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The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 1:00 pm to 4:00 pm on 03/29/2023 that penetrations need to be sealed in the following locations: Above ceiling at double doors at ER. Above ceiling at double doors at OB.

"Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device." - NFPA 101, 2012, 8.3.5.1.

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 1:00 pm to 4:00 pm on 03/29/2023 that the signatures of the staff that participated in the fire drills were not included.

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 1:00 pm to 4:00 pm on 03/29/2023 that some shower curtains did not have tags that state, "meets NFPA-701", Documentation that came with the shower curtains stating this requirement has been met, is acceptable.

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 1:00 pm to 4:00 pm on 03/29/2023 that the cylinders in the med gas yard needed additional chains to secure the cylinders from falling. No more than three per chain.

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 1:00 pm to 4:00 pm on 03/29/2023 that the electrical room was being used for storage. This is not allowed.

"Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)

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The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 1:00 pm to 4:00 pm on 03/29/2023 that the following was not met in the electrical room's life safety panel box.

"For fire alarm systems the circuit disconnecting means shall have a red marking." - NFPA 72, 2010, 10.5.5.2.3

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The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 1:00 pm to 4:00 pm on 03/29/2023 that the following requirements were not being met.

"The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
"(4) Generator set locations as follows:
(a) Task illumination,
(b) Battery charger for emergency battery-powered lighting unit(s),
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations." NFPA 99, 2012, 6.4.2.2.3.2

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 1:00 pm to 4:00 pm on 03/29/2023 that documents were not available for review for receptacle testing per the following requirement.

Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99), (K914).

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 1:00 pm to 4:00 pm on 03/29/2023 that documents for the generator's 36 month load bank test were not available for review.

Electrical Systems - Essential Electric System Maintenance and Testing:
36 month load bank test for 4 continuous hours. (See A.8, 8.4.9)

The inspector observed, while accompanied by the Facility Manager during the hours of the inspection from 1:00 pm to 4:00 pm on 03/29/2023 that documents for the following were not available for review.

Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99)