10/12 through 4/12/12, revealed the following:

1. The North Tower 6th Floor Employee Restroom by Room N671 revealed a paint like substance on the sprinkler head.

2. The North Tower 5th Floor East Corridor by the Women's Restroom revealed an escutcheon ring falling off the sprinkler head.

3. The North Tower 5th Floor revealed the sprinkler by the Clock and Chairs by Room 564 revealed the escutcheon ring was missing.

4. The North Tower 4th Floor Room 464 revealed a paint-like substance on the sprinkler head by the Restroom.

5. The North Tower 4th Floor Nourishment Room N426 revealed a build up of dust and dirt on the sprinkler head.

6. The North Tower 4th Floor Nurse's Station revealed a build up of dust and dirt on the sprinkler head (1 of 3).

7. The North Tower 3rd Floor Room N369 revealed a paint-like substance on the sprinkler head located just inside the room.

8. The North Tower 3rd Floor Room N370 revealed a paint-like substance on the sprinkler head located just inside the room.

9. The North Tower 3rd Floor Room N371 revealed a paint-like substance on the sprinkler heads located in the Restroom and located just inside the room from the corridor.

10. The North Tower 3rd Floor Room N378 revealed an escutcheon ring missing on the sprinkler head located above the bed.

11. The North Tower 2nd Floor Utility Room N235 revealed a missing escutcheon ring on the sprinkler head.

12. The North Tower 2nd Floor Women's Locker Room N213 revealed a missing escutcheon ring on the sprinkler head.

13. The North Tower 1st Floor Admissions/Patient Access Hallway revealed a missing escutcheon ring on the sprinkler above the plaques.

14. The Emergency Department Trauma 2 revealed a missing escutcheon ring on the sprinkler head located by the Corridor Door.

15. The North Tower Level A revealed 2 sprinkler pipes that were capped off where sprinkler heads should have been installed by the Electrical Distribution Panels.

16. The North Tower Level B Tube Room revealed a paint-like substance on the sprinkler head.

17. The North Tower Level B Fire Alarm Control Panel revealed trouble in the alarm that stated "Module PSC-12 at address 32" Negative Ground Fault."

18. The North Tower Level B Cath Lab Mechanical Room revealed a build-up of dust and dirt on the sprinkler head by the Large Duct.

19. The North Tower Level C Radiology Adult Holding revealed a build up of dust and dirt on the sprinkler head above the Nurse's Station.

20. The North Tower Level C Doctor Dictation Rear Room 1 revealed an escutcheon ring missing on the sprinkler head.

21. The North Tower 6th Floor Room N661 revealed an escutcheon ring around a sprinkler head that was not flush with the ceiling.

22. The North Tower 5th Floor North Wing revealed sprinkler heads that were not flush with the ceiling in the Staff Breakroom, Rooms N567, N569, N572, and N573.

23. The North Tower 5th Floor North Wing revealed an escutcheon ring around a sprinkler head that was installed upside-down in Room N578.

24. The North Tower 3rd Floor revealed escutcheon rings around sprinkler heads that were not flush with the ceiling in the Corridor by Rooms 301 and 305.

25. The North Tower 2nd Floor Room 205 revealed a missing escutcheon ring on the sprinkler head.

26. The Emergency Department Room 4 revealed a recessed sprinkler head that was missing its cover.

27. The Wound Healing Center revealed an escutcheon ring around a sprinkler head that was not flush with the ceiling located by the Electrical Panels.

28. The Wound Healing Center Exam Room 1 revealed an escutcheon ring that was missing from a sprinkler head.

29. The Blank Hospital Level A Utility Closet by Phlebotomy revealed the escutcheon ring on the sprinkler were not flush with the ceiling.

30. The Blank Hospital Level A Flow Cytometry Laboratory revealed the escutcheon rings on 2 sprinkler heads were not flush with the ceiling.

31. The Blank Hospital 1st Floor Hill Auditorium Control Room revealed a missing escutcheon ring on the sprinkler head.

32. The MOB 1 Children's Health Center Doctor's Office in the Northeast Corner revealed an escutcheon ring missing from the sprinkler head.

33. The MOB1 Children's Health Center Storage Room by the Northeast Corner Office revealed storage materials within 18 inches of the sprinkler head.

34. Record review of the Fire Pump documentation check sheet revealed that the electric pump for Methodist Main Hospital "will be exercised for 1-3 minutes weekly." Maintenance Staff A verified that the pump was excercised as per the documentation. The electrical fire pump is required to be excercised for at least 10 minutes weekly.

35. Record review of the Fire Pump documentation check sheet revealed that the electric fire pump for the Methodist West Hospital "will be exercised for 1-3 minutes weekly." Maintenance Staff A verified that the pump was exercised as per the documentation. The electrical fire pump is required to be excercised for at least 10 minutes weekly.

36. The West Des Moines Blank Pediatrics Therapy Swing Room revealed a missing escutcheon ring on the sprinkler head.

37. The West Des Moines Blank Pediatrics Therapy Main Sprinkler Riser revealed the cover device was missing on the Flow Switch.

38. The West Des Moines Blank Pediatrics Therapy Spare Sprinkler Head Box revealed the box contained only 2 spare sprinkler heads.

39. The West Des Moines Blank Pediatrics Therapy record review of the Sprinkler System documentations revealed the facility was not conducting quarterly flow tests of the Sprinkler System.

The Facility Maintenance Staff A and B confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain fire extinguishers in the building in accordance with the National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 1998 edition. This deficient practice would affect all residents and staff within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/10/12 and 4/11/12, revealed the following:

1. The North Tower 7th Floor North Mechanical Room revealed 3 fire extinguishers that were missing the March 2012 monthly visual inspection.

2. The North Tower 7th Floor West Elevator Equipment Room revealed a fire extinguisher that was sitting on the floor and was not properly mounted. This extinguisher did not receive the March 2012 monthly visual inspection.

3. The North Tower 7th Floor Main Lobby Elevator Penthouse revealed the extinguisher was not provided with the March 2012 monthly visual inspection.

4. The North Tower Helipad North Stairwell revealed the fire extinguisher was missing the March 2012 monthly visual inspection.

5. The North Tower North 9 Elevator Penthouse revealed the fire extinguisher was sitting on the ground and was not properly mounted. This fire extinguisher also revealed missing February and March 2012 monthly visuals.

6. The North Tower Laboratory Break Room revealed a fire extinguisher that was not mounted and was not provided with an inspection tag to identify the date of the last annual inspection.

