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Based on observation, it was determined that the facility failed to maintain the minimum Construction Type for this building. This deficient practice could compromise the fire resistant rating of the structure and affect staff and visitors in within a means of egress.

The finding is:

On 01/22/19 at 1:20pm while accompanied by the BOM and VPF, unprotected bottom flange of a fire proofed steel beam was observed. Location observed 4th floor Mechanical room #4029 (life safety floor plan) does not comply with Table 19.1.6.1, 19.1.6.4 and 19.1.6.5.

Based upon observation, not all interior framing within the Type I building is noncombustible, limited-combustible or sheathed fire retardant material as required. Failure to maintain noncombustible, limited combustible or properly sheathed fire retardant treated wood framing can compromise the safety of occupants by contributing to a fire/smoke condition.

Findings include:

On 01/22/19 at 1:30pm while in the company of the FM & EHSM, it was observed at the 8th floor Audio/Visual shop that the room adjacent the elevator contained exposed wood stud construction not in compliance with 19.1.6.4.

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

Findings include:

On 01/24/19 at 10:05am while in the company of the FM & PM, it was observed that the Pharmacy door G353H equipped with a magnetic locking device was not in full compliance with 7.2.1.6.2 Access-Controlled Egress Doors to comply with 19.2.2.2.4 because it lacked a manual release device to comply with 7.2.1.6.2(3).

Based upon observation, stairways are not maintained in accordance with Code requirements. Failure to maintain stairways can compromise the safety of occupants who must used the stairs as a means of egress during an emergency condition.

Findings include:

On 01/22/19 at 2:20pm while in the company of the FM & EHSM, it was observed that the Middle Stair which has a separation of 2' between the stair stringers lacks railing/guards that will restrict a 4" sphere to comply with 7.2.2.4.5.3.

Based on observation, not all exit stairs 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 exit stairs are not properly constructed and maintained.

Findings include:

On 01/23/19 at 10:42 AM while accompanied by the DFPO, observation determined that the First Floor landing of the North Exit Stair is used to store bicycles and other children's toys as prohibited by 7.1.3.2.3.

Based upon observation, exit stairs are not enclosed by fire rated construction in accordance with requirements. Failure to enclose exit stairs can compromise the safety of the exit to provide a protected path to the exterior of the building for any occupants who must use the exit.

Findings include:

A. On 01/23/2019 at 1:30pm while accompanied by VPF and BOM, incomplete stair enclosures were observed. This does not maintain the required fire resistance rating of the stair's enclosing walls to comply with 19.2.2.3, 7.1.3.2.2, 7.1.3.2.3

Locations observed:

1. Third floor, South Stair, two pipes penetrate the exit stair landing which do not serve the stair.

2. Second floor, Center Stair, fire rated soffit at landing does not provide fire rated separation due to:
i. Fire rated soffit contains a large hole.
ii. Fire rated soffit contains a recessed light fixture which compromises the soffit's fire rating.

3. First floor, South Stair, the adjacent shaft contains holes within the East wall of the shaft that penetrate into the exit stair enclosure. The holes are located at the top and bottom of a steel beam and adjacent to a corner pipe column.

4. First floor South Stair, an unprotected steel support beam was observed which is part of the stair enclosure. Location observed: mechanical shaft's East wall adjacent to the South Stair.

Based on observation, not all smoke/fire walls are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire emergency.

Findings include:

On 01/23/19 at 10:55am while accompanied by the BOM, on the fourth floor, two holes were observed above the pair of doors in the two hour fire rated horizontal exit wall not sealed for two hour fire rating. Sections 19.2.2.5 and 7.2.4.

Based upon observation, means of egress ramps are not maintained in accordance with Code requirements. Failure to maintain means of egress components can result in injury to users during use.

Findings include:

A. On 01/22/19 at 1:20pm while in the company of the FM & EHSM, it was observed that the ramp construction at the entry into the 7th floor Equipment room lacked the installation of the guard/handrail to comply with 7.2.5.4.

B. On 01/23/19 at 1:30pm while in the company of the FM & PM, it was observed that the ramp at the 1st floor which provides exiting for the Chapel into the Main House lacks at least one handrail to comply with 7.2.2.4.1.6.

