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Based on observations and interview with the Maintenance Director, the facility failed to properly maintain the required Fire/Smoke barrier penetration(s), which have not been fire stopped or smoke sealed per the requirements of NFPA 101. This condition could allow fire/smoke to travel from one smoke compartment to other smoke compartment, thus endangering occupants of facility.

The findings include:
During the facility tour with the Maintenance Director on 12/3/2014 10:00 AM, it was found that electrical room 142, Elevator/Mechanical room E103A, and Mechanical room 034 had conduit lines penetrating the wall and was not properly protected with the required fire caulk. An interview conducted with the maintenance director confirmed the finding.
Photograph(s) of the evidence is presented in the file. Photos will serve as supplemental information only.
per NFPA 101 (2000 Edition) 8.3.5 and 19.3.7

Based on document review, facility tour and interview with the Maintenance Director, the facility failed to: 1) conduct monthly and annual testing of the battery back-up emergency lighting, 2) Install a Battery back-up emergency light. Battery back-up emergency lighting is required to insure the safety of maintenance personnel in the event of a simultaneous failure of the public utility and the emergency generator.

Findings include:
On 12/3/2014 at 8:30 AM while reviewing documentation for the facility with the Maintenance Director, it was found that emergency lights were not tested monthly / annually and or documented. Emergency lighting is required to service the generator and switchgear in the event of a simultaneous failure of the electric utility that serves the facility and the generator. Periodic testing of emergency lighting equipment per standards of NFPA 101 (2000 edition) 7.9.3

On 12/3/2014 at 10:15 AM while on tour of the facility with the Maintenance Director, it was found that the facility failed to install Battery back-up emergency lighting in the ATS (automatic transfer switchgear) room 194.
Per NFPA 110 (1999 Edition) 7.3

Based on observation and interview with the maintenance director, the facility failed to maintain proper storage and handling for oxygen cylinders. Proper storage and handling of compressed gases is vital to the safety of staff, patients, and visitors within the facility.

The findings include:

During the facility tour with the Maintenance Director on 12/3/2014 at 10:55 AM, it was observed that wheeled carts for E-size oxygen cylinders (6 of 7 sampled) were missing the set screw to secure the tank in the cart. An interview conducted with the maintenance director confirmed the finding.
Photograph(s) of the evidence is presented in the file. Photos will serve as supplemental information only.
Per NFPA 99 (1999) 9.4.2.7, 9.4.3.3, 9.5.3.1.1

Based on observations and interview with the Maintenance Director, the facility failed to properly maintain the required Fire/Smoke barrier penetration(s), which have not been fire stopped or smoke sealed per the requirements of NFPA 101. This condition could allow fire/smoke to travel from one smoke compartment to other smoke compartment, thus endangering occupants of facility.

The findings include:
During the facility tour with the Maintenance Director on 12/3/2014 10:00 AM, it was found that electrical room 142, Elevator/Mechanical room E103A, and Mechanical room 034 had conduit lines penetrating the wall and was not properly protected with the required fire caulk. An interview conducted with the maintenance director confirmed the finding.
Photograph(s) of the evidence is presented in the file. Photos will serve as supplemental information only.
per NFPA 101 (2000 Edition) 8.3.5 and 19.3.7

Based on document review, facility tour and interview with the Maintenance Director, the facility failed to: 1) conduct monthly and annual testing of the battery back-up emergency lighting, 2) Install a Battery back-up emergency light. Battery back-up emergency lighting is required to insure the safety of maintenance personnel in the event of a simultaneous failure of the public utility and the emergency generator.

Findings include:
On 12/3/2014 at 8:30 AM while reviewing documentation for the facility with the Maintenance Director, it was found that emergency lights were not tested monthly / annually and or documented. Emergency lighting is required to service the generator and switchgear in the event of a simultaneous failure of the electric utility that serves the facility and the generator. Periodic testing of emergency lighting equipment per standards of NFPA 101 (2000 edition) 7.9.3

On 12/3/2014 at 10:15 AM while on tour of the facility with the Maintenance Director, it was found that the facility failed to install Battery back-up emergency lighting in the ATS (automatic transfer switchgear) room 194.
Per NFPA 110 (1999 Edition) 7.3

Based on observation and interview with the maintenance director, the facility failed to maintain proper storage and handling for oxygen cylinders. Proper storage and handling of compressed gases is vital to the safety of staff, patients, and visitors within the facility.

The findings include:

During the facility tour with the Maintenance Director on 12/3/2014 at 10:55 AM, it was observed that wheeled carts for E-size oxygen cylinders (6 of 7 sampled) were missing the set screw to secure the tank in the cart. An interview conducted with the maintenance director confirmed the finding.
Photograph(s) of the evidence is presented in the file. Photos will serve as supplemental information only.
Per NFPA 99 (1999) 9.4.2.7, 9.4.3.3, 9.5.3.1.1