7. The North Tower Laboratory Immunohematology Room revealed the fire extinguisher was obstructed by testing equipment.

8. The North Tower Cath Laboratory Mechanical Room revealed a "General" Brand fire extinguisher that was on recall.

9. The North Tower 7th Floor Mechanical Room revealed a "General" Brand fire extinguishers that was on recall.

10. The North Tower Life Flight Machine Shed revealed a "General" Brand fire extinguisher that was on recall. Documentation on the fire extinguisher indicated that the extinguisher was missing a March 2012 monthly visual inspection. This extinguisher was also mounted where the top of the extinguisher was at a height more than 5 feet off the ground.

11. The North Tower 3rd Floor Corridor by Room N301 revealed the fire extinguisher was missing the March 2012 monthly visual inspection.

12. The Laboratory revealed the facility failed to provide the February and March 2012 monthly visual inspections for fire extinguisher #PO4022.

13. The Northeast Addition-Northeast Elevator Penthouse revealed the fire extinguisher was missing the March 2012 monthly visual inspection.

The Facility Maintenance Staff A and B confirmed these findings on the date of inspection

Based on observation and interview, the facility failed to provide curtains or blinds that were flame retardant materials, in 1 location, meeting the provisions of 10.3.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observation and interview on 4/11/12, revealed a vinyl mini-blind located on the window in the Blank Hospital Control Room. The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to provide curtains that were provided with 1/2 inch mesh. This deficient practice would affect all residents within the affected zone.

Findings include:

Observation and interview on 4/17/12, revealed privacy curtains in the Men's and Women's Locker Rooms were constructed with mesh that was smaller than 1/2 inch in size. The Facility Maintenance Staff C confirmed this finding on the date of inspection.

(A) Based on observations and interview, the facility failed to properly maintain the building's suspended ceiling grid in proper working condition. This deficient practice would affect all residents and staff within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the dates of inspection.

Findings include:

Observations and interview on 4/10/12 through 4/12/12, revealed the following:

1. The Emergency Department Ambulance Garage revealed multiple suspended ceiling tiles missing on by the North Garage Door, the Southeast Corner of the Garage, and by the East Garage Door.

2. The North Tower 7th Floor Medical Personal Storage Room revealed a broken ceiling tile that revealed a gap (approximately 1/2 inch in size) in the ceiling tile grid.

3. The Microbiology Laboratory revealed communication lines running through the ceiling tile grid that left a gap (approximately 1/2 inch in size) in the ceiling tile grid.

4. The Blank Hospital Level A Utility Closet by Phlebotomy revealed several suspended ceiling tiles were missing.

5. The MOB1 Children's Health Center Clinic EVS Room revealed several missing smoke ceiling tiles in the grid.

The Facility Maintenance Staff A and B confirmed these findings on the dates of inspection.

(B) Based on observation and interview, the facility failed to maintain proper storage of 1 compressed helium bottle in 1 location. This deficient practice would affect all residents and staff within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents on the dates of inspection.

Findings include:

Observation and interview on 4/10/12, revealed an unsecured helium tank in the North Tower Gift Shop Storage Room. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

(C) Based on observation and interview, the facility failed to remove all unapproved air freshner devices within the facility. This deficient practice would affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents on the dates of inspection.

Findings include:

Observation and interview on 4/12/12 revealed a heated oil air freshner that plugged directly into the wall was in use in the MOB1 Children's Health Center Scheduling Office. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to properly maintain the suspended ceiling tile grid in areas throughout the building. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/11/12, revealed a missing ceiling tile in the Younkers 6th Floor Pediatrics OB Anesthesia Room 630 B. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on record review and interview, the facility failed to provide proper testing and documentation of the building's emergency generator in accordance with the National Fire Protection Association (NFPA) Standard 110, 1999 edition. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Record review and interview on 4/10/12, revealed that the monthly 30-minute load tests were conducted at 17% of the name plate. This did not meet the 30 minutes under load at 30% of the name plate. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's electrical system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and had a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/10/12 to 4/12/12 revealed the following:

1. The North Tower 6th Floor Main Lobby Elevator Penthouse revealed a fan plugged into a drop cord.

2. The North Tower 5th Floor Menu Room by N557 revealed permanently used fluorescent lighting that was not hardwired.

3. The North Tower 4th Floor Office N401 revealed an extension cord with a coffee pot plugged into it.

4. The Emergency Department Ambulance Garage East Garage Door revealed a missing cover device for the exposed electrical wiring in the Garage Door Opener.

5. The North Tower Level A Mechanical Room A revealed a drop cord that was in use in the A.H. Unit S3.

6. The North Tower Level A Mechanical Room A revealed 3 electrical junction boxes on the ceiling lid by the Electrical Distribution Panels that were not properly covered.

7. The North Tower 3rd Floor Locker Room revealed an electrical outlet that was not provided with ground fault circuit interruption and was installed within 6 feet of a sink.

8. The North Tower Level A Mechanical Room revealed an open gap in Electrical Panel P-B1.

9. The North Tower Level A 2 Hour Fire Wall near the Environmental Closet revealed an open electrical junction box without a cover located above the suspended ceiling tile.

10. Room S408 revealed a lamp plugged into a surge protector.

11. Room S231 revealed the Ground Fault Circuit Interrupter was faulty.

12. The Dialysis Break Room revealed a coffee pot and a refrigerator plugged into a surge protector.

13. The Blank Hospital Flow Cytometry Laboratory revealed a refrigerator plugged into a surge protector.

14. The Anna Blank Clinic Office LL20 revealed a lamp plugged into an extension cord.

15. The MOB1 Children's Health Center East Weight Room revealed a broken electrical outlet cover.

16. The Methodist West Hospital 3rd Floor Team Member Break Room revealed the facility failed to maintain the Ground Fault Circuit Interrupters in the West wall by the sink. The Ground Fault Circuit Interrupter electrical outlets failed to trip when tested and contained an open neutral. This building had a capacity of 83 residents and census of 23 residents at the time inspection.

17. The Methodist West Hospital Break Room Pharmacy revealed the facility failed to provide Ground Fault Circuit Interruptors for the electrical outlets next to the sink on the West wall. This building had a capacity of 83 residents and a census of 23 residents at the time of inspection.

The Facility Maintenance Staff A and B confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's electrical system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and had a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The Younkers 7th Floor Doctor On-Call Sleep Room revealed a microwave plugged into a surge protector.

