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Based on observation egress doors are locked in a manner not permitted by the Code. Failure to provide locking systems for means of egress doors in accordance with Code requirements can compromise the safety of occupants during a fire/smoke emergency by not providing the safeguards afforded by the Code for exiting from a fire/smoke condition.

Findings include:

A. On 09/09/2020 at 1:05pm accompanied by the FE, on the First floor between both Emergency Departments, a pair of cross corridor doors in an East/West corridor ( adjacent to Stair #5) contain delayed egress which does not comply with 7.2.1.6.1 due to the building being partially sprinkler protected.

B. On 09/09/2020 at 1:10pm accompanied by the FE, the First floor South Entry is is partially blocked by a blue box along with a locked door. This reduces the means of egress by half and contains a tripping hazard at the location of discharge which does not comply with 7.2.1.6.2.

Based on observation, not all stair components used within an exit stair are constructed to comply with 7.2. These deficiencies could affect any patients, staff, or visitors in the building by preventing them from evacuating the building under fire conditions.

Findings are:

A. On 09/09/2020 at 2:11pm while accompanied by the ED 2nd Floor, Exit Stair #6 entry door does not self close to a latched position. This arrangement does not comply with 7.7.3.4.

B. On 09/08/2020 at 1:17pm while accompanied by the ED 6th Floor, Exit Stair #12 entry door does not self close to a latched position. This arrangement does not comply with 7.7.3.4.

C. On 09/09/2020 at 3:15pm while accompanied by the ED 1st Floor, Exit Stair #8 is arranged to continue to the lower level and serve as an exit from the lower level as well as upper floors. A yellow chain stretches across the landing leading up from the lower level. This arrangement does not comply with 7.7.3.4 as an interrupter gate.

D. On 09/09/2020 at 2:50pm while accompanied by the ED Exit Stair # 3 contains furniture (chair, small table) which does not comply with 7.1.3.2.3.

E. On 09/09/2020 at 9:00am while accompanied by the ED 3rd floor Exit Stair #2 contains a sign on the stair entry door which reads "Physical Therapy on Stairs open door slowly". This stair is being used for a purpose other than as an exit which does not comply with 7.1.3.2.3.

F. On 09/10/2020 at 9:20am while accompanied by the ED and VP 1st floor Exit Stair #5 discharges into a vestibule which does not comply with 7.7.2(5) due to the following:

1. Stair #5 exit door is an aluminum store front with an aluminum frame and transom which does not comply with 7.1.3.2 and NFPA 80 2010 for a B-Label door, frame and fire rated hardware.

G. On 09/08/2020 at 1:15pm accompanied by the ED, Exit Stair #7 which serves Lower Level through 6th floor contains windows for the full height of the stair. The exit stair lacks protection from other portions of the building due to a 90 degree angle of exposure with the exit stair windows exposed to other building windows which are less than 3 feet away. This condition exists from the level of exit discharge to the 6th floor and does not comply with 7.2.2.5.2.

H. On 09/09/2020 at 1:30pm accompanied by the ED, Exit Stair #7 4th floor is open to a storage room due to the following:

1. No rated wall construction between the storage room controlled by facility carpenters and the stair landing.

2. Ductwork, conduit and pipe penetrate the wall between the storage room and continue above the suspended ceiling of the Stair landing.

Based on observation, dead end corridor lengths exist which exceed that permitted. This condition could require a person to traverse a longer route to reach an exit and may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

Findings are:

On 09/08/2020 while accompanied by the ED, designated egress corridors were observed with one means of egress to an exit. This condition produces a dead end corridor condition greater than 30 feet which does not comply with 19.2.5.2. This condition was observed through out patient care floors (partially sprinkler protected or not sprinkler protected).

Example locations observed:

1. At 1:30pm 6th floor North East corridor (containing Recovery) end of corridor to Stair #11

2. At 1:40pm 6th floor North West corridor (vacant) end of corridor to Stair #1

3. At 2:20pm 5th floor corridors except South East corridor refernced as a 1,500sf suite.

Based on observation, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

On 09/08/2020 at 1:10pm while accompanied by ED means of egress corridors were observed containing multiple pieces of equipment stored along walls. Materials reduce the required width of the egress path. This condition does not comply with 19.2.3.4 (4)(a).

