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Based on observation, on February 14, 2012 at approximately 7:30am onward, the rated access door did not self-close and latch for mechanical chase near room 562 - access door is located on corridor wall.

Based on observation, on February 14, 2012 at approximately 7:30am onward, hazardous area in the following area is incomplete:

1. mechanical room 1-22B, inactive leaf of fire door is not self-closing and latching.

Based on observation, on February 14, 2012 at approximately 7:30am onward, hazardous areas are incomplete in the following areas:

1. soiled utility/soiled linen room - there is no sprinkler or one hour enclosure for room located in wound care center.

2. storage room - room is equipped with a twenty-minute fire rated door; door to room is required to be a minimum forty-five minute rating.

A. Based on observation, on February 14, 2012 at approximately 7:30am onward, there are incomplete special locking arrangements in the following areas:

1. fifth floor near room 544 - master release switch is mounted greater than forty-eight inches above the finished floor.

2. cross corridor doors between ED & Radiology on second floor - there is no master release switch for electromagnetic locking arrangement.

B. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is an incomplete access controlled egress lock for door near operating room #4. There is no switch not greater than five feet from the door - switch must state "Push to Exit".

A. Based on observation, on February 14, 2012 at approximately 7:30am onward, exit access door from the third floor waiting area provides a clear opening less than forty-one and one half inches. The door serves greater than fifty occupants and does not open in the direction of egress.

B. Based on observation, on February 14, 2012 at approximately 7:30am onward, the hardware for door to surgical admissions is greater than forty-eight inches above finish floor. The dead-bolt hardware creates greater than a single motion of the hand to exit.

C. Based on observation, on February 14, 2012 at approximately 7:30am onward, the inactive door leaf contains manual flush-bolt hardware; and greater than a single hand motion to open, close, and latch doors to CT Scan #1. Doors are located on floor #2.

D. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is a dead-end corridor at tunnel located between stair and elevators on the first floor. The present arrangement does not allow reentry through door between corridor and tunnel.

Based on observation, on February 14, 2012 at approximately 7:30am onward, exit discharge lighting is wired to the equipment branch of the essential electrical system. The lighting serves stair tower #2 of the heart center.

Based on observation, on February 14, 2012 at approximately 7:30am onward, exit signage is incomplete in the following areas:

1. third floor waiting area - dimensions of exit sign do not comply with industry standard.

2. CT Scan #1 - exit sign directs occupants to a corridor less than eight feet minimum width.

Based on observation, on February 14, 2012 at approximately 7:30am onward, electrical equipment rooms in the following areas are not equipped with sprinklers:

1. fourth floor - room is not equipped with minimum two hour rated enclosure.

2. fifth floor - room is not equipped with minimum two hour rated enclosure.

Based on observation, on February 14, 2012 at approximately 7:30am onward, there are no sprinklers in the following areas:

1. front entrance vestibule located on second floor.

2. alcoves near fifth floor nurse manager office - located on south wing.

3. telephone equipment room - located on first floor near mechanical room 1-22B.

1. Based on observation, on February 14, 2012 at approximately 7:30am onward, the tamper switch supervisory signal did not function with valve closed - valve 0152 in first floor mechanical room.

2. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no electrical supervision of small dry system valve located in fire pump room. There are no high and low pressure switch with supervision for the dry-pipe system located in fire pump room.

3. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no high and low pressure switch for dry-pipe sprinkler system located in mechanical room under ED - near EMS entrance to ED.

4. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no high and low pressure switch for dry-pipe sprinkler system serving loading dock - valve is located in general storage room.

Based on observation, on February 14, 2012 at approximately 7:30am onward, the dry-pipe sprinkler system alarm valve and pressure switch valves are not electrically supervised.

Based on observation, on February 14, 2012 at approximately 7:30am onward, there is dust accumulation on sprinkler heat sensitive elements in the following areas:

1. first floor elevator lobby

2. seventh floor elevator lobby

Based on observation, on February 14, 2012 at approximately 7:30am onward, there are no emergency shut-down switches for air handlers serving the wound care center, and the rehabilitation center.

Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no emergency shutdown switch for air handler #3 in a supervised area.

Based on observation, on February 14, 2012 at approximately 7:30am onward, the laundry chute access door is not self-closing and latching - located in emergency department near discharge waiting area.

