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14701 179TH AVE SE

MONROE, WA 98272

No Description Available

Tag No.: K0012

Based upon observations and staff interviews on 04/30/2015 between approximately 09:00 and 15:00 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
1 hr fire resistant rated wall in elevator equipment room has penetration.
The above was discussed and acknowledged by the Maintenance Director.

No Description Available

Tag No.: K0021

This requirement is not met as evidenced by:

Based upon observations and staff interviews on 04/30/2015 between approximately 09:00 and 15:00 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close such doors upon activation of the fire alarm. This could result in the passage of smoke or fire one compartment into another compartment thereby exposing residents, staff and/or visitors to the toxic products of combustion.

The findings include, but are not limited to:
Cross corridor fire doors fail to latch near room B114.
The above was discussed and acknowledged by the Maintenance Director.

No Description Available

Tag No.: K0038

Based upon observations and staff interviews on 04/30/2015 between approximately 09:00 and 15:00 hours the facility has failed to maintain the exit discharge free of obstructions. This could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:
CCU emergency exit door leading outside fails to open with less than 30 lbs of pressure. This was determined by surveyor leaning into door.
Emergency exits fail to be maintained with imperious surface to the public way as listed
1. North side OB emergency exit
2. North side cafeteria emergency exit
3. East side cafeteria emergency exit
4. East emergency exit from wound care.
5. South emergency exit from behavior health
6. South emergency exit from main corridor
7. Surgery emergency exit east.
8. North side emergency exit main corridor
9. CCU emergency exit south
The above was discussed and acknowledged by the Maintenance Director.

No Description Available

Tag No.: K0050

Based upon record review and staff interviews on 04/30/2012 between approximately 09:00 and 15:00 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.

The findings include, but are not limited to:
Second quarter recovery center missing swing shift and night shift fire drills.
Third quarter recovery center missing day shift and night shift fire drills.
The above was discussed and acknowledged by the Maintenance Director.

No Description Available

Tag No.: K0062

Based upon observations and staff interviews on 04/30/2015 between approximately 09:00 and 15:00 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The facility has failed to maintain 18 inches of clearance in medical record storage room area B and gift shop stroage area.
Fire sprinkler escutcheon trim rim loose in Goddard room.
I.T. room above storage area in hallway missing escutcheon trim ring.
Room 230 Communications room missing escutcheon ring missing.

The above was discussed and acknowledged by the Maintenance Director.

No Description Available

Tag No.: K0072

Based upon observations and staff interviews on 04/30/2015 between approximately 09:00 and 15:00 hours the facility has failed to maintain the exit access corridors free of obstructions and impediments to full and instant use in the event of an emergency. This could result in the delays in smoke compartment evacuations or full evacuation of the building due to a fire or other emergency which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Emergency exit in kitchen blocked by food cart.

The above was discussed and acknowledged by the Maintenance Director.

No Description Available

Tag No.: K0076

Based upon observations and staff interviews on 04/30/2015 between approximately 09:00 and 15:00 hours the facility has failed to properly maintain the storage of medical gas in the facility. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Oxygen storage in room 220 oncology floor 2 fails to be secured properly.

The above was discussed and acknowledged by the Maintenance Director.

No Description Available

Tag No.: K0144

Based upon observations and staff interviews on 04/30/2015 between approximately 09:00 and 15:00 hours the facility has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that would result in the failure of the emergency generator that would not be detected by staff in a timely manner which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
The emergency generator does not have a remote emergency stop switch.
The above was discussed and acknowledged by the Maintenance Director.

NFPA 110 1999 Edition 3-5.6 All level 1 and 2 installations shall have a remote manual stop station of a similar type to a break-glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building.

A-3-5.5.6 For level 1 and level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

No Description Available

Tag No.: K0147

Based upon observations and staff interviews on 04/30/2015 between approximately 09:00 and 13:00 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
Microwave plugged into powerstrip.
Extension cord used in Everett clinics oncology patient area.
Oncology room 219 microwave plugged into powerstrip.
Open electrical wires connected to thermostat in I.T. server room on wire rack.
Eco lab powerstrip plugged into powerstrip at computer.
The above was discussed and acknowledged by the Maintenance Director.

Means of Egress - General

Tag No.: K0211

Based upon observations and staff interviews on 04/30/2015 between approximately 09:00 and 15:00 hours the facility has failed to properly install alcohol based hand rub dispensers. Dispensers installed improperly could result in hand rub coming in contact with an electrical source resulting in a fire causing potential endanger to residents, staff and/or visitors within the facility.

The findings include, but are not limited to:
ABHR in CT placed directly over light switch.
The above was discussed and acknowledged by the Maintenance Director.