2. The Younkers 6th Floor Nursery revealed exposed electrical wires where the clock used to be on the wall.

3. The Younkers 5th Floor Communications Room by Room 515 revealed an electrical junction box without a cover.

4. The Younkers 3rd Floor Smoke Doors by the Transition by Audiology revealed 2 open electrical junction boxes.

5. The Younkers 3rd Floor IT Communications Room by the Younker Elevators revealed 3 open electrical junction boxes.

6. The Younkers 8th Floor Communications Room on the East end of the South Hall revealed an electrical junction box without a cover.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to provide proper fire watch policy documentation for the sprinkler system outage policy. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Record review and interview on 4/12/12, revealed the facility's Sprinkler System Outage Policy for both Methodist West Hospital and the Methodist Main Hospital failed to provide contact information for the local Fire Department, the Iowa Department of Inspections and Appeals, the State Fire Marshal's Office, and the facility's Insurance Company. Contact information and phone numbers are required to be listed in the Sprinkler System Outage Policy. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on record review and interview, the facility failed to provide proper fire watch policy documentation for the fire alarm outage policy. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Record review and interview on 4/12/12, revealed the facility's Fire Alarm Outage Policy for both Methodist West Hospital and the Methodist Main Hospital failed to provide contact information for the local Fire Department, the Iowa Department of Inspections and Appeals, the State Fire Marshal's Office, and the facility's Insurance Company. Contact information and phone numbers are required to be listed in the Fire Alarm Outage Policy. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 Alcohol-Based Hand Rub in accordance with Section 19.3.2.7 of the 2000 Life Safety Code. This deficient practice affects 1 smoke zone. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observation and interview on 4/11/12, revealed an alcohol based hand rub dispenser located above an electrical source in Room S312. Maintenance Staff A verified this observation on the date of inspection.

Based on observations and interview, the facility failed to provide the 2 hour fire resistance separation between 2 different building types. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observations and interview on 4/10/12 through 4/12/12, revealed the following:

1. The North Tower 2 hour wall between the North Tower 2 and the North Main Lobby revealed a conduit penetration (approximately 1/4 inch in size) located above the suspended ceiling.

2. The North Tower 1st Floor 2 hour wall by the Younker Connector revealed a pipe & communications line penetration (approximately 3/16 inch in size) located above the suspended ceiling.

3. The North Tower Level A 2 hour fire wall to Blank Hospital revealed a wire bundle penetration (approximately 1/4 inch in size) located above the suspended ceiling.

4. The North Tower Level B 2 hour fire wall between the North Wing and the South Wing revealed a pipe penetration (approximately 4 inches in size), a hole (approximately 1 inch in size) located above the suspended ceiling.

5. The North Tower Level C 2 hour Fire Wall in Radiology by the Men's Locker Room revealed a blue pipe penetration (approximately 1/4 inch in size) located above the suspended ceiling.

6. The Northeast Addition Middle Corridor 2 hour Fire Wall revealed a conduit penetration (approximately 1/4 inch in size) located above the suspended ceiling.

7. The Northeast Addition 2nd Floor 2 hour Fire Wall by the Pharmacy revealed a conduit penetration (approximately 3/16 inch in size) located above the suspended ceiling.

8. The Blank Hospital Level C 2 hour wall to the North Wing revealed a pipe penetration (approximately 1/4 inch in size).

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and staff interview, it was determined the facility was a 6 story building and consisted of fire resistant construction equipped with an automatic sprinkler system. The facility failed to assure minimum building construction requirements were maintained by ensuring that holes and gaps around penetrations are sealed with one-hour fire rated materials to protect the adjacent floors. This deficient practice affects all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents at the time of inspection.

Findings include:

Observations and interview on 4/10/12, revealed the following;

1. The North Tower 6th Floor Room N669 revealed a vertical sprinkler head (1 of 2) penetration (approximately 1/2 inch in size) located in the ceiling lid above the Bed.

2. The North Tower 5th Floor Room N563 revealed a vertical sprinkler head penetration (approximately 1/2 inch in size) located in the ceiling lid above the Bed.

3. The North Tower 5th Floor by Room 565 revealed a vertical sprinkler head penetration (approximately 1/2 inch in size) due to a sprinkler escutcheon ring falling off the head.

4. The North Tower 4th Floor Room 460 revealed a vertical sprinkler head penetration (approximately 1/2 inch in size) located by the Chair.

5. The North Tower 4th Floor Nurse's Station revealed a vertical sprinkler head penetration (approximately 1/2 inch in size) located by the Medication Room N-424.

6. The North Tower 4th Floor by the Environmental Closet revealed a vertical gap (approximately 1/4 inch in size) located around the sprinkler head.

7. The North Tower 3rd Floor Room N377 revealed a vertical sprinkler penetration (approximately 1 inch in size) located above the Bed.

8. The North Tower Control Room 11 revealed a vertical sprinkler penetration (approximately 1/2 inch in size) located in the ceiling lid.

9. The North Tower 7th Floor Megavator Room revealed a missing piece of drywall (approximately 2 feet by 7 feet in size) off the wall. The absence of the drywall leaves the inner wall structure exposed. Maintenance Staff A indicated that the facility was in the process of repairing a leak in the roof of this area.

10. The North Tower 4th Floor revealed that the baseboard was missing from the bottom of all of the Corridor Walls throughout the floor.

11. The North Tower 3rd Floor Electrical Closet revealed an open pipe penetration (approximately 2 inches in size), extending through the wall of the North Tower.

12. The Microbiology Compressed Gas Storage Room revealed 4 penetrations (approximately 3/16 inch in size each) located around lines extending through the ceiling, a vertical insulated pipe penetration (approximately 3/16 inch in size) through the ceiling, and 2 vertical holes (approximately 1 inch in size each) located in the ceiling.

13. The Dietician's Office revealed a sprinkler pipe penetration (approximately 1/2 inch in size).

14. The Cooler #23 revealed a sprinkler pipe penetration (approximately 1/2 inch in size) into a resident's room.

15. The Level D EVS Break Room revealed 3 sprinkler pipe penetrations (approximately 1/2 inch in size each).

16. The MOB 1 Children's Health Center Cubicle Office Area revealed a vertical hole (approximately 1/2 inch in size) in the tile around the sprinkler head.

The Facility Safety Supervisor and Maintenance Staff B confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain 1 corridor room wall properly separated from the corridor. This deficient practice could affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents at the time of inspection.