Example Locations observed:

1. Fifth floor, exit access corridors contained carts, work stations on wheels and equipment stored along both sides of the means of egress corridor.

2. Fifth floor, exit access corridors adjacent to the elevator bank contained numerous work stations on wheels plugged into the walls and charging.

Based on observation, the facility failed to provide exit paths that are maintained as a continuously protected path to a public way. This deficient practice could affect staff and patients during egress due to a fire emergency evacuation from the building.

Findings include:

A. On 09/09/2020 at 10:30 am while in the company of the FE an exterior means of egress was observed in which the path is nonreliable. Location observed: Exit Stair 6 East side of South Building exterior discharge along a path directly adjacent to the building. The means of egress does not comply with 19.2.7 and 7.7.3.2 due to the following:

1. The exterior walking path to the public way is obstructed by the overgrowth of a bush.

2. The walking surface to the public way does not comply with 7.1.6.2 and 7.1.6.3 for a uniform level surface due to the heaving of the concrete sidewalk at the bottom of the sloped walkway. The walking surface is uneven forms a tripping hazard and is not suitible for any type of wheeled equipment or foot traffic.

B. On 09/09/2020 at 3:15pm accompanied by the FE, Exit Stair 3 West side of West Building, exterior discharge path contains a short exterior landing at the building discharge door which does not comply with the following:

1. The landing is approximately 2 feet deep which does not comply with 7.2.1.3.2.

2. The landing is 4 inches in height at the point of discharge and not distinguishable under all light conditions which does not comply with 7.1.7.2.4.

C. On 09/09/2020 at 11:30 am while in the company of the FE an exterior means of egress was observed in which the path is nonreliable. Location observed: Exit Stair 7 exterior discharge. The means of egress does not comply with 19.2.7 and 7.7.3.2 due to the following:

1. The exterior walking path to the public way is obstructed by chilled water piping.

2. The walking surface to the public way does not comply with 7.1.6.2 and 7.1.6.3 for a uniform level surface due to the installation of a wooden set of steps up and down over part of the water piping. The walking surface is uneven blacktop and forms multiple tripping hazards and is not suitible for any type of wheeled equipment or foot traffic.


D. On 09/09/2020 at 11:45 am while in the company of the FE an exterior means of egress was observed in which the path is nonreliable. Location observed: Exit Stair 8 exterior discharge. The means of egress does not comply with 19.2.7 and 7.7.3.2 due to the following:

1. The exterior means of egress to the public way is not reliable, evident to the user and unobstructed due to the location of trucks and equipment as part of the Loading Dock area.

2. The walking surface to the public way does not comply with 7.1.6.2 and 7.1.6.3 for a uniform level surface due uneven blacktop, holes and unmarked means of egress which forms multiple tripping hazards and is not suitible for any type of wheeled equipment or foot traffic

Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the lighting provided. Failure to maintain illumination of the means of egress can affect all persons in the facility required to utilize the exit(s) by preventing safe and unimpeded access to the public way.

The finding is:

On 09/09/2020 accompanied by the ED, numerous exit discharge lights were observed which the facility could not confirm to be of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3. Not all exit discharge locations were provided with multiple fixtures (or confirmed to be fixtures with multiple lamps) to comply with 7.8.1.4. Locations observed included the south facade exit door and the north facade exit doors. Main entry east doors may be similar.
Example locations observed:

1. At 2:10pm Exterior discharge Stair # 3

2. At 2:17pm Exterior discharge Stair # 7

3. At 2:40pm Exterior discharg Stair # 6

4. At 2:45pm Exterior discharge doors from the Outpatient Behavioral 2019 addition

Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes safety of all building occupants.

The finding is:

On 9/9/20 at 2:30 pm in the company of the ED & VP the facility failed to provide the documentation for the monthly and annual testing of facility's battery operated emergency lights as required by NFPA 101, 2012, 7.9.3.


