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Based upon observations, interviews and review of drawings, the fire rated floors have penetrations that are not fire stopped to maintain the required fire resistance of the floors.

Based upon observations, interviews and review of drawings, the fire rated steel beams have Fire Proofing missing that is needed to maintain the required fire resistance of the steel structure.

Findings include:

On 3-7-11 between the hours of 8 am and 6 pm it was revealed by observation that in the Surgery Center portion of the building, that the penetrations through the 2nd floor above the 1st and 2nd floors above the Electrical rooms on each floor were not properly sealed with an approved Ul Listed Penetration System.

On 3-7-11 between the hours of 8 am and 6 pm it was revealed by observation that in the Surgery Center portion of the building on the 1st and 2nd floors and in the Radiology Department on the 1st floor that the Structural Steel Members had many areas of the surface that had missing Fire Proofing.

In an interview with the VP of Operations and the Safety Director on 3-7-11 between 8 am and 6 pm the above observations were confirmed by the VP Of Operations and the Facility Safety Director.

Based upon observations, interviews and review of drawings, the Fire and Smoke Rated Walls had open penetrations allowing for the passage of Heat and Smoke from one area to another.

Findings include:

On 03-03-11 and 03-07-11 between the hours of 8 am and 6 pm it was revealed by observation that in the Labor and Delivery Breezeway to the Surgery Center on the 2nd floor and the old Charting Room on the 1st floor there were numerous open penetrations between the Fire and Smoke Rated Walls leading from one protected area to another.

In an interview with the VP of Operations and the Safety Director on 3-7-11 between 8 am and 6 pm the above observations were confirmed by the VP Of Operations and the Facility Safety Director.

Based upon observations and interviews , the Fire Sprinkler System was not complete (coverage areas of sprinkler heads) in the 3rd floor Mechanical room.

Findings include:

On 03-03-11 between the hours of 8 am and 6 pm it was revealed by observation that in the 3rd floor Mechanical Room that there were areas under HVAC Duct Work that there were missing Sprinkler Heads that by being missing did not afford adequate coverage as per NFPA 13 Sprinkler System requirements.

In an interview with the VP of Operations and the Safety Director on 3-7-11 between 8 am and 6 pm the above observations were confirmed by the VP Of Operations and the Facility Safety Director.

Based upon observations and interviews , the Kitchen Cooking Equipment and supporting system piping was not properly cleaned of residue, (grease build up).

Findings include:

On 03-03-11 between the hours of 8 am and 6 pm it was revealed by observation that in Kitchen, there were cooking appliances that had a build up of grease on the various sides and backs of the cooking equipment. In addition, much of the electrical conduit and gas piping was also covered with a residue of grease build up.

In an interview with the VP of Operations and the Safety Director on 3-7-11 between 8 am and 6 pm the above observations were confirmed by the VP Of Operations and the Facility Safety Director.

Based upon observations and interviews, the Emergency Generator did not have a remote announciator located at a 24 hour manned location.

Based upon observations and interviews, the space between the deck above and the ceiling tiles below there were many abandoned Fire Alarm and Communications Systems wires still in place and not removed. This was prevelant throughout the Facility on all floors.

Based upon observations and interviews, the space between the deck above and the ceiling tiles below there were many Fire Alarm and Communications Systems wires laying on Fire Sprinkler System Piping.This was prevelant throughout the Facility on all floors.

Based upon observations and interviews, the Electrical Room located with in the geographical bounderies of the Lab did not have the Egress Door swinging in the Direction of the Egress Pathe out of this room..

Findings include:

On 03-03-11 between the hours of 8 am and 6 pm it was revealed by observation that the Emergency Generator did not have a remote announciator located at a 24 hour manned location as per NFPA 110.

On 03-03-11 and 03-07-11 between the hours of 8 am and 6 pm it was revealed by observation the space between the deck above and the ceiling tiles below there were many abandoned Fire Alarm and Communications Systems wires still in place and not removed as required by NFPA 70, Articles 725 and 760.

On 03-03-11 and 03-07-11 between the hours of 8 am and 6 pm it was revealed by observation the space between the deck above and the ceiling tiles below there were many Fire Alarm and Communications Systems wires laying on Fire Sprinkler System Piping which is not allowed by NFPA 13.

On 03-07-11 between the hours of 8 am and 6 pm it was revealed by observation the Electrical Room located with in the geographical bounderies of the Lab did not have the Proper Egress Hardware on the Egress Door as required by NFPA 70, Article 110.33.

In an interview with the VP of Operations and the Safety Director on 3-7-11 between 8 am and 6 pm the above observations were confirmed by the VP Of Operations and the Facility Safety Director.

