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Based on observation and staff interview, the facility failed to maintain 1 hour fire rated wall construction in accordance with the following requirements of 2000 NFPA 101, Section 18.3.2.1.


Findings include:

On facility tour between 1:00 PM and 4:00 PM on 04/07-08/2014, observation revealed that the following was found:

1. Medical storage room # 140 - has a 12" by 12" hole in east wall above the drop in ceiling
2. Bio Hazardous room # 149 - north corridor door will not shut and latch

These deficient practices were confirmed by the Safety Administrator (RS) at the time of discovery.

Based on documentation review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.

Findings include:

On facility tour between 1:00 PM and 4:00 PM on 04/07-08/2014, a review of the annual fire sprinkler inspection records showed more than 12 months passed between the inspection conducted on 06-21-12 and the inspection conducted on 08-24-13.


This deficient practice was confirmed by the Safety Administrator (RS) at the time of discovery.

Based on observation and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not installed in accordance with the LSC, Section 18.5.2.1 and NFPA 90A, Section 3-4.6.2.

Findings include:

On facility tour between 1:00 PM and 4:00 PM on 04/07-08/2014, observation revealed that the fire/smoke damper located in the smoke barrier by laundry room has fire stopping material that will expand. This would cause the fire/smoke damper to fail in a fire.

Facility could not provide documentation that the proper fire stopping material was used.


This deficient practice was confirmed by the Safety Administrator (RS) at the time of discovery.

Based on documentation review and staff interview, the facility failed to test the emergency generator in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2.

Findings include:

On facility tour between 1:00 PM and 4:00 PM on 04/07-08/2014, documentation review revealed that the following following was found:

1. Weekly Emergency Generator inspection logs from April 2013 to April 2014 and the following weeks were missed:

3/24/2014, 7/22 and 12/2/2013

2. Monthly Emergency Generator logs from April 2013 to March 2014 indicated that the April 2013 monthly run was missed

3. Documentation review of the monthly emergency generator testing log (April 2013 to March 2014), indicated that the facility did not run the diesel emergency generator under load at 30% of nameplate rating or by one of the following means:

1. loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer or
2. under load of 30 percent or more of the nameplate rating of generator or
3. 2 hour load bank test ( first 30 minutes - 25%, next 30 minutes - 50%, and last 1 hour - 75%)


These deficient practices were confirmed by the Safety Administrator (RS) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain 1 hour fire rated wall construction in accordance with the following requirements of 2000 NFPA 101, Section 18.3.2.1.


Findings include:

On facility tour between 1:00 PM and 4:00 PM on 04/07-08/2014, observation revealed that the following was found:

1. Medical storage room # 140 - has a 12" by 12" hole in east wall above the drop in ceiling
2. Bio Hazardous room # 149 - north corridor door will not shut and latch

These deficient practices were confirmed by the Safety Administrator (RS) at the time of discovery.

Based on documentation review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.

Findings include:

On facility tour between 1:00 PM and 4:00 PM on 04/07-08/2014, a review of the annual fire sprinkler inspection records showed more than 12 months passed between the inspection conducted on 06-21-12 and the inspection conducted on 08-24-13.


This deficient practice was confirmed by the Safety Administrator (RS) at the time of discovery.

Based on observation and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not installed in accordance with the LSC, Section 18.5.2.1 and NFPA 90A, Section 3-4.6.2.

Findings include:

On facility tour between 1:00 PM and 4:00 PM on 04/07-08/2014, observation revealed that the fire/smoke damper located in the smoke barrier by laundry room has fire stopping material that will expand. This would cause the fire/smoke damper to fail in a fire.

Facility could not provide documentation that the proper fire stopping material was used.


This deficient practice was confirmed by the Safety Administrator (RS) at the time of discovery.

Based on documentation review and staff interview, the facility failed to test the emergency generator in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2.

Findings include:

On facility tour between 1:00 PM and 4:00 PM on 04/07-08/2014, documentation review revealed that the following following was found:

1. Weekly Emergency Generator inspection logs from April 2013 to April 2014 and the following weeks were missed:

3/24/2014, 7/22 and 12/2/2013

2. Monthly Emergency Generator logs from April 2013 to March 2014 indicated that the April 2013 monthly run was missed

3. Documentation review of the monthly emergency generator testing log (April 2013 to March 2014), indicated that the facility did not run the diesel emergency generator under load at 30% of nameplate rating or by one of the following means:

1. loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer or
2. under load of 30 percent or more of the nameplate rating of generator or
3. 2 hour load bank test ( first 30 minutes - 25%, next 30 minutes - 50%, and last 1 hour - 75%)


These deficient practices were confirmed by the Safety Administrator (RS) at the time of discovery.