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Based on observation, not all interior partitions are constructed of non-combustible or limited combustible materials as required. This deficient practice could affect patients, staff, and visitors in the immediate area by permitting smoke and fire to move through the smoke compartment housing them if non-combustible partitions are not provided.

Findings include:

On 09/19/18 at 3:07 PM, while accompanied by the MEHS, observation determined that the 14th Floor interior non-load bearing partition located at the northwest corner of the Nurses' Station (immediately east of the Electrical Closets) is not constructed of non-combustible materials, as required by 19.1.6.4, because it consists of wood studs supporting plywood.

Based on observation, not all egress paths are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress could be impeded under emergency conditions if they are not maintained.

Findings include:

A. On 09/19/18 at 9:35 AM while in the company of the MS, it was observed that the 1st Floor Corridor leading from the ED & Radiology suites to Stair #6 was being used for storage of 4 stretchers, wheel chairs and equipment within the width of the corridor in non-compliance with 19.2.1, 7.1.10, 19.3.2.1 & 19.3.6.1.

B. On 09/18/18 at 2:35 PM while in the company of the MS, it was observed that the Lower Level ED Storage Room had exit signage at designated locations to identify aisles for exit access but the paths were obstructed by stored beds, equipment and supplies to prevent their use in non-compliance with 19.2.1 & 7.1.10.


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C. On 09/19/18 at 9:55 AM, while accompanied by the MEHS, observation determined that equipment was being stored in the 10th Floor Pediatrics Unit Corridor as prohibited by 7.1.10.2.1.

Based on observation, not all egress doors are installed and maintained as required. This deficient practice could affect patients, staff, and visitors using the egress paths because their egress under emergency conditions could be impeded if they are not properly installed and maintained.

Findings include:

A. While in the company of the MS it was observed that doors equipped with magnetic locking devices are not fully compliant with 7.2.1.6.1 Delayed-Egress or 7.2.1.6.2 Access-Controlled Egress Doors to comply with 19.2.2.2.4.

Locations observed:

1. On 09/18/18 at 2:15 PM it was observed that the Lower Level Kitchen cooler doors are provided with Access-Controlled Egress Door magnetic locking devices. The south door sensor was not functioning to deactivate the magnet when approached to comply with 7.2.1.6.2(1).

2. On 09/18/18 at 3:15 PM it was observed that the 1st Floor Medical Staff Lounge corridor door is provided with Access-Controlled Egress magnetic locking device which lacks the sensor to comply with 7.2.1.6.2(1). Only a manual wall button is provided.

3. On 09/19/18 at 9:05 AM it was observed that the 1st Floor cross corridor doors (at one set of the 4-hour barrier vestibule) located between the Emergency Dept. Lobby and the corridor serving the Dialysis Unit had Delayed-Egress magnetic locks installed but lacked the signage to identify their function as required by 7.2.1.6.1.1(4).

4. On 09/19/18 at 9:20 AM it was observed that the 1st Floor double egress doors provided at the Emergency Dept. lobby entrance to the ED suite (which is a marked exit route only from the ED suite side) are provided with magnetic locking devices. Based upon staff interview the locking system is employed during the over-night period and is provided with card reader release only. The locking system lacks a manual switch in compliance with 7.2.1.6.2(3) to comply as an Access-Controlled Egress system or the locking system lacks signage to comply with 7.2.1.6.1.1(4) to comply as a Delayed-Egress system. The system was not otherwise indicated to meet all provisions to comply with 19.2.2.2.5.2.

5. On 09/19/18 at 9:30 AM it was observed at the 1st Floor cross corridor double egress doors near 111.1, that are marked as an exit access, are equipped with a Delayed-Egress locking system but lack the signage to comply with 7.2.1.6.1.1(4).

6. On 09/19/18 at 9:45 AM it was observed that the 1st Floor double egress doors marked as an exit route between the Radiology Dept. and the ED corridor leading to Stair #6 have magnetic locks which lack Delayed-Egress locking system & signage to comply with 7.2.1.6.1.1. The system was not otherwise indicated to have all provisions to comply with 19.2.2.2.5.2.


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B. On 09/19/18 at 10:13 AM while accompanied by the MEHS, observation determined that the 10th Floor south cross-corridor door (north leaf) to the Pediatrics Unit did not release within 15 seconds after the application of force as required by 7.2.1.6.1.1(3).
C. On 09/19/18 at 10:15 AM while accompanied by the MEHS, observation determined that the 10th Floor west door (east leaf) to the Pediatrics Unit was observed to lack a sign which reads "PUSH UNTIL ALARM SOUNDS - DOOR CAN BE OPENED IN 15 SECONDS" required by 7.2.1.6.1.1(4).

Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained.

Findings include:

A. On 09/18/18 at 1:30 PM while in the company of the MS, it was observed at the exterior stair for the Lower Level discharge of the west stair lacked at least one handrail to comply with 7.2.2.4.1.6.

B. On 09/18/18 at 3:00 PM while in the company of the MS, it was observed that the Lower Level exit passageway from the Northwest Stair contained stored bicycles locked in racks in non-compliance with 7.2.6.1 and 7.1.3.2.3.


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C. On 09/18/18 at 1:04 PM, while accompanied by the MEHS, observation determined that a light fixture, located a half flight above the 16th Floor in the South Exit Stair, was located lower than 6'-8" above the finished floor as prohibited by 7.1.5.3.

D. On 09/19/18 at 1:50 PM, while accompanied by the MEHS, the 4th Floor Mezzanine fire rated door to the South Exit Stair was observed to be held open by an unapproved device (an elevator sheave) as prohibited by 19.3.1.7, 8.3.3.3, and NFPA 80-2010 6.4.1.1.

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 include:

A. On 09/19/2018 at 1:15PM while accompanied by the RDSS, ACE, RSTM, the North Wing Exit Stair does not comply with 19.2.2.3, 7.2.2.4.5.3. The distance between guardrails in exit stair enclosures was observed to be in excess of 4".

B. On 09/19/2018 at 3:15PM while accompanied by the RDSS, 1st Floor, the Pavilion's Day Surgery, East exit Stair continues more than one-half story below the level of exit discharge without a means to prevent travel past the level of exit discharge. This condition does not comply with 7.7.3.4.

Based on observation, fire barrier doors are not maintained to provide separation of building areas. Failure to provide required separations can contribute to the spread of fire & smoke beyond the compartment of fire origin and compromise the safety of building occupants in adjacent compartments.

Findings include:

On 09/19/2018 at 11:05AM while in the company of the RDSS, a horizontal exit designated on the facility's Life Safety floor plan does not comply due to the following: This wall contains a pair of cross corridor fire rated barrier doors, however, the wall does not contain a fire rating to comply with 7.2.4.3.1. Location observed: First Floor - Pavilion, Entry to the Day Surgery Suite.

Based on observation, not all egress paths lead to an exit. This deficient practice could require a person to traverse a longer route to reach an exit. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

Findings include:

On 09/19/2018 at 10:10AM while accompanied by the RDSS, the designated means of egress at one end of corridor #1158 is into the Day Surgery Recovery (indicated as a suite on the Life Safety drawings) which does not comply with 19.2.5.2 and 19.2.5.4 due to a dead end corridor condition of excessive length. Location observed: 1st Floor, Pavilion

Based on observation, not all corridors provide access to at least two remote exits without passing through intervening rooms. This deficient practice could affect patients, visitors, and staff in the building because they could be prevented from exiting the building under emergency conditions if the required number of exits are not provided.

Findings include:

On 09/19/18 at 1:45 PM while accompanied by the MEHS, observation determined that building occupants in the 5th Floor South Corridor must pass into a designated (Intensive Care Unit) suite in order to gain access to the South Exit Stair as prohibited by 19.2.5.4.

Based on observation, means of egress are not maintained with a minimal level of lighting under all conditions. Failure to maintain means of egress illuminated can prevent occupants from reaching an exit in the event of a fire/smoke emergency.

Findings include:

A. On 09/19/2018 at 9:30 AM while in the company of the RDSS and RSTM, Passage T2066 (designated on facility life safety floor plan) is not illuminated when both sets of cross corridor doors close. This does not comply with 19.2.8 and 7.8.2.1. Location observed: 2nd Floor, passage between passage #T2065 and #T2092 (O.R. Suite leading to Pavilion's Upper Lobby).

B. On 09/19/2018 at 9:00 AM while in the company of the RDSS and RSTM, it was noted that the East Exit Stair from 1st Floor Surgery is not illuminated. This does not comply with 19.2.8 and 7.8.2.1.

Based upon observation and record document review, it could not be confirmed that testing of the battery powered emergency lighting systems was completed and accurately documented. Failure to properly record maintenance activities can result in failure of the lighting systems due to lack of periodic inspection and maintenance.