Based upon observations, interviews and review of drawings, the fire rated floors have penetrations that are not fire stopped to maintain the required fire resistance of the floors.

Based upon observations, interviews and review of drawings, the fire rated steel beams have Fire Proofing missing that is needed to maintain the required fire resistance of the steel structure.

Findings include:

On 3-7-11 between the hours of 8 am and 6 pm it was revealed by observation that in the Surgery Center portion of the building, that the penetrations through the 2nd floor above the 1st and 2nd floors above the Electrical rooms on each floor were not properly sealed with an approved Ul Listed Penetration System.

On 3-7-11 between the hours of 8 am and 6 pm it was revealed by observation that in the Surgery Center portion of the building on the 1st and 2nd floors and in the Radiology Department on the 1st floor that the Structural Steel Members had many areas of the surface that had missing Fire Proofing.

In an interview with the VP of Operations and the Safety Director on 3-7-11 between 8 am and 6 pm the above observations were confirmed by the VP Of Operations and the Facility Safety Director.

Based upon observations, interviews and review of drawings, the Fire and Smoke Rated Walls had open penetrations allowing for the passage of Heat and Smoke from one area to another.

Findings include:

On 03-03-11 and 03-07-11 between the hours of 8 am and 6 pm it was revealed by observation that in the Labor and Delivery Breezeway to the Surgery Center on the 2nd floor and the old Charting Room on the 1st floor there were numerous open penetrations between the Fire and Smoke Rated Walls leading from one protected area to another.

In an interview with the VP of Operations and the Safety Director on 3-7-11 between 8 am and 6 pm the above observations were confirmed by the VP Of Operations and the Facility Safety Director.

Based upon observations and interviews , the Fire Sprinkler System was not complete (coverage areas of sprinkler heads) in the 3rd floor Mechanical room.

Findings include:

On 03-03-11 between the hours of 8 am and 6 pm it was revealed by observation that in the 3rd floor Mechanical Room that there were areas under HVAC Duct Work that there were missing Sprinkler Heads that by being missing did not afford adequate coverage as per NFPA 13 Sprinkler System requirements.

In an interview with the VP of Operations and the Safety Director on 3-7-11 between 8 am and 6 pm the above observations were confirmed by the VP Of Operations and the Facility Safety Director.

Based upon observations and interviews , the Kitchen Cooking Equipment and supporting system piping was not properly cleaned of residue, (grease build up).

Findings include:

On 03-03-11 between the hours of 8 am and 6 pm it was revealed by observation that in Kitchen, there were cooking appliances that had a build up of grease on the various sides and backs of the cooking equipment. In addition, much of the electrical conduit and gas piping was also covered with a residue of grease build up.

In an interview with the VP of Operations and the Safety Director on 3-7-11 between 8 am and 6 pm the above observations were confirmed by the VP Of Operations and the Facility Safety Director.

Based upon observations and interviews, the Emergency Generator did not have a remote announciator located at a 24 hour manned location.

Based upon observations and interviews, the space between the deck above and the ceiling tiles below there were many abandoned Fire Alarm and Communications Systems wires still in place and not removed. This was prevelant throughout the Facility on all floors.

Based upon observations and interviews, the space between the deck above and the ceiling tiles below there were many Fire Alarm and Communications Systems wires laying on Fire Sprinkler System Piping.This was prevelant throughout the Facility on all floors.

Based upon observations and interviews, the Electrical Room located with in the geographical bounderies of the Lab did not have the Egress Door swinging in the Direction of the Egress Pathe out of this room..

Findings include:

On 03-03-11 between the hours of 8 am and 6 pm it was revealed by observation that the Emergency Generator did not have a remote announciator located at a 24 hour manned location as per NFPA 110.

On 03-03-11 and 03-07-11 between the hours of 8 am and 6 pm it was revealed by observation the space between the deck above and the ceiling tiles below there were many abandoned Fire Alarm and Communications Systems wires still in place and not removed as required by NFPA 70, Articles 725 and 760.

On 03-03-11 and 03-07-11 between the hours of 8 am and 6 pm it was revealed by observation the space between the deck above and the ceiling tiles below there were many Fire Alarm and Communications Systems wires laying on Fire Sprinkler System Piping which is not allowed by NFPA 13.

On 03-07-11 between the hours of 8 am and 6 pm it was revealed by observation the Electrical Room located with in the geographical bounderies of the Lab did not have the Proper Egress Hardware on the Egress Door as required by NFPA 70, Article 110.33.

In an interview with the VP of Operations and the Safety Director on 3-7-11 between 8 am and 6 pm the above observations were confirmed by the VP Of Operations and the Facility Safety Director.