HospitalInspections.org

Based on observation the facility failed to provide proper labeling for rated walls. Facility to verify all rated walls based on the latest Life Safety Plan and make sure all rated walls are properly marked (stenciling)
All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7.


Based on observation at the time of inspection, the facility failed to provide an updated Life Safety Plan. Provide updated plan showing all life safety feature of the building such as smoke compartments, rated walls, travel distances etc.

Based on observation at the time of inspection, the facility failed to provide proper directional signage to a required exit. At the point of intersection at corridors, exit signs shall direct to the 2 means of egress exits. At the time of the inspection, only one directional chevron was active.
Directional Exit Signs, A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. - NFPA 101, 2012 7.10.1.2.2

Based on observation at the time of inspection, the facility failed to provide a proper distance from the outside air intake of an existing rooftop unit to an existing exhaust fan.
ASHRAE, 2003, Applications Handbook - Hospital Facilities - "Outside Air Intakes. These intakes should be located as far as practical (on directionally different exposures whenever possible), bout not less than 25 ft, from combustion equipment stack exhaust outlets, ventilation exhaust outlets from the hospital or adjoining buildings, medical-surgical vacuum system, cooling towers, plumbing vent stacks, smoke control exhaust outlets, and areas that may collect vehicular exhaust and other noxious fumes. The bottom of the outside air intakes serving central systems should be located as high as practical (12 ft recommended) but not less that 6 ft above ground level or, if installed above the roof, 3 ft above the roof level."

Based on observation at the time of inspection, the facility failed to provide proper documentation identifying the Merv rating on the filters being replaced.

Based on observation at the time of inspection, the facility failed to provide properly updated directories to the essential electrical panels.
Panel directories shall be labeled to legibly identify the purpose or use of each circuit - NFPA 70, 2002: 408.4.


Based on observation at the time of inspection, the facility failed to provide proper labeling to the existing disconnect. All disconnects associated with the essential system must be properly labeled.
NFPA 70, 2011, 110.22 Identification of Disconnecting Means. (A) General. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.


Based on observation at the time of inspection, a flex conduit was noticed installed on electrical panel CLB-B. This is a critical panel; only hard conduit is allowed.
Mechanical protection of the emergency system. The wiring of the emergency system shall be mechanically protected by installation in nonflexible metal raceways in accordance with NFPA 70, 517.30(C )(3).

Based on observation at the time of inspection, the facility failed to provide proper documentation identifying tests and associated repairs to patent care receptacles.

Based on observation at the time of inspection, the facility failed to provide proper documentation identifying transfer switches testing during monthly testing reports.

Based on observation at the time of inspection, the facility failed to provide proper protections for sprinkler heads located inside freezers/coolers.
6.2.8? Guards. Sprinklers subject to mechanical injury shall be protected with listed guards.