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Based on observations during the tour of the hospital, it was observed that the new spray-applied fireproofing needs to be patched in mechanical room 2050. (18.1.1.4)

Based on observations during the tour of the hospital, it was observed that:
a. One of the pair of egress doors from the new cafeteria has required panic hardware and a magnetic lock which prevents the door from opening. In a public assembly occupancy where panic hardware is required, no other latch or lock is permitted. (7.1)

b. Work stations were located in the exit access corridor of human resources on the second floor, which is not permitted. (19.2.1)

c.. Storage shall be was noted and must be eliminated from the exit access corridor on the ground floor level near archives and plant maintenance. (10.2.1)

Based on observations during the tour of the hospital it was observed that the facility must correct the following sprinkler system related violations of this regulation:

a. West wing sprinklers were shut down on several floors due to an elevator project. These systems shall be placed back in service and maintained in service. (19.3.5)

b.. Equipment tracks obstructed the automatic sprinkler discharge in x-ray #1 on the first floor. (NFPA 13)

c.. The sprinkler in the new second floor data room shall be raised or a ceiling shall be installed in the room. (NFPA 13)

d. A sprinkler shall be added in the electrical room at the emergency room entrance. (NFPA 13)

e. The process of installing automatic sprinkler protection in non-sprinkled areas of the hospital shall continue. (NFPA 13)

Documentation shall be available for quarterly sprinkler testing and maintenance including main drain tests. (NFPA 25)

Based on observations during the tour of the hospital it was observed that portable fire extinguishers have been removed from extinguisher cabinets in the 6th floor psychiatric area and placed in secure areas. The cabinets shall be removed or covered to avoid confusion. (NFPA 10)

Based on observations during the tour of the hospital, it was observed that approved "No smoking or open flames" signes were not provided in oxygen storage and holding areas. (10.10.1)

Based on observations during the tour of the hospital, it was observed that the new spray-applied fireproofing needs to be patched in mechanical room 2050. (18.1.1.4)

Based on observations during the tour of the hospital, it was observed that:
a. One of the pair of egress doors from the new cafeteria has required panic hardware and a magnetic lock which prevents the door from opening. In a public assembly occupancy where panic hardware is required, no other latch or lock is permitted. (7.1)

b. Work stations were located in the exit access corridor of human resources on the second floor, which is not permitted. (19.2.1)

c.. Storage shall be was noted and must be eliminated from the exit access corridor on the ground floor level near archives and plant maintenance. (10.2.1)

Based on observations during the tour of the hospital it was observed that the facility must correct the following sprinkler system related violations of this regulation:

a. West wing sprinklers were shut down on several floors due to an elevator project. These systems shall be placed back in service and maintained in service. (19.3.5)

b.. Equipment tracks obstructed the automatic sprinkler discharge in x-ray #1 on the first floor. (NFPA 13)

c.. The sprinkler in the new second floor data room shall be raised or a ceiling shall be installed in the room. (NFPA 13)

d. A sprinkler shall be added in the electrical room at the emergency room entrance. (NFPA 13)

e. The process of installing automatic sprinkler protection in non-sprinkled areas of the hospital shall continue. (NFPA 13)

Documentation shall be available for quarterly sprinkler testing and maintenance including main drain tests. (NFPA 25)

Based on observations during the tour of the hospital it was observed that portable fire extinguishers have been removed from extinguisher cabinets in the 6th floor psychiatric area and placed in secure areas. The cabinets shall be removed or covered to avoid confusion. (NFPA 10)

Based on observations during the tour of the hospital, it was observed that approved "No smoking or open flames" signes were not provided in oxygen storage and holding areas. (10.10.1)