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Based on observation, the facility failed to maintain their corridor walls.

1. The operating room entry door has been relocated from a smoke resistive wall.

2. Unsealed penetrations exist above the smoke doors.
NFPA 101(2000 edition) chapter 19.3.6.2 requires corridor walls form a barrier to limit the transfer of smoke.

The findings include:

1. While on tour November 5, 2014, at 2:45 PM, at the operating room entrance door, with the Maintenance Director, the door was observed to have been removed from a smoke resistive wall. The Maintenance Director confirmed the entry door had been removed.

2. While on tour November 5, 2014 at 2:45 above the operating room entry and at 2:50 PM above the smoke doors next to the men's locker room, unsealed penetrations were observed above the smoke doors. The Maintenance Director confirmed the penetrations.

Based on observation, the facility has failed to properly maintain their fire sprinkler system.

1. A dirt dauber has built a nest around a sprinkler's glass bulb on the loading dock. NFPA 25( 1998 edition) chapter 2-2.1.1 requires sprinklers be replaced if loaded.

2. In the telemetry room, air-conditioning ducts over four feet wide obstruct fire sprinklers. NFPA 13 (1999 edition) chapter 5-5.5.3.1 requires sprinklers under fixed obstructions over four feet wide.

3. In the pharmacy, movable storage units are within 12 inches of a pendant fire sprinkler. NFPA 13 (1999 edition) chapter 5-5.5.2.1 requires a minimum of 18 inches between a sprinkler head and shelving.

The findings include:

While on tour November 5, 2014 with the Maintenance Director:

1. At 12:40 PM, on the loading dock, dirt dauber nests were observed on the pendant sprinklers protecting the loading dock. The Maintenance Director confirmed the fire sprinklers were loaded with dirt dauber nests.

2. At 12:41 PM, in the telemetry room, air-conditioning ducts are obstructing the fire sprinklers. The Maintenance Director confirmed the obstruction.

3. At 12:49 PM, in the pharmacy, movable storage units are within 12 inches of a pendant fire sprinkler. The Maintenance Director confirmed the obstruction.

Based on observation, the facility has allowed prohibited space heaters in the business office. NFPA 101(2000 edition) chapter 19.7.8 prohibits space heaters whose heating element exceeds 212 degrees F.

The findings include:

While on tour November 5, 2014, at 12:57 PM, under the Administrative Assistant's desk, a space heater was observed labeled with a warning to maintain a 3-foot distance from combustibles. The Maintenance Director confirmed the space heater.

Based on record review, the facility failed to provide an enviroment free from electrical hazards.

The facility failed to document the annual inspection of their essential electrical circuit's main and feeder circuit breakers and to document a program for the exercising of the breakers as required by NFPA 99 (1999 edition) chapter 3-4.4.1.2.

The findings include:

During record review November 5, 2014, the facility failed to provide documentation for the annual inspection of their essential electrical circuits main and feeder circuit breakers and to document a program for exercising the breakers. The Maintenance Director confirmed the breakers were not inspected annually.