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(a) Based on observations and discussion with the facility staff during the walk-through of the facility on 08/17/2011 with the plant operations director, it was noted that one centrally located communicating stairway (connecting the first and second floors) was designated as an exit on the second floor, by the placement of a exit sign at the stair door. This stairway is not a qualifying exit, as it opens to the interior corridor on the first floor at the center of the facility. A sign at the first floor stair door, stated that "this is not and exit". The facility has sufficient numbers of complying exit statirways, located at remote ends of the second floor that exit at grade directly to the exterior. This central communicating stairway should not have an exit sign at the second floor level.
(b) Based on observation and discussion with the facility staff during the walk-through of the facility on 08/17/2011 with the plant operations director, it was noted that a set of cross-corridor smoke barrier doors, on the second floor (near the communicating stairway as descussed above) lacked a directional exit sign located above the set of doors on the side of the doors viewed from the center of the building. When these doors are closed there was no indication that the direction of exit egress was through those doors toward the exit stairway, at the end of the corridor.

Based on observation during the walk-through of the facility on 08/17/2011, with the director of plant operations, one of the three emergency generators did not start when tested. (This generator did not serve the Life Safety Branch functions of this facility). The other two generators did start and function appropriately during testing conducted at the same time during this facility survey. The director of plant operations contacted a service company to schedule repairs to the non-starting generator, for this same date (08/17/2011).

based on a review of the documentation and records and discussions with the director of plant operations at the facility on 08/17/2011, it was noted that electrical safety testing of the grounding systems were not being tested periodically (annually for general care areas, and semi-annually for critical care areas). No written policy was availabel for review to indicate the requirement for the periodically testing of the grounding integrity of electrical outlets in patient care areas.