HospitalInspections.org

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:00 am to 12:30 pm on 02/15/2023 that documentation showing that the following door inspection requirement was not available for review.

Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101, 7.2.1.15

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:00 am to 12:30 pm on 02/15/2023 that the following deficiency was found.

In the 2nd floor EVS closet, there was a sprinkler head that was recessed too far above ceiling and the escutcheon plate was missing.
"Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of the listed sprinkler assembly." -NFPA 13, 2010, 6.2.7.2

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:00 am to 12:30 pm on 02/15/2023 that the following deficiency was found.
The outdoor oxygen tank storage shed has ventilation openings near the ceiling, but was missing ventilation openings near the floor per the following requirement.

"Outdoor locations surrounded by impermeable walls shall have protected ventilation opening located at the base of each wall to allow free circulation of air within the enclosure" - NFPA 99, 2002: 5.1.3.3.3.3

K911 Electrical Systems - Other

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:00 am to 12:30 pm on 02/15/2023 that the following deficiency was found.
Two electrical rooms on the second floor and one electrical room on the first floor were being used for storage. This is not allowed.
"Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)

K911 Electrical Systems - Other

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:00 am to 12:30 pm on 02/15/2023 that the following deficiency was found.
The 2nd floor electrical room has panel boxes that were not properly labeled per the following requirement.
"Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system." - NFPA 70, 2011, 700.10. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.