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Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th; it was observed that the facility failed to provide finish materials of at least a Class C rating within a room in accordance to NFPA 101 Sections 19.3.3.1 and 19.3.3.2 as evidenced by the following item(s). This deficient practice could affect the patients in this one smoke compartment of the 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 2:45 pm, it was observed that the north wall of the Storage room east of AHU 2.2 (formerly dietary storage) was covered with rigid insulation and masonite. These materials do not meet a Class C finish rating as required in NFPA 101 Section 19.3.3.2 for an existing building with a full sprinkler system.

This deficient practice was confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th; it was observed that the facility failed to provide exit access corridor walls that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 1:03 pm, it was observed that the paired doors into the exit corridor were not smoke-tight at the left leaf (when viewed from the corridor side).

2. On March 26th, 2014 at 8:42 am, it was observed that the paired doors into the exit corridor from the ED suite were not smoke-tight at the meeting edge of the door leafs. The astragals were not butted together.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th; it was observed that the facility failed to provide doors into the corridor that were positive latching in accordance to NFPA 101 Section 19.3.6.3.2 as evidenced by the following item(s). This deficient practice could affect the patients in this one smoke compartment of the 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 2:45 pm, it was observed that the paired doors into the exit corridor from OR #2 were not positively latched at the head of the door frame. These doors swung open with very little pressure from the corridor side of this opening.

This deficient practice was confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th; the facility failed to provide exit signs to direct occupants to the exit when the means of egress is not readily apparent. This is not in compliance to NFPA 101 Section 19.2.1 and Section 7.10.1.1 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 12:59 pm, it was observed that three different doors were located within close proximity to each other at the west end of the Kitchen. Only one of these doors led to the exit corridor and met code minimum standards. No exit sign was present in this area to eliminate any confusion to a person egressing the Kitchen.

This deficient practice was confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th, it was observed that the facility failed to provide and maintain the one-half hour fire-rating and smoke tightness of the smoke barrier walls in accordance to NFPA 101 Section 19.3.7.3 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 10:06 am it was observed that the west wall of the Corridor to the Loading Dock was not taped and plastered to a one-half hour fire-rating and smoke tight on both sides of this smoke compartment wall.

2. On March 25th, 2014 at 10:31 am it was observed that the west wall of Biohazards and the Telecommunication room were not taped and plastered to a one-half hour fire-rating and smoke tight on both sides of these smoke compartment walls.

3. On March 25th, 2014 at 11:04 am it was observed that the north wall the PT Gym above the paired doors had 3 holes for telecommunication wires that were not fire caulked. The top of the wall was not fire caulked to a one-half hour rating. Mineral wool insulation and fire caulk were not installed at the top of the wall on either face of this smoke compartment wall.

4. On March 25th, 2014 at 11:13 am it was observed that the south wall of the Locker room for PT did not have drywall installed above the ceiling and taped and plastered to a one-half hour rating for this smoke compartment wall.

5. On March 25th, 2014 at 11:15 am it was observed that the north and east walls of the Hydrotherapy room were not completely covered with gypsum wall board. Mineral wool was not installed at the top of the wall and covered with fire caulk. Additionally, 5 penetrations in these walls were not fire caulked to a one-half hour rating for these smoke compartment walls.

6. On March 26th, 2014 at 10:09 am it was observed that the telecommunication wires through the smoke compartment wall within the north patient corridor were not fire-caulked to a one-half hour fire rating and smoke tight.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th, it was observed that the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 [2000 Ed] Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect all of the patients in the smoke compartment where these rooms were located, as well as an undetermined number of staff and visitors. This facility contains 8 smoke compartments.

Findings include:

1. On March 25th, 2014 at 10:20 am it was observed that the north wall of Central Supply was not construction to a one-hour fire-rating. The wall was constructed of concrete block that did not extend up to the roof deck along 12 lineal feet of this wall. All penetrations were not fire caulked as required.

2. On March 25th, 2014 at 3:07 pm it was observed that the walls around of the Sterile supply and Soiled Supply had numerous pipe penetrations along the perimeters of both of these rooms that were not fire caulked to a one-hour fire rating.

3. On March 26th, 2014 at 8:30 am it was observed that Lab Storage did not have drywall installed above the ceiling to the deck along most of the perimeter walls of this space. This is a storage room with combustible storage greater than 100 square feet and should be constructed to a one-hour fire barrier rating.

4. On March 26th, 2014 at 8:48 am it was observed that Emergency Power electrical room which was constructed to a one-hour fire rating had a 20-minute rated door installed that led to the corridor. This door is required to be at least a 45-minute rated door from this room.

