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Based on observation the facility failed to provide proper directional exit marking from a conference room on B1 floor.

Based on observation the facility failed to provide proper identification to roof exit hatch. Provide larger directional exit sign.

Based on observation the facility failed to provide proper identification to low protruding objects inside of pump room (chains).

Based on observation the facility failed to provide adequate sprinkler protection throughout the entire building.
Portion of the 26th floor was not sprinkled, penthouse floor 27th and 28th were non-sprinklered also a portion of second floor less than 2,000 sf is currently non- sprinkled.

Based on observation the facility failed to provide adequate identification of sprinkler heads in pump room.

Provide identification of all heads outside of box. Per NFPA 13 6.2.9.7.1

Based on observation the facility failed to provide wrench required in sprinkler cabinet.

"One sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system." - NFPA 13, 2010, 6.2.9.6


Based on observation the facility failed to provide proper separation between buildings.

Separate buildings. Portions of a building divided horizontally with two-hour fire rated walls which are continuous (without offsets) from the foundation to above the roof shall be considered as a separate building. Communicating openings in the two-hour wall shall be limited to public spaces such as lobbies and corridors. All such openings shall be protected with self-closing one and one-half hour, Class B fire door assemblies. Title 25, TAC, Ch. 133, HLR. DSHS; 2007: 133.162(d)(C)

Based on observation the facility failed to provide gfci plug at sink located in mechanical room
Provide GFCI Per NFPA 70 218.8 (7)


Based on observation the facility failed to provide proper circuit locations for essential system circuits. Nurse call circuit on 25th floor located on equipment branch.
6.4.2.2.3.2 "The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with 101, Life Safety Code,
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code,
(3) Hospital communications systems, where used for issuing instruction during emergency conditions,
(4) Generator set locations as follows:
(a) Task illumination,
(b) Battery charger for emergency battery-powered lighting unit(s),
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations,
(5) Elevator cab lighting, control, communications, and signal systems,
(6) Electrically powered doors used for building egress,
(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code." - NFPA 99, 2012, 6.4.2.2.3.2


Based on observation the facility failed to provide proper labeling of essential panels. Please verify all panels located on patient care areas.

"Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system." - NFPA 70, 2002: 110-22 and 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.



Based on observation the facility failed to provide proper circuit locations for essential system circuits. Time clock and card reader located on Life Safety.

6.4.2.2.3.2 "The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with 101, Life Safety Code,
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code,
(3) Hospital communications systems, where used for issuing instruction during emergency conditions,
(4) Generator set locations as follows:
(a) Task illumination,
(b) Battery charger for emergency battery-powered lighting unit(s),
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations,
(5) Elevator cab lighting, control, communications, and signal systems,
(6) Electrically powered doors used for building egress,
(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code." - NFPA 99, 2012, 6.4.2.2.3.2