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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed wall and ceiling penetrations. This affected one of six floors, and could result in the passage of smoke to other areas in the event of a fire.

Findings:

During a tour of the facility, and interview with the Life Safety Officer (LSO), the walls and ceiling were observed.

8/15/17
1st Floor

1. At 1:16 p.m., the walls and ceiling in the Auditorium Computer Room, were observed. There were two, approximately two inch diameter penetrations in the Northeast corner of the ceiling, that had two metal conduits traveling through both.

2. At 2:05 p.m., the walls and ceiling in Room 1C104, were observed. There were two penetrations located together in the West Wall, ranging in size from approximately three inches to two inches in diameter. At 2:06 p.m., the LSO acknowledged the penetrations.

3. At 2:34 p.m., the walls and ceiling in the Men's Restroom door NWH53, were observed. There was an approximately one half-inch diameter penetration in the North Wall above the urinal.

Based on observation, and interview, the facility failed to maintain self-closing corridor doors in the exit passageways and the hazardous areas. This was evidenced by doors secured in the open position with unapproved devices, not interfaced with the Fire Alarm system (FAS). This affected one of six floors, and could allow the spread of smoke into adjoining compartments in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8 Self-Closing Devices.
7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door leaf becomes self-closing.

Findings:

During a facility tour, and interview with Life Safety Officer (LSO), the self-closing doors in the exit passageways, and the hazardous areas were observed.

1st Floor

1. On 8/15/17 at 2:50 p.m., the two self-closing corridor doors to the Specimen Processing Lab, were secured in the open position with friction hold-open devices that were not interfaced with the FAS for closure upon activation. Upon interview, the LSO confirmed the finding. On 8/16/17 at 9:15 a.m., activation of the FAS during testing did not activate the closure of the doors. Both doors remain in the closed position by Lab Staff.

2. On 8/15/17 at 2:55 p.m., the self-closing corridor door to the General Lab was secured in the open position with a friction hold-open device that was not interfaced with the FAS for closure upon activation. Upon interview, thevLSO confirmed the finding. On 8/16/17 at 9:15 a.m., activation of the FAS during testing did not activate the closure of the door. The door remains in the closed position by Lab Staff.

3. On 8/16/17 at 9:03 a.m., the double-set of cross corridor doors # 1D109 on Floor One, were observed during a facility tour along with Fire System (FAS) testing. The right leaf facing south was secured in the open position by a wedge stationed at the bottom of the door. The right leaf released from the magnetic hold-open device during FAS activation, but failed to close due to the hold-open wedge obstruction.

Based on observation, and interview, the facility failed to maintain their battery back-up emergency lighting. This was evidenced by 2 of 17 battery back-up lights in the Emergency Mental Health. This could delay evacuation in the event of an emergency. This affected one of six floors.

NFPA 101, Life Safety Code, 2012 Edition
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.2.5 Unit equipment and battery systems for emergency luminaires shall be listed to ANSI/UL 924, Standard for Emergency Lighting and Power Equipment.
7.9.2.6* Existing battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code.
7.9.2.7 The emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1)and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During the facility tour, and interview with the Facility Director (FD), the battery back-up emergency lighting was observed.

8/15/17
2nd Floor

1. At 2:53 p.m., 1 of 3 emergency battery back-up lights in room 2B152 indicated a battery failure.

2. At 2:58 p.m., 1 of 9 battery back-up lights in room 2B159, indicated a battery failure. At 3:08 p.m., during an interview, the FD explained that maintenance staff, had been dispatched to replace the faulty batteries. He also acknowledged, that there was a total of 17 ceiling light fixtures that were equipped with emergency back-up batteries, when three individual rooms and the corridor were included.

8/17/17

3. At 3:45 p.m., during an interview, the FD confirmed, that they had replaced the faulty batteries on the ceiling light fixtures in the Emergency Mental Health area.

Based on observation, and interview, the facility failed to maintain their vertical openings. This was evidenced by a stairwell door at the fifth floor, that failed to self close completely and latch. This could result in the spread of fire. This affected two of six floors.

NFPA 101, Life Safety Code, 2012 Edition
19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.