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Based on observation, not all portions of the building's Essential Electrical System (EES) are installed as required. This deficient practice could affect patients, staff, and visitors in the building because life support equipment could fail to operate under emergency conditions if the essential electrical system is not installed properly.

The finding is:

On 09/09/2020 at 10:20am, while accompanied by the ED it was determined that battery-powered emergency lights are not provided in all critical care areas to comply with NFPA 99 2012 6.3.2.2.11.4 and NFPA 70 2011 517-63A.
Example locations observed:

1. Operating room #1

2. Operating room #2

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition.

A. On 09/09/2020 at 10:30am while in the company of the BE it was observed that corridors (and passages within designated suites) lacked exit signs to clearly identify access to at least two remote means of egress from the building to comply with 19.2.4.3, 19.2.10 and 7.10.
Location observed: At 10:30am 'EXIT' signage was observed not being installed at the end of the exit corridor, to identify the secondary means of egress from Second floor Wing containing Stair #2 by Xray.


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B. On 09/09/2020 while accompanied by the ED corridors (and passages within designated suites) were obsrved to lack exit signs to clearly identify access to at least two remote means of egress from the building to comply with 19.2.4.3, 19.2.10 and 7.10.

Example locations are:

1. At 11:30am 3rd floor corridor (containing room # 313) cross corridor doors leading to elevator bank.

2. At 11:42am 3rd floor corridor (containing room #316) contains one exit sign.

3. At 1:50pm 1st floor main corridor (running North/South separating ED suite #1, CCU near Stair #7) cross corridor doors making up a vestibule.

4. At 3:00pm Lower Level corridor adjacent to Stair #7

Based on observation the facility failed to maintain compartment separations between floors/areas. This deficient practice could affect patients, staff and visitors to safely reach an exit on a floor level during a fire event on a separate level.

Findings include:

On 9/9/20 at 9:45am in the company of the FE, while touring the 7th floor of the North Building, the facility failed to provide fire protection devices (fire dampers) for the shaft penetration of the Class 1 duct (4 inch flex) penetrations supplying ventilation air to the room induction units on floors 2 through 5, as required by NFPA 90A, 2012, 5.3.2.1.

Based upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to block exiting.

On 09/09/2020 while accompanied by the BE hazardous areas were not maintained as fire and smoke proof enclosures to comply with 19.3.2. Location include:

1. At 10:00am: Lower Level North West Wing (containing Stair #1) Mechanical Room corridor wall was observed to have 2- 3" conduits penetrating the exit corridor wall, not sealed to resist the passage of smoke/fire.

2. At 10:10am: Lower Level North West Wing (containing Stair #1) Large mechanical and storage room door was popped opened with a heavy round piece, not easily to pushed, and also the door to exit corridor could not be closed easily to the damaged door.

3. At 10:15am. Lower Level North West Wing (containing Stair #1) Exit corridor alcove was observed being used to store large quantities of combustible cardboard boxes. 23 Boxes with stuff in were counted.

4. At 10:50am: Lower Level North East Wing (containing Stair #11) Record storage room door does not latch to a closed position in order to prevent the transfer of smoke/fire to the exit corridor and other areas.

5. At 11:10am: Lower Level North East Wing (containing Stair #11) Mechanical Room corridor wall was observed to have 2- 3" conduits penetrating the exit corridor wall, not sealed to resist the passage of smoke/fire.

6. At 11:25am: Lower Level North East Wing (containing Stair #11) Recovery -Storage room door to exit corridor was found smashed, thus compromising the door rating and not preventing to resist the passage of smoke/fire to the exit corridor.

7. At 11:40am Lower Level North East Wing (containing Stair #11) Recovery/Storage room three pipes penetrating the corridor wall were observed not sealed around the annular space to resist the passage of smoke/fire.

8. At 1:30pm it was observed Second floor of 1960 Building Lab has one 4" pipe penetrating the exit corridor wall was observed not sealed to resist the passage of smoke/fire.


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9. On 09/08/2020 at 2:05pm accompanied by the ED Corridor door to Storage #612 (former patient room) is not self closing door 19.3.2.1.3.

