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Based on observation and interview the right side fire door, in the Corridor into the Medical Office Building, is not closing and latching.

The findings were:

On December 17, 2012 at 2:46 PM, accompanied by the Plant Operations Director, the right side of the fire door, in the Corridor into the Medical Office Building, was observed to not close into the frame and latch.

Based on observation and interview penetrations in rated floor assemblies are not protected to provide a two hour fire resistance rating.

The findings were:

Accompanied by the Plant Operations Director, the following penetrations were observed not protected to afford a two hour fire resistance rating:

(1) On December 18, 2012 at 1:29 PM, a 1 1/2 inch PVC pipe from the 3rd floor to the 4th floor, in the Omni Cell Room at the shaft wall, is not sealed.

(2) On December 18, 2012 at 2:09 PM, a 3 inch pipe, in the floor of the 3rd Floor Computer Room in the Employee Lounge, is not sealed.

(3) On December 18, 2012 at 2:58 PM, a 4 inch pipe, in the floor of the 4th Floor Computer Room, is not sealed.

Based on observation and interview the smoke barrier wall is not complete in Triage 2 at the Men's Restroom in the Emergency Room Waiting Area.

The findings were:

On December 17, 2012 at 3:16 PM, accompanied by the Plant Operations Director, the construction of the smoke barrier wall, in Triage 2 at the Men's Restroom in the Emergency Room Waiting Area, was observed not continuous to the underside of the floor above.

Based on observation and interview penetrations in smoke barriers are not protected to provide a one-half hour fire resistance rating.

The findings were:

Accompanied by the Plant Operations Director, the following penetrations were observed not protected to afford a one-half hour fire resistance rating:

(1) On December 17, 2012 at 1:02 PM, a 1/2 inch fire alarm wiring conduit, above the duct above the suspended ceiling at the Emergency Room Reception Area, is not filled and sealed.

(2) On December 17, 2012 at 1:02 PM, a 3/4 inch conduit, at the right upper corner of the duct above the suspended ceiling at the Emergency Room Reception Area, is not filled.

(3) On December 17, 2012 at 1:02 PM, a 3/4 inch flexible conduit, to the right of the duct above the suspended ceiling at the Emergency Room Reception Area, is not filled and sealed.

(4) On December 17, 2012 at 1:09 PM, 2 yellow and 3 red wires, and a 1 1/4 inch conduit, above the suspended ceiling corner at the double fire doors into the Emergency Room from the Emergency Room Reception Area, are not sealed.

(5) On December 17, 2012 at 1:09 PM, a 1/2 inch conduit, above the duct above the double fire doors into the Emergency Room from the Emergency Room Reception Area, is not sealed.

(6) On December 17, 2012 at 1:12 PM, a 3 inch conduit containing 1 gray wire and a 3 inch conduit above it, above the suspended ceiling and to the right of the double fire doors into the Emergency Room from the Emergency Room Reception Area, are not filled and sealed.

(7) On December 17, 2012 at 1:37 PM, a 2 inch sleeve containing 2 yellow and 1 beige wires, above the suspended ceiling on both sides above the double corridor doors at Mammography, is not filled.

(8) On December 17, 2012 at 1:40 PM, a 3/4 inch conduit, a 1/2 inch conduit, 1 yellow wire, and 2 blue and 1 orange wires, above the suspended ceiling in Ultrasound, are not sealed.

(9) On December 17, 2012 at 2:05 PM, the new sheetrock joints, above the suspended ceiling on the corridor wall adjacent to the Emergency Room, are not sealed.

(10) On December 17, 2012 at 2:08 PM, 3 - 3/4 inch conduits, 3 insulated water pipes, and the attachment of the perpendicular metal stud wall, above the suspended ceiling on both sides above the Corridor Restroom at the Emergency Room, are not sealed.

(11) On December 17, 2012 at 2:08 PM, a 3/4 inch conduit, above the suspended ceiling above the Corridor Restroom at the Emergency Room, is not filled.

(12) On December 17, 2012 at 2:14 PM, a 1/2 inch conduit, above the suspended ceiling in the Corridor across from the Intensive Care Unit Staff Entrance, is not sealed.