Findings include:

Observation and interview on 4/10/12, revealed a white wire penetration (approximately 1/4 inch in size) located in the corridor wall of the IT/Communications Room of the North Building 4th Floor. The Facility Safety Supervisor confirmed this finding on the date of inspection

Based on observation and interview, the facility failed to maintain 1 corridor room wall properly separated from the corridor. This deficient practice could affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observation and interview on 4/11/12, revealed a sprinkler pipe penetration (approximately 1/2 inch in size) in the Closet wall of the Exit Hall to the Park. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 2 doors in 1 smoke zone in proper working condition. This deficient practice would affect all st within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/10/12, revealed the following:

1. The North Tower Level C Supervisor of Radiology Office Door revealed a kick down device on the door to prevent the door from swinging closed.

2. The North Tower Level C PACS Office Door revealed a kick down device on the door to prevent the door from swinging closed.

3. The Blank Hospital 6th Floor Restroom by Room 503A revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

4. The Blank Hospital 6th Floor Door to the Laundry Room 516 revealed the door was obstructed from opening fully due to a cart blocking the door.

5. The Blank Hospital 6th Floor Physician's Lounge 555 revealed a garbage can propping open the door to the Sleep Room Hallway.

6. The Anna Blank Clinic Conference Room LL04 revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

The Facility Safety Supervisor confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain several corridor doors in proper working condition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The Younker 7th Floor IT Closet by Room 715 revealed the door failed to close and latch into the door frame with the swing of the door closer when tested.

2. The Younker 5th Floor Orthopaedic Technician Office revealed 3 holes in the door where the previous hardware had been replaced.

3. The Younker 5th Floor Staff Restroom by the Family Room revealed the door failed to close and latch properly into the door frame with the swing of the door closer.

4. The Younker 3rd Floor CCU Supervisor's Office revealed the door was wedged in the open position.

5. The Younker 3rd Floor CCU Doors 305 A revealed the doors failed to close and latch properly into the door frame with the swing of the door closer.

6. The Younker 4th Floor "Powell 4 Medical Neurology" revealed the door closer for the door had been detached from the door.

7. The Younker 4th Floor "Powell 5 Unit Based Educator" revealed the door closer for the door had been detached from the door.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain proper 1 hour vertical fire separation in 1 location. This deficient practice could affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observation and interview on 4/11/12, revealed a center flexible conduit penetration (approximately 1/2 inch in size) located in the Corridor Wall to the Stairwell of Younker 3rd Floor by the Transition by Audiology. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the proper vertical separation between floors within the facility. This deficient practice would affect all staff and residents in the affected area. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observation and interview on 4/10/12, revealed the following:

1. The North Tower 4th Floor Elevator 2 Hour Fire Wall revealed a pipe penetration (approximately 1/4 inch in size).

2. The North Tower 4th Floor by Room 402 revealed the Stairwell door failed to close and latch properly into the door frame with the swing of the door closer.

3. The Methodist West Southwest Stairwell on Level 5 revealed a hole (approximately 1 inch in size) located in the East wall.

The Facility Safety Supervisor and Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects all residents and staff within the affected zones. This facility has a capacity of 674 and a census of 363 residents.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The Powell 4th Floor Smoke Barrier by Room P-438 revealed a pipe penetration (approximately 4 inches in size) located above the suspended ceiling.

2. The Powell 4th Floor Smoke Barrier by Room P439 revealed a pipe penetration (approximately 1/4 inch in size) located above the suspended ceiling.

3. The Powell 3rd Floor Smoke Barrier Wall #MP0000078 revealed a pipe penetration (approximately 4 inches in size) located above the suspended ceiling.

4. The Powell 3rd Floor Smoke Barrier Wall #MP0000077 revealed a pipe penetration (approximately 4 inches in size) located above the suspended ceiling.

The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain smoke barriers in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects all residents and staff within the affected zones. This facility has a capacity of 674 and a census of 363 residents.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The Younker 7th Floor Smoke Barrier by Room 719 revealed a hole (approximately 1/2 inch in size) located above the suspended ceiling tiles.

2. The Younker 6th Floor Smoke Barrier by Room Y648 revealed a wire penetration (approximately 1/2 inch in size) and a conduit sleeve penetration (approximately 1 inch in size) located above the suspended ceiling tile.

3. The Younkers 3rd Floor Smoke Barrier to Younker Elevator revealed a conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling tile.

4. The Younkers 3rd Floor Northeast Addition Smoke Barrier by the Staff Lounge 353 revealed a wire bundle penetration (approximately 1/2 inch in size) located above the suspended ceiling.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain smoke barriers within the facility in accordance with National Fire Protection Association (NFPA) Standard 101, 2000 edition, 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall and from floor to a roof extending through all concealed spaces. Smoke barriers shall have a fire resistance rating of not less than 1/2 hour. This deficient practice affects all residents and staff within the facility. This facility has a capacity of 674 and a census of 363 residents.

Findings include:

Observations and interview on 4/10/12, revealed the following:

1. The North Tower 4th Floor Smoke Barrier by Room 454 revealed a conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling.

2. The North Tower 3rd Floor by Room N376 revealed a pipe penetration (approximately 1/2 inch in size) located above the suspended ceiling.

3. The North Tower 2nd Floor Smoke Barrier by Storage Room N220 revealed a conduit penetration (approximately 1/2 inch in size) located above the suspended ceiling.

4. The North Tower Emergency Department Smoke Barrier to the Megavator revealed an IT wire bundle penetration (approximately 1/2 inch in size) located above the suspended ceiling.

5. The Emergency Department East Hallway Exit Smoke Barrier revealed a conduit penetration (approximately 1/2 inch in size).

6. The North Tower 3rd Floor Smoke Barrier Wall by Room N356 revealed 2 conduit penetrations (approximately 3/16 inch in size) located above the suspended ceilng.

7. The North Tower 3rd Floor Smoke Barrier by Room N362 revealed a conduit penetration (approximately 3/16 inch in size) located above the suspended ceiling.

8. The Northeast Addition on the 3rd Floor revealed a conduit penetration (approximately 3/16 inch in in the Smoke Barrier Wall in Pod A next to Room 311, located above the suspended ceiling.

9. The Northeast Addition on the 3rd Floor revealed a flexible conduit penetration (approximately 3/16 inch in size) located above the suspended ceiling tile in the Smoke Barrier Wall in Pod A next to Room 311.

10. The Methodist West 5th Floor Smoke Barrier by Room 5001 revealed 3 center conduit penetrations (approximately 1/2 inch in size each) located above the suspended ceiling tile.