Findings:

During the facility tour, and interview with the Facility Director (FD), the fire rated separation doors between floors at the stairwells, were observed.

8/17/17
5th Floor

1. At 10:32 a.m., the stairwell door # NW5254 near Room 5A118, was obstructed from fully closing and latching. The door failed to close the last 1/4 inch, and failed to latch. The door was retested but failed to latch in three of three attempts. At 10:33 a.m., the FD acknowledged that the door failed to close completely, and indicated the smoke seal was creating the obstruction to closing. The FD radio dispatched a request for an immediate repair.

Based on observation, and interview, the facility failed to maintain their hazardous areas. This was evidenced by self-closing enclosure doors that failed to fully close and latch, when tested. This affected one of six floors, and could result in a delay in containing smoke and/or fire to hazardous areas in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.2 Protection from Hazards.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During a facility tour, and interview with the Life Safety Officer (LSO), the hazardous areas were observed.

8/15/17
1st Floor

1. At 2:40 p.m., the Histology Lab corridor door 1A123, was observed. The door was equipped with self-closing and positive latching devices. The door was opened to the fullest extent and allowed to close. At 2:41 p.m., the LSO acknowledged that the door failed to fully close and latch.

2. At 2:45 p.m., the Chemistry Lab corridor door 1A112, was observed. The door was equipped with self-closing and positive latching devices. The door was opened to the fullest extent and allowed to close. The door failed to fully close and latch.

Based on observation, and interview, the facility failed to maintain the kitchen hood fire extinguishing system. This was evidenced by dislodged sprinkler nozzle caps. This affected one of six floors, and could result in the malfunction of the kitchen hood fire suppression system and/or a grease fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
10.2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.
10.2.2.1 The language and wording for the placard shall be approved by the authority having jurisdiction.
10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 Edition
4.3 Discharge Nozzles. (See also Section 5.5.)
4.3.1 Discharge nozzles shall be listed for their intended use.
4.3.1.1 Discharge nozzles shall be provided with an internal strainer or a separate listed strainer located immediately upstream of the nozzle.
4.3.1.2 Discharge nozzles shall be of brass, stainless steel, or other corrosion-resistant materials, or be protected inside and out against corrosion.
4.3.1.3 Discharge nozzles shall be made of noncombustible materials and shall withstand the expected fire exposure without deformation.
4.3.1.4* Discharge nozzles shall be permanently marked for identification.
4.3.1.5 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping.
4.3.1.6 The protection device shall blow off, blow open, or blow out upon agent discharge.

Findings:

During a facility tour, and interview with the Life Safety Officer (LSO), the kitchen hood fire extinguishing systems were observed.

8/15/17
1st Floor

1. At 1:25 p.m., two of five red sprinkler nozzle caps for the Cafeteria hood fire suppression system were dislodged, and hanging from the nozzles they were protecting. At 1:26 p.m., the LSO acknowledged the dislodged sprinkler head caps.

2. At 1:50 p.m., two of nine red sprinkler nozzle caps for the Main Kitchen hood fire suppression system, were dislodged and hanging from the nozzles they were protecting.

Based on document review, and interview, the facility failed to maintain their Fire Alarm System (FAS). This was evidenced by a Fire Alarm Control Panel (FACP) trouble display associated with the failure of an initiation device. This was also evidenced by no current smoke detector sensitivity testing, and no records of heat detector testing available. This affected six of six floors. This could result in failure of a smoke or fire notification device to activate and/or delay evacuation in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
Chapter 14 Inspection, Testing, and Maintenance
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.2.1.2.2 System defects and malfunctions shall be corrected.