C. On 01/23/19 at 3:00pm while in the company of the FM & PM, it was observed that the ramp at the 1st floor Kitchen discharging at the corridor leading to the Dining/Serving area lacks at least one handrail to comply with 7.2.2.4.1.6.

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:

A. On 01/23/19 while accompanied by the VPF and BOM, 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 (4)(a).

Location observed:

1. At 10:10am on the Second floor, exit access corridor serving the CT suite, contains 3 linen carts stored along the wall. The usable width of the corridor is reduced to less than 48".

2. At 11:30am on the Lower Level floor, Corridor #CL106 contained numerous crated and boxed equipment, including steris equipment which reduced the required width of the means of egress corridor to less than 48".

Based on observation, not all neccesary means of egress are maintained to meet corridor requirements. This deficient practice may compromise the prompt care and movement of patients, visitors and staff during a fire/smoke emergency.

The finding is:

On 01/23/19 at 2:30pm while accompanied by the BOM and the VPF a required second means of egress from one patient care non sleeping suite to the adjacent suite does not comply with 19.2.5.7.3.2 (c) for corridor separation requirements. A pair of doors within the separation wall do not comply with 19.3.6.3 for the requirements of corridor doors.

Location observed: First floor, pair of non latching doors from Patient Observation suite into Infusion Clinic.

Based on observation, not all exit discharge illumination is arranged to be either continuous in operation or capable of automatic operation without manual intervention. This could affect all occupants of the building during emergency situations.

Findings include:

A. On 01/24/19 at 10:30 am, while accompanied by the BOM, an exterior exit discharge was not provided with a light fixture to comply with Sections 19.2.8 and 7.8. Locations observed: Ground floor level exterior discharge door from corridor adjacent to SPD.

B. On 01/24/19 at 10:45 am while accompanied by the BOM, an exterior gate leading to exterior steps is not provided with illumination to comply 7.8.1.1 and 7.8.1.3. Location observed: Ground level, West end of building, area of lower helipad.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all occupants within the areas of the facility, by preventing them from readily identifying the path to an available exit from the building in case of an emergency.

Findings include:

A. On 01/24/19 at 9:40am while accompanied by the BOM, on the lower level, directional exit signs were found missing at five locations in the southwest exit corridor (to Main House) leading to the exit stairs. Sections 19.2.10.1 and 7.10


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B. On 01/22/19 while in the company of the BOM and VPF, exit signage was observed to be partially obstructed or missing which provides for dead end corridor conditions, and further does not comply with 19.2.5.2, 7.5.1, 7.10.1.2.1 or 7.10.1.5.1. Example locations:

1. At 1:00 pm 5th floor Cardiac ICU corridor #C5002, view looking North to Milestone building.

2. At 1:10 pm 5th floor corridor#C5104 view to the South

3. At 1:45 pm 4th floor center compartment corridor near elevators.

4. At 2:15 pm 3rd floor corridor #C3008 view to the East

5. At 2:50 pm 1st floor corridor adjacent to Pulmonary Function

6. At 2:55 pm 1st floor corridor #C1105 adjacent to Conference room

C. On 01/24/19 at 11:15am while in the company of the BOM and VPF, the direction of exterior egress travel from the Center Stair discharge is not readily apparent in order to comply with 7.7.3.2 and 7.10.1.5.1. Location observed: Exterior West end of building from Stair.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all occupants within the areas of the facility, by preventing them from readily identifying the path to an available exit from the building in case of an emergency.

Findings include:

On 01/23/19 at 1:25pm while accompanied by the BOM on second floor, directional exit sign was found missing in the exit corridor C2-9214 and at the intersection of exit corridors C1-9410 and C1-9407. Sections 19.2.10.1 and 7.10.

Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. These deficiencies could affect all occupants within the areas of the facility, by preventing them from readily identifying the path to an available exit from the building in case of an emergency.