The Facility Safety Supervisor and Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to maintain smoke barrier doors in proper working condition. This deficient practice would affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observation and interview on 4/11/12, revealed the Younker 5th Floor Smoke Barrier Doors by Room 515 failed to close and latch properly into the door frame with the swing of the door closers. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain 8 sets of smoke barrier doors in proper working condition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observations and interview on 4/10/12, revealed the following:

1. The North Tower 6th Floor Fire Doors by Room N675 revealed the doors failed to close and latch properly into the door frame with the swing of the door closers.

2. The North Tower 3rd Floor Smoke Barrier by the Employees Break Room revealed the Doors failed to close and latch properly into the door frame with the swing of the door closers.

3. The North Tower 2nd Floor Neonatal Overflow Area Smoke Barrier by Room N220 revealed a gap (approximately 1 1/2 inches in size) located between the bottom of the doors and the floor.

4. The North Tower 2nd Floor Neonatal Overflow Area Smoke Barrier by Room N236 revealed a gap (approximately 1 1/2 inches in size) located between the bottom of the doors and the floor.

5. The North Tower Level C Fire Doors to Radiology revealed the doors failed to close and latch properly into the door frame with the swing of the door closers.

6. The North Tower Level C Smoke Barrier Doors to to the Radiology Adult Holding Area revealed the doors failed to close and latch properly into the door frame with the swing of the door closers.

7. The North Tower Smoke Barrier Doors by Room N62 revealed the doors failed to close and latch properly into the door frame with the swing of the door closers.

8. The Methodist West Smoke Barrier Doors near Room 3125 revealed the doors failed to cloe and latch properly into the door frame with the swing of the door closers.

10. The MOB1 Children's Health Center West Lobby door to the Patient Area revealed the door failed to close and latch properly into the door frame with eh swing of the door closer.

The Facility Safety Supervisor and the Facility Maintenance Director confirmed these findings on the date of inspection.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. This deficient practice would affect allresidents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents.


Findings include:

Observation and interview on 4/11/12, revealed the Younkers 7th Floor Equipment Room by Room 717 door failed to close and latch properly into the door frame with the swing of the door closer. The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. This deficient practice would affect all residents and staff within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents.


Findings include:

Observations and interview on 4/10/12, revealed the following:

1. The North Tower 5th Floor Environmental Room N555 revealed a vertical sprinkler penetration (approximately 1/2 inch in size) located in the ceiling lid.

2. The North Tower Laboratory Wash Room revealed a vertical duct penetration (approximately 1/4 inch in size) located in the ceiling lid.

3. The North Tower Level B Megavotor Chair Storage Room revealed the Corridor Door failed to close and latch properly into the door frame with the swing of the door closer.

4. The North Tower Level C Housekeeping Closet by Room 13 revealed the door closer had been detached from the door.

5. The North Tower Level C Housekeeping Closet by Room 13 revealed a vertical pipe penetration (approximately 1/2 inch in size) located in the ceiling lid.

6. The Blank Hospital 3rd Floor Equipment Room 361A revealed the door failed to close and latch properly into the door frame with the swing of the door closer when tested.

7. The MOB1 Children's Health Center West Electrical Closet revealed a conduit sleeve penetration (approximately 1/2 inch in size) located in the corridor wall.

8. The Ankeny Blank Pediatric Therapy Garage Storage Area revealed the door was not equipped with a self-closing device on the door.

9. The Ankeny Blank Pediatric Therapy East Storage Rooms (4 rooms) failed to stay tightly latched whenin the door frames when tested. These doors were equipped with magnetic type latches instead of positive latches. This building was inspected on 4/17/12.

10. The West Des Moines Blank Pediatric Therapy 4 Closet Doors across from the Staff Restroom revealed that the doors did not stay tightly latched within the door frames. These doors were equipped with positive latching devices. This building was inspected on 4/17/12.

11. The West Des Moines Blank Pediatric Therapy 4 Closet Doors located in the Main Therapy Area revealed that the doors were not provided with positive latching devices. This building was inspected on 4/17/12.



The Facility Maintenance Director and the Facility Safety Supervisor confirmed these findings on the date of inspection.

Based on observations and staff interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, The Life Safety Code, 2000 edition, 19.3.2.1. This deficient practice would affect all residents within the affected zones.


Findings include:

Observations and interview on 4/17/12, revealed the following:

1. The Holding & Breakdown Room revealed a vertical pipe penetration (approximately 1 inch in size) located in the ceiling lid.

2. The Mechanical Room revealed a pipe penetration (approximately 2 inches in size) located above the corridor door.

3. The The OR3/Autoclave Room revealed 8 vertical conduit and pipe penetrations (approximately 1/4 inch in size) located in the ceiling lid.

The Facility Maintenance Staff C confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain exit pathways that were clear, unobstructed, and easily accessible at all times. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/10/12, revealed the following:

1. The 5th Floor of the North Building revealed Hinged Nursing Charting Stations attached to the walls that failed to be self-closing when pressure was released.

2. The North Building 3rd Floor Corridor revealed Hinged Charting Stations attached to the walls that failed to be self-closing when pressure was released.

3. The MOB1 Children's Health Center Doctor's Office Hallway revealed a chair in the Hallway.

4. The Anna Blank Clinic Basement Mechanical Door revealed the door failed to open when tested.

5. The Ankeny Blank Pediatrics Therapy revealed the 2 Northeast Mechanical Room Doors were closed and latched with slide locks that would not allow for access to an exit from the interior of the room. This building was inspected on 4/17/12.

The Facility Safety Supervisor confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain several emergency lighting units within the facility in proper working condition. This deficient practice would affect all residents and staff members within the affected zones. The facility had a capacity of 674 residents and census of 363 residents.

Findings include:

Observations and interview on 4/12/12, revealed the following:

1. The Blank Infusion Center Corridor by the Front Desk revealed the emergency lighting unit failed to illuminate when tested.

2. The Blank Infusion Center Corridor by Room 3 revealed the emergency lighting unit failed to illuminate when tested.

3. The Blank Infusion Center Corridor by Room 5 revealed the emergency lighting unit failed to illuminate when tested.

4. The Store Room "D" revealed the emergency lighting unit on the west side of the concrete pillar failed to illuminate when tested.

5. The Outpatient Therapy South revealed the emergency lighting unit located next to the Restroom failed to illuminate when tested. This building was inspected on 4/17/12.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to assure exit signs were properly displayed and visible throughout the facility in 2 locations. This deficient practice affects 1 smoke zone. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The facility failed to provide visible illuminated exit signs to indicate the path of egress in the middle of the East Hall, on the West Side of the smoke barriers on the 2nd, 3rd, 4th, and 5th Floors.

