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Based on observation and interview with staff, the facility failed to provide a common wall fire barrier having at least a two hour fire resistance rating. Findings include:

1) There is no fire rated separation between the licensed hospital and clinic spaces that are leased to another entity.

Based on observation and interview with staff, the facility failed to provide corridors that are separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. Findings include:

1) The corridor walls are not sealed with fire rated caulking between the top of the gypsum board and the bottom of the concrete roof structure. Open penetrations exist in the corridor walls.

Based on observation and interview with staff, the facility failed to provide smoke barriers constructed to provide at least a 1/2 hour fire resistance rating in accordance with 8.3. Findings include:

1) Smoke compartments are not sealed with fire rated caulking between the top of the gypsum board and the bottom of the concrete roof structure. Open penetrations exist in the smoke compartment walls. Note: Three smoke compartment walls exist in this facility.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99, Chapter 4. Findings include:

1) The bulk oxygen site is not provided with dual line pressure regulators.

Based on observation and interview with staff, the facility failed to provide master alarm panels in two separate locations having audible and visible signals. Findings include:

1) There is only one master alarm panel in the facility.

Based on observation and interview with staff, the facility failed to provide a Type I EES in accordance with NFPA 99, Section 3.4.2.2.2. Findings include:

1) There is no single line drawing that depicts the electrical distribution of the required Life Safety Branch, Critical Care Branch, and the Equipment Branch. There is no way to verify electrical distribution.
2) The distribution panels are not all labeled.
3) There is no 90 minute emergency back-up lighting over the transfer switch.

Based on observation and interview with staff, the facility failed to provide a common wall fire barrier having at least a two hour fire resistance rating. Findings include:

1) There is no fire rated separation between the licensed hospital and clinic spaces that are leased to another entity.

Based on observation and interview with staff, the facility failed to provide corridors that are separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. Findings include:

1) The corridor walls are not sealed with fire rated caulking between the top of the gypsum board and the bottom of the concrete roof structure. Open penetrations exist in the corridor walls.

Based on observation and interview with staff, the facility failed to provide smoke barriers constructed to provide at least a 1/2 hour fire resistance rating in accordance with 8.3. Findings include:

1) Smoke compartments are not sealed with fire rated caulking between the top of the gypsum board and the bottom of the concrete roof structure. Open penetrations exist in the smoke compartment walls. Note: Three smoke compartment walls exist in this facility.

Based on observation and interview with staff, the facility failed to provide a piped in medical gas system complying with NFPA 99, Chapter 4. Findings include:

1) The bulk oxygen site is not provided with dual line pressure regulators.

Based on observation and interview with staff, the facility failed to provide master alarm panels in two separate locations having audible and visible signals. Findings include:

1) There is only one master alarm panel in the facility.

Based on observation and interview with staff, the facility failed to provide a Type I EES in accordance with NFPA 99, Section 3.4.2.2.2. Findings include:

1) There is no single line drawing that depicts the electrical distribution of the required Life Safety Branch, Critical Care Branch, and the Equipment Branch. There is no way to verify electrical distribution.
2) The distribution panels are not all labeled.
3) There is no 90 minute emergency back-up lighting over the transfer switch.