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1) Based on observation and interview with staff, the facility failed to provide Doors that protect corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minute. Doors are provided with a means suitable for keeping the door closed. Findings include:

a) The door to CEO office is not provided with Latching Hardware.

1) Based on observation and interview with staff, the facility failed to provide electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2 Findings include:

a) The facility failed to maintain design features initially approved for construction. The building must be maintained in accordance with approved design specifications. Any variations shall require the approval of the authority having jurisdiction prior to the actual change NFPA101 2000 Life Safety Code 5.1.7.
(5.1.7* Maintenance of Design Features. The design features
required for the building to continue to meet the performance
goals and objectives of this Code shall be maintained for
the life of the building. Such performance goals and objectives
shall include complying with all documented assumptions and
design specifications. Any variations shall require the approval
of the authority having jurisdiction prior to the actual change.)
(See also 4.6.9.2) The ER room located adjacent to the Nurses station is not provided with emergency power in accordance with NFPA 70. The room, was re-purposed from patient rooms to over flow Emergency Room. The room was not provided with dedicated an emergency circuit from the Critical Care Branch of the Emergency Distribution System.

b) The facility failed to monitor the Bio-Medical equipment program. The facility did not have any documentation that the Bio-Medical services provided under contract had any way to identify quality and performance problems, implement appropriate corrective action, improvement activities, or to ensure the monitoring and sustainability of those corrective or improvement activities. See ?482.21 QAPI.

c) The facility failed to install a 90 minute Battery Operated Light over the transfer switch.

d) The electrical panels located through out the building were not accurate and labeled. Staff did not know and could demonstrate the distribution of the system.

1) Based on observation, review of meeting minutes, and interview with staff, the facility failed to conduct a approved fire watch system is provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1 Findings include:

a) The city water supply was off on 5/16/2014 at 2237 hours. The facility failed to document fire watch as required by NFPA 101.