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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:

On May 29, 2019 at 9:16 AM, while accompanied by the COO, observation determined that means of egress are not maintained continuously free of obstructions, as required by 7.1.10.2.1, because a water leak exists which is draining into Seventh Floor Corridor 7271, thus presenting a slipping hazard in the egress path.

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 May 29, 2019 at 9:30 AM, while accompanied by the COO, observation determined that pipe or other penetrations through the fire rated floor assembly at the pipe chase adjacent to Seventh Floor Storage Room 761 are not sealed against the passage of fire as required by 8.3.5.1.

Based on document review, the facility failed to inspect, test, and maintain its fire alarm system. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate under emergency conditions if the fire alarm system is not properly maintained.

Findings include:

A. On May 29, 2019, while accompanied by the COO, record review determined that supervisory signals, required to be tested by NFPA 72 2010 Table 14.3.1.9(i), were not repaired when found, based on a fire alarm service vendor report dated March 29, 2019, to be not functioning properly. The report notes that 28 such devices failed that periodic test and that 1 device was not tested.

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:

On May 29, 2019, while accompanied by the COO, observation determined that rooms exist in which ceiling tiles are out of place or missing, thus compromising the coverage of the room by standard pendant or upright spray sprinkler heads, as prohibited by NFPA 13 2010 8.6.4.1.1, because the activation of the sprinkler heads could be delayed due to heat rising past them. Locations observed include:

A. 9:34 AM: Seventh Floor Storage Room 745.

B. 9:37 AM: Seventh Floor Storage Room 7181.

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 May 29, 2019 at 9:14 AM, while accompanied by the COO, observation determined that medical gas manifold rooms lack a minimum 1 hour fire rating, required by NFPA 99 2012 5.1.3.3.2(4), because the west wall of the room does not extend to the underside of the deck above.

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:

A. On May 29, 2019 at 9:28 AM, while accompanied by the COO, observation determined that an electrical junction box (former wall clock location), in Seventh Floor Paging Room 759, lacks a cover plate required by NFPA 70 2011 314-28(C).

B. On May 29, 2019 at 9:28 AM, while accompanied by the COO, observation determined that a series of electrical panels, located in Seventh Floor Corridor 7271, exist at which the fuses have been removed, thus compromising the protection of conductors downstream in a manner required by NFPA 70 2011 240.4.