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Based on observation and interview with staff, the facility failed to provide a fire barrier having at least a two-hour fire resistance rating between the hospital and the adjacent spaces. Findings:

1) On the first floor between the hospital facility and the adjacent ambulatory surgical center, there are unrated penetrations in the two hour rated wall in the med gas room and above the double doors leading to the ambulatory surgical center.

2) On the third floor between the hospital facility and the adjacent tenant space, there are unrated penetrations in the wall. There are gaps between the top of the gypsum board and the spray applied fireproofing and around structural beams.

Based on observation and interview with staff, the facility failed to provide smoke barriers constructed to provide at least a one half hour fire resistance rating. Findings:

1) Many unrated penetrations exist through the smoke barrier (smoke compartment wall) along the length of the wall. The smoke barrier has gypsum board on one side only in the wall between the Nourishment and the South Corridor.

Based on observation and interview with staff, the facility failed to provide protection of hazardous areas. The protection shall be minimum one-hour fire rated.

1) On the second floor, there are unrated penetrations and open gaps between the top of the gypsum board and the spray applied fireproofing and around structural beams in the Soiled Workroom, Soiled Utility/Clean Supply, Equipment Room, Sterile Supply, and both Storage Rooms between the stairwells.

Based on observation and interview with staff, the facility failed to provide exit signs in accordance with Section 7.10. Findings:

1) There is not a exit sign that is visible from both directions as required on the third floor at the west elevator.

Based on observation and interview with staff, the facility failed to provide ventilation complying with NFPA 101, Section 9.2 Findings:

1) The exhaust fan in the third floor toilet room was not operable.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings:

1) There was junction box without a cover plate above the ceiling in the third floor waiting area.

Based on observation and interview with staff, the facility failed to provide a fire barrier having at least a two-hour fire resistance rating between the hospital and the adjacent spaces. Findings:

1) On the first floor between the hospital facility and the adjacent ambulatory surgical center, there are unrated penetrations in the two hour rated wall in the med gas room and above the double doors leading to the ambulatory surgical center.

2) On the third floor between the hospital facility and the adjacent tenant space, there are unrated penetrations in the wall. There are gaps between the top of the gypsum board and the spray applied fireproofing and around structural beams.

Based on observation and interview with staff, the facility failed to provide smoke barriers constructed to provide at least a one half hour fire resistance rating. Findings:

1) Many unrated penetrations exist through the smoke barrier (smoke compartment wall) along the length of the wall. The smoke barrier has gypsum board on one side only in the wall between the Nourishment and the South Corridor.

Based on observation and interview with staff, the facility failed to provide protection of hazardous areas. The protection shall be minimum one-hour fire rated.

1) On the second floor, there are unrated penetrations and open gaps between the top of the gypsum board and the spray applied fireproofing and around structural beams in the Soiled Workroom, Soiled Utility/Clean Supply, Equipment Room, Sterile Supply, and both Storage Rooms between the stairwells.

Based on observation and interview with staff, the facility failed to provide exit signs in accordance with Section 7.10. Findings:

1) There is not a exit sign that is visible from both directions as required on the third floor at the west elevator.

Based on observation and interview with staff, the facility failed to provide ventilation complying with NFPA 101, Section 9.2 Findings:

1) The exhaust fan in the third floor toilet room was not operable.

Based on observation and interview with staff, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code. Findings:

1) There was junction box without a cover plate above the ceiling in the third floor waiting area.