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Based on observations during the tour at the facility on the morning of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to maintain the smoke compartment barrier. At the smoke compartment walls above both sets of the fifth floor ' s cross-corridor doors, electrical conduit sleeve penetrations were not sealed to prevent the passage of smoke and the products of combustion. Another occurrence was at the smoke compartment wall above the second floor ' s cross-corridor doors near the lockers.

Based on observations during the tour at the facility on the afternoon of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to maintain a rated door. Second floor ' s surgical suite ' s soiled utility ' s door was held open with a cart providing an impediment to closing the door. Two other occurrences of the door not latching at the door frame when closed were at the fourth floor's med surg ' s soiled utility and second floor's stairwell A door.

Based on observations during the tour at the facility on the morning of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to maintain a rated barrier. At the wall separating the fifth floor's storage room from the corridor, this wall did not have 5/8 " gypsum wallboard up to deck on one side.


Based on observations during the tour at the facility on the morning of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to maintain a rated barrier. At the two hour wall in the EWS storage, a gap occurred around the steel beam.

Based on observations during the tour at the facility on the afternoon of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to maintain a clear and unobstructed egress path. The second floor ' s surgical suite ' s restricted corridor and the first floor ' s imaging corridor contained many carts and furniture which impeded egress path.

Based on observations during the tour at the facility on the afternoon of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to assure correct cross labeling of the FACP and the electrical panel that provides the power for the FACP. At third floor ' s electrical room and the first floor's electrical room, the FACP panel and subpanels were not labeled as to which electrical panel supplied the power for the FACP.

Based on observations during the tour at the facility on the morning of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to have compliant sprinkler heads. Sprinkler heads appear to touch the steel beam ' s fireproofing at fifth floor ' s storage room. Another occurrence was at first floor ' s mechanical room where the sprinkler head touched the duct ' s insulation.


Based on observations during the tour at the facility on the morning of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to have a compliant sprinkler system. The ducts appeared to be wider than four feet and no sprinkler head was below these ducts in the fifth floor ' s storage room.


Based on observations during the tour at the facility on the morning of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to have a compliant sprinkler system. Sprinkler heads were missing in the fifth floor ' s storage room and this storage room had a gypsum wallboard ceiling and was at the back corner of that large storage room..


Based on observations during the tour at the facility on the morning of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to have a compliant sprinkler system. No sprinkler head was located in the fifth floor ' s supervisor ' s office and the maintenance office and the EWS office.

Based on observations during the tour at the facility on the morning of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to maintain the sprinkler system's components.A upply of six spare sprinklers shall be maintined on the premises along with a wrench in a cabinet per NFPA 13 6.2.9

Based on observations during the tour at the facility on the morning of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to provide annual inspections on the fire extinguishers throughout the facility, except for the deli ' s K extinguisher. The fire extinguishers were tagged August 2010.

Based on observations during the tour at the facility on the morning of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to maintain the K extinguisher. In the first floor's deli, the K extinguisher was sitting on the floor. Fire extinguishers having a gross weight not exceeding 40 pounds shall be installed so that the top of the fire extinguisher is not more than 5 feet above the floor. Fire extinguishers having a gross weight greater than 40 pounds shall be so installed so that the top of the fire extinguisher is not more than 3.5 feet above the floor.

Based on observations during the tour at the facility on the afternoon of 9/6/2011, with the Director of Quality and Plant Operation Director, the facility failed to provide, at emergency generator set location, a task illumination and an emergency receptacle. The light fixture(s) illuminating the generator set must be energized by battery power. The battery in turn must be charged by an electrical connection to a life safety branch panel board. In addition an electrical outlet must be provided in proximity to the generator and this outlet must be circuited to a life safety branch panel board and red in color. Verify that the three conditions are in compliance.


Based on observations during the tour at the facility on the afternoon of 7/20/2011, with the Director of Engineering, the facility failed to assure that the essential electrical system was in full compliance. In the panel board 1HLSL, a circuit for contractor lighting was supplied with power from the life safety branch of the essential electrical system. It was not determined what this supplied power for. Verify what this is and if it does not meet one of the seven items listed below then it will need to be moved to the either the critical or equipment branch panel. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.