10. On 09/08/2020 at 1:50pm accompanied by the ED Corridor door to Ortho Equipment Storage #604 contains a manual hold open device 19.3.2.1.3 NFPA 80 2010 6.1.4.2.2.

11. On 09/09/2020 at 10:10am accompanied by the ED corridor doors to electrical closet EE #12 (1st floor adjacent to Stair #2) lack self closing devises to comply with 19.3.2.1.3.

12. On 09/08/2020 at 2:15pm accompanied by the ED Sterile Storage located adjacent to OR #1 contains a corridor door with an electric strike which does not latch to the closed position.

13. On 09/09/2020 while accompanied by FE, corridor door to the South Basement Storage room (not sprinkler protected) housing numerous fire extinguishers and combustibles contains a grille. This condition does not comply with a fire resistant enclosure.

Based on observation during the survey walk through the the facility failed to provide for all piped in medical gas systems to be installed and maintained code compliant. This condition could hinder the efficient shut off of any system in an emergency which will affect patients and staff within the immediate location.

The finding is:

On 09/08/2020 at 12:30pm while accompanied by the ED the location of the medical gas shut off valve for an Operating Room #1 is labeled as C-Section. this condition does not comply with NFPA 99, 2010, 5.1.4.8.7 and 5.1.4.8.7.2.
Location observed: 6th floor corridor adjacent to OR #1 entry doors.

Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes safety of all building occupants.

The finding is:

A. On 9/9/20 at 2:30 pm in the company of the ED & VP the facility failed to provide the documentation for the six month inspection testing of the kitchen and cafeteria grease hoods as required by NFPA 96, 2011, 11.2.


Based on observation during the survey walk through the facility failed to provide protection and identification for the fire extinguishing components. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

B. On 9/9/20 at 1:35 pm in the company of the ED the facility failed to provide the required K Fire Extinguisher in a convenient and accessible location for the cafeteria grill. NFPA 96, 2011, 10.10

C. On 9/9/20 at 1:35 pm in the company of the ED the facility failed to provide the required K Fire Extinguisher placard for the operation of the extinguisher for the cafeteria kitchen & grill and main kitchen. NFPA 10, 2010, 5.5.5.3

Based on observation the facility failed to provide protection and identification for the fire alarm components. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 9/9/20 at 11:35 am accompanied by the FE, it was observed that the fire alarm control panel located in the Basement fire alarm control panel room is not provided with smoke detection as required by NFPA 72, 2010, 10.15.

B. On 9/9/20 at 11:35 am accompanied by the FE, it was observed that the fire alarm control panel located in the Basement fire alarm control panel room is not provided with identification as to the location of the dedicated branch circuit disconnecting means as required by NFPA 72, 2010, 5.5.2.1.

C. On 9/9/20 at 1:05 pm accompanied by the ED, it was observed that the fire alarm panels located in the First floor fire alarm control panel room are not provided with smoke detection as required by NFPA 72, 2010, 10.15.

D. On 9/9/20 at 1:05 pm accompanied by the ED, it was observed that that 3 of 3 fire alarm control panels located in the First Floor fire alarm control panel room are not provided with identification as to the location of the dedicated branch circuit disconnecting means as required by NFPA 72, 2010, 5.5.2.1.


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Based on observation, not all fire alarm initiation devices are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, the fire alarm could fail to activate under emergency conditions.

The finding is:

E. On 09/09/2020 while accompanied by the ED, observation determined that fire alarm initiating devices (smoke detectors) are located so that airflow from HVAC diffusers within 3'-0" thus preventing their operation which does not comply with NFPA 72 2010 17.7.4.1.

Example locations include:

1. At 11:10am 1st floor OutPatient Center waiting area.

2. At 11:15am 1st floor OutPatient Center Reception desk.

3. At 11:20am 1st floor OutPatient Center corridor near Patient Holding Area.

4. At 2:30pm 4th floor North West Wing Med Surge corridor

Based on observation, the fire alarm system's operational integrity and control functions are not observed. The failure of staff response during a system malfunction can inhibit the proper staff response during an actual fire emergency.