Findings include:

On 01/24/19 at 10:20am while accompanied by the BOM, directional exit signs were observed missing at all intersections in the Tunnel leading to the exit. Sections 19.2.10.1 and 7.10

Based on observation, exit signs are not provided to define access to at least two means of egress from a floor level to comply with Code requirements. Failure to define exits can prevent occupants from reaching an alternate exit when the primary exit access is compromised during an emergency event.

Findings include:

A. On 01/22/19 while in the company of the FM & EHSM, the following areas were observed missing visible exit signs to comply with 19.2.10.1 and 7.10.

1. At 12:15 on the 9th floor mezzanine, exit signage to identify the 2nd exit is not provided.

2. At 12:35 on the 8th floor, exit signage at the east end of the mechanical space is obstructed and not visible from a point at a distance remote from the exit access door.

Based on observation, exit signs are not provided to define access to at least two means of egress from a floor level to comply with Code requirements. Failure to define exits can prevent occupants from reaching an alternate exit when the primary exit access is compromised during an emergency event.

Findings include:

On 01/22/19 at 2:30pm while in the company of the FM & EHSM, it was observed that the 5th floor 3-Elevator Lobby was missing exit signage to identify a 2nd exit access to comply with 19.2.10.1 and 7.10.

Based on observation, 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 01/23/19 while accompanied by the DFPO, observation determined that Second Floor egress paths, from the center of the building (near the Open Stair) to the available Exit Stairs to the north of that point are not identified by exit signs as required by 7.10.1.1. Locations observed include:

1. 9:53 AM: Egress path towards the Northeast Exit Stair.

2. 9:55 AM: Egress path towards the Northwest Exit Stair.

Based upon observation, vertical ducts between floor levels without fire dampers are enclosed in rooms constructed to serve as shaft enclosures. Failure to maintain the rooms as enclosure for the protection of vertical openings can compromise the safety of occupants on adjacent floor levels during a fire/smoke emergency.

Findings include:

A. On 01/22/19 at 12:55pm while in the company of the FM & EHSM, it was observed that the 7th floor room 7401 was being utilized as a shaft enclosure where storage use within the shaft enclosure was observed. The use of the shaft for storage of snack carts and supplies, considered to be in storage, does not comply with NFPA 90A-2012, 5.3.4.5(7).

B. On 01/22/19 at 1:15pm while in the company of the FM & EHSM, it was observed that the 7th floor 'A' building room adjacent the Elevator shaft, being used for communication equipment, appeared to form a portion of a shaft enclosure. The door accessing this room was not labeled and self-closing to maintain the required enclosure to comply with 8.6.4 & 8.3.4.

Based on observation, hazardous areas are not protected in accordance with Code requirements. Failure to provide protection of areas with a higher degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area.

A. On 01/22/19 at 12:40pm while in the company of the FM & EHSM, it was observed that the Linen Storage room near West Stair B lacked a self-closing door to comply with 39.3.2.1, 8.7.1.2 & 8.4.3.5.

B. On 01/23/19 at 10:10am while in the company of the FM & PM, it was observed that the Janitor room 4522 containing two housekeeping carts, each equipped with trash capacity greater than 32 gal., were stationed in the room where the corridor door was not closed due to the positioning of the carts and a non-approved weight acting to hold the door open in noncompliance with 19.3.2.1, 8.7.1.2 & 8.4.3.5.

C. On 01/23/19 at 2:45pm while in the company of the FM & PM, it was observed that the Kitchen storage room 1492 was a designated Hazardous Area storing combustible materials & packaging and lacked a self-closing door to comply with 19.3.2.1, 8.7.1.2 & 8.4.3.5.

Based on observation, the facility failed to correctly install kitchen ventilation equipment. This deficient practice could result in the uncontrolled spread of fire and products of combustion during kitchen cooking operations, which may affect patients, staff and visitors.

The finding is:

On 01/22/19 at 2:27 p.m. in the company of the Milestone BOM, in the first floor kitchen 1485 and 1481, it was observed that the grease hood filter segments were damaged and separated allowing grease laden vapor to bypass the filters in noncompliance with 19.3.2.5 / NFPA 96, 2008, 6.2.3.3.

Based upon observation, interior finishes are not maintained in accordance with Code requirements. Failure to restrict interior finishes to those permitted can accelerate the spread of fire/smoke conditions and compromise occupant safety during a fire/smoke emergency.