14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2.
Table 14.4.2.2 Test Methods
14. Initiating devices
(d) Heat detectors
(1) Fixed-temperature, rate-of-rise, rate of compensation, restorable line, spot type (excluding pneumatic tube type)
Heat test shall be performed with a heat source per the manufacturer's published instructions. A test method shall be used that is specified in the manufacturer's published instructions for the installed equipment, or other method shall be used that will not damage the non-restorable fixed-temperature element of a combination rate-of-rise/fixed-temperature element detector.
(2) Fixed-temperature, non-restorable line type Heat test shall not be performed. Functionality shall be tested mechanically and electrically. Loop resistance shall be measured and recorded. Changes from acceptance test shall be investigated.
(3) Fixed-temperature, non-restorable spot type
After 15 years from initial installation, all devices shall be replaced or 2 detectors per 100 shall be laboratory tested. The 2 detectors shall be replaced with new devices. If a failure occurs on any of the detectors removed, additional detectors shall be removed and tested to determine either a general problem involving faulty detectors or a localized problem involving 1 or 2 defective detectors. If detectors are tested instead of replaced, tests shall be repeated at intervals of 5 years.
(4) Non-restorable (general) Heat tests shall not be performed. Functionality shall be tested mechanically and electrically.
(5) Restorable line type, pneumatic tube only Heat tests shall be performed (where test chambers are in circuit), or a test with pressure pump shall be conducted.
(6) Single- and multiple-station heat alarms Functional tests shall be conducted according to manufacturer's published instructions. Non-restorable heat detectors shall not be tested with heat

Table 14.4.5 Testing Frequencies
15. Initiating Devices*
(e) Heat detectors (The requirements of 14.4.5.5 shall apply.) - Annually
14.4.5.4 Test frequency of interfaced equipment shall be the same as specified by the applicable NFPA standards for the equipment being supervised. 14.4.5.5 Restorable fixed-temperature, spot-type heat detectors shall be tested in accordance with 14.4.5.5.1 through 14.4.5.5.4.
14.4.5.5.1 Two or more detectors shall be tested on each initiating circuit annually.
14.4.5.5.2 Different detectors shall be tested each year.
14.4.5.5.3 Records shall be kept by the building owner specifying which detectors have been tested.
14.4.5.5.4 Within 5 years, each detector shall have been tested.
14.4.5.6* Circuit and pathway testing of each monitored circuit or pathway shall be conducted with initial acceptance or re-acceptance testing to verify signals are indicated at the control unit for each of the abnormal conditions specified in 23.5.2, 23.5.3, 23.6.2 through 23.6.5, 23.7.2 and 23.7.3

14.4.5.3 In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7.
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.
14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.
14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced.
14.4.5.3.7 The detector or smoke alarm sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector or smoke alarm.
Findings:

During the facility tour, document review, and interview with the Facilities Director (FD) and the Electrical Supervisor (ES), the Fire Alarm System (FAS) was observed, the fire the smoke detector sensitivity testing records and heat detector testing records were requested.

8/15/17
2nd Floor

1. At 8:50 a.m., the Main Fire Alarm Control Panel (FACP) was observed. The FACP displayed a trouble signal. Upon interview, ES confirmed that the trouble signal was due to a defective Zone Smoke Detector. ES also confirmed that the FAS is fully functional and transmitting testing activities to on-site Proprietary Monitoring. ES explained that the reason it had not been repaired yet was due to an incorrect device address and access issues with the rooms in use. A review of the Main FACP display history identified the trouble signal was first acknowledged on 7/11/17 at 06:14: 02 a.m.

8/16/17
2nd Floor

At 8:20 a.m., prior to FAS testing with ES, the Main FACP was observed. The FACP displayed a Normal System Mode. Upon interview, ES confirmed that the smoke detector was located and replaced.


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8/15/17

2. At 10:15 a.m., the fire alarm testing report dated from 2/27/17 to 3/4/17 included only functional testing of the smoke detectors. There was no current record of smoke detector sensitivity testing provided. The most recent record available for smoke detector sensitivity testing was dated 5/11/07.

3. At 10:20 a.m., the annual fire alarm inspection and testing report from 2/27/17 to 3/4/17 failed to include functional testing of the heat detectors. At 10:21 a.m., the FD acknowledged that there were no other records available.

8/16/17

4. At 8:40 a.m., during document review, and interview with the ES, the heat detector testing was reviewed. At 8:40 a.m., the ES explained that the heat detectors were checked by removal from their base. The ES explained there was no actual device testing using heat on the heat detectors, and no documented testing. The ES confirmed there were 4 non-restorable and 22 resetable heat detectors installed in the new Emergency Room portion of the building.

