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Based on observation and interview with staff, the facility failed to provide doors protecting corridor openings capable of resisting fire for at least 20 minutes and doors are not provided with a means suitable for keeping the door closed. Findings:

(1) The door to computer room door A-4 was provided with a transfer grill.

(2) The doors to rooms A-11,12,15,16,17,18,C-10,12,C-4,D-6, D-5, boiler room, dietary employees entrance, and ER waiting room have roller latches.

Based on observation and interview with staff, the facility failed to provide exit access arranged so that exits are readily accessible at all times.
Finding:

The addition to the hospital (CT addition) located on the north side of the hospital does not provide for safe access to a public way.

Based on observation and interview with staff, the facility failed to provide a fire alarm system tested in accordance with NFPA 70 National Electrical Code and NFPA 72.

Findings:
(1) The annual test report form was not signed by the facility or by the technician.
(2) The annual test did not test all equipment connected to the fire alarm system. The magnetic locking system on the exterior door is not noted on the annual test.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system that it is installed to provide complete coverage for all portions of the building. Findings:

(1) The CT addition and covered walk way is not sprinkled.
(2) The two storage buildings connected to the facility by a covered walk way on the north side of the building is not sprinkled.
(3) The glassed in main entry way is not sprinkled.
(4) The hot water heater room is not sprinkled.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4.

Findings include:

(1) The emergency receptacles in patient rooms were not identifiable in accordance with NFPA 99 1999 edition 3-4.2.2.4. The Director of Maintenance or Nurses could not identify which receptacles are powered by the emergency generator.

(2) The system does not have branches for Life Safety, Critical Care , and Equipment.

(3) The panels through out the facility are not provided with complete panel schedules and labeled to show where each one is fed from.

Based on observation, review of the Generation Operation Log Test report Form and interview with staff, the facility failed to provide Generators that are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

The Generator logs were not filled out completely, no indication who was conducting test , the facility failed to run or test the generator in July through October of 2011.

The facility shall provide information from NFPA 110 Emergency Power and Stand By Systems, chapter 8 of the 2005 edition ( Routine Maintenance and Operational Testing) for all of the information required to be used for documenting weekly and monthly test.

Based on observation and interview with staff, the facility failed to provide doors protecting corridor openings capable of resisting fire for at least 20 minutes and doors are not provided with a means suitable for keeping the door closed. Findings:

(1) The door to computer room door A-4 was provided with a transfer grill.

(2) The doors to rooms A-11,12,15,16,17,18,C-10,12,C-4,D-6, D-5, boiler room, dietary employees entrance, and ER waiting room have roller latches.

Based on observation and interview with staff, the facility failed to provide exit access arranged so that exits are readily accessible at all times.
Finding:

The addition to the hospital (CT addition) located on the north side of the hospital does not provide for safe access to a public way.

Based on observation and interview with staff, the facility failed to provide a fire alarm system tested in accordance with NFPA 70 National Electrical Code and NFPA 72.

Findings:
(1) The annual test report form was not signed by the facility or by the technician.
(2) The annual test did not test all equipment connected to the fire alarm system. The magnetic locking system on the exterior door is not noted on the annual test.

Based on observation and interview with staff, the facility failed to provide an automatic sprinkler system that it is installed to provide complete coverage for all portions of the building. Findings:

(1) The CT addition and covered walk way is not sprinkled.
(2) The two storage buildings connected to the facility by a covered walk way on the north side of the building is not sprinkled.
(3) The glassed in main entry way is not sprinkled.
(4) The hot water heater room is not sprinkled.

Based on observation and interview with staff, the facility failed to provide a Type I Essential Electrical System in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4.

Findings include:

(1) The emergency receptacles in patient rooms were not identifiable in accordance with NFPA 99 1999 edition 3-4.2.2.4. The Director of Maintenance or Nurses could not identify which receptacles are powered by the emergency generator.

(2) The system does not have branches for Life Safety, Critical Care , and Equipment.

(3) The panels through out the facility are not provided with complete panel schedules and labeled to show where each one is fed from.

Based on observation, review of the Generation Operation Log Test report Form and interview with staff, the facility failed to provide Generators that are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

The Generator logs were not filled out completely, no indication who was conducting test , the facility failed to run or test the generator in July through October of 2011.

The facility shall provide information from NFPA 110 Emergency Power and Stand By Systems, chapter 8 of the 2005 edition ( Routine Maintenance and Operational Testing) for all of the information required to be used for documenting weekly and monthly test.