(13) On December 17, 2012 at 2:16 PM, a 3 inch conduit, 3 blue wires, 1 white wire, 1 gray wire, 7 yellow wires and a 3 inch conduit with 1 red wire, above the suspended ceiling above the double fire doors from the Corridor to the Emergency Room, are not sealed.

(14) On December 17, 2012 at 2:20 PM, a copper hot water pipe, above the suspended ceiling in the Corridor across from the Intensive Care Unit Visitors Entrance, is not sealed.

(15) On December 17, 2012 at 2:14 PM, a 1/2 inch conduit, above the suspended ceiling in the Corridor across from the Intensive Care Unit Staff Entrance, is not sealed.

(16) On December 17, 2012 at 2:31 PM, a 1/2 inch conduit above the duct, above the suspended ceiling at the double fire doors from the Emergency Room to the Corridor, is not sealed.

(17) On December 17, 2012 at 2:37 PM, an insulated water pipe, a copper water line, and a 1/2 inch conduit above the water line valves, above the suspended ceiling in the corner of the Emergency Room Employee Break Room, are not sealed.

(18) On December 17, 2012 at 2:42 PM, 1 white wire, and 1 blue wire, above the suspended ceiling in the Corridor wall in Exam Room 11, are not sealed.

(19) On December 17, 2012 at 2:45 PM, a 2 inch conduit containing 1 blue and 1 yellow wire, above the suspended ceiling in the Restroom in the Emergency Room Employee Break Room, is not filled.

(20) On December 17, 2012 at 2:45 PM, a 1/2 inch conduit at the concrete beam, and a 1 inch conduit between the Restrooms, above the suspended ceiling in the Restroom in the Emergency Room Employee Break Room, are not sealed.

(21) On December 17, 2012 at 2:48 PM, 2 - 2 inch PVC pipes and the top of the perpendicular wall, above the suspended ceiling on the Soiled Utility Room wall in the Emergency Room Employee Restroom, are not sealed with an approved through penetration fire stop system.

(22) On December 17, 2012 at 2:48 PM, a 3/4 inch conduit, above the suspended ceiling on the Soiled Utility Room wall in the Emergency Room Employee Restroom, is not filled.

(23) On December 17, 2012 at 2:54 PM, a 2 inch PVC pipe, above the suspended ceiling in the Soiled Utility Room on the Restroom wall and on the Radiology wall, is not sealed with an approved through penetration fire stop system.

(24) On December 17, 2012 at 3:07 PM, a 3 inch sleeve and a 3/4 inch conduit beside the top 3 inch sleeve, above the suspended ceiling above the double Corridor doors into Radiology from the Emergency Room, are not filled.

(25) On December 17, 2012 at 3:10 PM, a 3/4 inch conduit above the metal angle brace, above the suspended ceiling between the double Corridor doors and Triage 1, is not filled.

(26) On December 18, 2012 at 10:11 AM, 8 - 1/2 inch conduits, above the suspended ceiling above the duct above the cabinets in ICU (above the clock receptacle), are not sealed.

(27) On December 18, 2012 at 10:15 AM, a 1/2 inch conduit, 2 red wires and 1 gray wire, above the suspended ceiling in the Corridor across from the Restroom at ICUabove the duct above the cabinets in ICU (above the clock receptacle), are not sealed.

(28) On December 18, 2012 at 10:17 AM, 1 gray wire, above the suspended ceiling in the Corridor at the corner across from the Computer Room, is not sealed.

(29) On December 18, 2012 at 10:22 AM, a 1/4 inch copper tube, above the suspended ceiling at the corner of the Stair and the Laboratory, is not sealed.

(30) On December 18, 2012 at 10:26 AM, a black coupling in a 3 inch PVC pipe and a sleeve containing 6 yellow wires, above the suspended ceiling in the Pharmacy at the Corridor wall, are not sealed.

