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Based on observation and record review, it was determined that the smoke barrier's partition and openings of such barrier were not installed, maintained, inspected, and serviced in accordance with NFPA 80.

Findings were:

On 01/26/2010 at 10:30 a.m. while reviewing records and touring the facility with staff M, it was determined that the fire sprinkler room was not separated from the laundry room by a door which was equipped with a self closing and latching device.

Based on observations and record review, it was determined that locations which present a degree of fire hazard to the building were not enclosed, protected by fire suppression, or provided with a level of safety which meets that requirement of the code standard.

Findings were:

1) On 01/26/2010 at 1:18 p.m. while reviewing records and touring the facility with staff M, it was determined that the Emergency Room (ER ) break/locker room was not equipped with a door which had a closing and latching device.

2) On 01/26/2010 at 10:55 a.m while reviewing records and touring the facility with staff M, it was determined that kitchen doors were not equipped with approved closing and latching devices. The surveyor observed that the closing devices were removed.

3) On 01/26/2010 at 3:09 p.m. while touring the facility with staff M, it was determined that room 104 (originally an old patient treatment room) was being used as a computer storage room. This room was not designed for the current observed usage. The following deficiencies were noted: the walls were not rated, fire sprinkler coverage was inadequate for ordinary hazard, the door was not 3/4 hour fire rated, the door was not equipped with a self closing device, the door was not equipped with a self latching device, and aisles were not established in the room.

Based on observation and record review, it was determined that the building fire alarm system and components were not installed, serviced, or maintained in accordance with NFPA 72.

Findings were:

1) On 01/26/2010 at 2:12 p.m. while touring the facility with staff M, it was determined from record review and observation that there was excessive lint on smoke and heat detectors in the laundry room.

2) On 01/26/2010 at 3:18 p.m. while reviewing records and touring the facility with staff M, it was observed that all abandoned heat detectors throughout the facility were not being maintained. These detectors did not operate and were not connected to the the building's fire alarm system. (The devices need to be maintained if required)

3) On 01/26/2010 at 11:11 a.m. while reviewing records and touring the facility with staff M, it was determined that the doctors' sleeping room near the ER lacked an approved smoke detector that was interconnected to the building's fire alarm system.

Based on observation and record review, it was determined that the fire sprinkler system was not installed, serviced, maintained, and inspected in accordance with NFPA 13 and NFPA 25.

Findings were:

1) On 01/26.2010 at 11:00 a.m. while reviewing records and touring the facility with staff M, it was determined that the water based fire sprinkler system was missing an approved spare wrench for recessed type sprinklers.

2) On 01/26/2010 at 11:13 a.m. while reviewing records and touring the facility with staff M, it was determined that the water based fire sprinkler system gauges were past due five year calibration or replacement.

3) On 01/26/2010 at 10:48 a.m. while reviewing records with staff M, it was determined that the water based fire sprinkler system was past due internal visual inspection. No records indicated that this service of the system had ever been conducted.

4) On 01/26/2010 at 11:11 a.m. while reviewing records and touring the facility with staff M, it was determined that the water based fire sprinklers were covered with lint, grease, paint, or dust in the following areas: laundry room, kitchen, doctors' sleeping room, storage room basement, and maintenance storage in basement at end of the corridor.

5) On 01/26/2010 at 11:45 a.m. while touring the facility with staff M, it was determined that the ceiling was not properly sealed around the sprinkler located in the basement telephone room.

6) On 01/26/2010 at 2:12 p.m. while touring the facility with staff M, it was determined that the water based fire sprinkler system coverage was not adequate in the storage room/closet in the administration office.

7) On 01/26/2010 at 3:18 p.m. while touring the facility with staff M, it was determined that the water based fire sprinkler system auxiliary drain located in the morgue was not equipped with approved signage.

Based on observation and record review, it was determined that the electrical system was not maintained in accordance with NFPA 70, NFPA 70E, NFPA 99, and/or manufacturers specification for equipment.

Findings were:

1) On 01/26/2010 at 2:23 p.m. while reviewing the records and touring the facility with staff M, it was determined that in the corner the fire sprinkler riser room electrical junction box was missing an electrical cover.

2) On 01/26/2010 at 11:55 a.m. while touring the facility with staff M, it was determined that electrical panels were not secured or equipped with an approved latching device located at: kitchen hall panel L, kitchen panel A1 sec. 1 and panel A1 sec. 2.

3) On 01/26/2010 at 2:32 p.m. while touring the facility with staff M, it was determined that electrical plug taps and strips were not mounted in an approved method with cord routed along the wall to prevent damage which is only allowed in non-patient care areas: administration offices, director of finance, labs, nurses station, and pharmacy.

4) On 01/26/2010 at 2:12 p.m while touring the facility with staff M, it was determined that in the kitchen cooler, the lighting fixture was not provided with an approved gasket on the fixture to establish an approved moisture tight seal.

5) On 01/26/2010 at 3:07 p.m. while touring the facility with staff M, it was determined that in the basement telephone room, combustible storage was noted within 30 inches of electrical equipment and electrical panels.

6) On 01/26/2010 at 3:37 p.m. while reviewing equipment records and touring the facility with staff M, it was determined that in OR #1, the flash sterilizer was past due an electrical service check as indicated by the tag on device. The tag indicated that service was due in 2007 and no other information was found on the equipment.

