HospitalInspections.org

Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the dietary department's office room 185 had a blocked egress route since office supplies blocked the door from fully opening.




Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the exit door at the stairs was not maintained. It is rusty and chipped.

Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the exit light was not operational near exam 7 and at the stairs.

Based on review of the records on 05-08-2021 for Cleveland Emergency Hospital ER - Deerbrook, door inspections were not conducted. The general aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7. Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the authority having jurisdiction, AHJ, per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA 101, 7.2.1.15

Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the kitchen hood suppression system's inspection report noted hood tanks hydro test was 2031.




Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the kitchen hood filters were not maintained and appeared very dirty and greasy.

Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the facility failed to maintain the duct detectors. The fire protection company noted on their report that a duct detector was not operational for rooftop unit. No document was presented indicating the non-operational duct detector was fixed.



Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, the past fire alarm report did not include 12 duct detectors. As part of your plan of corrections, include a current fire alarm report and inclusion of the noted duct detectors being tested.



Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, a current annual fire inspection report was missing. As part of your plan of corrections, include a current fire inspection report for Cleveland Hospital on South Travis Street.




Based on review of the records on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the fire alarm reports for the first, third and fourth quarters were missing.



Based on review of the records on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, a December 2020 quarterly inspection was missing for the fire alarm system.



Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, the past fire alarm reports showed that inspections were not being conducted per required scheduling. The facility was missing a fire alarm report for one of the required quarterly inspections.



Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, smoke detectors were dirty, with lots of dust and dirt on them.



Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, in the communication room, the smoke detector was not properly maintained. It was hanging from the ceiling.



Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, the past fire alarm reports were inconsistent. One report noted 176 audio/visual alarms and another report noted 186 audio/visual alarms.



Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, a red tag existed on the fire alarm panel. Provide documentation from local officials stating how they approved and when they approved the fire alarm system.




Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - Porter, with the Regional DON and the Nurse Manager, the FACP breaker address was incorrect.

Based on review of the records on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, a December 2020 quarterly inspection was missing for the fire sprinkler system. As part of this plan of corrections, a current fire alarm report shall be provided for Cleveland Hospital located at Crocket Street.




Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the past fire sprinkler reports showed that inspections were not being conducted per required scheduling. The facility was missing a fire sprinkler report for one of the required quarterly inspections.




Based on review of the records on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, the fire sprinkler reports for the first, third and fourth quarters were missing.





Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, the past sprinkler inspection reports were inconsistent, noting different device counts on August and October inspection reports.





Based on review of the records on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, a December 2020 quarterly inspection was missing for the fire sprinkler system. As part of this plan of corrections, a current sprinkler testing shall be provided for Cleveland Hospital located at Crocket Street.




Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the gauges on the sprinkler riser appear to be more than 5 years old and need replacement.





Based on review of the records on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, backflow preventer inspection report was missing.




Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, in the back corridor, the sprinkler escutcheons were not seated against the ceiling.




Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the escutcheon was missing from the women's restroom and at the electrical room; and the escutcheon plate is broken at dietary's women's toilet room; and escutcheon plate was missing in the medical records storage room.





Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, across from the CT room, the sprinkler escutcheon was not seated against the ceiling.




Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, paint was on the sprinkler head at room 175 and paint was on the sprinkler cover plate in the isolation room's bathroom and room 254.





Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, paint was on the sprinkler head at admitting supervisor office.



Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the sprinkler head at the non-patient exit, next the HVAC diffuser, was very dusty and dirty.




Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the sprinkler escutcheon was not seated against the ceiling in the physician break room and its toilet room.




Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the sprinkler escutcheon was three inches below the ceiling. Missing escutcheon plates was written in the 2567 report dated 08-01-2019.




Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the sprinkler head was missing at communication room. This was written in the 2567 report dated 08-01-2019.




Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the sprinkler head in exam 5 needs to be adjusted for adequate coverage.




Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the backflow on the sprinkler system had no inspection tags and it could not be proven that the backflow was inspected.




Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the riser room is being used as storage, making it in accessible to all parts of the riser. In addition, the riser room should not be used as a storage room.

Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, the fire extinguisher inspection records showed three different fire extinguisher counts: 12, 16 and 17.



Based on review of the records on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director the fire extinguisher inspection records showed three different fire extinguisher counts: 44, 45 and 47. How many fire extinguishers are provided in the above two listed locations?
NFPA 10, Standard for Portable Fire Extinguishers
7.2.4 Inspection Record Keeping.
7.2.4.3 Where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded.
7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self-expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for nonrechargeable extinguishers using push-to-test pressure indicators



Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the fire extinguisher was empty and had not been checked in two months located in the mechanical room.



Based on review of the records of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the fire extinguisher inspection reports were missing for 2020 and 2021.



Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the fire extinguisher near the non-patient exit door appeared not to be inspected.



Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the fire extinguisher was mounted on the wrong bracket and is not accessible to staff.



Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the incorrect fire extinguisher existed for this type of hazardous room.

Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the maintenance logs were not kept on site. They are stored at Texas Rural Hospitals located on 300 East Crockett. Each facility shall maintain maintenance logs at their specific site.




Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the nurse call dome light was not operational in the emergency department examination room.





Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the nurse call (pull chord) reported incorrect room location upon activation in patient toilet room 190 off the back corridor.




Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the nurse call (pull chord) was closer than 6" to the floor at the patient toilet room.




Based on review of the records on 05-08-2021 for Cleveland Emergency Hospital ER - Deerbrook and based on review of the records on 05-08-2021 for Cleveland Emergency Hospital ER - Porter, the facility failed to provide documentation of maintenance to Heating, Cooling, Ventilating, and Process Systems. Final filters and filter frames should be visually inspected for pressure drop and for bypass monthly. Filters should be replaced based on pressure drop or maintenance schedule with filters that provide the efficiencies specified. (ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures.) A log of filter replacements should be maintained for each air handler.

Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, and also based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, in the mechanical room, the mechanical units were not accessible for maintenance since they were obstructed by tools, non-mechanical supplies. This room is not to be used as a storage room. Mechanical units should be accessible.




Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, in the break room near the X-Ray room, the return air diffuser was not seated against the ceiling and a diffuser was damaged and hanging from the ceiling in the imaging records storage room.

Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, multiple patient toilet room's exhaust was not operational.





Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the toilet room's exhaust was not operations at the physician toilet room's exhaust, near break room, and the blood draw's patient toilet. Also, at this location, an exhaust was missing at the public toilet room, near the main entrance.




Based on observations during the tour of the facility on 05-08-2021 for Cleveland Emergency Hospital ER - Deerbrook, with the Administrator and the Plant Director, and based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - Porter, all the dirty rooms, such as toilet rooms, housekeeping room, soiled holding were all positively pressurized to the corridor. These rooms are to be negatively pressurized. In addition, the waiting room was positive to the other areas in the facility. As part of this plan of correction, provide a test and balance report for both facilities to ensure correct pressurization of the rooms.




Based on observations during the tour of the facility on 05-08-2021 for Cleveland Emergency Hospital ER - Deerbrook, with the Administrator and the Plant Director, mechanical ventilation system in the medical gas room was not operational. This room should be negatively pressurized. As part of this plan of correction, provide a test and balance report to ensure correct pressurization of the room.




Based on review of the records on 05-08-2021 for Cleveland Emergency Hospital ER - Deerbrook and based on review of the records on 05-08-2021 for Cleveland Emergency Hospital ER - Porter, the facility failed to provide disaster drills. Upon conducting disaster drills, the facility shall log and review the results of the event. The facility shall establish and maintain an emergency preparedness plan and review it annually. The facility shall provide a written report on mock disaster drill annually. The facility must document that they have made efforts to communicate with their state and local emergency preparedness officials to inquire about potential coordination.




Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, holes existed in the electrical room. Rodents and insects can gain access into the facility via these holes. As part of this plan of correction, provide photos of the corrective measure that were taken.





Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, a large hole existed in the ceiling of the women's restroom and broken ceiling tiles existed in imaging records storage room.

Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the life safety plans were missing. As part of your plan of corrections, include current readable life safety plans for the Cleveland Emergency Hospital on South Travis.




Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, and the during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, the evacuation egress plans were missing. As part of your plan of corrections, include current readable evacuation egress plans for all locations listed.

Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the fire drill was incorrectly marked. The report stated that fire alarm system was initiated for the fire drill but that same document stated that fire alarm was not used to initial fire drill in a different portion in that document.

Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, the flame spread documents were missing. As part of your plan of corrections, include a current flame spread document.

Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the medicine refrigerator was not secured, lockable.




Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the dietary department was not operational. How are meals supplied to patients? As part of the plan of corrections, provide a contract showing who provides the meals to the patients.




Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, janitor room 190 was being used as storage. This room is to be used as designed as a janitor closet is required for this area. Storage, other than housekeeping supplies, should be removed.




Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, it was mentioned that the nuclear med room was no longer a service of the hospital. In your plan of corrections, note if this service is still provided. If it is not used, the nurse call and medical gas should be removed from this room so that it is not patient ready. This room should not be used as storage unless it becomes a rated one-hour room and must be submitted to Architectural Review Unit as an application and will require an architectural inspection.




Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, it was mentioned that the radiology room 2 was no longer used. In your plan of corrections, note if this room provides diagnostic treatment to patients. If it is not used, the nurse call and if any medical gas is in the room, they should be removed from this room so that it is not patient ready. This room should not be used as storage unless it becomes a rated one-hour room and must be submitted to Architectural Review Unit as an application and will require an architectural inspection.



Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, patient room 254 was being used as a storage room. This room should not be used as storage unless it becomes a rated one-hour room, all medical gas is removed, hand-washing sink is removed, and a duty station is added (not nurse call). This must be submitted to Architectural Review Unit as an application and will require an architectural inspection.





Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, signage did not indicate the room's use at the medical records room, which shows that room to be a conference room. All signage should be correctly labeled to the function of that room. If the medical room is large than 100 square feet, the room's barrier should be one-hour rated, including 45-minute rated doors. Doors should have closures. An architectural application shall be submitted.




Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the rooms with signage stating "staff only" were incorrectly labeled because they were a nourishment room and a supply storage room and a soiled utility room. Rooms must be correctly identified with correct room signage as to their function. The use of the words "Staff only" can be used in addition to the rooms function, but not as a substitution.




Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the X-ray room is being used as storage. The X-ray room is a required service for emergency treatment. As part of the plan of corrections, provide photos of this room with operable X-ray equipment in place and no supply storage. This room must be patient ready.




Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, incorrect signage was located at the physician toilet room; the sign indicates that this is an exam room. Also, the signage at the ambulance break room indicates that the room is the critical care director. Also, signage indicates an examination room; however, no medical equipment was in the room and it appears to be only used as mental health secure holding room.





Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, near the elevator, the electrical room is used as storage room. Exposed wires exist in this room.




Based on observations during the tour of the facility on 05-05-2021 for Texas Rural Hospitals located on 300 East Crockett, with the Administrator and the Plant Director, the second-floor electrical room had abandoned nurse call components and broken thermostats existed in medical records office. Any abandoned system shall be removed from the site.

Based on review of the records on 05-08-2021 for Cleveland Emergency Hospital ER - Deerbrook, a risk assessment was missing. The building system categories are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel, see Chapter 4 (NFPA 99). The facility must define its risk assessment methodology, implement the methodology, and document the results in relation to the risk categories contained in the NFPA 99 Health Care Facilities Code. The facility will determine the procedure that most meets their needs within the requirement of the NFPA code. For additional information see the appendix of NFPA 99, A4.1 and A4.2.

Based on observations during the tour of the facility on 05-08-2021 for Cleveland Emergency Hospital ER - Deerbrook, with the Administrator and the Plant Director, the medical gas room's signage on the door was incorrect. Locations containing central supply systems or cylinders containing only oxygen or medical air shall have their door(s) labeled as follows:
CAUTION
Medical Gases
NO Smoking or Open Flame

Based on review of the records on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, the generator inspection report was missing. As part of your plan of corrections, include a current generator testing report for Cleveland Emergency Hospital on South Travis.




Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the generator appeared inoperable. Staff stated the when the winter storm hit in February, they had a hard time starting and testing the generator. As part of your plan of corrections, include a current generator testing report for Cleveland Emergency Hospital ER - The Woodlands.




Based on review of the records on 05-08-2021 for Cleveland Emergency Hospital ER - Deerbrook and based on review of the records on 05-08-2021 for Cleveland Emergency Hospital ER - Porter, the facility failed to provide documentation of the testing of grounding system at inpatient care areas. The electrical grounding of duplex outlets in general patient care areas shall be tested annually and critical care areas tested semi-annually. The facility must initiate a file on site to retain these records.
1) The physical integrity of each receptacle shall be confirmed by visual inspection.
2) The continuity of the grounding circuit in each electrical receptacle shall be verified.
3) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
4) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). (NFPA 99, 6.3.3.2)

Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, and based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - The Woodlands, with the Administrator and the Plant Director, the medicine refrigerator was not powered by the type 1 EES system's critical branch. This was written in the 2567 report dated 08-01-2019 for the Cleveland Hospital on South Travis Street.





Based on observations during the tour of the facility on 05-08-2021 for Cleveland Emergency Hospital ER - Deerbrook, with the Administrator and the Plant Director, the EES panels were under reconfiguration as such they were not inspected. What project is occurring at the EES panels.

Based on review of the records on 05-08-2021 for Cleveland Emergency Hospital ER - Deerbrook, the generator was not tested on 36-month load bank test for 4 continuous hours.
" The generator or other alternate power source and associated equipment is capable of supplying service within 10-seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
" Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel.
o Weekly inspections: fuel level, hoses, belts, oil level, cooling water level, radiator clear, battery electrolyte level, housekeeping of enclosure, and general visual inspection for damage.
o Monthly load tests meet NFPA 110 criteria. (See appendix A.8, 8.4.2, or 8.4.2.4 for natural gas.)
o If not meet monthly load tests, then annual load bank test. (See appendix A.8, 8.4.2.3)
o 36 month load bank test for 4 continuous hours. (See A.8, 8.4.9)
" Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements.
" Written records of maintenance and testing are maintained and readily available.

Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - Porter, with the Regional DON and the Nurse Manager, the life safety panel was not inadequately and incorrectly populated.




Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - Porter, with the Regional DON and the Nurse Manager, the generator was installed within 5 feet of the facility building wall.

Based on observations during the tour of the facility on 05-06-2021 for Cleveland Emergency Hospital ER - Porter, with the Regional DON and the Nurse Manager, the medical gas bottles were stored in the pharmacy room and the warning sign on the door was not correct. Remove the med gas bottles.

Based on observations during the tour of the facility on 05-04-2021 for Cleveland Emergency Hospital located at 1017 South Travis, with the Administrator and the Plant Director, the maintenance personnel did not appear to be training on their medical gas system and its component.