Findings include:

On 09/20/18 at 9:00 AM while in the company of the MS & MEHS, it was observed during record document review that information was not being recorded as to the condition of the battery powered lighting systems as provided for on the forms. The forms provided for indicating the results of the testing, but no indication of the results was provided. Only the date of the inspections and the locations were known. Documentation could not confirm periodic testing of the battery powered emergency lighting systems to comply with 19.2.8, 19.2.9, 7.9.3.1.1(5).

Based on observation and record review, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained.

Findings include:

A. On 09/19/18 at 9:35 AM while in the company of the MS, it was observed that the 1st Floor Corridor from the ED & Radiology suites leading to Stair #6 was not provided with an exit sign at the Stair entrance door. Only a "Stair" sign was provided which does not comply with 19.2.10 and 7.10.


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B. On 09/18/18 at 1:46 PM while accompanied by the MEHS, observation determined that the 16th Floor cross-corridor doors adjacent to the Staff Elevators, above which an exit sign was observed, were equipped with signage which read "NO ENTRY;' thus confusing egress in a manner prohibited by 7.10.1.1.

C. On 09/18/18 at 3:04 PM while accompanied by the MEHS, observation determined that the east side of an egress door, in the "angled" wall at the center of the North Corridor, lacked an egress sign required by 7.10.1.1.

D. On 09/19/18 at 1:54 PM while accompanied by the MEHS, observation determined that the 4th Floor Mechanical Room lacks exit signage which directs occupants toward either the North Exit Stair or the South Exit Stair, as required by 7.10.1.1, because the exit signs above the doors to those Exit Stairs are not visible from the remainder of the building story.

Based on observation, not all vertical openings in the building are protected as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass between building stories if vertical openings are not protected.

Findings include:

On 09/19/18, while accompanied by the MEHS, observation determined that non-fire rated medical gas zone valve boxes had been installed in the 2 hour fire rated enclosure walls for Ventilation Shafts, which breach the fire rating for those shafts in a manner prohibited by 19.3.1.1, 8.6.5(1), and 8.3.4.1.

Locations observed:

1. 9:25 AM, 11th Floor Ventilation Shaft immediately west of the North Exit Stair (medical gas zone valve box located in the west wall of the Shaft).

2. 10:03 AM, 10th Floor Ventilation Shaft immediately west of the North Exit Stair (medical gas zone valve box located in the west wall of the Shaft).

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:

A. On 09/19/18 at 9:25 AM accompanied by the ACE, while touring the 1964 North Addition, the facility failed to provide fire protection devices (fire dampers) for the through the floor Class 1 duct (4 inch flex) penetrations supplying ventilation air to the under window room induction units on floors 2 through 5, as required by NFPA 90A, 2012, 5.3.2.1.


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B. On 09/19/2018 at 10:50am while in the company of the RDSS and the ACE, a multi-story shaft is open to the ceiling cavity of the 4th floor. The shaft is not enclosed in fire rated construction to comply with 19.3.1.1, and/or NFPA 90A. Location observed: 4th floor shaft wall adjacent to corridor, shaft is adjacent to the North wing nurse station and elevator. The shaft wall above the ceiling on the corridor side is incomplete.

Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the remainder of the building if the hazardous areas are not protected as required.

Findings include:

On 09/19/18 while accompanied by the MEHS, observation determined that hazardous areas exist at which the doors in the enclosure walls are not self-closing as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80-2010 6.4.1.1.

Locations observed:

1. 10:00 AM, 10th Floor Supply Room 1042.

2. 10:02 AM, 10th Floor Utility Room 1040.

Based on observation, not all portions of the building's fire alarm system are installed as required. This deficient practice could affect patients, staff, and visitors in the building because they could be unaware of a fire condition if the fire alarm system is not properly installed.

Findings include:

A. On 09/18/18 at 3:00 PM while in the company of the MS, it was observed that the Lower Level exit passageway serving the Northwest Stair lacked a manual pull station within 5' of the exterior exit door to comply with NFPA 72-2010, 17.14.6.


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B. On 09/19/18 at 9:28 AM while accompanied by the MEHS, observation determined that the smoke detector in 11th Floor Supply Room 1153 is located so that airflow from an adjacent supply air diffuser could prevent its operation as prohibited by NFPA 72-2010 17.7.4.1.

Based on observation, not all portions of the building's fire alarm system are installed and maintained as required. This deficient practice could affect patients, staff, or visitors in the building because the fire alarm system could fail to activate under emergency conditions if the components are not properly installed and maintained.