5. On March 26th, 2014 at 10:09 am it was observed that Soiled Utility near patient room #222 was not taped and mudded to a one-hour fire barrier rating along most of the perimeter of this space. It was observed that the screw heads were not mudded. These conditions occurred on both side of this one-hour enclosure.

6. On March 26th, 2014 at 10:24 am it was observed that Pharmacy Storage was not taped and mudded to a one-hour fire barrier rating along the entire perimeter of this space. This condition occurred on both side of this required one-hour enclosure. The use of this space changed from a non-rated room as originally constructed to this storage room greater than 100 square feet in area which requires a one-hour fire barrier enclosure.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor, between March 24th and March 26th, it was observed that the facility failed to provide and maintain the stairwells with a minimum clearance height in accordance to NFPA 101 Section 19.2.1, Chapter 7 and Section 7.1.5 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 9:08 am it was observed that the headroom on the exit stairwall (near the Boiler room) was less than the 6'-8" minimum from a plane parallel and tangent to the foremost portion of the stair tread measured vertically to the ceiling surface.

This deficient practice was confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor, between March 24th and March 26th, it was observed that the facility failed to provide and maintain a sprinkler system that was installed in accordance to the Life Safety Code [2000 Ed] Sections 19.3.5.1 and 9.7.1.1 and NFPA 13 [1999 Ed] Section 5.1.1. The deficient practice could affect all the patients, staff and an undeterminable number of visitors within the 8 smoke compartments of this building.

Findings include:

1. On March 25th, 2014 at 9:22 am, it was observed that wood framing from an old skylight and plywood decking were found within the ceiling space above the Corridor leading to the Car Port. This combustible material within a concealed space triggers sprinkler protection which was not present and hence does not meet NFPA 13 (1999 Ed) Section 5-13.1.1.

2. On March 25th, 2014 at 10:38 am, it was observed that plywood decking was found covering a hole in the steel decking within the ceiling space above the Corridor leading to the Loading Dock. This combustible material within a concealed space triggers sprinkler protection which was not present and hence does not meet NFPA 13 (1999 Ed) Section 5-13.1.1.

3. On March 25th, 2014 at 10:40 am, it was observed that wood blocking was found within the ceiling space above the Biohazard room near the Car Port. This combustible material within a concealed space triggers sprinkler protection which was not present and hence does not meet NFPA 13 (1999 Ed) Section 5-13.1.1.

4. On March 25th, 2014 at 3:27 pm, it was observed that 5 pendent sprinkler heads were found within the Radiology workstation that were all spaced less than 6'-0" apart. This spacing between the 5 different pendent heads did not meet NFPA 13 (1999 Ed) Section 5-6.3.4.

5. On March 26th, 2014 at 9:31 am, it was observed that a pendent sprinkler head was found within a closet of Room #235 that was not provided with 18" clear space below the sprinkler deflector. This obstruction to the sprinkler discharge did not meet NFPA 13 (1999 Ed) Section 5-6.5.3.

6. On March 26th, 2014 at 10:24 am, it was observed that pendent sprinkler heads installed within most of the Patient Room Closets did not provide the 18" clear space below the sprinkler deflector. This obstruction to the sprinkler discharge did not meet NFPA 13 (1999 Ed) Section 5-6.5.3.

7. On March 26th, 2014 at 10:39 am, it was observed that no sprinkler head was installed within Electrical closet near ICU. This omission of a sprinkler head within this space did not meet NFPA 13 (1999 Ed) Section 5-13.11.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on record review and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th, it was observed that the facility failed to provide documentation that the generator(s) installed was(were) exercised and run for 30 minutes on a weekly basis and maintained to comply with NFPA 101 [2000 Ed] Sections 19.2.9.1 and 7.9.2.3 along with NFPA 99 [1999 Ed] Sections 3-4.4.1.1 and 3-4.4.2 were not in compliance as evidenced by the following item(s). This deficiency could affect all of the patients within this facility, as well as an undetermined number of staff and visitors.

Findings Include:

1. On March 25th, 2014 at 7:44 am, it was discovered during document review that the 275 Kilowatt (KW) Generator #3 installed with the ED addition had less than 30% connected load. Upon further investigation, it was found that this diesel generator had not been load banked on annual basis for the past several years. The missing load bank test did not meet NFPA 110 [1999 Ed] for maintenance on this unit.

