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

The inspector observed, while accompanied by the Hospital CEO, Plant Manager, maintenance personnel, and two mechanics during the hours of the inspection from 11:15 am to 1:30 pm on 01/09/2014 that there were penetrations in the smoke barriers at the following locations: 1) on the second floor the walls above the smoke barrier cross corridor doors. 2) On the first floor the walls above the smoke barrier cross corridor doors at the kitchen passageway. 3) On the first floor the walls above the smoke barrier cross corridor doors at the X-ray hallway. 4) on the first floor the walls above the smoke barrier cross corridor doors at the kitchen passageway..

There was door astragal missing at the following location: 1) 2st floor at two smoke barrier cross corridor doors.

There was smoke detector missing at the following location: 1) 2st floor at the smoke barrier cross corridor door at the south-east side.

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

The inspector observed, while accompanied by the Hospital CEO, Plant Manager, maintenance personnel, and two mechanics during the hours of the inspection during the hours of the inspection from 11:15 am to 1:30 pm on 01/09/2014 that there were the following issues.

A.) There were missing sprinkler head at the following locations: 1) on the first floor Mechanical room 3. 2) On the first floor Mechanical room 5. 3) On the first floor the electrical room inside the Mechanical room 5. 4) On the first floor under the 4 ' -0 " duct work at the Mechanical room 5.

B.) There were missing escutcheon plates at the following locations: 1) on the first floor at the Lab hallway. ) 2nd floor IT room.

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

Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. - NFPA 13, 1999, 5-6.3.3.

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.

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

The inspector observed, while accompanied by the Hospital CEO, Plant Manager, maintenance personnel, and two mechanics during the hours of the inspection during the hours of the inspection from 11:15 am to 1:30 pm on 01/09/2014 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 CEO, Plant Manager, maintenance personnel, and two mechanics during the hours of the inspection during the hours of the inspection from 11:15 am to 1:30 pm on 01/09/2014 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 a) the generator set location and b) the essential automatic transfer switch location.

(2). FACP breaker was not provided in red breaker and labeled in red signage permanently.

3) Identify the FACP panel, and med gas alarm panels were powered form life safety branch and the vacuum pump from the equipment branch.

4) The crash cart was not powered from the critical branch.

" 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 CEO, Plant Manager, maintenance personnel, and two mechanics during the hours of the inspection from 11:15 am to 1:30 pm on 01/09/2014 that there were penetrations in the smoke barriers at the following locations: 1) on the second floor the walls above the smoke barrier cross corridor doors. 2) On the first floor the walls above the smoke barrier cross corridor doors at the kitchen passageway. 3) On the first floor the walls above the smoke barrier cross corridor doors at the X-ray hallway. 4) on the first floor the walls above the smoke barrier cross corridor doors at the kitchen passageway..

There was door astragal missing at the following location: 1) 2st floor at two smoke barrier cross corridor doors.

There was smoke detector missing at the following location: 1) 2st floor at the smoke barrier cross corridor door at the south-east side.

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

The inspector observed, while accompanied by the Hospital CEO, Plant Manager, maintenance personnel, and two mechanics during the hours of the inspection during the hours of the inspection from 11:15 am to 1:30 pm on 01/09/2014 that there were the following issues.

A.) There were missing sprinkler head at the following locations: 1) on the first floor Mechanical room 3. 2) On the first floor Mechanical room 5. 3) On the first floor the electrical room inside the Mechanical room 5. 4) On the first floor under the 4 ' -0 " duct work at the Mechanical room 5.

B.) There were missing escutcheon plates at the following locations: 1) on the first floor at the Lab hallway. ) 2nd floor IT room.

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

Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. - NFPA 13, 1999, 5-6.3.3.

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.

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

The inspector observed, while accompanied by the Hospital CEO, Plant Manager, maintenance personnel, and two mechanics during the hours of the inspection during the hours of the inspection from 11:15 am to 1:30 pm on 01/09/2014 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 CEO, Plant Manager, maintenance personnel, and two mechanics during the hours of the inspection during the hours of the inspection from 11:15 am to 1:30 pm on 01/09/2014 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 a) the generator set location and b) the essential automatic transfer switch location.

(2). FACP breaker was not provided in red breaker and labeled in red signage permanently.

3) Identify the FACP panel, and med gas alarm panels were powered form life safety branch and the vacuum pump from the equipment branch.

4) The crash cart was not powered from the critical branch.

" 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 "