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The inspector observed, while accompanied by The CEO, CQO, CND, facility supervisor, nursing supervisor, facility manager, nutrition director, radiology director, and maintenance personnel, during the hours of the inspection from 02:30 PM to 06:30 PM on 05/10/2018 that there were the following issues. They were the following issues:

A) The sprinkler system were not provided at numerous rooms and suites such as management suite, health information suite, CT bathroom, and other rooms and suites etc

The inspector observed, while accompanied by The CEO, CQO, CND, facility supervisor, nursing supervisor, facility manager, nutrition director, radiology director, and maintenance personnel, during the hours of the inspection from 02:30 PM to 06:30 PM on 05/10/2018 that there were the following issues. They were the following issues:

A) There were doors were not released from the magnetic lock device upon activate the fire alarm system which prevent from free egress out of building.



B) The thumb turn lock was installed at the pharmacy exit doors.
NFPA 101 (2003): 7.2.1.5.9.1. The releasing mechanism shall open the door with not more than one releasing operation.

The inspector observed, while accompanied by The CEO, CQO, CND, facility supervisor, nursing supervisor, facility manager, nutrition director, radiology director, and maintenance personnel, during the hours of the inspection from 02:30 PM to 06:30 PM on 05/10/2018 that there were the following issues. They were the following issues:

A.) The 45 minutes door fire label was not provided at the medical gas storage room door and frame and the soiled work room door and frame.



B.) There was not a door closer provided at the medical gas storage room, soiled work rooms and the dietary dry storage room.



C.) The hold open device is utilized at the dietary dry storage room and please remove the device or the device released upon the fire alarm activated and only used for occasionally delivery usage. This door shall remained closed at all time.



D.) There was louver at the dietary dry storage room and please remove it.

The inspector observed, while accompanied by The CEO, CQO, CND, facility supervisor, nursing supervisor, facility manager, nutrition director, radiology director, and maintenance personnel, during the hours of the inspection from 02:30 PM to 06:30 PM on 05/10/2018 that there were the following issues. They were the following issues:

A) There was not a smoke detector provided at the nourishment room where an open space is adjacent to the egress corridor. Please provide a smoke detector. NFPA 101, 2003, 18.3.6.1(1). - "Corridors shall be separated from all other areas by partitions and protective opening designed to limit the transfer of smoke unless otherwise permitted by the following: (a) the spaces are not used for patient sleeping, treatment, or hazardous areas, (b) the corridors onto which the spaces open are protected by an electrically supervised automatic smoke detection system or the entire smoke compartment is protected by quick -response sprinklers, (c) the open space is protected by a automatic smoke detection system or the entire space is arranged to allow direct supervision by the facility staff from a nurses' station, and (d) the space does not obstruct access to required exits.




B) The fire alarm pull was not provided within 5'-0" of the exit door at the management department area.

The inspector observed, while accompanied by The CEO, CQO, CND, facility supervisor, nursing supervisor, facility manager, nutrition director, radiology director, and maintenance personnel, during the hours of the inspection from 02:30 PM to 06:30 PM on 05/10/2018 that there were the following issues. They were the following issues.

(A) There was a missing receptacle powered from life safety branch and the battery powered operated light fixture at the essential automatic transfer switch location. This is not in accordance with NFPA 99, 1999: 3-4.2.2.2.(b)5. "The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location"

The inspector observed, while accompanied by The CEO, CQO, CND, facility supervisor, nursing supervisor, facility manager, nutrition director, radiology director, and maintenance personnel during the hours of the inspection from 02:30 PM to 06:30 PM on 05/10/2018 that there were the following issues. They were the following issues.


A) There were no isolation between the metal hanger supports and the copper med gas pipes.



B) There was not a dedicated mechanical exhaust systems that draw air from within 1 foot of the floor and operate continuously inside the medical storage rooms or natural ventilation provided at 72 sq. ft. within 12" of ceiling and at 72 sq. ft. within 12"of the floor. This does not comply with NFPA 99 as followed: Re. NFPA 99, 2002: 5.1.3.3.3.1(E). Where the total volume of medical gases connected and in storage is less than 3000 cu.ft. at STP, natural ventilation shall be permitted - NFPA 99, 2002: 5.1.3.3.1(D). Where natural ventilation is permitted, it shall consist of two louvered openings, each having a minimum free area of 72 in. sq., with one located within 1 ft. of the floor and one located within 1 ft. of the ceiling. Re. NFPA 99, 2002: 5.1.3.3.3.1(B). - Where the total volume of medical gases connected and in storage is greater than 3,000 cu.ft. at STP, indoor supply locations shall be provided with dedicated mechanical ventilation systems that draw air from within 1 foot of the floor and operate continuously Re. NFPA 99, 2002: 5.1.3.3.3.1(F).- Louvered natural ventilation opening shall not be located in an exit corridor. Re. NFPA 99, 2002: 5.1.3.3.3.1(G).- Mechanical natural ventilation shall be provided if the requirements of 5.1.3.3.3.1 cannot be met.



C) Medical gas alarm panels were not operational and was not maintained certified status annually.



D) There is no permanent signage provided for all medical gas storage room door. This does not comply with NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:
CAUTION
Medical Gases
NO Smoking or Open Flame
Where nitrous oxide is used, the medical gas closet shall have a door labeled: Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:
CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering