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Based on observation, means of egress doors are locked using noncompliant methods. Failure to install locking devices for means of egress doors in full compliance with all requirements can result in building occupants not being able to reach an area of safety or an exit during a fire/smoke event.

Findings include:

A. On 6/14/22 at 2:50pm while accompanied by the PM delayed egress doors were observed to be provided with an automatic reset after activation. This condition does not comply with 7.2.1.6.1 (3)(d) manual relocking requirements. Location observed: 6th floor Elevator Lobby #K600.

B. On 6/15/22 at 10:12am while accompanied by the PM delayed egress doors were observed as labeled for delayed egress, however, were deactivated. The same doors contain a maglock which is activated by a "hugs" system. The signage on the exit stair door reads "if light is flashing the patient protection system has locked the stair door. Do not push the opener or an alarm will sound". Surveyor saw no light, and questions if someone sets off the fire alarm will the door unlock and the "light" stop flashing? signage is misleading, the delayed egress signage does not comply with 7.2.1.6.1.1 for installation on a door which is deactivated.

C. On 6/15/22 at 2:10pm while in the company of the PM a delayed egress door was observed with labels "swipe card must be used to access NICU or alarm will sound", "Staff only beyond this point" and the 15 second delay egress sign was on the opposite door not the door with the 15 second delay. This installation does not comply with 7.2.1.6.1.1 and 7.10.1.2 and 19.2.2.2.

Based on observation vertical enclosures are not protected from other parts of the building. This deficient practice compromises the use of a stair as an exit and could affect all visitors, staff and patients when evacuating a floor or building during a fire smoke event.

The finding is:

On 06/16/2022 at 9:15am accompanied by the PM, Exit Stair #K 1 which serves Basement through 7th floor contains windows (full height of the stair) located approximately 1'-0" from the adjacent building wall. The adjacent exterior building wall contains a curtain wall system. The angle of exposure is less than 180 degrees therefore protection of either the stair or the adjacent wall is to comply with 7.2.2.5.2.1 and 7.2.2.5.2.2 for a minimum 10'-0".

Example location observed: First floor of Exit stair #K 1 (North stair)

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 6/15/2022 while accompanied by the PM means of egress 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.
Example Locations observed:

1. At 11:00am 4th floor, exit access corridors contained work stations on wheels, an upholstered chair, shelving units with 5 levels containing combustible materials all stored along both sides of the means of egress corridor leading to Stair K4.

2. At 12:59pm 3rd floor, Recovery suite, contained numerous shelving units containing linens and combustibles, work stations on wheels, bed side tables on both sides of the means of egress leading to the east end pair of doors.

3. At 1:25pm 3rd floor corridor leading to north exit stair #K3 contains two gurneys, and a chair impeding the means of egress to the exit stair.

4 At 2:20pm 2nd floor south end of corridor #K2COR-D contains a sculpture which impedes exiting from NICU suite #K250

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 and staff during a fire/smoke emergency.

The finding is:

On 06/15/22 at 10:23 AM while accompanied by FM, 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.

Example Locations observed: Sixth floor, exit access corridors contained carts, rolling storage, beds, and equipment stored along both sides of the means of egress corridor.

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 normal power supply. 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 6/16/2022 at 10:00am while in the company of the PM, through staff interview it was determined that exterior exit discharge lighting was not on the Life Safety branch of the emergency system and was not 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. Location observed: The discharge gate near the public sidewalk for the Healing Garden.

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 6/15/2022 at 1:27 PM while accompanied by EHS it was identified on the 2nd floor Operating Room 6 the emergency lighting wall pack did not illuminate when tested. This does not comply with NFPA 99, 6.3.2.2.11.1.

Based on observation, exit and directional exit signage are not provided to adequately identify means of egress from floors to an exit discharge. This deficiency could affect all patients, visitors and staff during emergency.

Findings include:

A. On 6/15/22 at 1:30pm while accompanied by the FM, Third floor, contains no directional exit signage installed at cross corridors.
B. On 6/15/22 at 2:10pm while accompanied by the FM, Second floor, contains no directional exit signage installed at cross corridors.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

The finding is:

On 6/14/22 while accompanied by the PM, means of egress were observed which lack designated access to remote exits due to the lack or incorrectly identified paths of egress which does not comply with 7.10 and 19.2.10.1.
Locations observed:

1. At 1:52pm a Fire Evacuation Sign adjacent to Public corridor #118 indicates the means of egress through a pair of cross corridor doors which lack an exit sign.

2. At 1:54pm a Public Corridor #464 indicates exiting through a pair of cross corridor doors due to the location of an exit sign, however, the Fire Evacuation Sign does not show this to be a designated means of egress.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily identifying the path to an available exit from the building.

The finding is:

On 6/15/22 while accompanied by the PM, corridors were observed in which exit signs are partially covered by ceiling construction are missing or misdirecting which does not comply with 7.10 and 19.2.10.1.
Location observed:

1. At 1:10pm First floor corridor leading toward the building south end toward Play Area.

2. At 11:25am Third floor corridor #K380 north end pair of doors lacks an exit sign

3. At 1:30pm third floor corridor #K3COR-B contains an exit sign which leads to a suite (19.2.5.4).

4. At 1:50pm 4th floor corridor adjacent to west end public elevator lobby exit sign does not appear to be lit.

5. At 10:15am 2nd floor north end of corridor #K2COR-F exit sign is mis located above a door which opens against egress.

Based on observation, not all designated fire separation between the floors is constructed and maintained as required. This deficient practice could affect all patients, staff and visitors if smoke/fire penetrates other floors are not properly constructed/maintained.

Findings include:

A. On 6/15/22 at 1:40pm while accompanied by the FM, conduits penetrating an electrical room on third floor to other floors are not protected for transfer smoke/fire.

B. On 6/15/22 at 3:15 pm while accompanied by the FM, conduits penetrating electrical room on first floor to floors above are not protected for transfer smoke/fire.

Based on observation, hazardous areas are not separated from the required means of egress. Failure to separate hazardous areas can expose occupants to fire conditions before evacuation may occur.

Findings include:

A. On 6/14/2022 at 1:45 PM while accompanied by EHS it was identified on the 6th floor Storage Closet 6818 was not sprinkler protected per 19.3.2.1.

B. On 6/14/2022 at 2:10 PM while accompanied by EHS it was identified on the 5th floor Environmental Storage Closet was not installed with a self-closing device per 19.3.2.1.3.

C. On 6/15/2022 at 9:30 AM while accompanied by EHS it was identified on the 5th floor Soiled Utility Room Door 5105 did not close and latch to the door frame. The door was caught on the door frame and prevented closing per 19.3.2.1.3.

D. On 6/15/2022 at 10:11 AM while accompanied by EHS it was identified on the 4th floor the Storage Room 4705 door did not latch to the door frame when tested per 19.3.2.1.3.

E. On 6/15/2022 at 10:18 AM while accompanied by EHS it was identified on the 5th floor, Storage Room 4707 that the lower portion of the west wall was damaged and missing. Interior wall insulation and metal studs were showing. This damage prevents the proper fire rating to be maintained per 19.3.2.1.

F. On 6/15/2022 at 12:35 PM while accompanied by EHS it was identified on the 2nd floor Environmental Storage Closet 2210, door was not installed with a self-closing device per 19.3.2.1.3.

G. On 6/15/2022 at 12:48 PM while accompanied by EHS it was identified on the 2nd Data Storage Room contained a 4-inch conduit through the fire rated wall that was not fire stopped.

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 6/15/22 while accompanied by the PM the medical gas shut off valve serving the 3rd floor Recovery #K333 is labeled for rooms on the 4th floor. This condition does not comply with NFPA 99, 2010, 5.1.4.8.7 and 5.1.4.8.7.2.

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:

A. On 06/15/22 at 9:49 AM in the company of the FM, the facility failed to provide the required K Fire Extinguisher in a convenient and accessible location in room 7-740 Cafeteria Kitchen. NFPA 96, 2011, 10.10

B. On 06/15/22 at 9:49 AM in the company of the FM, the facility failed to provide the required K Fire Extinguisher placard for the operation of the extinguisher in room 7-740 Cafeteria Kitchen. NFPA 10, 2010, 5.5.5.3

Based on observation, the fire alarm system is not installed in accordance with Code requirements. Failure to install the fire alarm system in accordance with Code requirements can result in delayed activation and notification of occupants of a fire/smoke condition present in the building.

The finding is:

A. On 06/15/2022 at 11:05am while accompanied by the MST it was observed that a fire alarm manual pull station was not installed at the first-floor South exit in Public Lobby 01205 to comply with NFPA 72-2010, 17.14.6.


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Based on observation smoke detectors are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation during an emergency. If devices do not function properly, then building occupants may not be alerted to an emergency in a timely manner.

The finding is:

B. Detectors were observed to be located where airflow may prevent normal operation of the device as written in NFPA 72-2012 17.7.4.1. Locations & conditions observed include the following:

1. On 06/15/22 at 10:06 AM, accompanied by the FM, a smoke detector was observed within 3"-0" of an HVAC diffuser. Location observed: Sixth floor corridor near room 6-448.

2. On 06/15/22 at 10:21 AM, accompanied by the FM, a smoke detector was observed within 3"-0" of an HVAC diffuser. Location observed: Sixth floor corridor near room 6-750.

3. On 06/15/22 at 10:25 AM, accompanied by the FM, a smoke detector was observed within 3"-0" of an HVAC diffuser. Location observed: Sixth floor corridor between rooms 6-816 and 6-850

Based on observation smoke detectors are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation during an emergency. If devices do not function properly, then building occupants may not be alerted to an emergency in a timely manner.

The finding is:

On 06/15/22 at 2:15 PM, accompanied by the FM, a smoke detector was observed within 3"-0" of an HVAC diffuser which may prevent normal operation of the device as written in NFPA 72-2012 17.7.4.1. . Location observed: First floor Trash Room 1408.

Based on observation and staff interview the facility lacks complete sprinkler protection. 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 6/14/22 at 2:00pm accompanied by the EDFO, it was observed and confirmed by the EDFO that the elevator machine rooms are not provided with fire sprinkler protection. This is not in compliance with NFPA 13, 2010, 8.1.


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B. On 6/15/2022 at 9:31am while accompanied by the MST it was observed that a sprinkler head was missing an escutcheon ring in the eleventh-floor Elevator Lobby. This installation does not comply with NFPA 13-2010, 6.2.7.2.

Based on observation during the building tour the facility lacks complete sprinkler protection. 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 6/14/22 at 10:45am accompanied by the EDFO, it was observed that the emergency generator installation is not provided with fire sprinkler protection. This is not in compliance with NFPA 13, 2010, 8.1.


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B. On 6/15/2022 at 10:46 AM while accompanied by EHS it was identified on the 3rd floor at the bridge connection to the Comer building above the ceiling a sprinkler head was identified within 2-inches of the ceiling tile. This installation does not comply with NFPA 13, 8.6.5.3.2.

C. On 6/15/2022 at 11:10 AM while accompanied by EHS it was identified on the 2nd floor Kitchen, Dishwashing area contained one sprinkler head that was missing an escutcheon ring. This does not comply with NFPA 13, 6.2.7.2.

D. On 6/15/2022 at 11:14 AM while accompanied by EHS it was identified on the 2nd floor Kitchen, walk-in freezer contained one sprinkler head that was missing a cove plate. This does not comply with NFPA 13, 6.2.7.2.

E. On 6/15/2022 at 11:16 AM while accompanied by EHS it was identified on the 2nd floor Kitchen, Walk-in cooler contained one sprinkler head that was missing a cove plate. This does not comply with NFPA 13, 6.2.7.2.

F. On 6/15/2022 at 2:04 PM while accompanied by EHS it was identified in the sub-basement Elevator Equipment room 0446B was not sprinkler protected.


