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Based upon observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not maintain corridor walls to resist the passage of smoke in accordance with NFPA 101: 19.3.6.1.

Findings include:

1. There was a 1 " wall opening above the ceiling of cross-corridor doors by medical surgery.
2. There was a ? " wall opening above the ceiling in the main linen closet.

Based upon observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101: 19.3.2.1.

Findings include:

The laundry room had 2 " wall opening around the utility pipes that would not resist the passage of smoke and fire.

Based upon observation of fire drill documentation made in the presence of the plant manager on 10/4/11, it was determined that the facility did not conduct fire drills at unexpected times and varying conditions at least quarterly on each shift in accordance with NFPA 101: 19.7.1.2.

Findings include:

The facility held the graveyard fire drills within 60 minutes for each quarter during the previous 12-month period.

Based upon staff interview and observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not prohibit the display of vertically hung loose fabrics that are not either inherently flame retardant or treated to be flame resistant in accordance with NFPA 101: 19.7.5.2 and 10.3.1.

Findings include:

The imaging room had a 4 ' x 7 ' loosely hanging fabric decoration hanging on the wall. The decoration was lacking documentation that the display was either inherently flame retardant or treated to be flame resistant.

Based upon observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not continuously maintain medical gas storage in accordance with NFPA 99.

Findings include:

The medical gas storage room was door was missing a door closer so the door could self-close and positive latch.

Based upon observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 70, The National Electrical Code.

Findings include:

The nurse administration office had a daisy chain surge suppressor plugged into electronic equipment.

Based upon observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not maintain corridor walls to resist the passage of smoke in accordance with NFPA 101: 19.3.6.1.

Findings include:

1. There was a 1 " wall opening above the ceiling of cross-corridor doors by medical surgery.
2. There was a ? " wall opening above the ceiling in the main linen closet.

Based upon observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not maintain hazardous areas to be fire and smoke separated from other sections of the facility in accordance with NFPA 101: 19.3.2.1.

Findings include:

The laundry room had 2 " wall opening around the utility pipes that would not resist the passage of smoke and fire.

Based upon observation of fire drill documentation made in the presence of the plant manager on 10/4/11, it was determined that the facility did not conduct fire drills at unexpected times and varying conditions at least quarterly on each shift in accordance with NFPA 101: 19.7.1.2.

Findings include:

The facility held the graveyard fire drills within 60 minutes for each quarter during the previous 12-month period.

Based upon staff interview and observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not prohibit the display of vertically hung loose fabrics that are not either inherently flame retardant or treated to be flame resistant in accordance with NFPA 101: 19.7.5.2 and 10.3.1.

Findings include:

The imaging room had a 4 ' x 7 ' loosely hanging fabric decoration hanging on the wall. The decoration was lacking documentation that the display was either inherently flame retardant or treated to be flame resistant.

Based upon observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not continuously maintain medical gas storage in accordance with NFPA 99.

Findings include:

The medical gas storage room was door was missing a door closer so the door could self-close and positive latch.

Based upon observations made in the presence of the plant manager on 10/4/11, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 70, The National Electrical Code.

Findings include:

The nurse administration office had a daisy chain surge suppressor plugged into electronic equipment.