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Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Hospital COO, and the Director of the Maintenance during the hours of the inspection from 11:20 pm to 1:40 pm on 12/10/2013 that there were penetrations not sealed in the fire rated partitions at the following locations: 1) ceiling above the smoke barrier cross corridor doors at the LDRP suite, at 300 bed suite, at imaging suite, PT hallway, ER suite, and at the main hallway. 2) The Med Gas room.

Based on observation the facility failed to provide a complete sprinkler system.

The inspector observed, while accompanied by the Hospital COO, and the Director of the Maintenance during the hours of the inspection from 11:20 pm to 1:40 pm on 12/10/2013 that there were the following issues:

A.) There were missing sprinkler head at the following locations: 1) Server room. 2) Education room. 3) X-ray room

B.) There were missing escutcheon plates at the following locations: 1) storage room

Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. - NFPA 13, 1999, 5-5.5.3.1.

Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by the Hospital COO, and the Director of the Maintenance during the hours of the inspection from 11:20 pm to 1:40 pm on 12/10/2013 that there were the following issues:


A.) Based on observation the facility failed to provide individual chains for the medical gases bottles. This does not comply with the following NFPA code. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

Based on observation the facility failed to provide adequate receptacles and battery powered lighting units.

The inspector observed, while accompanied by the Hospital COO, and the Director of the Maintenance during the hours of the inspection from 11:20 pm to 1:40 pm on 12/10/2013 that there were the following issues.

(1). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the generator set location. (2). FACP breaker was not provided in red breaker and labeled in red signage permanently.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

" NFPA 72, 2002: 4.4.1.4.2.2 -The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. " The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3 "

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Hospital COO, and the Director of the Maintenance during the hours of the inspection from 11:20 pm to 1:40 pm on 12/10/2013 that there were penetrations not sealed in the fire rated partitions at the following locations: 1) ceiling above the smoke barrier cross corridor doors at the LDRP suite, at 300 bed suite, at imaging suite, PT hallway, ER suite, and at the main hallway. 2) The Med Gas room.

Based on observation the facility failed to provide a complete sprinkler system.

The inspector observed, while accompanied by the Hospital COO, and the Director of the Maintenance during the hours of the inspection from 11:20 pm to 1:40 pm on 12/10/2013 that there were the following issues:

A.) There were missing sprinkler head at the following locations: 1) Server room. 2) Education room. 3) X-ray room

B.) There were missing escutcheon plates at the following locations: 1) storage room

Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. - NFPA 13, 1999, 5-5.5.3.1.

Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by the Hospital COO, and the Director of the Maintenance during the hours of the inspection from 11:20 pm to 1:40 pm on 12/10/2013 that there were the following issues:


A.) Based on observation the facility failed to provide individual chains for the medical gases bottles. This does not comply with the following NFPA code. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

Based on observation the facility failed to provide adequate receptacles and battery powered lighting units.

The inspector observed, while accompanied by the Hospital COO, and the Director of the Maintenance during the hours of the inspection from 11:20 pm to 1:40 pm on 12/10/2013 that there were the following issues.

(1). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the generator set location. (2). FACP breaker was not provided in red breaker and labeled in red signage permanently.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

" NFPA 72, 2002: 4.4.1.4.2.2 -The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. " The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3 "