Findings include:

A. On 09/19/2018 at 10:20AM while accompanied by the RDSS and ACE and RSTM, a fire alarm manual pull stations was not provided within 5' of a designated exit which does not comply with NFPA 72-2010, 17.14.6. Location observed: 1st floor Pavilion, designated horizontal exit from Day Surgery Waiting area leading to Day Surgery Recovery.

B. On 09/19/2018 at 9:25AM while accompanied by the RDSS and RSTM, visual notification devices were not provided to comply with NFPA 72-2010, 19.5.4.3. Location observed: 2nd Floor Patient Rehabilitation room.

Based on document review and interview, the facility failed to provide a properly functioning fire alarm system. This deficient practice could affect patients, staff and visitors if the fire alarm system failed to function properly during a fire event.

Findings include:

On 09/19/2018 between 2:00 PM - 3:00 PM while accompanied by the MEHS, document review of the fire alarm "Discrepancy Report" along with the "Proposed Solutions Report" does not indicate all items have been inspected or corrected. For example:
1. 148 duct detectors were tested and passed, no indication of failure. However, the document indicates that the total number of detectors is 150. There is no written indication that all detectors were tested.
2. 48 heat detectors were tested, however, the document indicates there are 55 heat detectors.
3. 24 batteries tested, report indicates 12 failed. These batteries are similar to a UPS system and are located in the FACP room on racks. The test was conducted in June 2018, the facility received the report September, 2018. Between this time the facility was unaware that 12 batteries on racks 4, 6, 3 and 5 did not function. This does not comply with NFPA 72-2010, 10.5.7.3.1.

Based on observation, not all use areas are separated from exit access corridors as required. These deficiencies could affect patients, staff, or visitors in the building because smoke or fire could pass from the use areas into the remainder of the building.

Findings include:

A. On 09/19/2018 at 10:30AM while accompanied by the RDSS and the RSTM, Waiting #15142 on the 1st Floor of the Pavilion is open to the 2nd Floor Elevator Lobby #2045. This same space includes a skylight which extends upward past the 2nd floor ceiling. This extended ceiling height lacks a smoke detector to comply with 19.3.6.1(2)(b).

B. On 09/19/2018 at 11:30AM while accompanied by the RDSS and the RSTM, Room # 1598H on the 1st Floor lacks a smoke detector to comply with 19.3.6.1.

C. On 09/18/2018 at 10:10AM while accompanied by the RDSS, the Resale Shop lacks a smoke detector to cover all rooms/areas to comply with 19.3.6.1. The Resale Shop is deemed a hazardous area due to the storage of combustible materials.

Based on observation, the facility failed to provide a complete automatic sprinkler system where installed. This deficient practice could affect patients, staff, and visitors in the building because the automatic sprinkler system may fail to extinguish a fire if it is not properly installed.

Findings include:

A. On 09/18/18 at 1:57 AM while in the company of the MS, it was observed at the Lower Level Soiled Linen room LL34 that ceiling tile was missing to contain the room relative to sprinkler activation to comply with NFPA 13-2010, 8.6.4. The room was open to the above ceiling space.


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B. On 09/18/18 at 1:06 PM while accompanied by the MEHS, observation determined that the 17th Floor Mezzanine Elevator Machine Rooms lack sprinkler heads, within 2 feet of existing heat detectors, as required by NFPA 13-2010 8.1.1(1) and NFPA 72-2010 21.4.2.

Based on observation the facility failed to install a complete building fire suppression system. This deficient practice could result in the delayed response and suppression during a fire event, which may affect patients, staff and visitors.

The finding is:
On 09/18/18 accompanied by the ACE, at the following times, it was observed that fire sprinkler protection for the facilities traction elevator machine rooms is not provided. NFPA 13, 2010, 8.1.1

1. 1:25 PM Elevators #1, #2, & #3

2. 2:55 PM Elevator #4

Based on observation, the facility failed to install and maintain automatic sprinkler protection in accordance with the code requirements. This deficient practice could impair activation of a sprinkler head and delay an emergency response.

Findings include:

A. On 09/18/2018 while accompanied by the RDSS, sprinkler head escutcheons were missing which does not comply with NFPA 25-2011 5.2.1.1.2(3).
Locations include: At 2:30 PM 4th Floor Storage room #4N02.