(31) On December 18, 2012 at 10:32 AM, a 3 inch metal pipe from PVC pipe, a 3/4 inch conduit and a 1/2 inch conduit, above the suspended ceiling in the Pharmacy above the shelves on the ICU wall, are not sealed.

(32) On December 18, 2012 at 10:35 AM, a 1/2 inch conduit, above the suspended ceiling above the microwave cabinets in the Pharmacy on the Laboratory side, is not sealed.

(33) On December 18, 2012 at 10:38 AM, 4 - 1/2 inch conduits, above the suspended ceiling in the Pharmacy Piggy Back Room, are not sealed.

(34) On December 18, 2012 at 10:43 AM, a 2 inch metal pipe from PVC pipe, above the suspended ceiling in the Pharmacy Clean Room, is not sealed.

(35) On December 18, 2012 at 11:06 AM, a 2 inch PVC pipe, above the suspended ceiling in Sterile Supply, is not sealed with an approved through penetration fire stop system.

(36) On December 18, 2012 at 11:09 AM, a 2 inch PVC pipe, above the suspended ceiling in the Laboratory Hood Room on the Corridor wall, is not sealed with an approved through penetration fire stop system.

(37) On December 18, 2012 at 11:09 AM, 1 gray wire under the duct, and 1 gray wire to the left of the column, above the suspended ceiling in the Laboratory Hood Room on the Corridor wall, are not sealed.

(38) On December 18, 2012 at 11:11 AM, a 4 inch PVC pipe, above the suspended ceiling in the Laboratory Hood Room on the back wall, is not sealed with an approved through penetration fire stop system.

(39) On December 18, 2012 at 11:11 AM, a 3 inch black iron pipe, above the suspended ceiling in the Laboratory Hood Room on both sides of the back wall, is not sealed.

(40) On December 18, 2012 at 11:11 AM, 2 blue wires under the 4 inch PVC pipe, above the suspended ceiling in the Laboratory Hood Room on the back wall, are not sealed.

(41) On December 18, 2012 at 11:19 AM, a square hole containing 1 gray wire, and a square hole containing a flexible conduit, above the suspended ceiling to the right of the fire damper above the Blood Bank, are not sealed.

(42) On December 18, 2012 at 11:22 AM, a flexible conduit, and a black iron sprinkler pipe, above the suspended ceiling on the Laboratory side above the door to the HVAC Closet, are not sealed.

(43) On December 18, 2012 at 11:22 AM, conduits at the top, above the suspended ceiling on both sides in the Laboratory HVAC Closet, are not sealed.

(44) On December 18, 2012 at 11:26 AM, a flexible conduit, 1 tan wire, 1 black cable, 1 bare wire, a flexible conduit under the duct above the Medica Pro, and 2 - 1/2 inch conduits, above the suspended ceiling on the Laboratory and Central Supply wall, are not sealed.

(45) On December 18, 2012 at 11:26 AM, a 1 1/2 inch PVC pipe, above the suspended ceiling on the Laboratory and Central Supply wall, is not sealed with an approved through penetration fire stop system.

(46) On December 18, 2012 at 11:34 AM, insulation, above the suspended ceiling in the Corridor at the electrical panels across from X-ray, is not sealed.

(47) On December 18, 2012 at 11:45 AM, a 1 1/2 inch blue painted PVC pipe, above the suspended ceiling above the Laboratory HVAC Closet, is not sealed with an approved through penetration fire stop system.

(48) On December 18, 2012 at 11:45 AM, the corner of the perpendicular wall, above the suspended ceiling above the Laboratory HVAC Closet, is not sealed.

(49) On December 18, 2012 at 11:49 AM, 2 copper pipes, above the suspended ceiling above Sterile Supply, are not sealed.

(50) On December 18, 2012 at 11:51 AM, a sheetrock joint, above the suspended ceiling above Sterile Supply, is not sealed.

(51) On December 18, 2012 at 12:03 PM, an 8 inch PVC pipe, above the suspended ceiling from PACU into the Stairway, is not sealed with an approved through penetration fire stop system.

(52) On December 18, 2012 at 1:20 PM, 4 insulated pipes, above the suspended ceiling at the corner of the Elevator at the top of the smoke wall, are not sealed.