The finding is:

On 09/09/2020 at 8:35am while accompanied by the ED it was noted that a continuous beeping sound was heard. The fire alarm panel located in the Visitor's Lobby contained a trouble signal. Upon asking what was the origin of the trouble, the facility representative was unsure and thought it may be due to work conducted on a building elevator. When asked later, the facility representative had not previously verified the origin of the trouble signal. Therefore, the facility staff response does not comply with 9.6.1.3, 9.6.7.5 and 19.7.2.3.2 (2).

Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes safety of all building occupants.

The finding is:

On 9/9/20 at 2:30 pm in the company of the ED & VP the facility failed to provide documentation for the minimum requirements for testing of the fire alarm system as required by NFPA 72, 2010, Table 14.4.5.

Based on observation the facility failed to maintain the enclosure for quick response of fire protection appliances. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 9/9/20 at 1:45 pm in the company of the ED in the Dietary Dishwashing Room, the ceiling around the dishwasher exhaust duct is open allowing heat and products of combustion to rise to the interstitial space above the ceiling system. This allows for bypass of the installed fire sprinklers and a delayed response. NFPA 13, 2010, 8.6.4.1

B. On 9/9/20 at 1:45 pm in the company of the ED in the Pharmacy the center movable shelving system obstructs the ceiling fire sprinkler. NFPA 13, 2010, 8.5.6.1


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C. On 09/09/2020 at 3:10pm while in the company of the VP and FE it was observed that a separation was not provided from the above ceiling cavity at the east edge of a suspended acoustical tile ceiling to resist the passage of heat and smoke to the above ceiling cavity. This condition does not provide containment of the space to provide effective response of the sprinkler system to comply with NFPA 13-2010, 4.1 and 3.3.6

Location observed: Lower Level, finished ceiling (located directly across from the main electrical room, near north south corridor containing Stair #8).

Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes of all building occupants.
Findings include:

A. On 9/9/20 at 2:30 pm in the company of the ED & VP the facility failed to provide the minimum requirements for testing of the fire sprinkler system as required by NFPA 25, 2011, Table 5.1.1.2.

B. On 9/9/20 at 2:30 pm in the company of the ED & VP the facility failed to provide the minimum requirements for testing of the fire pump as required by NFPA 25, 2011, 8.3 & 8.3.3.

Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes safety of all building occupants.

Findings include:

A. On 9/9/20 at 2:30 pm in the company of the ED & VP the facility failed to provide the documentation for the fire extinguisher monthly inspection and annual maintenance as required by NFPA 10, 2010, 7.2 & 7.3. Also during the facility tour it was observed that numerous portable fire extinguisher had missing or incomplete inspection tags.


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B. On 09/09/2020 while accompanied by FE, numerous fire extinguishers were observed within a room containing labels from various years including 2020, 2017 and 2016. The type of fire extinguishers varies from class ABC and K. The facility lacks record keeping to indicate the purpose and condition for the extinguishers located within this room (removed from service, additional use etc.). This condition does not comply with NFPA 10 2010, 7.2.4 and 7.3.3.
Location observed South Basement Storage room.

Based on observation, not all corridor doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass into corridors if the corridor doors are not installed in a compliant manner.

The finding is:

On 09/09/2020 while accompanied by the ED corridor doors do not latch to a closed position which does not comply with 19.3.6.3.
Example locations observed:

1. At 11:05am 1st floor pair of cross corridor doors North of elevators 4,5and 6 elevators contain a mag lock and do not latch.

2. At 9:00am 6th floor cross corridor door located North of elevators 4, 5 and 6 contains tape wrapped around the top latching device.

3. At 9:10am 6th floor OR#1 corridor entry doors do not contain a latching mechanism.

Based on document review and staff interview the facility failed to provide documentation for the maintenance and testing of life safety systems. Failure to maintain these systems jeopardizes safety of all building occupants.

The finding is:

On 9/9/20 at 2:30 pm in the company of the ED & VP the facility failed to provide the documentation for the fire damper/smoke damper testing as required by NFPA 80, 2010, 19.4.1.1 & NFPA 105 2010, 6.5.2.