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G. On 6/16/2022 at 10:15am while accompanied by the MST it was observed that there is no sprinkler protection provided in Voice Data 0018A on the lower level. The installation is not in compliance with NFPA 13-2010, 8.1.1(1).

H. On 6/16/2022 at 10:20am while accompanied by the MST it was observed that a sprinkler head was missing an escutcheon ring in Storage Room 0013 on the lower level. This installation does not comply with NFPA 13-2010, 6.2.7.2.

I. On 6/16/2022 at 10:29am while accompanied by the MST it was observed that a ceiling tile was missing in Laundry Room 0603 on the lower level. This condition can delay activation of a sprinkler head by allowing heat and products of combustive materials to bypass the sprinkler. This condition does not comply with NFPA 13-2010, 8.6.4.1.


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J. On 06/15/22 at 9:47 AM, accompanied by the FM, the surveyor observed a missing escutcheon ring on a sprinkler head in the MRI Control Room (Room 0128). This does not comply with NFPA 13, 2010 6.2.7.1.

K. On 06/15/22 at 2:14 PM, accompanied by the FM, it was observed that there is a gap at the suspended ceiling tile around water supply pipes in the first floor trash room (Room 1408.) This condition can delay activation of a sprinkler head by allowing heat and combustive materials to by pass the sprinkler. This condition does not comply with NFPA 13-2010, 8.6.4.1.

Based on observation the facility failed to install complete fire protection sprinkler coverage. Failure to install and maintain a complete fire protection system may affect patients, staff and visitors during a fire event.

The finding is:

On 6/14/22 at 2:51pm in the company of the PM a communication closet containing a j-box Notifier L3M25 on the 3rd floor near Passage #F3100 is not provided with fire sprinkler protection to comply with NFPA 13, 2010, 8.1.1 for a fully sprinklered building.

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.

The finding is:

On 6/15/22, at 2:34pm while accompanied by the PM, observation determined that materials are being stored less than 18 inches below standard pendant sprinkler heads which does not comply with NFPA 13 2010 8.5.6.1.
Location observed: 2nd floor Equipment Storage room #K221.

Based on observation the facility lacks complete sprinkler protection. 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.

The finding is:

On 06/15/22 at 1:21 PM , accompanied by the FM, sprinkler heads are not installed to comply with NFPA 13, 2010, 8.1. Location observed: First floor Elevator Machine Room (EL152M1).

Based on observation, the facility failed to conduct required maintenance and testing necessary to maintain the sprinkler system. This deficient practice could affect patients, staff and visitors, if a sprinkler system failed to function as designed due to the lack of required maintenance and testing.

Findings include:

A. On 6/14/2022 at 1:50 PM while accompanied by EHS it was identified on the 6th floor Environmental Storage Closet 6732A contained a sprinkler head that was corroded. This does not comply with NFPA 25 5.2.1.1.1.

B. On 6/15/2022 at 11:05 while accompanied by EHS it was identified on the 2nd floor kitchen, dishwashing area contained sprinkler heads that were corroded and will need to be replaced. This does not comply with NFPA 25 5.2.1.1.1.

C. On 6/15/2022 at 11:17 while accompanied by EHS it was identified on the 2nd floor kitchen, main kitchen area contained numerous sprinkler heads that were corroded and will need to be replaced. This does not comply with NFPA 25 5.2.1.1.1.

D. On 6/14/2022 at 2:30 PM while accompanied by EHS it was identified on the 4th floor that sprinkler head in room 4319 was dust and dirt covered and not in compliance per NFPA 25, 5.2.1.1.1.

E. On 6/14/2022 at 2:10 PM while accompanied by EHS it was identified on the 4th floor that numerous sprinkler heads throughout the 4th floor were dust and dirt covered. This created a pattern of noncompliance and did not comply with NFPA 25, 5.2.1.1.1.


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F. On 06/16/22 at10:30am while accompanied by the MST it was observed that the facility had failed to maintain the sprinkler heads free of foreign materials. Sprinkler heads in Laundry Room 0603 on the lower level were covered in an excessive amount of lint and corrosion. This condition does not comply with NFPA 25-2011, 5.2.1.1.1.