2. On March 25th, 2014 at 7:46 am, it was discovered during interview that the 275 KW Generator #3 installed with the ED addition had been tested on a weekly basis for 30 minutes since installation. However, any documentation of these run times was not available. The Hospital was told by the generator installer that all runs were internally recorded; but the software could not generate any documentation to verify that these runs had occurred. This did not meet NFPA 99 [1999 Ed] Section 3-4.4.2 for record keeping on this unit.

These deficient practices were confirmed by record review and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th, it was observed that the facility failed to provide an electrical system that was installed in accordance to NFPA 70 - National Electrical Code, Section 9.1.2 as evidenced by the following item(s). This deficient practice could affect all of the patients of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 2:40 pm, it was observed that two receptacles within 6'-0" of a sink within the Set-up room (between OR 1 and OR 2) were not equipped with ground fault circuit interruption (GFCI) protection.

2. On March 25th, 2014 at 2:45 pm, it was observed that two (2) emergency and four (4) normal receptacles within 6'-0" of a sink within the Nurse station for the Operating area were not equipped with GFCI protection.

3. On March 25th, 2014 at 2:50 pm, it was observed that two (2) emergency receptacles within 6'-0" of a sink located in Recovery #133 were not equipped with GFCI protection.

4. On March 25th, 2014 at 3:18 pm, it was observed that two (2) receptacles within 6'-0" of a sink located in Ultrasound were not equipped with GFCI protection.

5. On March 25th, 2014 at 3:18 pm, it was observed that two (2) receptacles within 6'-0" of a sink located in Ultrasound were not equipped with GFCI protection.

6. On March 25th, 2014 at 3:30 pm, it was observed that one (1) receptacle within 6'-0" of a sink located in Radiography was not equipped with GFCI protection.

7. On March 25th, 2014 at 3:31 pm, it was observed that one (1) receptacle within 6'-0" of a sink located in R&F was not equipped with GFCI protection.

8. On March 26th, 2014 at 8:32 am, it was observed that four (4) power strips within 6'-0" of sinks located in the Lab were not equipped with GFCI protection. The strips were identified as PA#3, PA#5, CPI-Bkr #4 and Pnl PA Bkr#32.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th; it was observed that the facility failed to provide finish materials of at least a Class C rating within a room in accordance to NFPA 101 Sections 19.3.3.1 and 19.3.3.2 as evidenced by the following item(s). This deficient practice could affect the patients in this one smoke compartment of the 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 2:45 pm, it was observed that the north wall of the Storage room east of AHU 2.2 (formerly dietary storage) was covered with rigid insulation and masonite. These materials do not meet a Class C finish rating as required in NFPA 101 Section 19.3.3.2 for an existing building with a full sprinkler system.

This deficient practice was confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th; it was observed that the facility failed to provide exit access corridor walls that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 1:03 pm, it was observed that the paired doors into the exit corridor were not smoke-tight at the left leaf (when viewed from the corridor side).

2. On March 26th, 2014 at 8:42 am, it was observed that the paired doors into the exit corridor from the ED suite were not smoke-tight at the meeting edge of the door leafs. The astragals were not butted together.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th; it was observed that the facility failed to provide doors into the corridor that were positive latching in accordance to NFPA 101 Section 19.3.6.3.2 as evidenced by the following item(s). This deficient practice could affect the patients in this one smoke compartment of the 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 2:45 pm, it was observed that the paired doors into the exit corridor from OR #2 were not positively latched at the head of the door frame. These doors swung open with very little pressure from the corridor side of this opening.

This deficient practice was confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th; the facility failed to provide exit signs to direct occupants to the exit when the means of egress is not readily apparent. This is not in compliance to NFPA 101 Section 19.2.1 and Section 7.10.1.1 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 12:59 pm, it was observed that three different doors were located within close proximity to each other at the west end of the Kitchen. Only one of these doors led to the exit corridor and met code minimum standards. No exit sign was present in this area to eliminate any confusion to a person egressing the Kitchen.

This deficient practice was confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th, it was observed that the facility failed to provide and maintain the one-half hour fire-rating and smoke tightness of the smoke barrier walls in accordance to NFPA 101 Section 19.3.7.3 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 10:06 am it was observed that the west wall of the Corridor to the Loading Dock was not taped and plastered to a one-half hour fire-rating and smoke tight on both sides of this smoke compartment wall.

2. On March 25th, 2014 at 10:31 am it was observed that the west wall of Biohazards and the Telecommunication room were not taped and plastered to a one-half hour fire-rating and smoke tight on both sides of these smoke compartment walls.

