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Based on observation the facility failed to provide acceptable smoke barrier separations.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there were six locations where there were penetrations above the cross corridor doors.

Based on observation the facility failed to keep storage of materials the correct distance below the sprinkler heads and that there was incomplete sprinkler coverage in one suite.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there was storage within an IT room, the sterile processing room and the material management room that was above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward. Items may not be stored above this plane because this can interfere with the sprinkler coverage. Also, there was incomplete coverage at bed #1 in the pre-operatory suite due to a renovation.

Based on observation the facility failed to provide an acceptable medical gas enclosure.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there were several problems with the medical gas enclosure. There was a switch and a fire alarm pull located below the 60 " plane of allowable devices mounted on the wall. These must be moved above the 60 " plane from the floor. The room requires mechanical ventilation due to the amount of oxidizing gases stored in the room. Also, the door must be properly labeled with the following information:
CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

Based on observation the facility failed to provide an acceptable separation between medical gas outlets and the zone control valves.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there were two imaging rooms linked by a control area. Both imaging rooms had zone control valves within the room with the gas outlets. The control area within the space does not create a room separation between the outlets and the control valves. The valves shall be located outside of the imaging rooms.

Based on observation the facility failed to provide an acceptable essential electrical system in accordance with NFPA 99.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there were numerous problems with the essential electrical system. They were: 1) all essential electrical panels must be labeled as either " Life Safety " , " Critical " , or " Equipment " with permanent engraved labels, 2) the life safety panel LRS1A had non-life safety equipment connected to this panel such as breaker 28 and 30 that was Hologic Equipment (only life safety functions are allowed on the life safety panels), 3) panel EML1A was a mixture of branches and must be separated out into the correct branch circuits, and 4) panel HRS1A had the emergency exterior signs, large motors, air handlers and a life safety sub-panel mixed in the same panel.

Based on observation the facility failed to provide an acceptable electrical system in accordance with NFPA 70.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there were numerous problems with the electrical system. They were: 1) in panel LLIB breaker 4 supplies the fire alarm control panel and must be labeled " fire alarm circuit control " and painted red, 2) the main fire alarm control panel was not properly referenced to the panel and breaker supplying it power, 3) all electrical receptacles in critical areas such as the post-operatory area shall have permanent labels that reference the panel and breaker number, and 4) panel LC1F, a critical panel, did not have a directory.

Based on observation the facility failed to provide acceptable smoke barrier separations.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there were six locations where there were penetrations above the cross corridor doors.

Based on observation the facility failed to keep storage of materials the correct distance below the sprinkler heads and that there was incomplete sprinkler coverage in one suite.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there was storage within an IT room, the sterile processing room and the material management room that was above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward. Items may not be stored above this plane because this can interfere with the sprinkler coverage. Also, there was incomplete coverage at bed #1 in the pre-operatory suite due to a renovation.

Based on observation the facility failed to provide an acceptable medical gas enclosure.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there were several problems with the medical gas enclosure. There was a switch and a fire alarm pull located below the 60 " plane of allowable devices mounted on the wall. These must be moved above the 60 " plane from the floor. The room requires mechanical ventilation due to the amount of oxidizing gases stored in the room. Also, the door must be properly labeled with the following information:
CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

Based on observation the facility failed to provide an acceptable separation between medical gas outlets and the zone control valves.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there were two imaging rooms linked by a control area. Both imaging rooms had zone control valves within the room with the gas outlets. The control area within the space does not create a room separation between the outlets and the control valves. The valves shall be located outside of the imaging rooms.

Based on observation the facility failed to provide an acceptable essential electrical system in accordance with NFPA 99.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there were numerous problems with the essential electrical system. They were: 1) all essential electrical panels must be labeled as either " Life Safety " , " Critical " , or " Equipment " with permanent engraved labels, 2) the life safety panel LRS1A had non-life safety equipment connected to this panel such as breaker 28 and 30 that was Hologic Equipment (only life safety functions are allowed on the life safety panels), 3) panel EML1A was a mixture of branches and must be separated out into the correct branch circuits, and 4) panel HRS1A had the emergency exterior signs, large motors, air handlers and a life safety sub-panel mixed in the same panel.

Based on observation the facility failed to provide an acceptable electrical system in accordance with NFPA 70.

The inspector observed while accompanied by the C.E.O., the Facility Safety Officer, and other support staff during the hours of the inspection from 8:30 am to 1:30 pm that there were numerous problems with the electrical system. They were: 1) in panel LLIB breaker 4 supplies the fire alarm control panel and must be labeled " fire alarm circuit control " and painted red, 2) the main fire alarm control panel was not properly referenced to the panel and breaker supplying it power, 3) all electrical receptacles in critical areas such as the post-operatory area shall have permanent labels that reference the panel and breaker number, and 4) panel LC1F, a critical panel, did not have a directory.