Based on observation and record review, it was determined that the smoke barrier's partition and openings of such barrier were not installed, maintained, inspected, and serviced in accordance with NFPA 80.

Findings were:

On 01/26/2010 at 10:30 a.m. while reviewing records and touring the facility with staff M, it was determined that the fire sprinkler room was not separated from the laundry room by a door which was equipped with a self closing and latching device.

Based on observations and record review, it was determined that locations which present a degree of fire hazard to the building were not enclosed, protected by fire suppression, or provided with a level of safety which meets that requirement of the code standard.

Findings were:

1) On 01/26/2010 at 1:18 p.m. while reviewing records and touring the facility with staff M, it was determined that the Emergency Room (ER ) break/locker room was not equipped with a door which had a closing and latching device.

2) On 01/26/2010 at 10:55 a.m while reviewing records and touring the facility with staff M, it was determined that kitchen doors were not equipped with approved closing and latching devices. The surveyor observed that the closing devices were removed.

3) On 01/26/2010 at 3:09 p.m. while touring the facility with staff M, it was determined that room 104 (originally an old patient treatment room) was being used as a computer storage room. This room was not designed for the current observed usage. The following deficiencies were noted: the walls were not rated, fire sprinkler coverage was inadequate for ordinary hazard, the door was not 3/4 hour fire rated, the door was not equipped with a self closing device, the door was not equipped with a self latching device, and aisles were not established in the room.

Based on observation and record review, it was determined that the building fire alarm system and components were not installed, serviced, or maintained in accordance with NFPA 72.

Findings were:

1) On 01/26/2010 at 2:12 p.m. while touring the facility with staff M, it was determined from record review and observation that there was excessive lint on smoke and heat detectors in the laundry room.

2) On 01/26/2010 at 3:18 p.m. while reviewing records and touring the facility with staff M, it was observed that all abandoned heat detectors throughout the facility were not being maintained. These detectors did not operate and were not connected to the the building's fire alarm system. (The devices need to be maintained if required)

3) On 01/26/2010 at 11:11 a.m. while reviewing records and touring the facility with staff M, it was determined that the doctors' sleeping room near the ER lacked an approved smoke detector that was interconnected to the building's fire alarm system.

Based on observation and record review, it was determined that the fire sprinkler system was not installed, serviced, maintained, and inspected in accordance with NFPA 13 and NFPA 25.

Findings were:

1) On 01/26.2010 at 11:00 a.m. while reviewing records and touring the facility with staff M, it was determined that the water based fire sprinkler system was missing an approved spare wrench for recessed type sprinklers.

2) On 01/26/2010 at 11:13 a.m. while reviewing records and touring the facility with staff M, it was determined that the water based fire sprinkler system gauges were past due five year calibration or replacement.

3) On 01/26/2010 at 10:48 a.m. while reviewing records with staff M, it was determined that the water based fire sprinkler system was past due internal visual inspection. No records indicated that this service of the system had ever been conducted.

4) On 01/26/2010 at 11:11 a.m. while reviewing records and touring the facility with staff M, it was determined that the water based fire sprinklers were covered with lint, grease, paint, or dust in the following areas: laundry room, kitchen, doctors' sleeping room, storage room basement, and maintenance storage in basement at end of the corridor.

5) On 01/26/2010 at 11:45 a.m. while touring the facility with staff M, it was determined that the ceiling was not properly sealed around the sprinkler located in the basement telephone room.

6) On 01/26/2010 at 2:12 p.m. while touring the facility with staff M, it was determined that the water based fire sprinkler system coverage was not adequate in the storage room/closet in the administration office.

7) On 01/26/2010 at 3:18 p.m. while touring the facility with staff M, it was determined that the water based fire sprinkler system auxiliary drain located in the morgue was not equipped with approved signage.

Based on observation and record review, it was determined that the electrical system was not maintained in accordance with NFPA 70, NFPA 70E, NFPA 99, and/or manufacturers specification for equipment.

Findings were:

1) On 01/26/2010 at 2:23 p.m. while reviewing the records and touring the facility with staff M, it was determined that in the corner the fire sprinkler riser room electrical junction box was missing an electrical cover.

2) On 01/26/2010 at 11:55 a.m. while touring the facility with staff M, it was determined that electrical panels were not secured or equipped with an approved latching device located at: kitchen hall panel L, kitchen panel A1 sec. 1 and panel A1 sec. 2.

3) On 01/26/2010 at 2:32 p.m. while touring the facility with staff M, it was determined that electrical plug taps and strips were not mounted in an approved method with cord routed along the wall to prevent damage which is only allowed in non-patient care areas: administration offices, director of finance, labs, nurses station, and pharmacy.

4) On 01/26/2010 at 2:12 p.m while touring the facility with staff M, it was determined that in the kitchen cooler, the lighting fixture was not provided with an approved gasket on the fixture to establish an approved moisture tight seal.

5) On 01/26/2010 at 3:07 p.m. while touring the facility with staff M, it was determined that in the basement telephone room, combustible storage was noted within 30 inches of electrical equipment and electrical panels.

6) On 01/26/2010 at 3:37 p.m. while reviewing equipment records and touring the facility with staff M, it was determined that in OR #1, the flash sterilizer was past due an electrical service check as indicated by the tag on device. The tag indicated that service was due in 2007 and no other information was found on the equipment.