Based on document review and interview, the facility failed to maintain interim fire measures. This was evidenced by failure to provide written protocol to ensure that if the fire alarm system was out of service for more than 4 hours in a 24 hour period, the authority having jurisdiction (AHJ) would be notified. This affected six of six floors, and could result in the AHJ not having the ability to exercise oversight, if the fire alarm system should become inoperable.

Findings:

During document review, and interview with the Life Safety Offier (LSO), the interim fire measures and policy were requested.

8/15/17

At 9:55 a.m., the approved Fire Watch policy available for review, did not include notification to the Department of Public Health if the fire alarm system was out of service for more than 4 hours in a 24 hour period. Upon interview, the LSO confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the battery operated single-station smoke alarms. This was evidenced by failure to test the smoke alarms in accordance with manufacturer specifications. This affected four of six floors, and could result in the malfunction of smoke alarms in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm Signaling Code, 2010 Edition
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.1.2 The inspection, testing, and maintenance of single and multiple-station smoke and heat alarms and household fire alarm systems shall comply with the requirements of this
chapter.
14.2.1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this Code and conform to the equipment manufacturer's published instructions.

Findings:

8/17/17

During document review, and interview with the Electrical Supervisor (ES), the battery operated smoke alarm records were requested.

1. At 8:30 a.m., the ES indicated the facility had 20 of 20 battery operated single-station smoke alarms in the On Call Rooms located on Floors Three, Four, Five, and Six. At 8:33 a.m., the ES confirmed that the smoke alarms had been installed approximately over four months earlier, and that no routine testing of the alarms had been performed. The ES explained that there was no smoke alarm testing documentation available for review.

During the facility tour, and interview with the Life Safety Officer (LSO) the smoke alarms were observed.

2. At 9:40 a.m., during a facility tour with the LSO, On-Call Room 6B114 was observed with a single station battery operated smoke alarm. The manufacturer testing requirements indicated, "weekly testing required." Upon interview, the LSO confirmed the finding.

Based on observation, and interview, the facility failed to maintain the integrity of the automatic fire sprinkler system. This was evidenced by system pressure that exceeded the rating of an alarm valve, sprinklers covered with debris, and missing or displaced escutcheons on fire sprinkler heads. This affected two of six floors, and could result in the a delay activating the fire sprinkler and a delay in egress during a fire emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5 Extinguishment Requirements.
19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
13.5.7 Fire Pump Pressure Relief Valves.
13.5.7.1 All circulation relief valves shall be inspected weekly.
13.5.7.1.1 The inspection shall verify that water flows through the valve when the fire pump is operating at shutoff pressure (i.e., churn) to prevent the pump from overheating.
13.5.7.1.2 During the annual fire pump test, the closure of the circulation relief valve shall be verified to be in accordance with the manufacturer's specifications.
13.5.7.2 All pressure relief valves shall be inspected weekly.
13.5.7.2.1 The inspection shall verify that the pressure downstream of the relief valve fittings in the fire pump discharge piping does not exceed the pressure for which the system components are rated.

Table 13.8.1 Summary of Component Replacement Action Requirements
Pressure relief valve - fire pump installation - Adjust, or Repair/Recondition, or Replace - see 8.3.3.3 and 13.5.7 - Inspection, Test, and Maintenance Procedures
Pressure relief valve - other than fire pump installation - Replace - Verify relief valve is listed or approved for the application and set to the correct pressure.

Findings:

8/15/17
2nd Floor

During the facility tour, and interview with the Facility Director (FD), and the LSO, the fire sprinkler system was observed

1. At 1:46 p.m.,in the Eye Clinic reception area, there were two missing fire sprinkler head escutcheons.

2. From 1:47 p.m. to 1:48 p.m., there were three fire sprinkler heads in the Eye Clinic with gaps ranging from 1/4 inch to 1/2 inch between the ceiling and the escutcheons in Room 3, Room 6, and the clean utility room.

3. From 2:15 p.m. to 2:20 p.m., there were two fire sprinkler heads in Nuclear Medicine with gaps ranging from 1/4 inch to 3/4 inch between the ceiling and the escutcheons in rooms SE2160 and SE2210. At 2:21 p.m., the FD acknowledged the escutcheons do not stay in place consistently.