Findings include:

On 01/22/19 at 12:45pm while in the company of the FM & EHSM, it was observed that the 7th floor Traction room 7412 located in a designated Business occupancy floor had 25% or greater of its wall & ceiling finish covered with pegboard which could not be confirmed to carry a flame spread rating of at least Class C to comply with 39.3.3.2.2.

Based on observation, the fire pull stations are not properly located. This could affect patients, staff and visitors of the areas served if the fire alarm system does not operate properly during a fire emergency.

The finding is:

A. On 01/23/19 at 2:50pm while in the company of VPF and BOM, manual pull stations are not located within 5 feet of the designated exit door to comply with 9.6.2.3 for the 2nd floor exit passageway between Center Stair #S2102 and Stair #S2101.
Locations observed:

1. West end of Corridor #C2107

2. South end of Corridor #C2101.

3. North end of Corridor #C2124

Based on observation, not all fire alarm control functions are installed 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 as required.

Findings include:

On 01/23/19 at 10:45 AM while accompanied by the DFPO, observation determined that the room housing the Fire Alarm Control Unit (located in the First Floor West Electrical Room), which is not continuously occupied, lacks a smoke detector required by NFPA 72 2010 10.15.

Based on observation, not all fire alarm control functions are installed 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 as required.

Findings include:

On 01/23/19 at 12:42 PM while accompanied by the FM, observation determined that the room housing the Fire Alarm Control Unit (located in the Basement Electrical Room), which is not continuously occupied, lacks a smoke detector required by NFPA 72 2010 10.15.

Based on observation, 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 01/23/19 at 10:08 AM while accompanied by the DFPO, observation determined that the location of the branch circuit disconnecting means for the Fire Alarm Control Unit (located in the building's First Floor Main Lobby) is not identified on it as required by NFPA 72 2010 10.6.5.2.1.

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.

Findings include:

A. On 01/22/19 at 12:10am while in the company of the FM & EHSM, it was observed at the 9th floor mezzanine that a duct wider than 4'-0" was not provided with sprinkler coverage under the duct to comply with NFPA 13-2010, 8.6.5.3.3.

B. On 01/23/19 at 11:10am while in the company of the FM & PM, it was observed at Electrical Closet 3434 that a penetration for a conduit was not sealed to provide an effective enclosing wall to separate the room from the adjacent above ceiling space to afford prompt sprinkler activation to comply with NFPA 13-2010, 4.1 & 3.3.6.


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C. On 1/24/19 at 10:10 a.m. in the company of the CRDFO, that sprinkler protection has not been provided beneath AHU 2300 relief air duct more than 4 feet in width in the HVAC Building. (NFPA 13, 2010, 8.6.5.3.3)

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 findings are:
A. On 01/22/19 at 12:25 p.m. in the company of BOM, sprinkler protection has not been provided under the stair landing in passage S2-9720 to Mechanical Room 7-9206 7th floor. (NFPA 13, 2010, 4.1)

B. On 01/23/19 at 10:10 a.m. in the company of the CRDFO, sprinkler protection has not been provided for the medical gas manifold room G-9000. (NFPA 13, 2010, 4.1)

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 during a fire/smoke event.

Findings include:

On 01/23/19 at 2:10pm while accompanied by the BOM, on first floor, observation determined that Sub waiting rooms 9408 and 9409A are open to the exit corridor C1-9407 are not installed with smoke detectors. Section 19.3.6.1 (2)(b).

Based upon observation, use areas are not separated from Corridors to comply with Code requirements. Failure to maintain Corridors as protected paths can compromise the safety of patients, staff & visitors who must use them as a means of egress or movement in the event of a fire condition.

Findings include:

On 01/23/19 at 11:20am while in the company of the FM & PM, it was observed at the 3rd floor bridge (functioning as a Corridor between the Main House and Gerlach), that 7 stretchers were being stored for Gerlach Surgery use. Stretcher storage in the corridor does not comply with 19.3.2.1 and 19.3.6.1.

