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Based on record review and observation it was determined that smoke barriers were not constructed to provide at lease a one hour fire resistance rating and constructed in accordance with 8.3 of NFPA 101.

On 03/03/2014 at 08:55 am while touring the facility with staff M it was determined based on record review and observation that:

1) Forth floor North Smoke Barrier above the ceiling was noted with unsealed sleeve with cable penetrations of one hour smoke barrier. (corrected during the inspection).

2) First floor near Radiology the smoke barrier above the ceiling was noted with unsealed penetrations.

Based on record review and observation it was determined that the fire rated enclosure of hazard area was not enclosed in accordance with NFPA 101 and NFPA 80.

On 03/03/2014 at 3:45pm while touring the facility with staff M it was determined during record review and observation that:

1) Forth floor Environmental Service Closet corridor door closer to the janitor closed was not provided.

2) First floor at Environmental Services Room in the Clinical Labs to corridor was not provided with self closing device.

3) First floor Hyberbaric Room was not provided with one hour fire rated enclosure.

4) First floor Unit 102 one hour fire rated enslosure was noted not having a self closing device on corridor door. (corrected during inspection).

Based on record review and observation it was determined that the construction, maintenance, and use of the exit and exit enclosure was not in accordance with NFPA 101.

On 03/03/2014 at 3:20 pm while touring the facility with staff M it was determined based on record review and observation that:

1) Forth floor south corridor on wall charting fold down desk top would not retract automatically and obstructed corridor clear width. (corrected during the inspection).

2) Forth floor South Stair hinge on stair fire door were missing fasteners.

3) Forth floor Storage Room corridor door at Director of Education Office was not provided with "NOT AN EXIT" sign.

Based on observation and record review it was determined that the building fire alarm system and components were not installed, serviced, or maintained in accordance with NFPA 72.

On 03/04/2014 at 2:54pm while touring the facility with staff M it was determined from record review and observation that:

1) Forth floor corridor at room 429 smoke detector was mounted within 36 inches of the air handling grill. (corrected during the inspection)

2) Forth floor corridor at Staff Elevator smoke detector was mounted within 36 inches of the air handling grill. (corrected during the inspection)

Based on observation and record review it was determined that the building water based fire sprinkler system was not installed, maintained, and serviced in accordance with NFPA 13 and NFPA 25.

On 03/03/2014 at 4:30pm while touring the facility with staff M it was determined by record review and observation that:

1) Forth floor in Medical I.V. Storage room above the ceiling wiring and cables were noted on fire sprinkler piping. (corrected during inspection)

2) Forth floor in corridor at Room 429 above the ceiling fire sprinkler hanger was missing on piping arm over exceeding 24 inches in horizontal length.

3) Forth floor in Room 429 above the ceiling air handling duct was supported by fire sprinkler piping. (corrected during inspection)

4) First floor Kitchen Pantry Dry Storage was not provided with 18 inch clearance between sprinkler and material. (corrected during the inspection)

5) First Floor Physical Plant fire sprinkler room was not provided with socket and wrench which fit the fire sprinklers provided.

6) First Floor ER Clean Room fire sprinkler was noted with storage within 18 inches of items.

Based on observation, record review, and staff interview it was determined that building mechanical system failed to comply with codes.

On 03/03/2014 while touring with staff M it was determined that the following items failed to comply with minimum requirements of the code:

1) Roof on 4th floor, two mechanical controllers for air handling unit were not suitable for wet locations and device was not supported properly. (corrected during inspection visit)

Based on record review and observation it was determined that medical gas storage and administration areas were not protected, used, and maintained in accordance with NFPA 99, Standard for Health Care Facilities.

On 03/03/2014 at 1:30pm while touring the facility with staff M it was determined by record review and observation that:

1) Forth floor in Mechanical Room an R-12 was strapped to the medical gas piping (unapproved location) (corrected during the inspection).

2) Forth floor Clean Supply Room was noted with oxygen cylinders and door was not posted with sign. (typical in several locations).

Based on record review and observation it was determined that the buildings electrical system did not meet the requirements of NFPA 70 or was not maintained in accordance with electrical equipment specifications.

On 03/03/2014 at 2:00 am while touring with staff M it was determined that the following deficiencies were noted failing to meet code requirements:

1) Forth floor in corridor above ceiling at room 429, smoke detector electrical conduit was damaged and broken.

2) Forth floor in main mechanical room electrical plug tap and cord was not secured to wall and cord protected from damage.

3) Forth floor at Pediatrics North wing at Nurses Station electrical plug tap and cord was not secured to wall and cord protected from damaged.

4) Forth floor in Case Manager Office electrical plug tap and cord was not secured to wall and cord protected from damaged.

5) First floor Kitchen at socket #9 was noted with frayed electrical code.

6) Second floor Authrisation Office electrical panel box blocked by storage.

7) Second floor throughout above the ceiling low voltage wiring was not supported properly.

8) Second floor at Cypress Medical above the ceiling grid light ballast wiring was exposed and not protected in accordance with code.

9) First floor Radiology above the ceiling was noted with low voltage was not supported properly.

10) First floor Nurses Station low voltage wiring at nurses station was not installed properly. (corrected during the inspection).

11) First Floor Treatment Room #5 electrical receptacle duplex was not provided with panel number and circuit posted on faceplate.

12) First Floor Treatment Room #16 in exit corridor was noted with storage in corridor (corrected during the inspection).

13) First Floor Treatment Room #9 unapproved storage in exit corridor.

14) First Floor Admissions was noted with unapproved electrical box mounted in floor.

