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Based on observation, it was determined that the facility failed to ensure that all corridors are separated from use by walls constructed with fire resistance rating.

Findings include:

On 9/30/13 at 10:05 AM, in the presence of Staff #45, it was observed that there was a penetration in the wall between the Wimpheimer Building and the corridor of the BBR Building.

Based on observation, it was determined that the facility failed to ensure that there were no impediments to the closing of the door.

Findings include:

On 9/30/13 at 10:10 AM, in the presence of Staff #45, it was observed that the smoke door on the Ground Floor North Wing could not close.

Based on observation, it was determined that the facility failed to ensure that rated construction for the use of the room was provided.

Findings include:

On 10/30/13 at 10:10 AM, in the presence of Staff #45, it was observed that in Room #G306, there were 2 penetrations in the rated wall.

Based on observation, it was determined that the facility failed to ensure that continuous illumination of exit lights was provided.

Findings include:

On 9/30/13 at 10:50 AM, in the presence of Staff #45, it was observed that the exit light at the Ground Floor Maintenance Building corridor was not lit.

Based on observation, it was determined that the facility failed to ensure that the fire alarm system was maintained.

Findings include:

1. On 10/30/13 at 11:10 AM, in the presence of Staff #45, it was observed that a construction cap was on the fire alarm detector in Room #G304A.

2. On 10/30/13 at 2:30 PM, in the presence of Staff #45, it was observed that a construction cap was on the fire alarm detector in Room #C579.

Based on observation, it was determined that the facility failed to ensure that the sprinkler system is maintained in reliable operating condition.

Findings include:

1. On 10/30/13 at 11:20 AM, in the presence of Staff #45, it was observed that in Room #G3165, (5) boxes of supplies were stored within 18" of the sprinkler system.

2. On 10/30/13 at 1:50 PM, in the presence of Staff #45, it was observed that in Room #R417, a basket and files were stored within 18" of the sprinkler system.

Based on observation, it was determined that the facility failed to ensure that cubical curtains that meet the requirements of NFPA 13, Standards for the Installation of Sprinkler Systems, are provided.

Findings include:

On 10/30/13 at 2:30 PM, in the presence of Staff #45, it was observed that the cubical curtains in Room #C576 through Room #C585 had mesh that was too small for a sprinklered environment.

Based on observation, it was determined that the facility failed to ensure that medical gas in storage was protected in accordance with NFPA 99 4-3.1.1.1.

Findings include:

Reference: NFPA 99 4-3.1.1.1 states, "Cylinders in service and in storage shall be secured and located to prevent falling or being knocked over."

1. On 9/30/13 at 10:50 AM, in the presence of Staff #45, it was observed that in the main medical gas tank room, six (6) tanks of medical gas were not secured.

2. On 10/30/13 at 2:25 PM, in the presence of Staff #45, it was observed that in the BBR Building, 5th floor corridor, a tank of medical gas was not secured.

Based on observation, it was determined that the facility failed to ensure that all corridors are separated from use by walls constructed with fire resistance rating.

Findings include:

On 9/30/13 at 10:05 AM, in the presence of Staff #45, it was observed that there was a penetration in the wall between the Wimpheimer Building and the corridor of the BBR Building.

Based on observation, it was determined that the facility failed to ensure that there were no impediments to the closing of the door.

Findings include:

On 9/30/13 at 10:10 AM, in the presence of Staff #45, it was observed that the smoke door on the Ground Floor North Wing could not close.

Based on observation, it was determined that the facility failed to ensure that rated construction for the use of the room was provided.

Findings include:

On 10/30/13 at 10:10 AM, in the presence of Staff #45, it was observed that in Room #G306, there were 2 penetrations in the rated wall.

Based on observation, it was determined that the facility failed to ensure that continuous illumination of exit lights was provided.

Findings include:

On 9/30/13 at 10:50 AM, in the presence of Staff #45, it was observed that the exit light at the Ground Floor Maintenance Building corridor was not lit.

Based on observation, it was determined that the facility failed to ensure that the fire alarm system was maintained.

Findings include:

1. On 10/30/13 at 11:10 AM, in the presence of Staff #45, it was observed that a construction cap was on the fire alarm detector in Room #G304A.

2. On 10/30/13 at 2:30 PM, in the presence of Staff #45, it was observed that a construction cap was on the fire alarm detector in Room #C579.

Based on observation, it was determined that the facility failed to ensure that the sprinkler system is maintained in reliable operating condition.

Findings include:

1. On 10/30/13 at 11:20 AM, in the presence of Staff #45, it was observed that in Room #G3165, (5) boxes of supplies were stored within 18" of the sprinkler system.

2. On 10/30/13 at 1:50 PM, in the presence of Staff #45, it was observed that in Room #R417, a basket and files were stored within 18" of the sprinkler system.

Based on observation, it was determined that the facility failed to ensure that cubical curtains that meet the requirements of NFPA 13, Standards for the Installation of Sprinkler Systems, are provided.

Findings include:

On 10/30/13 at 2:30 PM, in the presence of Staff #45, it was observed that the cubical curtains in Room #C576 through Room #C585 had mesh that was too small for a sprinklered environment.

Based on observation, it was determined that the facility failed to ensure that medical gas in storage was protected in accordance with NFPA 99 4-3.1.1.1.

Findings include:

Reference: NFPA 99 4-3.1.1.1 states, "Cylinders in service and in storage shall be secured and located to prevent falling or being knocked over."

1. On 9/30/13 at 10:50 AM, in the presence of Staff #45, it was observed that in the main medical gas tank room, six (6) tanks of medical gas were not secured.

2. On 10/30/13 at 2:25 PM, in the presence of Staff #45, it was observed that in the BBR Building, 5th floor corridor, a tank of medical gas was not secured.