2. The West Des Moines Blank Pediatric Therapy revealed the exit sign by the Soiled Utility Room did not indicate egress to the West Exit Door due to the arrowed chevron not being removed.

Maintenance Staff A confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to provide fire drills of varied times of the day for 4 of 4 quarters review. This deficient practice would affect all residents within the facility. The facility had a capacity of 83 residents and a census of 23 residents on the date of inspection.

Findings include:

Record review and interview on 4/10/12, revealed the facility Fire Drill documentation for the Methodist West Hospital showed that 4 of the 3rd Shift drills were conducted at approximately the same time. The Third Shifts were conducted as follows: 3/6/11 at 10:51 p.m., on 6/7/11 at 1043 p.m., on 9/9/11 at 10:50 p.m., and on 12/18/11 at 10:53 p.m. The Facility Maintenance Staff A confirmed this finding.

Based on observations, record review, and interview, the facility failed to maintain the building's fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Observations, record review, and interview on 4/10/12, revealed

1. The North Building 2nd Floor Intern's Lounge revealed a smoke detector that was installed within 3 feet of an air diffuser.

2. The Fire Alarm Panel located in the North Tower 3rd Floor Electrical Closet indicated that the system was in trouble. Maintenance Staff A indicated that the problem was a bad smoke detector.

3. The North Tower 4th Floor revealed a smoke detector covered with blue painter's tape in Room 479.

4. The Outpatient Infusion Area revealed a smoke detector that was installed within 3 feet of an air diffuser in the Corridor.

5. The Wound Healing Center by Exam Room 1 revealed a smoke detector that was installed within 3 feet of an air diffuser.

6. The North Tower Level A Mechanical Room revealed the Fire Alarm Control Panel circuit breaker located in Electrical Panel ELSA 120 B01 was not properly locked out.

7. The Blank Hospital 1st Floor across from the Physician's Neonatal Locker Room revealed a smoke detector that was installed within 3 feet of an air diffuser.

8. The MOB1 Children's Health Center Southwest Doctor's Office Corridor revealed a smoke detector installed within 3 feet of an air diffuser.

9. The MOB1 Children's Health Center Nurse's Station revealed a smoke detector installed within 3 feet of an air diffuser.

10. The MOB1 Children's Health Center East Weight Room Hallway revealed a smoke detector that was installed within 3 feet of an air diffuser.

11. The MOB1 Children's Health Center East Waiting Room Area revealed a smoke detector that was installed within 3 feet of an air diffuser.

12. The Methodist West Hospital 5th Floor Corridor by Room 5057 revealed a smoke detector that was installed within 3 feet of an air diffuser. This facility had a capacity of 83 residents and a census of 23 residents.

13. The West Des Moines Blank Pediatrics Therapy revealed the facility provided only an annual inspection of the building's Fire Alarm System.

The Facility Maintenance Staff A and B confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to provide proper sprinkler protection in 1 location within the facility in accordance with the National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler System, 1999 edition. This deficient practice would affect all residents and staff in the affected zone. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observation and interview on 4/11/12, revealed a mixture of a quick response sprinkler head and standard response sprinkler head in the Younkers 4th Floor EVS Closet on the East end of the West Hall. This room also revealed the two sprinkler heads were installed within 6 feet of each other. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to provide proper sprinkler protection in 4 locations within the facility in accordance with the National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler System, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observation and interview on 4/10/12, revealed the following:

1. The Laboratory Walk-in Cooler failed to be provided with any sprinkler coverage.

2. The Nuclear Medicine Room 5 revealed the room was not protected with any sprinkler coverage.

3. The Kitchen revealed the Walk-in Cooler failed to be provided with any sprinkler coverage.

4. The Kitchen revealed the Walk-in Freezer failed to be provided with any sprinkler coverage.

The Facility Maintenance Staff A and B confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspections, Testing, and Maintenance for Sprinkler Systems, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The Younkers 4th Floor Younkerville revealed a gap between the sprinkler head and the ceiling tile located above the East Therapy Mat by the "Smiley Face" ceiling tile.

2. The Younkers 4th Floor Younkerville revealed "branches" off the fake tree were within 18 inches of sprinkler heads located in the center of the room.

The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observations, record review, and interview, the facility failed to maintain the building's sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspections, Testing, and Maintenance for Sprinkler Systems, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations, record review, and interview on 4/10/12 through 4/12/12, revealed the following:

1. The North Tower 6th Floor Employee Restroom by Room N671 revealed a paint like substance on the sprinkler head.

2. The North Tower 5th Floor East Corridor by the Women's Restroom revealed an escutcheon ring falling off the sprinkler head.

3. The North Tower 5th Floor revealed the sprinkler by the Clock and Chairs by Room 564 revealed the escutcheon ring was missing.

4. The North Tower 4th Floor Room 464 revealed a paint-like substance on the sprinkler head by the Restroom.

5. The North Tower 4th Floor Nourishment Room N426 revealed a build up of dust and dirt on the sprinkler head.

6. The North Tower 4th Floor Nurse's Station revealed a build up of dust and dirt on the sprinkler head (1 of 3).

7. The North Tower 3rd Floor Room N369 revealed a paint-like substance on the sprinkler head located just inside the room.

8. The North Tower 3rd Floor Room N370 revealed a paint-like substance on the sprinkler head located just inside the room.

9. The North Tower 3rd Floor Room N371 revealed a paint-like substance on the sprinkler heads located in the Restroom and located just inside the room from the corridor.

10. The North Tower 3rd Floor Room N378 revealed an escutcheon ring missing on the sprinkler head located above the bed.

11. The North Tower 2nd Floor Utility Room N235 revealed a missing escutcheon ring on the sprinkler head.

12. The North Tower 2nd Floor Women's Locker Room N213 revealed a missing escutcheon ring on the sprinkler head.

13. The North Tower 1st Floor Admissions/Patient Access Hallway revealed a missing escutcheon ring on the sprinkler above the plaques.

14. The Emergency Department Trauma 2 revealed a missing escutcheon ring on the sprinkler head located by the Corridor Door.

15. The North Tower Level A revealed 2 sprinkler pipes that were capped off where sprinkler heads should have been installed by the Electrical Distribution Panels.

16. The North Tower Level B Tube Room revealed a paint-like substance on the sprinkler head.

17. The North Tower Level B Fire Alarm Control Panel revealed trouble in the alarm that stated "Module PSC-12 at address 32" Negative Ground Fault."

