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The inspector observed, while accompanied by The CEO, Director of the quality, Corporate regional director of quality, Clinical service director, Regional director of the plant operation, during the hours of the inspection from 01:30 PM to 04:30 PM on 11/14/2017 that there were the following issues. They were the following issues:

A.) The door stop was utilized at the dietary storage room.

The inspector observed, while accompanied by The CEO, Director of the quality, Corporate regional director of quality, Clinical service director, Regional director of the plant operation, during the hours of the inspection from 01:30 PM to 04:30 PM on 11/14/2017 that there were the following issues. They were the following issues:

A) The plywood permanent installed on the wall did not have a fire rated label to be classified as class A, B, or C of flame spreading.

The inspector observed, while accompanied by The CEO, Director of the quality, Corporate regional director of quality, Clinical service director, Regional director of the plant operation, during the hours of the inspection from 01:30 PM to 04:30 PM on 11/14/2017 that there were the following issues. They were the following issues:

A) The manual fire alarm boxes were not provided in the path of egress near each required exits. Reference NFPA 101, 18.3.4.2.1, 18.3.4.2.2, 193.4.2.1, 19.3.4.2.2, 9.6.2.5.

The inspector observed, while accompanied by The CEO, Director of the quality, Corporate regional director of quality, Clinical service director, Regional director of the plant operation, during the hours of the inspection from 01:30 PM to 04:30 PM on 11/14/2017 that there were the following issues. They were the following issues.

(A) Please verify the bonding wire provided between the normal and essential branch-circuits panel boards. This does not comply with NFPA 70, 2002: 517-14. - Panelboard bonding requires the equipment grounding terminal buses of the normal and essential branch-circuits panelboards serving the same individual patient vicinity be bonded together with an insulated continuous copper conductor not smaller than # 10 AWG.



(B) The crash cart was not plugged into the emergency critical branch of generator. NFPA 99,: 6.4.2.2.4.2 The critical branch shall supply power for task illumination, fixed equipment, select receptacles, and select power circuits serving the following areas and functions related to patient care: Additional task illumination, receptacles, and select power circuits needed for effective facility operation, including single-phase fractional horsepower motors, which are permitted to be connected to the critical branch



(C) There was not a receptacle powered from the life safety branch of emergency generator. NFPA 99, 2002, 4.4.2.2.2.2. - The life safety branch of the essential electrical system shall supply power for the following: 1) illumination of means of egress, 2) exit signs and exit direction signs, 3) fire alarm and medical gas alarm, 4) hospital communication systems where used for emergency conditions, 5) generator set location and the ATS location that includes task illumination, battery charger for battery-powered lighting, and selected receptacles, 6) elevator cab lighting, control, communication, and signal systems, 7) automatic doors used for building egress, and 8) auxiliary functions of the fire alarm combination systems complying with NFPA 72. No other functions than those listed above shall be connected to the life safety branch, NFPA 99, 2002, 4.4.2.2.2.2.