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G. On 06/15/22 at 2:12 PM, accompanied by the FM, an observation determined that the facility had failed to maintain the sprinkler heads free of foreign materials. Sprinkler heads were covered in an excessive amount of lint. This practice is was not per NFPA 25 2011 Edition, Section 5.2.1.1. Locations observed include the following:

1. 1402/1408 Corridor
2. 1500 Corridor
3. MRI Suite

Based on observation, the facility failed to conduct required maintenance and testing necessary to maintain the sprinkler system. This deficient practice could affect patients, staff and visitors, if a sprinkler system failed to function as designed due to the lack of required maintenance and testing.

The finding is:

On 06/15/22 at 9:47 AM, accompanied by the FM, an observation determined that the facility had failed to maintain the sprinkler heads free of foreign materials. Sprinkler heads were covered in an excessive amount of lint. This practice is was not per NFPA 101, 2012 Edition, Sections 9.7.1 and, NFPA 25 2011 Edition, Section 5.2.1. Location observed: Walk in cooler in kitchen area, Room 7-720.

Based on observation the facility failed to provide spaces which are open to the corridor as allowed by code. Having areas open to the corridor which do not meet the criteria will affect the means of egress for staff, visitors and patients during a smoke, fire event.

The finding is:

On 6/15/22 at 2:05pm while accompanied by the PM the surveyor observed a doctor's work room/lounge open to the corridor without staff supervision. During an interview with staff, it was determined that the space had been modified to prevent observation from the adjacent nurse station. The room/area contains shelving on all walls with numerous combustible materials. This space does not comply with 19.3.6.1 and 19.3.4.5.2 for detection in spaces open to the corridor. Location observed: 2nd floor room #K243

Based on observation, corridors are not maintained as smoke tight separations from other areas. Failure to separate areas can expose patients, visitors and staff before evacuation may occur.

The finding is:

While accompanied by FM, the space at the walls and deck was not smoke/fire stopped to resist the passage of fire/smoke to different areas from electrical rooms to other areas and corridors.

1. At 9:40am Sixth Floor

2. At 10:30 am, Fifth Floor

3. At 10:50 am, Fourth Floor

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 6/15/22 at 2:25pm while accompanied by the PM, pair of corridor doors did not self close to the latched position to comply with 19.3.6.3
Location observed : 2nd floor pair of doors from NICU suite #K250 to corridor.

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 6/14/2022 at 2:18 PM while accompanied by EHS it was identified on the 5th floor that door 5326-3 has a damaged hinge preventing the door to close and latch to the frame when tested per 19.3.6.3.

Based on observation the facility failed to provide adequate smoke/fire separation between adjacent compartments. By not restricting the movement of smoke/fire from one compartment to the adjacent compartment this condition could affect the visitors, staff and patients of two smoke compartments.

Findings include:

A. On 6/14/2022 at 2:15 PM while accompanied by EHS it was identified on the 5th floor, cross corridor double doors 5229-1 did not close to the frame when tested per 19.3.7.8.

B. On 6/15/2022 at 10:30 AM while accompanied by EHS it was identified on the 4th floor, cross corridor double doors adjacent to room 4110 south door leaf did not close to the frame when tested per 19.3.7.8.

C. On 6/15/2022 at 10:55 AM while accompanied by EHS it was identified on the 3rd floor, cross corridor double doors 3212-1 was installed with a 1'-0" door leaf that was not provided with a door closing device per 19.3.7.8.