(53) On December 18, 2012 at 1:41 PM, an insulated pipe, above the suspended ceiling above the door to Room 310, is not sealed on the top.

(54) On December 18, 2012 at 1:46 PM, a 2 inch PVC pipe, above the suspended ceiling on both sides between the 3rd Floor Nurses Station and Dictation, is not sealed with an approved through penetration fire stop system.

(55) On December 18, 2012 at 2:02 PM, 2 insulated pipes, above the suspended ceiling in the shaft Corridor wall across from the Storage Cubby, are not sealed.

(56) On December 18, 2012 at 2:40 PM, a 1 inch opening, above the suspended ceiling in the 4th Floor Medi-Prep Room at the Nurses Station to the right of the door and above the Omni Cell unit side wall, is not sealed.

(57) On December 20, 2012 at 9:50 AM, sheetrock joints, anchors for the concrete T's, and sprinkler pipe, above the suspended ceiling above the walk-in cooler and freezer along the Corridor wall, are not sealed.

(58) On December 20, 2012 at 9:54 AM, a 1 1/4 inch galvanized pipe, above the suspended ceiling in the Corridor across from the Plant Operations Director's Office and the Maintenance Office, is not sealed.

(59) On December 20, 2012 at 10:01 AM, a 3/4 inch conduit, above the suspended ceiling at the Vending side wall at the Corridor double doors, is not sealed.

(60) On December 20, 2012 at 10:06 AM, 1 beige wire and 1 gray wire, above the suspended ceiling on the Vending side of the Corridor wall above the door, is not sealed.

(61) On December 20, 2012 at 10:10 AM, a 3/4 inch conduit containing 2 yellow wires, above the suspended ceiling at the 2nd Floor Elevators on the Materials Management wall, is not sealed.

Based on observation and interview exits and exit accesses do not provide ready access at all times.

The findings were:

(1) On December 17, 2012 at 1:19 PM, accompanied by the Plant Operations Director, the entrance and egress access control system, installed on the double doors in the Emergency Room Reception Corridor leading into the Emergency Room Waiting Area, is not provided with all the following criteria:

(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.

(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.

(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 inches to 48 inches vertically above the floor and within 5 feet of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:

PUSH TO EXIT

When operated, the manual release device shall result in direct interruption of power to the lock -- independent of the access control system electronics -- and the doors shall remain unlocked for not less than 30 seconds.

(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

(2) On December 18, 2012 at 3:07 PM, accompanied by the Plant Operations Director, the exterior from the middle Stairway exit does not provide a hard surface in all weather conditions to the public way.

Based on observation and interview wheel chairs protruded into the exit access corridor at the Bereavement Sub-Waiting Room.

The findings were:

On December 17, 2012 at 3:19 PM, accompanied by the Plant Operations Director, wheel chairs were observed protruding into the exit access corridor at the Bereavement Sub-Waiting Room.

Based on observation and interview the automatic sprinkler system is not being maintained in accordance with NFPA 25.

The findings were:

(1) On December 17, 2012 at 11:22 AM accompanied by the Plant Operations Director, while reviewing the November 8, 2012 SimplexGrinnell Sprinkler Inspection Report, the report indicated:

(A) Control valves for the antifreeze system are not secured and properly identified;

(B) Solution in the antifreeze system needs to be corrected; and

(C) The dry system air compressor is not hard wired, no control valve signage, no spare sprinkler heads, wrench or cabinet.

The report also indicated that the fire pump and water storage tank are no longer in service.

(2) On December 17, 2012 at 12:43 PM accompanied by the Plant Operations Director, ready accessibility was not provided to the sprinkler control equipment in the Gift Shop Storage Room.

(3) On December 18, 2012 at 1:42 PM accompanied by the Plant Operations Director, the ceiling grid, above the suspended ceiling above the door in Room 310, is supported by the sprinkler pipe hanger.

(4) On December 18, 2012 at 2:13 PM accompanied by the Plant Operations Director, the ceiling tiles, in the 3rd Floor Computer Room in the Employees Lounge, provide openings that could delay the operation of the automatic sprinkler.