Based on observation, on February 14, 2012 at approximately 7:30am onward, the laundry chute terminal room is not equipped with a minimum 1.5 hour door with listed hardware assembly. The door provided is rated for forty-five minutes.

1. Based on observation, on February 13, 2012 at approximately 7:30am onward, there are impediments in the exit discharge to the rear terrace located on the first floor.(stair exit passageway located near first floor elevator)

2. Based on observation, on February 13, 2012 at approximately 7:30am onward, there are impediments to egress in the ICU. The ICU area is not defined within a suite meeting prescriptive requirements of the Life Safety Code.

Based on observation, on February 14, 2012 at approximately 7:30am onward, medical gas cylinders are not secured or labeled properly in the following areas:

1. medication preparation room on seventh floor - full and empty cylinders are not identified.

2. bulk oxygen, near loading dock, cylinders are not individually secured.

A. Based on observation, on February 14, 2012 at approximately 7:30am onward, normal and emergency panels are not distinguished through color coding. Receptacles on emergency power are red, panels serving emergency receptacles have black labels.

B. Based on observation, on February 14, 2012 at approximately 7:30am onward, there are no lights on the critical branch of the essential electrical system - main switchgear room.

C. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no signaling devices for a three hour fuel capacity remaining in the main fuel tanks for the essential electrical system. The devices must register signals on the annunciator panel for the essential electrical system.

D. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no test switch for generator annunciator audible signaling device - Onan annunciator panel located in security room.

E. Based on observation, on February 15, 2012 at approximately 6:20am onward, the emergency power system required approximately thirteen seconds to transfer from normal to emergency power during loss of normal power to the ATS-LS-19.

F. Based on observation, on February 15, 2012 at approximately 6:20am onward, the annunciator panel did not read emergency power supplying load with loss of power to ATS-LS-19.

Based on observation, on February 14, 2012 at approximately 7:30am onward, the circuit directory is missing for electrical panel - located beside equipment panel QFPHB in mechanical, and electrical equipment room.

Based on observation, on February 14, 2012 at approximately 7:30am onward, there is an alcohol based hand sanitizer located beside a light switch in the child birth suite.

Based on observation, on February 14, 2012 at approximately 7:30am onward, the rated access door did not self-close and latch for mechanical chase near room 562 - access door is located on corridor wall.

Based on observation, on February 14, 2012 at approximately 7:30am onward, hazardous area in the following area is incomplete:

1. mechanical room 1-22B, inactive leaf of fire door is not self-closing and latching.

Based on observation, on February 14, 2012 at approximately 7:30am onward, hazardous areas are incomplete in the following areas:

1. soiled utility/soiled linen room - there is no sprinkler or one hour enclosure for room located in wound care center.

2. storage room - room is equipped with a twenty-minute fire rated door; door to room is required to be a minimum forty-five minute rating.

A. Based on observation, on February 14, 2012 at approximately 7:30am onward, there are incomplete special locking arrangements in the following areas:

1. fifth floor near room 544 - master release switch is mounted greater than forty-eight inches above the finished floor.

2. cross corridor doors between ED & Radiology on second floor - there is no master release switch for electromagnetic locking arrangement.

B. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is an incomplete access controlled egress lock for door near operating room #4. There is no switch not greater than five feet from the door - switch must state "Push to Exit".

A. Based on observation, on February 14, 2012 at approximately 7:30am onward, exit access door from the third floor waiting area provides a clear opening less than forty-one and one half inches. The door serves greater than fifty occupants and does not open in the direction of egress.

B. Based on observation, on February 14, 2012 at approximately 7:30am onward, the hardware for door to surgical admissions is greater than forty-eight inches above finish floor. The dead-bolt hardware creates greater than a single motion of the hand to exit.

C. Based on observation, on February 14, 2012 at approximately 7:30am onward, the inactive door leaf contains manual flush-bolt hardware; and greater than a single hand motion to open, close, and latch doors to CT Scan #1. Doors are located on floor #2.

D. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is a dead-end corridor at tunnel located between stair and elevators on the first floor. The present arrangement does not allow reentry through door between corridor and tunnel.

Based on observation, on February 14, 2012 at approximately 7:30am onward, exit discharge lighting is wired to the equipment branch of the essential electrical system. The lighting serves stair tower #2 of the heart center.

