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Based on observation the facility failed to provide adequate smoke barrier.

The inspector observed, while accompanied by The Administrative Assistance, The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at the above ceiling of the fire rate and smoke barrier partitions.
B.) While performing the fire alarm testing the cross corridor door located at the smoke barrier partition were not fully closed.
C.) There were missing astragals at two the cross corridor door located at the smoke barrier partition.

The inspector observed, while accompanied by The Administrative Assistance, The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:

A.) There were missing door closure at the following hazardous areas: Soiled Work Room at ER, Dry Storage Room in Dietary suite, and the Soiled Work Room in Rehabilitation suite.
B.) There was missing fire rated door or door frame rating at the following hazardous areas: Soiled Work Room at ER, and the Medical Gas Storage Room.
C.) There were some penetration was not sealed by the fire rated sealant at the Boiler Room.

Based on observation the facility failed to maintain the fire alarm system operation.

The inspector observed, while accompanied by The Administrative Assistance, The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:

A.) An Audible and visible fire alarm notification device need to be installed inside the OR suite.


" 9.6.3.10.1 Audible and visible fire alarm notification appliances shall be used only for fire alarm system or other emergency purposes. "

Based on observation the facility failed to provide adequate medical gas system storage requirement.

The inspector observed, while accompanied by The Administrative Assistance, The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:


A.) There was no signage provided at the medical gas bulk storage tank area. Provide the following signage:

Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

CAUTION
Medical Gases
NO Smoking or Open Flame

The inspector observed, while accompanied by The Administrative Assistance , The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:



1) The Grounding system testing at inpatient areas on TDSHS form were not performed.
2) Line isolation monitor - Grounding system testing on TDSHS form were not performed.
3) The letters indicating preferred customer status report in case of emergency situation for water and fuel source was not available.

The inspector observed, while accompanied by The Administrative Assistance, The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:

A.) The flexible conduits were utilized for the essential electrical panels - life safety critical panels, and equipment panels. Please provide hard conduits.
B.) The crash cart was not powered from the critical branch of the emergency power.

Based on observation the facility failed to provide adequate smoke barrier.

The inspector observed, while accompanied by The Administrative Assistance, The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at the above ceiling of the fire rate and smoke barrier partitions.
B.) While performing the fire alarm testing the cross corridor door located at the smoke barrier partition were not fully closed.
C.) There were missing astragals at two the cross corridor door located at the smoke barrier partition.

The inspector observed, while accompanied by The Administrative Assistance, The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:

A.) There were missing door closure at the following hazardous areas: Soiled Work Room at ER, Dry Storage Room in Dietary suite, and the Soiled Work Room in Rehabilitation suite.
B.) There was missing fire rated door or door frame rating at the following hazardous areas: Soiled Work Room at ER, and the Medical Gas Storage Room.
C.) There were some penetration was not sealed by the fire rated sealant at the Boiler Room.

Based on observation the facility failed to maintain the fire alarm system operation.

The inspector observed, while accompanied by The Administrative Assistance, The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:

A.) An Audible and visible fire alarm notification device need to be installed inside the OR suite.


" 9.6.3.10.1 Audible and visible fire alarm notification appliances shall be used only for fire alarm system or other emergency purposes. "

Based on observation the facility failed to provide adequate medical gas system storage requirement.

The inspector observed, while accompanied by The Administrative Assistance, The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:


A.) There was no signage provided at the medical gas bulk storage tank area. Provide the following signage:

Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

CAUTION
Medical Gases
NO Smoking or Open Flame

The inspector observed, while accompanied by The Administrative Assistance , The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:



1) The Grounding system testing at inpatient areas on TDSHS form were not performed.
2) Line isolation monitor - Grounding system testing on TDSHS form were not performed.
3) The letters indicating preferred customer status report in case of emergency situation for water and fuel source was not available.

The inspector observed, while accompanied by The Administrative Assistance, The Nurse Manager, and The Maintenance Safety Officer during the hours of the inspection from 1:00 PM to 3:30 PM on 06/03/2015 that there was the following issues:

A.) The flexible conduits were utilized for the essential electrical panels - life safety critical panels, and equipment panels. Please provide hard conduits.
B.) The crash cart was not powered from the critical branch of the emergency power.