18. The North Tower Level B Cath Lab Mechanical Room revealed a build-up of dust and dirt on the sprinkler head by the Large Duct.

19. The North Tower Level C Radiology Adult Holding revealed a build up of dust and dirt on the sprinkler head above the Nurse's Station.

20. The North Tower Level C Doctor Dictation Rear Room 1 revealed an escutcheon ring missing on the sprinkler head.

21. The North Tower 6th Floor Room N661 revealed an escutcheon ring around a sprinkler head that was not flush with the ceiling.

22. The North Tower 5th Floor North Wing revealed sprinkler heads that were not flush with the ceiling in the Staff Breakroom, Rooms N567, N569, N572, and N573.

23. The North Tower 5th Floor North Wing revealed an escutcheon ring around a sprinkler head that was installed upside-down in Room N578.

24. The North Tower 3rd Floor revealed escutcheon rings around sprinkler heads that were not flush with the ceiling in the Corridor by Rooms 301 and 305.

25. The North Tower 2nd Floor Room 205 revealed a missing escutcheon ring on the sprinkler head.

26. The Emergency Department Room 4 revealed a recessed sprinkler head that was missing its cover.

27. The Wound Healing Center revealed an escutcheon ring around a sprinkler head that was not flush with the ceiling located by the Electrical Panels.

28. The Wound Healing Center Exam Room 1 revealed an escutcheon ring that was missing from a sprinkler head.

29. The Blank Hospital Level A Utility Closet by Phlebotomy revealed the escutcheon ring on the sprinkler were not flush with the ceiling.

30. The Blank Hospital Level A Flow Cytometry Laboratory revealed the escutcheon rings on 2 sprinkler heads were not flush with the ceiling.

31. The Blank Hospital 1st Floor Hill Auditorium Control Room revealed a missing escutcheon ring on the sprinkler head.

32. The MOB 1 Children's Health Center Doctor's Office in the Northeast Corner revealed an escutcheon ring missing from the sprinkler head.

33. The MOB1 Children's Health Center Storage Room by the Northeast Corner Office revealed storage materials within 18 inches of the sprinkler head.

34. Record review of the Fire Pump documentation check sheet revealed that the electric pump for Methodist Main Hospital "will be exercised for 1-3 minutes weekly." Maintenance Staff A verified that the pump was excercised as per the documentation. The electrical fire pump is required to be excercised for at least 10 minutes weekly.

35. Record review of the Fire Pump documentation check sheet revealed that the electric fire pump for the Methodist West Hospital "will be exercised for 1-3 minutes weekly." Maintenance Staff A verified that the pump was exercised as per the documentation. The electrical fire pump is required to be excercised for at least 10 minutes weekly.

36. The West Des Moines Blank Pediatrics Therapy Swing Room revealed a missing escutcheon ring on the sprinkler head.

37. The West Des Moines Blank Pediatrics Therapy Main Sprinkler Riser revealed the cover device was missing on the Flow Switch.

38. The West Des Moines Blank Pediatrics Therapy Spare Sprinkler Head Box revealed the box contained only 2 spare sprinkler heads.

39. The West Des Moines Blank Pediatrics Therapy record review of the Sprinkler System documentations revealed the facility was not conducting quarterly flow tests of the Sprinkler System.

The Facility Maintenance Staff A and B confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain fire extinguishers in the building in accordance with the National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers, 1998 edition. This deficient practice would affect all residents and staff within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/10/12 and 4/11/12, revealed the following:

1. The North Tower 7th Floor North Mechanical Room revealed 3 fire extinguishers that were missing the March 2012 monthly visual inspection.

2. The North Tower 7th Floor West Elevator Equipment Room revealed a fire extinguisher that was sitting on the floor and was not properly mounted. This extinguisher did not receive the March 2012 monthly visual inspection.

3. The North Tower 7th Floor Main Lobby Elevator Penthouse revealed the extinguisher was not provided with the March 2012 monthly visual inspection.

4. The North Tower Helipad North Stairwell revealed the fire extinguisher was missing the March 2012 monthly visual inspection.

5. The North Tower North 9 Elevator Penthouse revealed the fire extinguisher was sitting on the ground and was not properly mounted. This fire extinguisher also revealed missing February and March 2012 monthly visuals.

6. The North Tower Laboratory Break Room revealed a fire extinguisher that was not mounted and was not provided with an inspection tag to identify the date of the last annual inspection.

7. The North Tower Laboratory Immunohematology Room revealed the fire extinguisher was obstructed by testing equipment.

8. The North Tower Cath Laboratory Mechanical Room revealed a "General" Brand fire extinguisher that was on recall.

9. The North Tower 7th Floor Mechanical Room revealed a "General" Brand fire extinguishers that was on recall.

10. The North Tower Life Flight Machine Shed revealed a "General" Brand fire extinguisher that was on recall. Documentation on the fire extinguisher indicated that the extinguisher was missing a March 2012 monthly visual inspection. This extinguisher was also mounted where the top of the extinguisher was at a height more than 5 feet off the ground.

11. The North Tower 3rd Floor Corridor by Room N301 revealed the fire extinguisher was missing the March 2012 monthly visual inspection.

12. The Laboratory revealed the facility failed to provide the February and March 2012 monthly visual inspections for fire extinguisher #PO4022.

13. The Northeast Addition-Northeast Elevator Penthouse revealed the fire extinguisher was missing the March 2012 monthly visual inspection.

The Facility Maintenance Staff A and B confirmed these findings on the date of inspection

Based on observation and interview, the facility failed to provide curtains or blinds that were flame retardant materials, in 1 location, meeting the provisions of 10.3.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observation and interview on 4/11/12, revealed a vinyl mini-blind located on the window in the Blank Hospital Control Room. The Facility Maintenance Staff A confirmed these findings on the date of inspection.

Based on observation and interview, the facility failed to provide curtains that were provided with 1/2 inch mesh. This deficient practice would affect all residents within the affected zone.

Findings include:

Observation and interview on 4/17/12, revealed privacy curtains in the Men's and Women's Locker Rooms were constructed with mesh that was smaller than 1/2 inch in size. The Facility Maintenance Staff C confirmed this finding on the date of inspection.

(A) Based on observations and interview, the facility failed to properly maintain the building's suspended ceiling grid in proper working condition. This deficient practice would affect all residents and staff within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the dates of inspection.

Findings include:

Observations and interview on 4/10/12 through 4/12/12, revealed the following:

1. The Emergency Department Ambulance Garage revealed multiple suspended ceiling tiles missing on by the North Garage Door, the Southeast Corner of the Garage, and by the East Garage Door.