B. On 09/19/2018 at 1:45 PM while accompanied by the RDSS, a sprinkler head is covered with an accumulation of lint and dust which does not comply with NFPA 25-2011, 5.2.1.1.2(5).
Location observed: Bottom landing of designated exit stair at the East end of 1st Floor Surgery

Based on observation, not all spaces open to exit access corridors are protected in accordance with Code requirements. Failure to provide protective features can compromise the use of corridors during a fire condition.

Findings include:

Waiting areas open to the corridor were observed, while in the company of the MS, that lacked smoke detection or continuous supervision to comply with 19.3.6.1.

Locations observed:

A. On 09/19/18 at 9:00 AM, two benches were observed in the corridor near the entrance to the 1st Floor Dialysis Unit.

B. On 09/19/18 at 9:50 AM, chairs stationed in the alcove open to the 1st Floor Corridor near Radiology #4.

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.

Findings include:

On 9/19/2018 at 9:45AM while accompanied by the RDSS, suite entry corridor doors do not latch which does not comply with 19.3.6.3.
Location observed: 2nd Floor Pavillion pair of cross corridor doors at Passage #2092 leading into Elevator Lobby #2095.

Based on observation, the facility failed to install its ventilation system in the required manner. This deficient practice could affect patients, staff, and visitors in the hospital because smoke and fire could be permitted to move between building stories and fire compartments if the system is not properly installed.

Findings include:

On 09/19/18 while accompanied by the MEHS, observation determined that ducts penetrating ventilation shaft enclosures lack fire dampers required by 8.3.5.7, 9.2.1, and NFPA 90A-2012 5.3.4.6.

Locations observed:

A. 9:10 AM, 11th Floor: Ventilation Shaft across from Room 1111; 8 in. x 6 in. duct.
B. 9:58 AM, 10th Floor: Ventilation Shaft across from Room 1011; 8 in. x 6 in. duct.

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. On 09/19/2018 at 9:45AM while accompanied by the RDSS, the designated 2-hour fire rated wall separation contains a duct penetration without a fire damper. This condition does not comply with 8.3.5.7, 9.2.1.
Location observed: First Floor, Entrance door to the Radiology Suite adjacent to Stair S.



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B. On 09/19/2018 at 8:45AM accompanied by the RDSS, installed access doors located at a soffit, for inspection and maintenance of the shaft enclosed fire dampers, are of a size and location which does not allow access to the dampers. This inaccessible condition does not comply with NFPA 80-2010, 19.2.3.
Location observed: South Wing, 4th Floor, South end of corridor adjacent to Stair S.

Based on observation during the survey walk through, the facility failed to install required electrical disconnects. Failure to install a single means to disconnect as required could leave the elevator car without power for the services required. This deficient practice could affect patients, staff and visitors.

The finding is:
On 09/18/18 at 2:54 PM accompanied by the ACE, it was observed that a lockable disconnecting means is not provided for the car lights, receptacles and ventilation for Elevator #4. (NFPA 101, 2012, 19.5.3 / NFPA 70, 2011, 620.53)

Based upon observation and review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

Findings include:

While in the company of the MS, fire rated doors and corridor doors which serve as separation of hazardous areas were observed to lack fully functional hardware to provide proper separation to comply with 19.3.2.1, 8.4.3 and 19.3.6.3.

Locations observed:

A. On 09/18/18 at 1:35 PM the Lower Level NW Materials Management Room pair of corridor doors lack a functional flush bolt and coordinator to provide doors which fully close and latch.

B. On 09/18/18 at 1:40 PM the Lower Level West and SW Materials Management Room corridor doors did not close and latch. Room doors include two single doors and one pair of doors.

C. On 09/18/18 at 1:50 PM the Lower Level Incident Command Office Storage Room door was not self-closing due to stored material blocking the door open.

D. On 09/18/18 at 1:55 PM the Lower Level Clean Linen Storage Room corridor pair of doors did not self-close to a latched condition due to non-functional flush bolts.

E. On 09/18/18 at 2:10 PM the Lower Level Loading Dock corridor doors were observed to be propped open by materials & equipment, the coordinator was broke and the doors did not latch upon closure.

F. On 09/18/18 at 2:15 PM the Lower Level Kitchen Dry Storage Room door was observed not to be self-closing due to being held open by a non-approved hold-open device (chain from the adjacent storage rack) in non-compliance with 7.2.1.8.

G. On 09/18/18 at 2:20 PM the Lower Level Kitchen west door to the Corridor was observed to be held open by a non-approved hold-open device (wood wedge) in non-compliance with 7.2.1.8.

