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The inspector observed, while accompanied by The director of the facility, during the hours of the inspection from 01:40 PM to 05:30 PM on 05/08/2019 that there were the following issues. They were the following issues.


A) Some of the smoke barrier cross corridor doors was not fully closed upon the fire alarm activation.

The inspector observed, while accompanied by The director of the facility, during the hours of the inspection from 01:40 PM to 05:30 PM on 05/08/2019 that there were the following issues. They were the following issues.

(A) There was door stop installed at the fire hazardous room or fire rated doors at corridor which is not permissible. Please remove the door stop.



(B) The fire caulking at the fire rated room were not provided at the fire hazardous rooms and the fire rated partitions such as between new PT are and the hospital.

The inspector observed, while accompanied by The director of the facility, during the hours of the inspection from 01:40 PM to 05:30 PM on 05/08/2019 that there were the following issues. They were the following issues.

A) The fire alarm pull was not provided within 5'-0" of the exit door near the house keeping room.

The inspector observed, while accompanied by The director of the facility, during the hours of the inspection from 01:40 PM to 05:30 PM on 05/08/2019 that there were the following issues. They were the following issues.

(A) The door inspection was not performed annually and the log was not available.

The inspector observed, while accompanied by The director of the facility, during the hours of the inspection from 01:40 PM to 05:30 PM on 05/08/2019 that there were the following issues. They were the following issues.

(A) There was a missing battery powered light unit at the generator set location.



(B) The electrical directory was not updated in accordance to the new or modified receptacles.



(C) There were flexible conduits utilized from emergency electrical outlet for crash cart at the corridor. This wiring system shall be a nonflexible metal raceway.



(D) Receptacles were not tested or logged. Electrical Systems -Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. The facility shall establish a testing interval and maintain testing records.



(E) One of the fire alarm control panel shown to be powered from the critical branch. Please verify and correct it back to the life safety branch.



(F) There were carts stored in front of the electrical panel. Please provide required clearance in front of each electrical panel.



(G) There was not a remote shut down switch / bottom provided for the generators.



(H) There were two fire alarm booster panels and one FACP were not powered from the life safety branch at the hospital and the PT area.



(I) There was not a panel and circuit number labels provided on the FACP.

The inspector observed, while accompanied by The director of the facility, during the hours of the inspection from 01:40 PM to 05:30 PM on 05/08/2019 that there were the following issues. They were the following issues.

(A) There was not a signage provided at the medical gas storage yard for no smoking and no open flame.