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Based on observation, the facility failed to assure corridor fire doors will close to a positive latch upon activation of the fire alarm system.

The findings include:

Observation on January 8, 2013 at 10:00 a.m. revealed the fire doors on the third floor near patient room 321 failed to close to a positive latch upon testing.


This finding was verified by the Plant Operations Director and acknowledged by the Administrator during the exit conference on January 8, 2013.

Based on observation, the facility failed to assure hazardous area one (1) hour fire rated construction is maintained.

The findings include:

Observation on January 8, 2013 at 9:47 a.m. revealed numerous penetrations in the one (1) hour fire rated walls of the third floor hazardous utility closet.

Observation on January 8, 2013 at 10:00 a.m. revealed numerous penetrations in the one (1) hour fire rated walls of the main electrical room on the first floor.


These findings were verified by the Plant Operations Director and acknowledged by the Administrator during the exit conference on January 8, 2013.

Based on observation, the facility failed to assure the proper automatic sprinkler heads were installed.

The findings include:

Observation on January 8, 2013 at 11:00 a.m. revealed the second and third floors have two corridors; the front corridor of each floor has newly installed quick response sprinkler heads leaving the existing standard heads in the back corridors untouched. This deficiency list mixed matched heads for each compartment of both floors.


This finding was verified by the Plant Operations Director and acknowledged by the Administrator during the exit conference on January 8, 2013.

Based on observation, the facility failed to assure electrical wiring is installed in accordance with NFPA 70.

The findings include:

Observation on January 8, 2013 at 9:47 a.m. revealed one (1) electrical junction box installed above the ceiling on third floor near the elevators with no protective cover installed.

Observation on January 8, 2013 at 9:53 a.m. revealed one (1) electrical junction box installed above the ceiling on third floor near the exit doors with no protective cover installed.

Observation on January 8, 2013 at 9:55 a.m. revealed one (1) electrical junction box installed above the ceiling on third floor near patient room 324 with no protective cover installed.

Observation on January 8, 2013 at 10:22 a.m. revealed one (1) electrical junction box installed above the ceiling on third floor near the supply room with no protective cover installed.


These findings were verified by the Plant Operations Director and acknowledged by the Administrator during the exit conference on January 8, 2013.

Based on observation, the facility failed to assure corridor fire doors will close to a positive latch upon activation of the fire alarm system.

The findings include:

Observation on January 8, 2013 at 10:00 a.m. revealed the fire doors on the third floor near patient room 321 failed to close to a positive latch upon testing.


This finding was verified by the Plant Operations Director and acknowledged by the Administrator during the exit conference on January 8, 2013.

Based on observation, the facility failed to assure hazardous area one (1) hour fire rated construction is maintained.

The findings include:

Observation on January 8, 2013 at 9:47 a.m. revealed numerous penetrations in the one (1) hour fire rated walls of the third floor hazardous utility closet.

Observation on January 8, 2013 at 10:00 a.m. revealed numerous penetrations in the one (1) hour fire rated walls of the main electrical room on the first floor.


These findings were verified by the Plant Operations Director and acknowledged by the Administrator during the exit conference on January 8, 2013.

Based on observation, the facility failed to assure the proper automatic sprinkler heads were installed.

The findings include:

Observation on January 8, 2013 at 11:00 a.m. revealed the second and third floors have two corridors; the front corridor of each floor has newly installed quick response sprinkler heads leaving the existing standard heads in the back corridors untouched. This deficiency list mixed matched heads for each compartment of both floors.


This finding was verified by the Plant Operations Director and acknowledged by the Administrator during the exit conference on January 8, 2013.

Based on observation, the facility failed to assure electrical wiring is installed in accordance with NFPA 70.

The findings include:

Observation on January 8, 2013 at 9:47 a.m. revealed one (1) electrical junction box installed above the ceiling on third floor near the elevators with no protective cover installed.

Observation on January 8, 2013 at 9:53 a.m. revealed one (1) electrical junction box installed above the ceiling on third floor near the exit doors with no protective cover installed.

Observation on January 8, 2013 at 9:55 a.m. revealed one (1) electrical junction box installed above the ceiling on third floor near patient room 324 with no protective cover installed.

Observation on January 8, 2013 at 10:22 a.m. revealed one (1) electrical junction box installed above the ceiling on third floor near the supply room with no protective cover installed.


These findings were verified by the Plant Operations Director and acknowledged by the Administrator during the exit conference on January 8, 2013.