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Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide an acceptable means to protect the corridor. The corridor doors into the clean linen and nursery equipment storage rooms did not latch when closed.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to assure that the smoke barriers were constructed to resist the movement of smoke. Few penetrations in the smoke barrier above the cross corridor doors were not sealed and holes were in the wall, thereby jeopardizing the effectiveness of the barrier. The facility shall ensure that all barriers are smoke tight in order that the integrity is restored.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide cross corridor doors in smoke barrier openings, near the lobby, with features at the meeting edges to make them smoke resistant, such as bevels, rabbets, or astragal. Per NFPA 101, Life Safety Code, 2000: ? 18.3.7.8 ..... Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to assure an acceptable enclosure of hazardous areas. An office had been converted to a storage room of combustible material (i.e. cardboard boxes and medical records) and did not have a closure on the door, the walls of these rooms did not go up to the deck and were not 1-hour rated. Ensure that either the room is converted back to office or that this room has a 1-hour fire rated enclosure (1-hour fire rated walls with 3/4-hour fire rated door assemblies with closure on door).

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide the direction of the egress path. An exit sign appeared to indicate the exit path went through the physical therapy suite (Wellness Center).

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide a sprinkler head in the purchasing office. Therefore the fire sprinkler system did not comply with NFPA 13.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide, at emergency generator 2, a distinctive color at the generator emergency system ' s electrical receptacle. This receptacle is required to be red with the circuit and panelboard numbers on the receptacle ' s plate. Per NFPA 99; 1999: ? 3-5.2.2.4(b) ... ... The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, it could not be determined, at emergency generator 2, that a task illumination was supplied and powered from the essential electrical system ' s life safety branch.


Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide, at emergency generator 1, a task illumination and an emergency receptacle supplied with power from the essential electrical system ' s life safety branch.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to assure that the essential electrical system was in full compliance. Smoke fire dampers are supplied with power from the life safety branch of the essential electrical system and are required to be moved to the equipment branch panel. Nurse call systems are required by NFPA 99 to be powered from the Critical Branch of the EES. The X-Ray machine receptacle can either be on critical or equipment branch of the EES, but not life safety branch.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems; " 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide an acceptable means to protect the corridor. The corridor doors into the clean linen and nursery equipment storage rooms did not latch when closed.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to assure that the smoke barriers were constructed to resist the movement of smoke. Few penetrations in the smoke barrier above the cross corridor doors were not sealed and holes were in the wall, thereby jeopardizing the effectiveness of the barrier. The facility shall ensure that all barriers are smoke tight in order that the integrity is restored.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide cross corridor doors in smoke barrier openings, near the lobby, with features at the meeting edges to make them smoke resistant, such as bevels, rabbets, or astragal. Per NFPA 101, Life Safety Code, 2000: ? 18.3.7.8 ..... Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to assure an acceptable enclosure of hazardous areas. An office had been converted to a storage room of combustible material (i.e. cardboard boxes and medical records) and did not have a closure on the door, the walls of these rooms did not go up to the deck and were not 1-hour rated. Ensure that either the room is converted back to office or that this room has a 1-hour fire rated enclosure (1-hour fire rated walls with 3/4-hour fire rated door assemblies with closure on door).

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide the direction of the egress path. An exit sign appeared to indicate the exit path went through the physical therapy suite (Wellness Center).

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide a sprinkler head in the purchasing office. Therefore the fire sprinkler system did not comply with NFPA 13.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide, at emergency generator 2, a distinctive color at the generator emergency system ' s electrical receptacle. This receptacle is required to be red with the circuit and panelboard numbers on the receptacle ' s plate. Per NFPA 99; 1999: ? 3-5.2.2.4(b) ... ... The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, it could not be determined, at emergency generator 2, that a task illumination was supplied and powered from the essential electrical system ' s life safety branch.


Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to provide, at emergency generator 1, a task illumination and an emergency receptacle supplied with power from the essential electrical system ' s life safety branch.

Based on observations during the tour of the facility on the afternoon of 03/02/2011, with the Director of Facility Management, the facility failed to assure that the essential electrical system was in full compliance. Smoke fire dampers are supplied with power from the life safety branch of the essential electrical system and are required to be moved to the equipment branch panel. Nurse call systems are required by NFPA 99 to be powered from the Critical Branch of the EES. The X-Ray machine receptacle can either be on critical or equipment branch of the EES, but not life safety branch.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems; " 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions;
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.