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Based on observation and interview with staff, the facility failed to separate hazardous areas from other space with doors that are self-closing, Finding:

The door to central supply was held open with plastic door scotches which prevented the door from being self-closing.

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

The front entry canopy, the loading dock area, the new connecting corridor and CT scan room do not have automatic sprinkler system coverage.

Based upon observation and interview with staff, the facility failed to provide ashtrays of noncombustible material and safe design and metal containers with self-closing cover devices into which ashtrays can be emptied in all areas where smoking is permitted. Finding:

The loading dock was being used as a smoking area and a plastic trash can was being used as an ashtray.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system that comply's with NFPA 99, Chapter 4. Findings:

1) The medical gas storage alarms are disconnected.
2) The filling pad is too small (asphalt is located within 5 feet of the bulk fill connection).
3) The Emergency Department is not provided with area alarms.

Based on interview with staff, and review of the Generator Weekly Run Log, the facility failed to properly inspect, exercise under load for 30 minutes per month and document in accordance with NFPA 99. 3.4.4.1 Findings,

1) On 2-2-12 the Generator was documented on the hour meter as starting at 50.8 and stopping at 51; thus, not running the required 30 minutes.
2) The required 30% load was not shown for the run time.
3) The amps were not logged on the report form for any of the run times.

Based on observation and interview with staff, the facility failed to provide a Type I EES that is divided into the critical branch, life safety branch in accordance with NFPA 99. 3.4.2.2.2 Findings,

1) There is not a 90 minute battery pack light light was over the transfer switch and generator.
2) The patient rooms are not provided with emergency power,
3) The Life Safety, Critical Care and Equipment Branches were not marked to show that the emergency distribution system is properly separated.

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

1) The receptacles located in patient rooms are not hospital grade.
2) Impedance ground testing has not been performed in patient care areas.
3) The retention force of the grounding blades of electrical receptacles is less than the 4 oz. required. Cords plugged into receptacles in multiple areas are hanging down at the prongs, indicating the receptacles do not have proper retention.
4) The Line Isolation Monitors across from the Nurses Station are disconnected. The grounding has been compromised and no other alternate grounding method has been provided.

Based on observation and interview with staff, the facility failed to separate hazardous areas from other space with doors that are self-closing, Finding:

The door to central supply was held open with plastic door scotches which prevented the door from being self-closing.

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

The front entry canopy, the loading dock area, the new connecting corridor and CT scan room do not have automatic sprinkler system coverage.

Based upon observation and interview with staff, the facility failed to provide ashtrays of noncombustible material and safe design and metal containers with self-closing cover devices into which ashtrays can be emptied in all areas where smoking is permitted. Finding:

The loading dock was being used as a smoking area and a plastic trash can was being used as an ashtray.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system that comply's with NFPA 99, Chapter 4. Findings:

1) The medical gas storage alarms are disconnected.
2) The filling pad is too small (asphalt is located within 5 feet of the bulk fill connection).
3) The Emergency Department is not provided with area alarms.

Based on interview with staff, and review of the Generator Weekly Run Log, the facility failed to properly inspect, exercise under load for 30 minutes per month and document in accordance with NFPA 99. 3.4.4.1 Findings,

1) On 2-2-12 the Generator was documented on the hour meter as starting at 50.8 and stopping at 51; thus, not running the required 30 minutes.
2) The required 30% load was not shown for the run time.
3) The amps were not logged on the report form for any of the run times.

Based on observation and interview with staff, the facility failed to provide a Type I EES that is divided into the critical branch, life safety branch in accordance with NFPA 99. 3.4.2.2.2 Findings,

1) There is not a 90 minute battery pack light light was over the transfer switch and generator.
2) The patient rooms are not provided with emergency power,
3) The Life Safety, Critical Care and Equipment Branches were not marked to show that the emergency distribution system is properly separated.

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

1) The receptacles located in patient rooms are not hospital grade.
2) Impedance ground testing has not been performed in patient care areas.
3) The retention force of the grounding blades of electrical receptacles is less than the 4 oz. required. Cords plugged into receptacles in multiple areas are hanging down at the prongs, indicating the receptacles do not have proper retention.
4) The Line Isolation Monitors across from the Nurses Station are disconnected. The grounding has been compromised and no other alternate grounding method has been provided.