Based on observation, the facility failed to provide a means within the ventilation duct system to properly convey products of combustion. Failure to install and maintain an exhaust system could result in the passage of combustibles from one fire compartment to another. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 6/15/22 at 2:50pm while accompanied by the PM a dryer vent pipe was observed connected to a nearby toilet room exhaust duct which then continued through to the corridor wall containing a damper. Further, the vertical riser installation did not appear to contain a means for cleanout. This dryer exhaust duct installation is not known to comply with U.L. 2158 Standard for Safety Electric Clothes Dryers with reference to section 504, 2012 edition of the International Mechanical Code and the manufacturer's requirements. This single residential style dryer serves a minimum of 7 Family Sleeping rooms. Location observed: 2nd floor Family Rooming in Area

Based on observation during the building tour the facility failed to install components for the elevator firefighter service and recall systems. Failure to install and maintain these systems could result in malfunction and response of the recall function. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 6/16/22 at 10:25am accompanied by the EDFO, it was observed in a penthouse elevator machine room that heat detectors are not installed within 2 feet of each sprinkler head for elevator shutdown. (NFPA 101, 2012, 19.5.3 / ANSI A17.1, 2007, 2.8.3.3.2 & NFPA 72, 2010, 21.4.2)


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B. On 6/16/22 at 10:28pm accompanied by the PM, it was observed in a elevator machine room that there were no ground fault protected electrical outlets to comply with NFPA 70 2011 620.85.

Based on observation during the building tour the facility failed to install components for the elevator firefighter service and recall systems. Failure to install and maintain these systems could result in malfunction and response of the recall function. This deficient practice could affect patients, staff and visitors during a fire event.

Findings include:

A. On 6/14/22 at 1:25pm accompanied by the PM, it was observed in a elevator machine room that heat detectors are installed however, there are no sprinkler heads for elevator shutdown. (NFPA 101, 2012, 19.5.3 / ANSI A17.1, 2007, 2.8.3.3.2 & NFPA 72, 2010, 21.4.2)

B. On 6/14/22 at 1:28pm accompanied by the PM, it was observed in a elevator machine room that there were no ground fault protected electrical outlets to comply with NFPA 70 2011 620.85.

Based on observation and staff interview during the building tour the facility lacks complete protection of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients, staff and visitors.

The finding is:

On 6/14/22 at 2:30pm accompanied by the EDFO, it could not be confirmed that electrical bonding of the buildings medical gas piping system has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B).

Based on observation and staff interview during the building tour the facility lacks complete protection of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients, staff and visitors.

The finding is:
On 6/16/22 at 10:30am accompanied by the EDFO, it could not be confirmed that electrical bonding of the building's medical gas piping system has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B).

Based on staff interview during the building tour the facility lacks complete protection of the medical gas piping system. Failure to install and maintain this installation could result in the piping system to become electrically energized. This deficient practice could affect patients, staff and visitors.

The finding is:

A. On 6/16/22 at 10:45am accompanied by the EDFO, it could not be confirmed that electrical bonding of the building's medical gas piping system has been completed. This is not in compliance with NFPA 70, 2011, 250.104 (B).


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Based on observation the piped medical gas system manifold room is not separated from other areas in the facility as required. This deficient practice can affect the safety of all patients, staff, and visitors.

Findings include:

B. On 6/16/2022 at 9:30am while accompanied by MST it was identified in Mechanical Room 0725 on the lower level that there are multiple penetrations along the west section of the north wall. This condition does not comply with NFPA 99-2012, 5.1.3.3.2(4).

C. On 6/16/2022 at 9:33am while accompanied by MST it was identified in Mechanical Room 0725 on the lower level that the door along the north wall was propped open by a box fan and the door lacks the proper fire rating. This condition does not comply with NFPA 99-2012, 5.1.3.3.2(4).

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

The finding is:

On 6/15/2022 at 9:31am while in the company of the MST it was observed that a cover plate was missing on an exposed electrical junction box in the eleventh-floor elevator equipment room. This condition does not comply with NFPA 70-2011, 314.28(C).

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

The finding is:

On 6/16/2022 at 9:32am while in the company of the MST it was observed that a cover plate was missing on an exposed electrical junction box in Mechanical Room 0725 on the lower level. This condition does not comply with NFPA 70-2011, 314.28(C).

Based on observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

The finding is:

On 06/15/22 at 2:21 PM, accompanied by the FM, it was observed on the first floor that a receptacle which is less than 6'-0" from a sink in Room 1529A is not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(5). Interview with FM was unable to confirm if the outlet is on a GFCI breaker or other means of protection.