3. On March 25th, 2014 at 11:04 am it was observed that the north wall the PT Gym above the paired doors had 3 holes for telecommunication wires that were not fire caulked. The top of the wall was not fire caulked to a one-half hour rating. Mineral wool insulation and fire caulk were not installed at the top of the wall on either face of this smoke compartment wall.

4. On March 25th, 2014 at 11:13 am it was observed that the south wall of the Locker room for PT did not have drywall installed above the ceiling and taped and plastered to a one-half hour rating for this smoke compartment wall.

5. On March 25th, 2014 at 11:15 am it was observed that the north and east walls of the Hydrotherapy room were not completely covered with gypsum wall board. Mineral wool was not installed at the top of the wall and covered with fire caulk. Additionally, 5 penetrations in these walls were not fire caulked to a one-half hour rating for these smoke compartment walls.

6. On March 26th, 2014 at 10:09 am it was observed that the telecommunication wires through the smoke compartment wall within the north patient corridor were not fire-caulked to a one-half hour fire rating and smoke tight.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th, it was observed that the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 [2000 Ed] Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect all of the patients in the smoke compartment where these rooms were located, as well as an undetermined number of staff and visitors. This facility contains 8 smoke compartments.

Findings include:

1. On March 25th, 2014 at 10:20 am it was observed that the north wall of Central Supply was not construction to a one-hour fire-rating. The wall was constructed of concrete block that did not extend up to the roof deck along 12 lineal feet of this wall. All penetrations were not fire caulked as required.

2. On March 25th, 2014 at 3:07 pm it was observed that the walls around of the Sterile supply and Soiled Supply had numerous pipe penetrations along the perimeters of both of these rooms that were not fire caulked to a one-hour fire rating.

3. On March 26th, 2014 at 8:30 am it was observed that Lab Storage did not have drywall installed above the ceiling to the deck along most of the perimeter walls of this space. This is a storage room with combustible storage greater than 100 square feet and should be constructed to a one-hour fire barrier rating.

4. On March 26th, 2014 at 8:48 am it was observed that Emergency Power electrical room which was constructed to a one-hour fire rating had a 20-minute rated door installed that led to the corridor. This door is required to be at least a 45-minute rated door from this room.

5. On March 26th, 2014 at 10:09 am it was observed that Soiled Utility near patient room #222 was not taped and mudded to a one-hour fire barrier rating along most of the perimeter of this space. It was observed that the screw heads were not mudded. These conditions occurred on both side of this one-hour enclosure.

6. On March 26th, 2014 at 10:24 am it was observed that Pharmacy Storage was not taped and mudded to a one-hour fire barrier rating along the entire perimeter of this space. This condition occurred on both side of this required one-hour enclosure. The use of this space changed from a non-rated room as originally constructed to this storage room greater than 100 square feet in area which requires a one-hour fire barrier enclosure.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor, between March 24th and March 26th, it was observed that the facility failed to provide and maintain the stairwells with a minimum clearance height in accordance to NFPA 101 Section 19.2.1, Chapter 7 and Section 7.1.5 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 8 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 9:08 am it was observed that the headroom on the exit stairwall (near the Boiler room) was less than the 6'-8" minimum from a plane parallel and tangent to the foremost portion of the stair tread measured vertically to the ceiling surface.

This deficient practice was confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor, between March 24th and March 26th, it was observed that the facility failed to provide and maintain a sprinkler system that was installed in accordance to the Life Safety Code [2000 Ed] Sections 19.3.5.1 and 9.7.1.1 and NFPA 13 [1999 Ed] Section 5.1.1. The deficient practice could affect all the patients, staff and an undeterminable number of visitors within the 8 smoke compartments of this building.

Findings include:

1. On March 25th, 2014 at 9:22 am, it was observed that wood framing from an old skylight and plywood decking were found within the ceiling space above the Corridor leading to the Car Port. This combustible material within a concealed space triggers sprinkler protection which was not present and hence does not meet NFPA 13 (1999 Ed) Section 5-13.1.1.

2. On March 25th, 2014 at 10:38 am, it was observed that plywood decking was found covering a hole in the steel decking within the ceiling space above the Corridor leading to the Loading Dock. This combustible material within a concealed space triggers sprinkler protection which was not present and hence does not meet NFPA 13 (1999 Ed) Section 5-13.1.1.

3. On March 25th, 2014 at 10:40 am, it was observed that wood blocking was found within the ceiling space above the Biohazard room near the Car Port. This combustible material within a concealed space triggers sprinkler protection which was not present and hence does not meet NFPA 13 (1999 Ed) Section 5-13.1.1.

