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Based on observation the facility failed to provide adequate protection from smoke penetrating smoke barriers.

The inspector observed, while accompanied by the Chief Operating Officer and the Mechanic during the hours of the inspection from 9:30 am to 4:45 pm on 12/2/2014 that there were the following issues. 1) Fire stop caulking is needed around wiring in the above ceiling wall above corridor door located near room D-500. 2) Fire stop caulking is needed around pipe located above ceiling in corridor smoke barrier near room B302 3) Fire stop caulking is needed around pipe sleeve located above ceiling in " A-Wing " corridor smoke barrier. 4) Fire stop caulking is needed around bundle of wiring in located above corridor fire doors near room A-407.

Based on observation the facility failed to provide adequate sprinkler requirements.

The inspector observed, while accompanied by the Chief Operating Officer and the Mechanic during the hours of the inspection from 9:30 am to 4:45 pm on 12/2/2014 that there was the following issues: 1) The sprinkler head in room C-201 bathroom did not have a cover plate. 2) The sprinkler head in room D-508 did not have a cover plate 3) The label for the Inspector Test Valve needs to be changed from " Drain Valve " to " Inspector ' s Test Valve " . 4) Main shut off valve for tamper test needs a label.

Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.

Identification of Valves. All control, drain and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification. Signs . . . per 1999 NFPA 13 §3-8.3

Based on observation the facility failed to provide adequate protection from dissimilar metal contact between copper piping and steel support hangers.

The inspector observed, while accompanied by the Chief Operating Officer and the Mechanic during the hours of the inspection from 9:30 am to 4:45 pm on 12/2/2014 that there were the following issues. They were: located at the following locations. 1) Above ceiling in room B-305. 2) Above ceiling in corridor smoke barrier near room B302

" Connections of surface-mounted medical gas rail systems to piping systems of dissimilar metals shall require plating of the connecting components to prevent interaction between dissimilar metals. " - NFPA 99, 1999, 4-3.1.2.5(f).

Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a current record for receptacle testing per NFPA 99: 3-3.3.3. for patient care areas.

The inspector observed, while accompanied by the Chief Operating Officer and the Mechanic during the hours of the inspection from 9:30 am to 4:45 pm on 12/2/2014 that record for current year receptacle testing was not available.


Generator Set Location

" The emergency generator location shall have " task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location. " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Based on observation the facility failed to provide adequate generator requirements.

The inspector observed, while accompanied by the Chief Operating Officer and the Mechanic during the hours of the inspection from 9:30 am to 4:45 pm on 12/2/2014 that there were the following issues. They were: 1) The generator is missing emergency light and receptacle. 2) " The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Based on observation the facility failed to provide adequate electrical system.

The inspector observed, while accompanied by the Chief Operating Officer and the Mechanic during the hours of the inspection from 9:30 am to 4:45 pm on 12/2/2014 that there were the following issues. 1) In patient care rooms the facility failed to provide hospital grade receptacles.

All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulted copper conductor sized in accordance the Table 250-122. NFPA 70, 1999, 517-18 (b).