Based on record review and observation it was determined that smoke barriers were not constructed to provide at lease a one hour fire resistance rating and constructed in accordance with 8.3 of NFPA 101.

On 03/03/2014 at 08:55 am while touring the facility with staff M it was determined based on record review and observation that:

1) Forth floor North Smoke Barrier above the ceiling was noted with unsealed sleeve with cable penetrations of one hour smoke barrier. (corrected during the inspection).

2) First floor near Radiology the smoke barrier above the ceiling was noted with unsealed penetrations.

Based on record review and observation it was determined that the fire rated enclosure of hazard area was not enclosed in accordance with NFPA 101 and NFPA 80.

On 03/03/2014 at 3:45pm while touring the facility with staff M it was determined during record review and observation that:

1) Forth floor Environmental Service Closet corridor door closer to the janitor closed was not provided.

2) First floor at Environmental Services Room in the Clinical Labs to corridor was not provided with self closing device.

3) First floor Hyberbaric Room was not provided with one hour fire rated enclosure.

4) First floor Unit 102 one hour fire rated enslosure was noted not having a self closing device on corridor door. (corrected during inspection).

Based on record review and observation it was determined that the construction, maintenance, and use of the exit and exit enclosure was not in accordance with NFPA 101.

On 03/03/2014 at 3:20 pm while touring the facility with staff M it was determined based on record review and observation that:

1) Forth floor south corridor on wall charting fold down desk top would not retract automatically and obstructed corridor clear width. (corrected during the inspection).

2) Forth floor South Stair hinge on stair fire door were missing fasteners.

3) Forth floor Storage Room corridor door at Director of Education Office was not provided with "NOT AN EXIT" sign.

Based on observation and record review it was determined that the building fire alarm system and components were not installed, serviced, or maintained in accordance with NFPA 72.

On 03/04/2014 at 2:54pm while touring the facility with staff M it was determined from record review and observation that:

1) Forth floor corridor at room 429 smoke detector was mounted within 36 inches of the air handling grill. (corrected during the inspection)

2) Forth floor corridor at Staff Elevator smoke detector was mounted within 36 inches of the air handling grill. (corrected during the inspection)

Based on observation and record review it was determined that the building water based fire sprinkler system was not installed, maintained, and serviced in accordance with NFPA 13 and NFPA 25.

On 03/03/2014 at 4:30pm while touring the facility with staff M it was determined by record review and observation that:

1) Forth floor in Medical I.V. Storage room above the ceiling wiring and cables were noted on fire sprinkler piping. (corrected during inspection)

2) Forth floor in corridor at Room 429 above the ceiling fire sprinkler hanger was missing on piping arm over exceeding 24 inches in horizontal length.

3) Forth floor in Room 429 above the ceiling air handling duct was supported by fire sprinkler piping. (corrected during inspection)

4) First floor Kitchen Pantry Dry Storage was not provided with 18 inch clearance between sprinkler and material. (corrected during the inspection)

5) First Floor Physical Plant fire sprinkler room was not provided with socket and wrench which fit the fire sprinklers provided.

6) First Floor ER Clean Room fire sprinkler was noted with storage within 18 inches of items.

Based on observation, record review, and staff interview it was determined that building mechanical system failed to comply with codes.

On 03/03/2014 while touring with staff M it was determined that the following items failed to comply with minimum requirements of the code:

1) Roof on 4th floor, two mechanical controllers for air handling unit were not suitable for wet locations and device was not supported properly. (corrected during inspection visit)

Based on record review and observation it was determined that medical gas storage and administration areas were not protected, used, and maintained in accordance with NFPA 99, Standard for Health Care Facilities.

On 03/03/2014 at 1:30pm while touring the facility with staff M it was determined by record review and observation that:

1) Forth floor in Mechanical Room an R-12 was strapped to the medical gas piping (unapproved location) (corrected during the inspection).

2) Forth floor Clean Supply Room was noted with oxygen cylinders and door was not posted with sign. (typical in several locations).

Based on record review and observation it was determined that the buildings electrical system did not meet the requirements of NFPA 70 or was not maintained in accordance with electrical equipment specifications.

On 03/03/2014 at 2:00 am while touring with staff M it was determined that the following deficiencies were noted failing to meet code requirements:

1) Forth floor in corridor above ceiling at room 429, smoke detector electrical conduit was damaged and broken.

2) Forth floor in main mechanical room electrical plug tap and cord was not secured to wall and cord protected from damage.

3) Forth floor at Pediatrics North wing at Nurses Station electrical plug tap and cord was not secured to wall and cord protected from damaged.

4) Forth floor in Case Manager Office electrical plug tap and cord was not secured to wall and cord protected from damaged.

5) First floor Kitchen at socket #9 was noted with frayed electrical code.

6) Second floor Authrisation Office electrical panel box blocked by storage.

7) Second floor throughout above the ceiling low voltage wiring was not supported properly.

8) Second floor at Cypress Medical above the ceiling grid light ballast wiring was exposed and not protected in accordance with code.

9) First floor Radiology above the ceiling was noted with low voltage was not supported properly.

10) First floor Nurses Station low voltage wiring at nurses station was not installed properly. (corrected during the inspection).

11) First Floor Treatment Room #5 electrical receptacle duplex was not provided with panel number and circuit posted on faceplate.

12) First Floor Treatment Room #16 in exit corridor was noted with storage in corridor (corrected during the inspection).

13) First Floor Treatment Room #9 unapproved storage in exit corridor.

14) First Floor Admissions was noted with unapproved electrical box mounted in floor.