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The inspector observed, while accompanied by The Safety manager and the facility director, during the hours of the inspection from 01:40 PM to 05:30 PM on 04/11/2019 that there were the following issues. They were the following issues.


A) There were doors were not released from the magnetic hold open device upon activate the fire alarm system on the 1st floor.

The inspector observed, while accompanied by The Safety manager and the facility director, during the hours of the inspection from 01:40 PM to 05:30 PM on 04/11/2019 that there were the following issues. They were the following issues.


A) Some of the smoke barrier cross corridor doors was not fully closed upon the fire alarm activation on the 1st floor, second floor, and the 3rd floor.

The inspector observed, while accompanied by The Safety manager and the facility director, during the hours of the inspection from 01:40 PM to 05:30 PM on 04/11/2019 that there were the following issues. They were the following issues.

(A) There was not a door closer for some of the storage rooms throughout the facility, the elevator machine room, the door for the living quarter and especially the basement storage rooms.



(B) There was not a door UL fire rated label for some of the storage rooms throughout the facility, the elevator machine room, the door for the living quarter and especially the basement storage rooms.



(C) The fire caulking at the fire rated room were not provided at the boiler room, storage rooms, etc.

The inspector observed, while accompanied by The Safety manager and the facility director, during the hours of the inspection from 01:40 PM to 05:30 PM on 04/11/2019 that there were the following issues. They were the following issues.

(A) There was not a smoke detector provided at the sub-waiting area where an open space is adjacent to the egress corridor. Please provide a smoke detector.

The inspector observed, while accompanied by The Safety manager and the facility director, during the hours of the inspection from 01:40 PM to 05:30 PM on 04/11/2019 that there were the following issues. They were the following issues.

(A) The door inspection was not performed annually and the log was not available.

The inspector observed, while accompanied by The Safety manager and the facility director, during the hours of the inspection from 01:40 PM to 05:30 PM on 04/11/2019 that there were the following issues. They were the following issues.

(A) There was a missing receptacle powered from life safety branch at the automatic transfer switch location.



(B) The electrical directory was not updated in accordance to the new or modified receptacles.



(C) There were flexible conduits utilized from emergency electrical outlet for crash cart at the corridor. This wiring system shall be a nonflexible metal raceway.



(D) Receptacles were not tested or logged. Electrical Systems -Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. The facility shall establish a testing interval and maintain testing records.



(E) One of the fire alarm control panel shown to be powered from the critical branch. Please verify and correct it back to the life safety branch.

The inspector observed, while accompanied by The Safety manager and the facility director, during the hours of the inspection from 01:40 PM to 05:30 PM on 04/11/2019 that there were the following issues. They were the following issues.

(A) The material constructed to enclose the medical gas cylinder was wood fence and was not limited or none-combustible material.




(B) There was not a signage provided at the medical gas storage yard.