4. At 2:31 p.m., there were two sprinkler head escutcheons missing in rooms 2C194 and 2C197.

8/16/17
1st Floor

5. At 10:04 a.m., the fire sprinkler system gauge pressure exceeded the rating of the alarm check valve located on the first floor of Stairwell #6. The gauge pressure readings during testing ranged from 170 pounds per square inch (PSI) to 215 PSI. The Alarm valve was rated for 175 PSI. At 10:06 a.m., the FD explained that it was difficult to prevent high pressure spikes created by the jockey pump, which maintained the elevated pressures to compensate for pressure reductions at the upper floors.


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1st Floor

6. At 1:10 p.m., 14 of 14 pendant style sprinkler heads located under the Main Entrance roof over-hang were covered in foreign debris. At 1:11 p.m., the LSO confirmed the finding.

Based on document review, and interview, the facility failed to maintain interim fire measures. This was evidenced by failure to provide written protocol to ensure that if the automatic fire sprinkler system was out of service for more than 10 hours in a 24 hour period, the authority having jurisdiction (AHJ) would be notified. This affected six of six floors, and could result in the AHJ not having the ability to exercise oversight if the sprinkler system should become inoperable.

During document review, and interview with the LSO, the interim fire measures and policy were reviewed.

8/15/17

At 9:55 a.m., the approved Fire Watch policy was reviewed. The policy did not include notification to the Department of Public Health if the sprinkler system was out of service for more than 10 hours in a 24 hour period. Upon interview, the LSO confirmed the finding.

Based on observation, and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by fire extinguishers that were unsecured, and mounted higher than the maximum allowed height of sixty inches. This affected one of six floors, and could result in damage to the extinguisher, and/or the inability of staff to readily access the fire extinguisher in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010, Edition
6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses

6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.
6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor.
6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).

Findings:

During a tour of the facility and interview with the Life Safety Officer (LSO), the portable fire extinguishers were observed.

8/15/17
1st Floor

1. At 1:45 p.m., the portable ABC-class fire extinguisher located in the Dietary-Dry Storage Room, was mounted to the wall with the top of the operative handle at 61 and one half inches above the floor.

2. At 2:00 p.m., the portable ABC-class fire extinguisher located in Room 1C104, was free-standing on the floor, unsecured. At 2:01 p.m., the LSO acknowledged the fire extinguisher was not mounted.

3. At 2:15 p.m., the portable ABC-class fire extinguisher located in the Discharge Clearance Unit, was mounted to the wall with the top of the operative handle at 70 inches above the floor.

4. At 3:10 p.m., the portable ABC-class fire extinguisher located in Room 1D132, was free-standing on top of the file cabinet, unsecured. At 3:11 p.m., the LSO acknowledged the fire extinguisher was not mounted.

Based on observation, and interview, the facility failed to maintain the corridor and aisle way doors. This was evidenced by 20 minute fire rated doors that were obstructed from fully closing, and failed to positive latch upon closure. This affected four of six floors, and could result in the inability to contain smoke and/or fire to a room in the event of a fire.

Findings:

During a tour of the facility, and interview with the Life Safety Officer (LSO), the doors were observed.

1. On 8/15/17 at 1:15 p.m., the East corridor door to the Main Auditorium, was observed. The door was equipped with a self-closing device. The door was held-open and obstructed from fully closing and latching by a coat stand. At 1:16 p.m., the LSO acknowledged the obstructed door.

2. On 8/15/17 at 2:12 p.m., the door to Room 1B114 was observed. The door was equipped with a self-closing device. The door was held-open to the fullest extent and allowed to close. The door failed to fully close and latch.

3. On 8/17/17 at 10:10 a.m., the door to Room 6A123 was observed. The door was equipped with a self-closing device. The door was held-open, and was obstructed from fully closing and latching by a television.

4. On 8/17/17 at 12:44 p.m., the door to Room SE4191 was observed. The door was equipped with a self-closing device. The door was held-open and obstructed from fully closing and latching by a rubber wedge stationed at the bottom of the door.

