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Based upon observations made in the presence of the plant manager and administrator on 12/15/14, it was determined that the facility did not maintain corridors constructed with at least ½ hour fire resistant rating in accordance with NFPA 101 19.3.6.2.1.

This deficiency affected 1 of numerous smoke compartments.

Findings include:

During the tour of the facility it was observed that the corridor wall by X-ray room 1 had a bundle of wires passing through an unused access door running the digital developer for the x-rays. Corridor was need to form a barrier to limit the transfer of smoke in accordance with NFPA 101 19.3.6.2.2.

Based upon observations made in the presence of the plant manager on 12/15/14, it was determined that the facility did not maintain the corridor doors to be positively latching to resist the passage of smoke in accordance with NFPA 101 19.3.6.3.3.

This deficiency affected 4 of numerous facility corridor doors.

Findings include:

During the facility tour it was observed that doors were being held open via inappropriate means of floor wedges, as seen at the pharmacy, tub room and clean room in nursing corridor, and room 29.. Corridor doors are allowed to be held open with a device that will release with a push or pull in accordance with NFPA 101 19.3.6.3.3.

Based upon observations made in the presence of the plant manager on 12/15/14, 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.

This deficiency affected 3 of numerous hazardous areas.

Findings include:

During the tour of the facility it was observed that the electrical room by the emergency department and the oxygen manifold room both had pipes that penetrated the walls that were left unsealed against the transfer of smoke or fire.

During the tour of the facility it was observed that the door to the electrical room in the boiler room was not closing to the latch position.

Based upon observations made in the presence of the plant manager on 12/15/14, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101 19.3.5.1.

This deficiency affected 1 of numerous storage areas.

Findings include:

During the tour of the facility it was observed that the fire sprinkler head in the nursery store room was obstructed with storage items not leaving 18 " of clearance between the head and the storage in accordance with NFPA 19.3.5.1; 9.7.1.1; NFPA 13 5-5.6.

During the tour of the facility it was observed that the fire sprinkler riser pressure gauges were past due to be replaced or recalibrated in accordance with NFPA 19.3.5.1; 9.7.5; NFPA 25 9-2.8.2. Riser gauges are to be replaced or recalibrated every 5 years, the date on the existing gauges was 2008.

Based upon observations made in the presence of the plant manager on 12/15/14, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 101 19.3.2.4 and NFPA 99 4-3.1.1.2.

This deficiency affected 1 of numerous smoke compartments.

Findings include:

During the tour of the facility it was observed that a loose CO2 tank was placed in the operating room corridor to signal that the cylinder needed to be changed.

Based upon observations made in the presence of the plant manager and administrator on 12/15/14, it was determined that the facility did not maintain corridors constructed with at least ½ hour fire resistant rating in accordance with NFPA 101 19.3.6.2.1.

This deficiency affected 1 of numerous smoke compartments.

Findings include:

During the tour of the facility it was observed that the corridor wall by X-ray room 1 had a bundle of wires passing through an unused access door running the digital developer for the x-rays. Corridor was need to form a barrier to limit the transfer of smoke in accordance with NFPA 101 19.3.6.2.2.

Based upon observations made in the presence of the plant manager on 12/15/14, it was determined that the facility did not maintain the corridor doors to be positively latching to resist the passage of smoke in accordance with NFPA 101 19.3.6.3.3.

This deficiency affected 4 of numerous facility corridor doors.

Findings include:

During the facility tour it was observed that doors were being held open via inappropriate means of floor wedges, as seen at the pharmacy, tub room and clean room in nursing corridor, and room 29.. Corridor doors are allowed to be held open with a device that will release with a push or pull in accordance with NFPA 101 19.3.6.3.3.

Based upon observations made in the presence of the plant manager on 12/15/14, 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.

This deficiency affected 3 of numerous hazardous areas.

Findings include:

During the tour of the facility it was observed that the electrical room by the emergency department and the oxygen manifold room both had pipes that penetrated the walls that were left unsealed against the transfer of smoke or fire.

During the tour of the facility it was observed that the door to the electrical room in the boiler room was not closing to the latch position.

Based upon observations made in the presence of the plant manager on 12/15/14, it was determined that the facility did not maintain the fire sprinkler system in accordance with NFPA 101 19.3.5.1.

This deficiency affected 1 of numerous storage areas.

Findings include:

During the tour of the facility it was observed that the fire sprinkler head in the nursery store room was obstructed with storage items not leaving 18 " of clearance between the head and the storage in accordance with NFPA 19.3.5.1; 9.7.1.1; NFPA 13 5-5.6.

During the tour of the facility it was observed that the fire sprinkler riser pressure gauges were past due to be replaced or recalibrated in accordance with NFPA 19.3.5.1; 9.7.5; NFPA 25 9-2.8.2. Riser gauges are to be replaced or recalibrated every 5 years, the date on the existing gauges was 2008.

Based upon observations made in the presence of the plant manager on 12/15/14, it was determined that the facility did not maintain medical gas storage in accordance with NFPA 101 19.3.2.4 and NFPA 99 4-3.1.1.2.

This deficiency affected 1 of numerous smoke compartments.

Findings include:

During the tour of the facility it was observed that a loose CO2 tank was placed in the operating room corridor to signal that the cylinder needed to be changed.