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Based on observations during the tour at the facility on the afternoon of 7/20/2011, with the Director of Engineering, the facility failed to maintain a rated barrier. Storage door, near nursery, was missing a closure to keep the door in a closed position.

Based on observations during the tour at the facility on the afternoon of 7/20/2011, with the Director of Engineering, the facility failed to maintain a rated barrier. Second floor ' s fire exit stair door D ' s closure did not allow the door to completely close.

Based on observations during the tour at the facility on the afternoon of 7/20/2011, with the Director of Engineering, the facility failed to maintain a rated barrier. The door did not latch at the door frame when closed at the decontam room and the trash chute room, which are both hazardous areas. Also the door did not latch at day surgery

Based on observations during the tour at the facility on the afternoon of 7/20/2011, with the Director of Engineering, the facility failed to maintain a clear and unobstructed egress path. The ICU corridor contained a copier which impeded egress path.

Based on observations during the tour at the facility on the afternoon of 7/20/2011, with the Director of Engineering, the facility failed to maintain the exit signs. The exit sign was not lit in Radiology.

Based on observations during the tour at the facility on the afternoon of 7/20/2011, with the Director of Engineering, the facility failed to assure correct cross labeling of the FACP and the electrical panel that provides the power for the FACP. The FACP panel and subpanels were not always labeled as to which electrical panel and breaker supplied the power for the FACP. Also the breakers shall be labeled at the panel that supplies power to the FACP. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker shall be colored red.

Based on observations during the tour at the facility on the afternoon of 7/20/2011, with the Director of Engineering, the facility failed to provide a sprinkler head in the receiving room and the material management ' s alcove leading into its storage room. Therefore the fire sprinkler system did not comply with NFPA 13

Based on observations during the tour at the facility on the afternoon of 7/20/2011, with the Director of Engineering, the facility failed to assure that the essential electrical system was in full compliance. Floor camera and infant security system was supplied with power from the life safety branch of the essential electrical system and needs to be moved to the either the critical or equipment branch panel. 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.