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The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels in approved frames. A minimum of two separate compartments are provided on each floor as required by the referenced LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.
On 08/29/17 at 09:30 AM and at times throughout the day the surveyor, accompanied by the Safety Program Officer, observed that the windows installed in the corridor walls outside of the sixth (6th) and seventh (7th) floor Med Rooms are not rated for installation in a fire rated wall, not meeting the requirements of the referenced LSC standard.

The facility did not ensure that Emergency and Standby Power Systems were being inspected and maintained as required in NFPA 110 "Standard for Emergency and Standby Power Systems".
On 08/29/17 at 09:30 AM the surveyor was not provided with documentation from the Safety Program Officer that the facility emergency generator was being maintained as required by NFPA 110 "Standard for Emergency and Standby Power Systems" Chapter 6 section 1.1. i.e. no documentation of a Level 1 or Level 2 maintenance conducted within the past year.