4. On March 25th, 2014 at 3:27 pm, it was observed that 5 pendent sprinkler heads were found within the Radiology workstation that were all spaced less than 6'-0" apart. This spacing between the 5 different pendent heads did not meet NFPA 13 (1999 Ed) Section 5-6.3.4.

5. On March 26th, 2014 at 9:31 am, it was observed that a pendent sprinkler head was found within a closet of Room #235 that was not provided with 18" clear space below the sprinkler deflector. This obstruction to the sprinkler discharge did not meet NFPA 13 (1999 Ed) Section 5-6.5.3.

6. On March 26th, 2014 at 10:24 am, it was observed that pendent sprinkler heads installed within most of the Patient Room Closets did not provide the 18" clear space below the sprinkler deflector. This obstruction to the sprinkler discharge did not meet NFPA 13 (1999 Ed) Section 5-6.5.3.

7. On March 26th, 2014 at 10:39 am, it was observed that no sprinkler head was installed within Electrical closet near ICU. This omission of a sprinkler head within this space did not meet NFPA 13 (1999 Ed) Section 5-13.11.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on record review and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th, it was observed that the facility failed to provide documentation that the generator(s) installed was(were) exercised and run for 30 minutes on a weekly basis and maintained to comply with NFPA 101 [2000 Ed] Sections 19.2.9.1 and 7.9.2.3 along with NFPA 99 [1999 Ed] Sections 3-4.4.1.1 and 3-4.4.2 were not in compliance as evidenced by the following item(s). This deficiency could affect all of the patients within this facility, as well as an undetermined number of staff and visitors.

Findings Include:

1. On March 25th, 2014 at 7:44 am, it was discovered during document review that the 275 Kilowatt (KW) Generator #3 installed with the ED addition had less than 30% connected load. Upon further investigation, it was found that this diesel generator had not been load banked on annual basis for the past several years. The missing load bank test did not meet NFPA 110 [1999 Ed] for maintenance on this unit.

2. On March 25th, 2014 at 7:46 am, it was discovered during interview that the 275 KW Generator #3 installed with the ED addition had been tested on a weekly basis for 30 minutes since installation. However, any documentation of these run times was not available. The Hospital was told by the generator installer that all runs were internally recorded; but the software could not generate any documentation to verify that these runs had occurred. This did not meet NFPA 99 [1999 Ed] Section 3-4.4.2 for record keeping on this unit.

These deficient practices were confirmed by record review and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with the Facility Director and the Maintenance Supervisor between March 24th and March 26th, it was observed that the facility failed to provide an electrical system that was installed in accordance to NFPA 70 - National Electrical Code, Section 9.1.2 as evidenced by the following item(s). This deficient practice could affect all of the patients of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On March 25th, 2014 at 2:40 pm, it was observed that two receptacles within 6'-0" of a sink within the Set-up room (between OR 1 and OR 2) were not equipped with ground fault circuit interruption (GFCI) protection.

2. On March 25th, 2014 at 2:45 pm, it was observed that two (2) emergency and four (4) normal receptacles within 6'-0" of a sink within the Nurse station for the Operating area were not equipped with GFCI protection.

3. On March 25th, 2014 at 2:50 pm, it was observed that two (2) emergency receptacles within 6'-0" of a sink located in Recovery #133 were not equipped with GFCI protection.

4. On March 25th, 2014 at 3:18 pm, it was observed that two (2) receptacles within 6'-0" of a sink located in Ultrasound were not equipped with GFCI protection.

5. On March 25th, 2014 at 3:18 pm, it was observed that two (2) receptacles within 6'-0" of a sink located in Ultrasound were not equipped with GFCI protection.

6. On March 25th, 2014 at 3:30 pm, it was observed that one (1) receptacle within 6'-0" of a sink located in Radiography was not equipped with GFCI protection.

7. On March 25th, 2014 at 3:31 pm, it was observed that one (1) receptacle within 6'-0" of a sink located in R&F was not equipped with GFCI protection.

8. On March 26th, 2014 at 8:32 am, it was observed that four (4) power strips within 6'-0" of sinks located in the Lab were not equipped with GFCI protection. The strips were identified as PA#3, PA#5, CPI-Bkr #4 and Pnl PA Bkr#32.

These deficient practices were confirmed by observation and interview with Staff B (Facilities Director) and Staff G (Maintenance Supervisor) at the time of discovery.