5. On 8/17/17 at 1:05 p.m., the door to Room 4A101 was observed. The door was equipped with a self-closing device. The door was held-open to the fullest extent, and allowed to close. The door failed to fully close and latch.

6. On 8/17/17 at 1:12 p.m., the door to Room 4D114 was observed. The door was equipped with a self-closing device. The door was held-open, and obstructed from fully closing and latching by a rubber wedge stationed at the bottom of the door. At 1:31 p.m, the LSO acknowledged the obstructed door.

7. On 8/17/17 at 1:30 p.m., the door to Room 4C126 was observed. The door was equipped with a self-closing device. The door was held-open to the fullest extent, and allowed to close. The door failed to fully close and latch.

8. On 8/17/17 at 2:35 p.m., the door to Room NE2139 was observed. The door was equipped with a self-closing device. The door was held-open, and obstructed from fully closing and latching by a cart stationed in the swing path of the door.

9. On 8/17/17 at 2:40 p.m., the door to Room 2B102 was observed. The door was equipped with a self-closing device. The door was held-open to the fullest extent, and allowed to close. The door failed to fully close and latch.

10. On 8/17/17 at 3:20 p.m., the door to Room NW2140 was observed. The door was equipped with a self-closing device. The door was held-open to the fullest extent and allowed to close. The door failed to fully close and latch.

Based on observation, and interview, the facility failed to maintain the integrity of the fire/smoke barrier walls. This was evidenced by not sealing a penetration with a fire rated material. This affected two of six floors, and could allow the spread of smoke and/or fire in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1)This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a)Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b)Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.
8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, 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 smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.
8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.
8.5.6.4 Where sprinklers penetrate a single membrane of a fire resistance-rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 1/2 in. (13 mm), measured between the edge of the membrane and the sprinkler.
8.5.6.5 Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be securely set in the smoke barrier, and the space between the item and the sleeve shall be filled with a material capable of restricting the transfer of smoke.

Findings:

During a facility tour, and interview with the Life Safety Officer (LSO), the fire/smoke barrier walls were observed.

1. On 8/15/17 at 2:10 p.m., the two hour rated fire/smoke barrier wall above the cross corridor doors and drop-ceiling by Room 1B115A, was observed. There was an approximately 1/2 inch diameter penetration in the lower left area of the wall. Upon interview, the LSO confirmed the finding.

2. On 8/17/17 at 11:25 a.m., the two hour rated fire/smoke barrier wall above the cross corridor doors and drop-ceiling located at the entrance to Unit 4-B Entrance, was observed. There was an approximately four inch diameter penetration inside a metal conduit with cables traveling through. The fire caulking that was previously sealing the inside of the conduit had fallen out, and was laying beside it. Upon interview, the LSO confirmed the finding.

Based on observation, and interview, the facility failed to maintain their smoke barrier doors. This was evidenced by two pairs of smoke barrier doors that failed to close completely. This could result in the spread of smoke and fire in the event of a fire. This affected one of six floors.

NFPA 101, Life Safety Code, 2012 Edition
19.3.7.8* Doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.

8.5.4.4* Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

7.2.1.5.11 Where pairs of door leaves are required in a means of egress, one of the following criteria shall be met:
(1) Each leaf of the pair shall be provided with a releasing device that does not depend on the release of one leaf before the other.
(2) Approved automatic flush bolts shall be used and arranged such that both of the following criteria are met:
(a) The door leaf equipped with the automatic flush bolts shall have no doorknob or surface-mounted hardware.
(b) Unlatching of any leaf shall not require more than one operation.

Findings:

During the facility tour, and interview with the Facilities Director (FD) the smoke barrier doors were observed.

8/17/17
5th Floor

1. At 10:18 a.m., the east leaf of the smoke barrier doors at the east entrance to Unit 5A, failed to close completely. At 10:19 a.m., the FD explained that the smoke seal was too tight.

2. At 10:49 a.m., the south leaf of the elevator lobby doors ( #11) was obstructed from self closing. The door sequencer stopped the door from closing the last one foot, but failed to release the door to close once the opposite leaf had fully closed. At 10:50 a.m., the FD confirmed, that the door sequencer was obstructing the door closing.