Based on observation, on February 14, 2012 at approximately 7:30am onward, exit signage is incomplete in the following areas:

1. third floor waiting area - dimensions of exit sign do not comply with industry standard.

2. CT Scan #1 - exit sign directs occupants to a corridor less than eight feet minimum width.

Based on observation, on February 14, 2012 at approximately 7:30am onward, electrical equipment rooms in the following areas are not equipped with sprinklers:

1. fourth floor - room is not equipped with minimum two hour rated enclosure.

2. fifth floor - room is not equipped with minimum two hour rated enclosure.

Based on observation, on February 14, 2012 at approximately 7:30am onward, there are no sprinklers in the following areas:

1. front entrance vestibule located on second floor.

2. alcoves near fifth floor nurse manager office - located on south wing.

3. telephone equipment room - located on first floor near mechanical room 1-22B.

1. Based on observation, on February 14, 2012 at approximately 7:30am onward, the tamper switch supervisory signal did not function with valve closed - valve 0152 in first floor mechanical room.

2. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no electrical supervision of small dry system valve located in fire pump room. There are no high and low pressure switch with supervision for the dry-pipe system located in fire pump room.

3. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no high and low pressure switch for dry-pipe sprinkler system located in mechanical room under ED - near EMS entrance to ED.

4. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no high and low pressure switch for dry-pipe sprinkler system serving loading dock - valve is located in general storage room.

Based on observation, on February 14, 2012 at approximately 7:30am onward, the dry-pipe sprinkler system alarm valve and pressure switch valves are not electrically supervised.

Based on observation, on February 14, 2012 at approximately 7:30am onward, there is dust accumulation on sprinkler heat sensitive elements in the following areas:

1. first floor elevator lobby

2. seventh floor elevator lobby

Based on observation, on February 14, 2012 at approximately 7:30am onward, there are no emergency shut-down switches for air handlers serving the wound care center, and the rehabilitation center.

Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no emergency shutdown switch for air handler #3 in a supervised area.

Based on observation, on February 14, 2012 at approximately 7:30am onward, the laundry chute access door is not self-closing and latching - located in emergency department near discharge waiting area.

Based on observation, on February 14, 2012 at approximately 7:30am onward, the laundry chute terminal room is not equipped with a minimum 1.5 hour door with listed hardware assembly. The door provided is rated for forty-five minutes.

1. Based on observation, on February 13, 2012 at approximately 7:30am onward, there are impediments in the exit discharge to the rear terrace located on the first floor.(stair exit passageway located near first floor elevator)

2. Based on observation, on February 13, 2012 at approximately 7:30am onward, there are impediments to egress in the ICU. The ICU area is not defined within a suite meeting prescriptive requirements of the Life Safety Code.

Based on observation, on February 14, 2012 at approximately 7:30am onward, medical gas cylinders are not secured or labeled properly in the following areas:

1. medication preparation room on seventh floor - full and empty cylinders are not identified.

2. bulk oxygen, near loading dock, cylinders are not individually secured.

A. Based on observation, on February 14, 2012 at approximately 7:30am onward, normal and emergency panels are not distinguished through color coding. Receptacles on emergency power are red, panels serving emergency receptacles have black labels.

B. Based on observation, on February 14, 2012 at approximately 7:30am onward, there are no lights on the critical branch of the essential electrical system - main switchgear room.

C. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no signaling devices for a three hour fuel capacity remaining in the main fuel tanks for the essential electrical system. The devices must register signals on the annunciator panel for the essential electrical system.

D. Based on observation, on February 14, 2012 at approximately 7:30am onward, there is no test switch for generator annunciator audible signaling device - Onan annunciator panel located in security room.

E. Based on observation, on February 15, 2012 at approximately 6:20am onward, the emergency power system required approximately thirteen seconds to transfer from normal to emergency power during loss of normal power to the ATS-LS-19.

F. Based on observation, on February 15, 2012 at approximately 6:20am onward, the annunciator panel did not read emergency power supplying load with loss of power to ATS-LS-19.

Based on observation, on February 14, 2012 at approximately 7:30am onward, the circuit directory is missing for electrical panel - located beside equipment panel QFPHB in mechanical, and electrical equipment room.