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The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:00 am to 12:00 pm on 3/11/2020 that there were the following issues. They were: Located above the double doors (near Nuclear Medicine) the rated wall had penetrations that needed to be sealed.

"Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device." - NFPA 101, 2012, 8.3.5.1.



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In a consult room, there was a sprinkler head that was missing its escutcheon plate.

"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 12:00 pm on 3/11/2020 that there were the following issues. They were: There was a type ABC portable fire extinguisher that was located too close (25 feet) to the cooking griddle and or frying areas.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:00 am to 12:00 pm on 3/11/2020 that there were the following issues. They were: Documents showed that Risk Assessment was being documented. However, they did not correspond to the categories as outlined in NFPA 99, Chapter 4. A4.1 and A4.2

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:00 am to 12:00 pm on 3/11/2020 that there were the following issues. They were:

Locations for central supply systems and the storage of positive pressure gases shall meet the following requirements: (5) *Be compliant with NFPA 70, National Electrical Code, for ordinary locations." - NFPA 99, 2012, 5.1.3.3.2(5). "Electrical devices should be physically protected, such as by use of a protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing physical damage to the cylinders or containers. For example, the device could be located at or above 5 feet above finished floor or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device as required by this section." - NFPA 99, 2012, A.5.1.3.3.2(5).

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 9:00 am to 12:00 pm on 3/11/2020 that there were the following issues. They were:

The mechanical/electrical room was being used for storage. Electrical rooms are not allowed to be used for storage per the following.

"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)

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Battery powered backup lighting was not observed for the emergency electrical generator.

"The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
"(4) Generator set locations as follows:
(a) Task illumination,
(b) Battery charger for emergency battery-powered lighting unit(s),
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations." NFPA 99, 2012, 6.4.2.2.3.2