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Based on a tour of the hospital it was observed that door openings in one set of smoke barriers on the forth floor behavioral health unit did not have vision panels that are of fire-rated glazing or wired glass panels and steel frames. ( 19.3.7.5).

Based on a tour of the hospital it was observed that the doors to the refrigerators in the laboratory were not provided with signage indicating the flammable liquid storage was not permitted. (NFPA 99)

Based on a tour of the hospital it was observed that exit components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1 as evidenced by:

During the tour of the hospital it was observed that:
? One set of egress doors in an exit enclosure did not swing in the direction of travel ( NFPA 101, 7.2.1.4.2). One of the fifth floor doors was reversed and did not swing in the direction of exit travel .
? The vision panel on the rated stairway door in the behavioral health unit on the fourth floor did not have approved wired glass or approved rated clear glazing.

Based on a tour of the hospital it was observed that three sets of exit doors serving the cafeteria and having an occupancy of 50 or more persons did not swing in the direction of travel (NFPA 101 , 7.2.1.4.2). The doors must be arranged to swing in the direction of exit travel or other approved exit doors shall be provided. (19.2.3.1)

Based on a tour of the hospital it was observed that exit access was not marked on one corridor . The corridor on the third floor in the area of room SW374 appeared to be a dead end corridor, about 60 feet in length. An illuminated exit sign at the door to the adjacent area will correct this issue.

Based on a tour of the hospital it was observed that in three areas sprinkler were not installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (19.3.5)
? An additional sprinkler was required at the doors in the area of the room SW260.
? An additional sprinkler is needed in the entry sallyport area of the emergency room.
? Sidewall sprinklers are appropriate only when installed at a wall or an approved bulkhead . Several existing sidewall sprinklers in the third floor ICU area are located in the middle of the room where walls may have once existed. The automatic sprinkler coverage in this area must be corrected.

Based on a tour of the hospital it was observed that required automatic sprinkler systems have valves supervised so that at least a local alarm will sound when the valves are closed. (NFPA 72, 9.7.2.1) It was observed that electrical supervisions were not provided for the OS&Y valve located on the suction side of the fire pump.

Based on a tour of the hospital, it was observed that the hospital did not have posted signs stating " no smoking or open flames" in areas where oxygen was stored or used.

Based on a tour of the hospital it was observed that door openings in one set of smoke barriers on the forth floor behavioral health unit did not have vision panels that are of fire-rated glazing or wired glass panels and steel frames. ( 19.3.7.5).

Based on a tour of the hospital it was observed that the doors to the refrigerators in the laboratory were not provided with signage indicating the flammable liquid storage was not permitted. (NFPA 99)

Based on a tour of the hospital it was observed that exit components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1 as evidenced by:

During the tour of the hospital it was observed that:
? One set of egress doors in an exit enclosure did not swing in the direction of travel ( NFPA 101, 7.2.1.4.2). One of the fifth floor doors was reversed and did not swing in the direction of exit travel .
? The vision panel on the rated stairway door in the behavioral health unit on the fourth floor did not have approved wired glass or approved rated clear glazing.

Based on a tour of the hospital it was observed that three sets of exit doors serving the cafeteria and having an occupancy of 50 or more persons did not swing in the direction of travel (NFPA 101 , 7.2.1.4.2). The doors must be arranged to swing in the direction of exit travel or other approved exit doors shall be provided. (19.2.3.1)

Based on a tour of the hospital it was observed that exit access was not marked on one corridor . The corridor on the third floor in the area of room SW374 appeared to be a dead end corridor, about 60 feet in length. An illuminated exit sign at the door to the adjacent area will correct this issue.

Based on a tour of the hospital it was observed that in three areas sprinkler were not installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (19.3.5)
? An additional sprinkler was required at the doors in the area of the room SW260.
? An additional sprinkler is needed in the entry sallyport area of the emergency room.
? Sidewall sprinklers are appropriate only when installed at a wall or an approved bulkhead . Several existing sidewall sprinklers in the third floor ICU area are located in the middle of the room where walls may have once existed. The automatic sprinkler coverage in this area must be corrected.

Based on a tour of the hospital it was observed that required automatic sprinkler systems have valves supervised so that at least a local alarm will sound when the valves are closed. (NFPA 72, 9.7.2.1) It was observed that electrical supervisions were not provided for the OS&Y valve located on the suction side of the fire pump.

Based on a tour of the hospital, it was observed that the hospital did not have posted signs stating " no smoking or open flames" in areas where oxygen was stored or used.