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Based on observations made during a tour of the facility on the morning of 11/08/11 with the maintenance director, the observation was made that the facility was not in full compliance with the requirements of NFPA 101, 19.1.1.4 for fire separation between a hospital and a non conforming building.

(1) The 2-hour fire wall above the cross corridor doors between the hospital and the rural health clinic had communication wiring penetrations that were not sealed to prevent the passage of smoke and the products of combustion.

(2) The 2-hour fire wall above the cross corridor doors between the hospital and the cardiac rehabilitation clinic had communication wiring penetrations that were not sealed to prevent the passage of smoke and the products of combustion.

Based on observations made during a tour of the facility on the morning of 11/08/11 with the maintenance director, the observation was made that the facility was not in full compliance with the requirements of NFPA 101, 8.4.1, 19.3.5.4, and 19.3.2.1 for the protection of hazardous areas.

(1) The central supply room had a 1 1/2-hour rated door that was not self-closing.

(2) There was an alcove next to a door to the surgical suite that was open to an exit access corridor, and was filled with combustible materials such as cardboard boxes.

Based on observations made during a review of the policies and procedures of the facility on the morning of 11/08/11 with the maintenance director, the director of nurses, the administrative secretary, and the infection control director, the observation was made that the facility was not in full compliance with the following requirements:

(1) Disaster drills were being conducted and reported annually, but not semi-annually as required per NFPA 99, 11.3.5.9.

(2) Biomedical equipment testing reports, as required per NFPA 99,:3.3.2, were not being kept in the hospital.

(3) Grounding system testing reports of receptacles in patient care areas were not being kept in the hospital, as required per NFPA 99, 3.3.2 and 3.3.3.3.

Based on observations made during a review of the policies and procedures of the facility on the morning of 11/08/11 with the maintenance director, the observation was made that the facility was not in full compliance with the requirements of NFPA 99, 3.4.4.1 and NFPA 110, 8.4.2 for testing of the emergency generator.

(1) There were no logs to show that the emergency generator was being inspected and started up on a weekly basis.

(2) The generator logs showed that the it was being run under load monthly for only 2 or 3 minutes, instead of a minimum of 30 minutes.

Based on observations made during a tour of the facility on the morning of 11/08/11 with the maintenance director, the observation was made that the facility was not in full compliance with the requirements of NFPA 99, 3.4.2.2.2 for Type I essential electrical systems.

Treadmills in the exercise room were on the same emergency panel, 'DPE', as life safety items such as emergency lighting in the means of egress, and exit signs.

Based on observations made during a tour of the facility on the morning of 11/08/11 with the maintenance director, the observation was made that the facility was not in full compliance with the requirements of NFPA 70, 9.1.2 for electrical wiring and equipment.

(1) The emergency electrical receptacles in the laboratory were not color coded to identify them as components of the essential electrical system.

(2) The emergency receptacles in the labor/delivery rooms were not color coded to identify them as components of the essential electrical system.

Based on observations made during a tour of the facility on the morning of 11/08/11 with the maintenance director, the observation was made that the facility was not in full compliance with the requirements of NFPA 101, 19.1.1.4 for fire separation between a hospital and a non conforming building.

(1) The 2-hour fire wall above the cross corridor doors between the hospital and the rural health clinic had communication wiring penetrations that were not sealed to prevent the passage of smoke and the products of combustion.

(2) The 2-hour fire wall above the cross corridor doors between the hospital and the cardiac rehabilitation clinic had communication wiring penetrations that were not sealed to prevent the passage of smoke and the products of combustion.

Based on observations made during a tour of the facility on the morning of 11/08/11 with the maintenance director, the observation was made that the facility was not in full compliance with the requirements of NFPA 101, 8.4.1, 19.3.5.4, and 19.3.2.1 for the protection of hazardous areas.

(1) The central supply room had a 1 1/2-hour rated door that was not self-closing.

(2) There was an alcove next to a door to the surgical suite that was open to an exit access corridor, and was filled with combustible materials such as cardboard boxes.

Based on observations made during a review of the policies and procedures of the facility on the morning of 11/08/11 with the maintenance director, the director of nurses, the administrative secretary, and the infection control director, the observation was made that the facility was not in full compliance with the following requirements:

(1) Disaster drills were being conducted and reported annually, but not semi-annually as required per NFPA 99, 11.3.5.9.

(2) Biomedical equipment testing reports, as required per NFPA 99,:3.3.2, were not being kept in the hospital.

(3) Grounding system testing reports of receptacles in patient care areas were not being kept in the hospital, as required per NFPA 99, 3.3.2 and 3.3.3.3.

Based on observations made during a review of the policies and procedures of the facility on the morning of 11/08/11 with the maintenance director, the observation was made that the facility was not in full compliance with the requirements of NFPA 99, 3.4.4.1 and NFPA 110, 8.4.2 for testing of the emergency generator.

(1) There were no logs to show that the emergency generator was being inspected and started up on a weekly basis.

(2) The generator logs showed that the it was being run under load monthly for only 2 or 3 minutes, instead of a minimum of 30 minutes.

Based on observations made during a tour of the facility on the morning of 11/08/11 with the maintenance director, the observation was made that the facility was not in full compliance with the requirements of NFPA 99, 3.4.2.2.2 for Type I essential electrical systems.

Treadmills in the exercise room were on the same emergency panel, 'DPE', as life safety items such as emergency lighting in the means of egress, and exit signs.

Based on observations made during a tour of the facility on the morning of 11/08/11 with the maintenance director, the observation was made that the facility was not in full compliance with the requirements of NFPA 70, 9.1.2 for electrical wiring and equipment.

(1) The emergency electrical receptacles in the laboratory were not color coded to identify them as components of the essential electrical system.

(2) The emergency receptacles in the labor/delivery rooms were not color coded to identify them as components of the essential electrical system.