2. The North Tower 7th Floor Medical Personal Storage Room revealed a broken ceiling tile that revealed a gap (approximately 1/2 inch in size) in the ceiling tile grid.

3. The Microbiology Laboratory revealed communication lines running through the ceiling tile grid that left a gap (approximately 1/2 inch in size) in the ceiling tile grid.

4. The Blank Hospital Level A Utility Closet by Phlebotomy revealed several suspended ceiling tiles were missing.

5. The MOB1 Children's Health Center Clinic EVS Room revealed several missing smoke ceiling tiles in the grid.

The Facility Maintenance Staff A and B confirmed these findings on the dates of inspection.

(B) Based on observation and interview, the facility failed to maintain proper storage of 1 compressed helium bottle in 1 location. This deficient practice would affect all residents and staff within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents on the dates of inspection.

Findings include:

Observation and interview on 4/10/12, revealed an unsecured helium tank in the North Tower Gift Shop Storage Room. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

(C) Based on observation and interview, the facility failed to remove all unapproved air freshner devices within the facility. This deficient practice would affect all residents within the affected zone. The facility had a capacity of 674 residents and a census of 363 residents on the dates of inspection.

Findings include:

Observation and interview on 4/12/12 revealed a heated oil air freshner that plugged directly into the wall was in use in the MOB1 Children's Health Center Scheduling Office. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to properly maintain the suspended ceiling tile grid in areas throughout the building. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/11/12, revealed a missing ceiling tile in the Younkers 6th Floor Pediatrics OB Anesthesia Room 630 B. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on record review and interview, the facility failed to provide proper testing and documentation of the building's emergency generator in accordance with the National Fire Protection Association (NFPA) Standard 110, 1999 edition. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Record review and interview on 4/10/12, revealed that the monthly 30-minute load tests were conducted at 17% of the name plate. This did not meet the 30 minutes under load at 30% of the name plate. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's electrical system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and had a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/10/12 to 4/12/12 revealed the following:

1. The North Tower 6th Floor Main Lobby Elevator Penthouse revealed a fan plugged into a drop cord.

2. The North Tower 5th Floor Menu Room by N557 revealed permanently used fluorescent lighting that was not hardwired.

3. The North Tower 4th Floor Office N401 revealed an extension cord with a coffee pot plugged into it.

4. The Emergency Department Ambulance Garage East Garage Door revealed a missing cover device for the exposed electrical wiring in the Garage Door Opener.

5. The North Tower Level A Mechanical Room A revealed a drop cord that was in use in the A.H. Unit S3.

6. The North Tower Level A Mechanical Room A revealed 3 electrical junction boxes on the ceiling lid by the Electrical Distribution Panels that were not properly covered.

7. The North Tower 3rd Floor Locker Room revealed an electrical outlet that was not provided with ground fault circuit interruption and was installed within 6 feet of a sink.

8. The North Tower Level A Mechanical Room revealed an open gap in Electrical Panel P-B1.

9. The North Tower Level A 2 Hour Fire Wall near the Environmental Closet revealed an open electrical junction box without a cover located above the suspended ceiling tile.

10. Room S408 revealed a lamp plugged into a surge protector.

11. Room S231 revealed the Ground Fault Circuit Interrupter was faulty.

12. The Dialysis Break Room revealed a coffee pot and a refrigerator plugged into a surge protector.

13. The Blank Hospital Flow Cytometry Laboratory revealed a refrigerator plugged into a surge protector.

14. The Anna Blank Clinic Office LL20 revealed a lamp plugged into an extension cord.

15. The MOB1 Children's Health Center East Weight Room revealed a broken electrical outlet cover.

16. The Methodist West Hospital 3rd Floor Team Member Break Room revealed the facility failed to maintain the Ground Fault Circuit Interrupters in the West wall by the sink. The Ground Fault Circuit Interrupter electrical outlets failed to trip when tested and contained an open neutral. This building had a capacity of 83 residents and census of 23 residents at the time inspection.

17. The Methodist West Hospital Break Room Pharmacy revealed the facility failed to provide Ground Fault Circuit Interruptors for the electrical outlets next to the sink on the West wall. This building had a capacity of 83 residents and a census of 23 residents at the time of inspection.

The Facility Maintenance Staff A and B confirmed these findings on the date of inspection.

Based on observations and interview, the facility failed to maintain the building's electrical system in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would affect all residents within the affected zones. The facility had a capacity of 674 residents and had a census of 363 residents on the date of inspection.

Findings include:

Observations and interview on 4/11/12, revealed the following:

1. The Younkers 7th Floor Doctor On-Call Sleep Room revealed a microwave plugged into a surge protector.

2. The Younkers 6th Floor Nursery revealed exposed electrical wires where the clock used to be on the wall.

3. The Younkers 5th Floor Communications Room by Room 515 revealed an electrical junction box without a cover.

4. The Younkers 3rd Floor Smoke Doors by the Transition by Audiology revealed 2 open electrical junction boxes.

5. The Younkers 3rd Floor IT Communications Room by the Younker Elevators revealed 3 open electrical junction boxes.

6. The Younkers 8th Floor Communications Room on the East end of the South Hall revealed an electrical junction box without a cover.

The Facility Maintenance Director confirmed these findings on the date of inspection.

Based on record review and interview, the facility failed to provide proper fire watch policy documentation for the sprinkler system outage policy. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Record review and interview on 4/12/12, revealed the facility's Sprinkler System Outage Policy for both Methodist West Hospital and the Methodist Main Hospital failed to provide contact information for the local Fire Department, the Iowa Department of Inspections and Appeals, the State Fire Marshal's Office, and the facility's Insurance Company. Contact information and phone numbers are required to be listed in the Sprinkler System Outage Policy. The Facility Maintenance Staff A confirmed this finding on the date of inspection.

Based on record review and interview, the facility failed to provide proper fire watch policy documentation for the fire alarm outage policy. This deficient practice would affect all residents throughout the facility. The facility had a capacity of 674 residents and a census of 363 residents.

Findings include:

Record review and interview on 4/12/12, revealed the facility's Fire Alarm Outage Policy for both Methodist West Hospital and the Methodist Main Hospital failed to provide contact information for the local Fire Department, the Iowa Department of Inspections and Appeals, the State Fire Marshal's Office, and the facility's Insurance Company. Contact information and phone numbers are required to be listed in the Fire Alarm Outage Policy. The Facility Maintenance Staff A confirmed this finding on the date of inspection.