Based on observation, the facility failed to maintain the electrical wiring and connections. This was evidenced by a missing electrical outlet cover plate. This affected one of six floors, and could result in electrical shock, or the ignition of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of section 9.1

9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.

Findings:

During a tour of the facility with the LSO, the electrical wiring and connections were observed.

On 8/17/17 at 9:30 a.m., Room 6B114 was observed with exposed wiring in an electrical outlet junction box in the ceiling, that was missing a cover plate.

Based on observation, interview, and record review, the facility failed to ensure their main and feeder circuit breakers and the Automatic Transfer Switches (ATS) were inspected or serviced annually. This was evidenced by incomplete records of annual inspections and services. This could result in a loss of electrical power affecting six of six floors.

NFPA 99, Health Care Facilities, 2012 Edition
6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

6.5.4.1.1.2 Inspection and Testing. Generator sets shall be inspected and tested in accordance with 6.4.4.1.1.3.
6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems,Chapter 8.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition
8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.

8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer

8.3.5* Transfer switches shall be subjected to a maintenance and testing program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.3.6 Paralleling gear shall be subject to an inspection, testing, and maintenance program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

Finding:

During the facility tour, record review, and interview with the ES, the records for testing and inspecting the emergency and normal power feeders, main breakers, and the automatic transfer switches were requested.

8/17/17

1. At 2:10 p.m., there were incomplete records of annual service, inspections, and periodic testing of the automatic transfer switches, main and feeder circuit breakers. At 2:11 p.m., the ES explained that there were a total of 14 ATS along with the associated normal and emergency feeder breakers. He further explained that the inspection, testing, and servicing was a work in progress and the currently available records were attached as service tags on the equipment.

2. At 2:15 p.m. to 2:50 p.m., the service tags dates that were observed on the feeder breakers ranged from 8/8/05 to 4/20/16. The switchgear that was observed for Substation A and Substation B were both dated 4/15/15. There were no service tags observed on the ATS in the main electrical rooms.

Based on observation, and interview, the facility failed to maintain their electrical wiring and connections. This was evidenced by appliances plugged into surge protectors, by surge protectors plugged into surge protectors, and by unapproved use of extension cords as a substitute for the fixed wiring. This affected three of six floors, and could result in electrical shock and/or fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1.1 Utilities shall comply with the provisions of section 9.1
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
240.5 Protection of Flexible Cords, Flexible Cables, and Fixture Wires. Flexible cord and flexible cable, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either 240.5(A) or (B).
(A) Ampacities. Flexible cord and flexible cable shall be protected by an overcurrent device in accordance with their ampacity as specified in Table 400.5(A)(1) and Table 400.5(A)(2). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402.5. Supplementary overcurrent protection, as covered in 240.10, shall be permitted to be an acceptable means for providing this protection.
(B) Branch-Circuit Overcurrent Device. Flexible cord shall be protected, where supplied by a branch circuit, in accordance with one of the methods described in 240.5(B)(1), (B)(3), or (B)(4). Fixture wire shall be protected, where supplied by a branch circuit, in accordance with 240.5(B)(2).

400.8 Uses Not Permitted. Unless specifically permitted in 400.7 in, flexible cords and cables shall not be used for the following:
(1)As a substitute for the fixed wiring of a structure
(2)Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3)Where run through doorways, windows, or similar openings
(4)Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B).
(5)Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6)Where installed in raceways, except as otherwise permitted in this Code
(7)Where subject to physical damage

400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals.
Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable.
Informational Note: Some methods of preventing pull on a cord from being transmitted to joints or terminals are knotting the cord, winding with tape, and fittings designed for the purpose.

NFPA 99, Healthcare Facilities Code, 2012 Edition
10.2.3.5 Cord Strain Relief.
10.2.3.5.1 Cord strain relief shall be provided at the attachment of the power cord to the appliance so that mechanical stress, either pull, twist, or bend, is not transmitted to internal connections.
10.2.3.5.2 A strain relief molded onto the cord shall be bonded to the jacket and shall be of compatible material.

Finding:

During the facility tour, and interview with the Facility Director (FD), the electrical devices and wiring connections were observed.

8/15/17
2nd Floor

1. At 11:10 p.m., there was a coffee pot plugged into a 3-way extension cord, which was plugged into a wall outlet in the break room for the Hospital Administration.

