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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 July 18, 2018 at 10:14 AM, while accompanied by the DOF, observation determined that the door to the Basement Medical Records Room is not self-closing as required by 19.3.2.1.3, Table 8.3.4.2, and NFPA 80 2010 6.4.1.1.

Based on observation during the survey walk-through, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate if its controls are not installed and do not function as required.

Findings include:

On July 17, 2018 at 1:37 PM, while accompanied by the DOF, observation determined that the First Floor Housekeeping Closet, which houses a fire alarm system NAC Panel and which is not continuously occupied, lacks a smoke detector required by NFPA 72 2010 10.15.

Based on observation, not all electrical receptacles are installed as required. This deficient practice could affect patients, staff, and visitors in the building because electrical power may not be available for use when required if they are not installed properly.

Findings include:

On July 17, 2018 at 11:44 AM, while accompanied by the DOF, observation determined that general care patient beds exist at which at least 1 branch circuit is not served by the Critical Branch of the hospital's Type 1 Essential Electrical System (EES) as required by NFPA 70 2011 517.18(A). Locations observed include all Patient Sleeping Rooms on the Second Floor, with the Exception of the former Hospice Room now used as a general care Patient Sleeping Room.