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A. The facility did not ensure doors protecting corridor doors were capable of resisting the passage of smoke as required by section 18.3.6.3.1 of NFPA 101 Life Safety Code.
On 07/18/17 at 09:00 AM the surveyor, accompanied by the Director of Maintenance, observed that the construction barrier and corridor door within the Antenatal Testing Area on the fifth (5th) floor had penetrations, and missing pieces of drywall, negating the assembly's ability to resist the passage of smoke as required by the referenced LSC standard.

B. The facility did not ensure that vertical openings between floors were enclosed with construction having a resistance to the passage of smoke as required by section 8.6.1 of NFPA 101 Life Safety Code.
On 07/18/17 at 09:00 AM the surveyor, accompanied by the Director of Maintenance, observed vertical opening voids and penetrations between the fifth (5th) and sixth (6th) floor within the Antenatal Testing Area, not meeting the requirements of the referenced LSC standard.

The facility did not ensure that piped in medical gas systems are in compliance with chapter 5 of NFPA 99.
On 07/19/17 at 11:00 AM the surveyor was not provided with documentation from facility staff that would indicate that the deficiencies noted on the medical gas inspection report dated 12/06/16 have been corrected. i.e; medical gas testing contractor noted on the report that the facility lacks WAGD inlets in anesthetizing locations within the facility, not complying with section 5.1.5.16 of NFPA 99.