H. On 09/18/18 at 2:25 PM the Lower Level "Biohazard" Garbage Room corridor door was observed not to be self-closing to a latched condition.

I. On 09/18/18 at 2:30 PM the Lower Level single swing cross corridor 4-hour barrier doors near the Housekeeping Managers's Office was observed not to be self-closing to a latched condition.

J. On 09/19/18 at 8:50 AM the 1st Floor ICU suite 4-hour barrier corridor doors did not close to a latched condition.

K. On 09/19/18 at 8:55 AM the 1st Floor East & West cross corridor pairs of doors in the 4-hour barrier outside the entrance to Surgery were observed not to self-close to a latched condition.

L. On 09/19/18 at 10:10 AM the 1st Floor Entry Lobby Atrium west 4-hour barrier doors were observed not to self-close to a latched condition.

M. On 09/19/18 at 10:20 AM the 1st Floor Gift Shop Storage Room door was observed to be held open by a non-approved hold-open device (wood wedge) in non-compliance with 7.2.1.8.

N. On 09/19/18 at 10:30 AM the 1st Floor Surgical Core Area door to the Cysto OR was observed not to be capable of full self-closure due to an electrical cord obstructing the door jamb.

O. On 09/19/18 at 10:35 AM the 1st Floor Surgery Anesthesia Supply Room 181 (noted to be part of the Surgical Center Core) did not have a self-closing (suite corridor) door to provide separation of the designated hazardous area due to a manual hold-open device not in compliance with 7.2.1.8.

P. On 09/19/18 at 10:55 AM the 1st Floor OR #3 used as a storage room is considered to be part of the Center Core hazardous area but the (suite corridor) door is not self-closing to fully closed condition.

Q. On 09/19/18 at 10:00 AM the 1st Floor Dialysis Unit rooms 123, 125, & 126 are used for storage and lack self-closing doors to comply as properly separated hazardous areas.

R. On 09/19/18 at 10:05 AM the 1st Floor old Radiology Rooms #1 & 138E are used for storage and lack self-closing doors to comply as properly separated hazardous areas..

S. On 09/19/18 at 1:40 PM while in the company of the RSTM it was observed that the 3rd Floor West Meeting Room defined exit exterior door did not operate within the required forces to comply with 7.2.1.4.5.1.

T. On 09/19/18 at 1:50 PM while in the company of the RSTM it was observed that the 3rd Floor Northeast Administration Suite A/V Tech Room 304E, deemed to be a hazardous area storage/repair shop function, was observed to have self-closing door but was provided with a non-approved hold-open feature not in compliance with 7.2.1.8.

Based on observation, the facility failed to install and maintain its piped-in medical gas system in the manner required. This deficient practice could affect patients, staff, and visitors in the building because the medical gas piping system could fail to operate when needed if not properly installed and maintained.

Findings include:

On 09/19/2018 at 9:17 AM while accompanied by the RDSS, medical gas piping located above the finished ceilings of patient rooms are not labeled to comply with NFPA 99, 2012 5.1.11.1.2(2). Example locations: 1st Floor Pavilion, Patient Recovery Room #15161 and #15166 within the Day Surgery suite.

Based on observation, not all basic electrical components are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical system could fail to operate properly when needed if the electrical components are not properly installed and maintained.

Findings include:

On 09/19/18 at 1:52 PM while accompanied by the MEHS, observation determined that the egress door from the 4th Floor Mezzanine Automatic Transfer Switch Room gear rooms lacks panic hardware required by NFPA 70-2011 450.43(C).

Based upon observation, not all emergency power system receptacles are identified in the same consistent manner and accurately labeled. Failure to utilize a consistent means of identification to distinguish the emergency system from the normal system can cause confusion when needing to locate operational electrical supply during failure of the normal power supply.

Findings include:

A. On 09/19/18 at 8:30 AM while in the company of the MS, it was observed in the 1st Floor PACU that not all emergency power receptacles used the same method of red color to identify those receptacles served from the essential electrical system to comply with NFPA 99-2012, 6.4.2.2.6.2. The open bays appeared to use an ivory receptacle with a glow light and the other individually separated bays used red receptacles.

B. On 09/19/18 at 8:30 AM while in the company of the MS, it was observed in the 1st Floor PACU that not all emergency power receptacles were labeled to identify the panel & circuit from which they were fed to comply with NFPA 70-2011, 517-19A. The open bays had engraved cover plates, but the labeling convention could not be determined to identify and locate the panel and circuit from which the receptacle was fed. Example: "1-474".