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Based on observation, the facility failed to provide access to fire protection appliances within the ventilation duct system. Failure to install and maintain this installation could result in the passage of fire and products of combustion from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. While accompanied by the FE installed access panels located at a duct for inspection and maintenance of fire dampers lack labeling to identify if the damper is abandoned or active. This condition exists throughout the facility and does not comply with NFPA 80-2010, 19.2.3
Example location observed:

1. On 09/09/2020 at 1:46pm 4th floor large mechanical room located between South and North building.

2. On 09/09/2020 at 2:03pm South building Subbasement duct work located above and near the South steam, West/South condensate and chilled water lines.

Based on observation during the survey walkthrough, the facility failed to comply with the requirements for a hazardous room with a single designation. By allowing areas/rooms to serve multiple functions the spread of smoke and fire throughout a smoke compartment is increased and the evacuation of patients, staff and visitors is delayed.

Findings include:

A. On 9/8/20 at 11:10 AM while accompanied by the BE, Trash collection room on lower level, the chute discharge door was observed with trash piled to the bottom of the door and covering the fusible link. This condition does not comply with NFPA 82, 2009, 10.2.1 for a clear and unobstructed door at all times.


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B. On 09/08/2020 at 2:20pm while accompanied by the ED a 6th floor chute access door which is open directly onto a means of egress corridor (found unlocked). There is no record of annual inspection and maintenance for the chute loading doors to comply with NFPA 82 2009, 10.2.1 and 10.2.2.

Based on document review and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills.

The finding is:

On 09/09/2020 at 2:45pm during document review with the ED and VP, Facility fire drill documentation for the past 12 months is incomplete and does not comply with 19.7.1.4, 19.7.1.6 and 19.7.1.8. due to the following examples:

1. Not all Departments within the facility are shown on the fire drills as participating, fill out the forms or indicate the protocol. For example there is no indication of where the "fire" was located (19.7.1.6).

2. Fire Drills do not indicate the device which was activated (19.7.1.4).

3. There is no fire drill documentation between October of 2019 and August of 2020.

4. There is no indication that a signal was received by the fire department or monitoring service.

Based on observation, not all portions of the building electrical system are installed in accordance with the code. These deficiencies could affect any or all patient care areas, due to electrical power is unavailable for their treatment.

The finding is:

A. On 9/09/2020 at 2:15pm: Medical surgical rooms on the fourth floor were found not to be installed with alternate source of power (emergency outlets) tied to the Emergency Generator, as required by NFPA 70, 2011 517-18(a). Surveyor was informed by the facility representative that this condition exists on other Medical Surgical floors.


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Based upon observation, electrical systems are not maintained in conformance with Code requirements. Failure to maintain the electrical system can lead to confusion when selected components require shut-down for maintenance and power circuits cannot be accurately identified.

The findings are:

B. On 09/08/2020 at 11:45am while accompanied by the ED, critical care patient rooms containing emergency outlets were observed which did not identify the electrical panel that served them. This condition was observed within all critical care patient areas. The condition does not comply with NFPA 70-2011, 408.4.

Example locations observed:

1. OR #1

2. OR #2

3. Recovery Stage 1 rooms

C. On 09/08/2020 at 11:45am while accompanied by the ED, facility staff were not able to determine which ATF switch serves the isolation panels provided for each O.R. This condition was observed within each O.R. Due to this condition it is unknown which branch of the essential electrical system provides power to the isolation panels which provide power to the emergency outlets within each O.R. The condition does not comply with NFPA 70-2011, 408.4.

Base on observation the facility failed to provide protected storage for medical gas cylinders. This deficient practice could result in the uncontrolled spread of fire which may affect patients, staff and visitors.

Findings include:

A. On 9/9/20 at 2:20 pm in the company of the ED at the medical gas manifold and cylinder storage room numerous tanks are unrestrained. NFPA 99, 2012, 5.1.3.3.2 (7).

B. On 9/9/20 at 2:20 pm in the company of the ED at the medical gas manifold and cylinder storage room the amount of storage is more than 3000 cubic feet of compressed gas and is not provided with natural or mechanical exhaust to the outside. NFPA 99, 2012, 9.3.7.5