(5) On December 18, 2012 at 2:51 PM accompanied by the Plant Operations Director, the Shower in Room 415 was observed not adequately protected by the automatic sprinkler.

(6) On December 18, 2012 at 2:58 PM accompanied by the Plant Operations Director, the ceiling tiles, in the 4th Floor Computer Room, provide openings that could delay the operation of the automatic sprinkler.

(7) On December 18, 2012 at 3:11 PM accompanied by the Plant Operations Director, the underside of ducts, for air handling unit #3, greater than 4 feet wide, in the 2nd Floor Mechanical Room, are not provided with automatic sprinkler protection.

(8) On December 18, 2012 at 3:15 PM accompanied by the Plant Operations Director, the underside of ducts, for air handling unit #1, greater than 4 feet wide, in the 2nd Floor Mechanical Room, are not provided with automatic sprinkler protection.

Based on observation and interview penetrations in smoke barriers by ducts are not protected to provide a one-half hour fire resistance rating.

The findings were:

(1) On December 17, 2012 at 2:05 PM, accompanied by the Plant Operations Director, the square metal duct penetrating both sides of the corridor wall, above the suspended ceiling adjacent to the Emergency Room, is not sealed.

(2) On December 17, 2012 at 2:37 PM, accompanied by the Plant Operations Director, the duct above the ceiling grill, above the suspended ceiling in the corner of the Emergency Room Employee Break Room, is not sealed.

(3) On December 17, 2012 at 2:45 PM, accompanied by the Plant Operations Director, an exhaust duct, above the suspended ceiling in the Restroom in the Emergency Room Employee Break Room, is not sealed.

(4) On December 17, 2012 at 3:03 PM, accompanied by the Plant Operations Director, a 5 inch open duct is installed, above the suspended ceiling at Electrical Panel C in the Emergency Room Corridor at the double doors to Radiology.

(5) On December 18, 2012 at 11:17 PM, accompanied by the Plant Operations Director, the left corner angle of a duct, above the suspended ceiling above the Blood Bank, is not sealed.

(6) On December 20, 2012 at 9:50 AM, accompanied by the Plant Operations Director, the duct, above the suspended ceiling, on both sides, above the walk-in cooler and freezer along the Corridor wall, is not sealed.

Based on observation and interview electrical wiring was not in accordance with NFPA 70, National Electrical Code.

The findings were:

(1) On December 17, 2012 at 12:50 PM accompanied by the Plant Operations Director, open wire splices were observed, above the suspended ceiling in the Emergency Room Communication Room. The Plant Operations Director advised they possibly controlled the exterior sign(s).

(2) On December 17, 2012 at 1:47 PM accompanied by the Plant Operations Director, clearance was not provided in front of the electrical disconnect, in the Radiology HVAC Closet.

(3) On December 18, 2012 at 10:34 AM accompanied by the Plant Operations Director, an electrical junction box was not provided with a cover, above the suspended ceiling in the Pharmacy open shelves area.

(4) On December 18, 2012 at 10:44 AM accompanied by the Plant Operations Director, an electrical junction box was not provided with a cover, above the suspended ceiling in the Pharmacy Restroom.

(5) On December 18, 2012 at 1:55 PM accompanied by the Plant Operations Director, a metal flexible conduit, above the suspended ceiling at the 3rd Floor Nurses Station, is not secured to the junction box.

(6) On December 18, 2012 at 2:16 PM accompanied by the Plant Operations Director, a metal flexible conduit, above the suspended ceiling at the 4th Floor Elevators, is not secured to the junction box.

(7) On December 18, 2012 at 2:44 PM accompanied by the Plant Operations Director, an electrical junction box was not provided with a cover, above the suspended ceiling at the 4th Floor shaft wall in the Soiled Utility Room.

(8) On December 20, 2012 at 10:07 AM accompanied by the Plant Operations Director, a 12 inch X 12 inch electrical junction box was not provided with a cover, above the suspended ceiling on the Vending Room side along the Corridor.