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Based on observation the facility failed to provide an acceptable flame spread rating for the telephone backboard.

The inspector observed while accompanied by the Director of Plant Operations during the hours of the inspection from 2:00 pm to 4:45 pm that there was a telephone backboard with an unknown flame spread rating. Interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. NFPA 101, 2000, 19.3.3.2.

Based on observation the facility failed to maintain the fire resistance rating of the smoke barriers.

The inspector observed while accompanied by the Director of Plant Operations during the hours of the inspection from 2:00 pm to 4:45 pm that there were numerous penetrations of smoke barriers. In addition to a previous penetration study there were also penetrations in the following locations: 1) by the lab, 2) at medical records, and 3) adjacent to room 216.

Based on observation the facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

The inspector observed while accompanied by the Director of Plant Operations during the hours of the inspection from 2:00 pm to 4:45 pm that the breaker for the fire alarm control panel in electrical panel ILE was not colored red.

Based on observation the facility failed to provide an acceptable medical gas installation.

The inspector observed while accompanied by the Director of Plant Operations during the hours of the inspection from 2:00 pm to 4:45 pm that there was a medical gas line that did not have ample support at medical records near a smoke barrier. Second, the lines were color coded when they should have labels on the lines as described as follows. Pipe labels shall be located as follows: (1) at intervals of not more than 20 ft., (2) at least once in or above every room, (3) on both sides of walls or partitions penetrated by the piping, and (4) at least once in every story height traversed by risers - NFPA 99, 2002: 5.1.11.1.4. Third, on the second floor there were zone valve boxes without covers and the appropriate language that should appear on the cover. Zone shutoff valves shall be identified as follows: (1) the name or chemical symbol for the specific medical gas or vacuum system, (2) the room or areas served, and (3) a caution to not close or open the valve except in emergency re. NFPA 99, 2002, 5.1.11.2.1.

Based on observation the facility failed to provide an acceptable emergency generator location.

The inspector observed while accompanied by the Director of Plant Operations during the hours of the inspection from 2:00 pm to 4:45 pm that there was not a light located at the emergency generator that had a battery backup that would last 90 minutes. 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 " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Based on observation the facility failed to provide an acceptable clearance around the bulk oxygen tanks.

The inspector observed while accompanied by the Director of Plant Operations during the hours of the inspection from 2:00 pm to 4:45 pm that there was parking near the bulk oxygen tanks. Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft. of outside storage locations - NFPA 99, 1999, 8-3.1.11.2(i).

Based on review of the records the facility failed to provide an acceptable letter for emergency water supplies.

The inspector observed while accompanied by the Director of Plant Operations during the hours of the inspection from 2:00 pm to 4:45 pm that the facility had not been able to obtain a letter from a vendor that will provide preferred customer status in case of emergency for water.

Based on observation the facility failed to provide an acceptable electrical installation.

The inspector observed while accompanied by the Director of Plant Operations during the hours of the inspection from 2:00 pm to 4:45 pm that there was a missing directory on panel ILEXC in the 1st floor equipment room.