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Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in corridors, in exits, and in any space not separated from corridors and exits by partitions capable of retarding the passage of smoke; and Class A, Class B, or Class C in all other areas [Re: NFPA 101. Life Safety Code. 2000: ? 19.3.3.2.]

Findings: The staff did not have the required flame spread data for inspection at the time of the survey.

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in corridors, in exits, and in any space not separated from corridors and exits by partitions capable of retarding the passage of smoke; and Class A, Class B, or Class C in all other areas [Re: NFPA 101. Life Safety Code. 2000: ? 19.3.3.2.]

Findings: The staff did not have the required flame spread data for inspection at the time of the survey.

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor wall [rated wall separation] above the double door and lay-in ceiling in the Central Supply/Lab corridor was not sealed properly. Communication cable penetrations in the rated wall were not sealed. Similarly, above the ceiling panels in the med surg corridor near the nurses station was not sealed properly. Sleeves that penetrated the wall were not sealed properly. The facility shall affirm that all penetrations have been caulked properly.

a. Fire Alarm Control Panel

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: The FACP, located in the nurses ' station, did not meet this requirement. The facility shall ensure that this requirement is met.

b. Supervisory Signals

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Supervisory signal devices shall be exercised quarterly [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(j).] Waterflow devices shall be exercised semi-annually [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(k).] Valve tamper switches shall be exercised semi-annually [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(l).]

Findings: The staff was not able to confirm that these required tests were conducted. The facility shall ensure that this requirement is met.

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 19.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over [Re: NFPA 99, Health Care Facilities, 1999: ? 4-3.1.1.1.]

Findings: The medical gas cylinders were observed and they were not individually constrained as required.

a. Line isolation Monitor Tests

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed far intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators [Re: NFPA 99, Health Care Facilities, 1999: ? 3-3.3.4.2(b).]

Findings: The staff indicated these tests are not performed and logs of the tests were not available for review.

b. Disaster Drills

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 99 and the State licensing rules were not met.

At least one semi-annual drill shall rehearse mass casualty response for emergency services, disaster receiving stations, or both. At least one annual " after action report " shall be available for review [Re: NFPA 99, Health Care Facilities, 2002: ?11-5.3.9]

These reports shall be retained for a period of three years [Re: 25 TAC HLR, 2007: ? 133.142[c][3].]

Findings: These reports were not available for review.

c. Circuit Breakers

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

The circuit breakers that are impacted by transfer switch operation shall be exercised annually pursuant to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 2002: ? 3-4.4.1.2.]

Findings: The staff indicated that these tests were not conducted and records were not available for review.

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in corridors, in exits, and in any space not separated from corridors and exits by partitions capable of retarding the passage of smoke; and Class A, Class B, or Class C in all other areas [Re: NFPA 101. Life Safety Code. 2000: ? 19.3.3.2.]

Findings: The staff did not have the required flame spread data for inspection at the time of the survey.

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Interior wall and ceiling finish complying with 10.2.3 shall be Class A or Class B in corridors, in exits, and in any space not separated from corridors and exits by partitions capable of retarding the passage of smoke; and Class A, Class B, or Class C in all other areas [Re: NFPA 101. Life Safety Code. 2000: ? 19.3.3.2.]

Findings: The staff did not have the required flame spread data for inspection at the time of the survey.

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor wall [rated wall separation] above the double door and lay-in ceiling in the Central Supply/Lab corridor was not sealed properly. Communication cable penetrations in the rated wall were not sealed. Similarly, above the ceiling panels in the med surg corridor near the nurses station was not sealed properly. Sleeves that penetrated the wall were not sealed properly. The facility shall affirm that all penetrations have been caulked properly.

a. Fire Alarm Control Panel

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: The FACP, located in the nurses ' station, did not meet this requirement. The facility shall ensure that this requirement is met.

b. Supervisory Signals

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Supervisory signal devices shall be exercised quarterly [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(j).] Waterflow devices shall be exercised semi-annually [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(k).] Valve tamper switches shall be exercised semi-annually [Re: NFPA 72, National Fire Alarm Code, 2002: ? 7-3.2 and Table 7-3.2(15)(l).]

Findings: The staff was not able to confirm that these required tests were conducted. The facility shall ensure that this requirement is met.

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 19.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over [Re: NFPA 99, Health Care Facilities, 1999: ? 4-3.1.1.1.]

Findings: The medical gas cylinders were observed and they were not individually constrained as required.

a. Line isolation Monitor Tests

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed far intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators [Re: NFPA 99, Health Care Facilities, 1999: ? 3-3.3.4.2(b).]

Findings: The staff indicated these tests are not performed and logs of the tests were not available for review.

b. Disaster Drills

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 99 and the State licensing rules were not met.

At least one semi-annual drill shall rehearse mass casualty response for emergency services, disaster receiving stations, or both. At least one annual " after action report " shall be available for review [Re: NFPA 99, Health Care Facilities, 2002: ?11-5.3.9]

These reports shall be retained for a period of three years [Re: 25 TAC HLR, 2007: ? 133.142[c][3].]

Findings: These reports were not available for review.

c. Circuit Breakers

Observation and discussion with the Chief Executive Officer, the Director of Plant Operations and the Chief Financial Officer between 9:00 am and 11:30 am on 9/7/2011 revealed that certain requirements stipulated in NFPA 99 were not met.

The circuit breakers that are impacted by transfer switch operation shall be exercised annually pursuant to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 2002: ? 3-4.4.1.2.]

Findings: The staff indicated that these tests were not conducted and records were not available for review.