2. At 1:15 p.m., at the Secretary's desk for the Chief Medical Office, there was desktop equipment plugged into a surge protector which was plugged into a second surge protector and then into the wall outlet. At 1:16 p.m., the FD confirmed, that there was no outlet within reach of the first surge protected extension cord.

3. At 2:27 p.m., in the Nursing Administration break room, there was a micro-wave oven, a refrigerator, and a freezer plugged into a surge protector, which was plugged into a wall outlet.

4. At 2:28 p.m., there was a toaster oven plugged into a surge protector, which was plugged into a wall outlet in the Nursing Administration Break Room.

5. At 2:33 p.m., in 2C197, there was a refrigerator plugged into a surge protector, which was plugged into a second surge protector, and then into the wall outlet.

6. At 2:38 p.m., in the Department of Medical Administration room #2B182, there was a coffee maker plugged into a surge protector, which was plugged into a wall outlet.

8/17/17
5th Floor

7. At 9:40 a.m., in the Intermediate Care Unit Fellows Room #5B108, there was refrigerator plugged into a surge protector, which was plugged into a wall outlet.

8. At 9:53 a.m., in the Supervisors Office room #5C107, there was refrigerator plugged into a surge protector, which was plugged into a wall outlet.

3rd Floor

9. At 11:45 a.m., in Operating Room #5, there was a surge protector and power cords draped across a laminar flow filter wall in the shape of a smile. The electrical wall outlet, and the flexible cord connections for patient care equipment, and the surge protector were both under tension. At 11:46 p.m., the FD acknowledged that the connections were under tension in their current configuration.

10. At 12:05 p.m., in the Nurse's Lounge room #3A107, there a was a coffee maker plugged into a surge protector ,which was plugged into a wall outlet.


32973

8/17/17
2nd Floor

11. At 2:55 p.m., the electrical equipment in the Out-Patient Pharmacy, was observed. A red colored extension cord was tacked to the North Wall by the computer stations, traveling over and around a door. The extension cord was used to power a multi-outlet power strip, that had multiple electronic devices plugged into it. Upon interview, the LSO confirmed the finding.

Based on observation, and interview, the facility failed to maintain their oxygen cylinder storage. This was evidenced by incomplete precautionary signage on an indoor oxygen storage enclosure with greater than 300 cubic feet of cylinder storage, and by an outdoor nitrous oxide storage enclosure with greater than 3000 cubic feet of cylinder storage. This was also evidenced by an electrical outlet, and light switch that were located less than 60 inches from the floor in the indoor oxygen enclosure. This affected one of six floors, and could result in in fire.

NFPA 99, Health Care Facilities, 2012 Edition
11.3 Cylinder and Container Storage Requirements.
11.3.2* Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3.
11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
11.3.2.2 Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1.2 hour

11.3.2.7 Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 6.1 m (20 ft) of outside storage locations.

11.3.4 Signs.
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft.), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION:
OXIDIZING GAS (ES) STORED WITHIN
NO SMOKING

11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall not be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb.) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes or heat ducting

Findings:

During the facility tour, and interview with the FD, the oxygen storage locations were observed.

8/17/17
3rd Floor

1. At 10:42 p.m., there was more than 300 cubic feet of oxygen storage inside the Gas Cylinder Storage Room #3B116. The electrical devices and connections were not located at least 60 inches above the floor. The light switch was less than 48 inches, and the electrical wall outlet, was less than 24 inches off of the floor.

2. At 4:08 p.m., there was a sign posted on the corridor door to Room #3B116 that did not include the complete statement:
CAUTION:
OXIDIZING GAS (ES) STORED WITHIN
NO SMOKING
8/18/17
Facility Grounds

3. At 10:32 a.m., there was exterior fenced storage area of more than 3000 cubic feet of oxidizing gas in addition to a manifold type supply of nitrous oxide located in a non-combustible enclosure next to the bulk oxygen storage area. The separate fenced area and enclosure were not labeled on all accessible sides with the following statement:

CAUTION:
OXIDIZING GAS (ES) STORED WITHIN
NO SMOKING