Based on observation, not all exit access corridors are separated from use areas. This deficiency could affect any patients, staff, or visitors in the immediate area by permitting smoke to enter the egress corridor.

The finding is:

On 01/22/19 at 12:45 pm, while accompanied by the BOM and VPF, a telecommunication closet is open to the adjacent corridor above the finished ceiling. This does not comply with the 19.3.6.2.1 and 19.3.6.2.3 for a smoke tight barrier. Location observed: Fifth floor, Closet #5052 (life safety floor plan).

Based on observation, not all smoke/fire walls are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire emergency.

Findings include:

On 01/23/19 at 12:35pm while accompanied by the BOM, on the second floor, holes were observed in the two hour fire rated wall not sealed for two hour fire rating in the exit corridor between Waiting and Staff Break Room. Sections 19.3.2, 19.3.5.9 and 8.7.1.

Based on observation, not all smoke/fire walls are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire emergency.

Findings include:

On 1/22/19 at 2:15PM while accompanied by the CRDFO, it was observed that the third floor smoke barrier wall near the Elevator Lobby/Nursing Station was found open thru on both sides. Sections 19.3.2, 19.3.5.9 and 8.7.1.

Based upon observation and document review, smoke barriers are not maintained to provide required compartmentalization. Failure to provide accurate identification & construction of compliant compartmentalization can result in confusion of building occupants during a fire/smoke event.
Findings include:

A. On 01/22/19 at 2:25pm while in the company of the FM & EHSM, it was noted that the fire safety reference plans identified three separate smoke compartments on the 6th floor, but only two were observed to exist because a pair of cross corridor doors did not exist where indicated on the plans. Staff response to move occupants to the identified adjacent smoke compartment would not provide a degree of safety for occupants when the compartmentalization does not exist.

B. On 01/22/19 at 2:45pm while in the company of the FM & EHSM, it was noted that the smoke barrier cross corridor doors near room 5465 to comply with 19.3.7.8 did not remain closed after being manually released from their hold-open devices due to the air pressure relationship on each side of the door.

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.

The finding is:

A. On 01/23/19 accompanied by the VPF and BOM, installed access panels located at a duct for inspection and maintenance of fire dampers lack labeling to identify if the damper is abandoned or active. This condition does not comply with NFPA 80-2010, 19.2.3

Locations observed:

1. At 2:30pm Second floor Doctor's Reading room/Office #2039 (life safety floor plan).

2. At 10:15am Third floor Clean holding room, #3038A, (life safety floor plan) west wall above ceiling.

Based on document review, the facility failed to conduct periodic fire drills as required. This deficient practice could affect patients, staff, and visitors in the hospital because the hospital staff may not be properly prepared for a fire emergency if fire drills are not conducted properly.

Findings include:

A. On 01/22/19 at 12:58pm, while accompanied by the CRDFO, document review determined that Second Shift fire drills are not conducted under varying conditions, as required by 19.7.1.6, because the fire drills for the quarters listed below were all conducted at similar times. This condition was found as listed:

1. January 25, 2018: 3:48 PM.

2. April 26, 2018: 3:03 PM.

3. July 26, 2018: 3:21 PM.

4. December 13, 2018: 2:35 PM.

Based on document review, the facility failed to conduct periodic fire drills as required. This deficient practice could affect patients, staff, and visitors in the hospital because the hospital staff may not be properly prepared for a fire emergency if fire drills are not conducted properly.

Findings include:

On 01/22/19 at 12:56pm while accompanied by the CRDFO, document review determined that fire drills are not conducted under varying conditions, as required by 19.7.1.6, because the fire drills for the shifts and quarters listed below were all conducted at similar times. This condition was found as listed:

A. Second Shift:

1. January 25, 2018: 4:00 PM.

2. April 26, 2018: 2:45 PM.

3. July 26, 2018: 3:02 PM.

4. November 5, 2018: 4:53 PM.

B. Third Shift:

1. January 25, 2018: 4:24 AM.

2. April 26, 2018: 4:15 AM.

3. July 26, 2018: 4:04 AM.

4. October 30, 2018: 4:18 AM.

Based on document review, the facility failed to conduct periodic fire drills as required. This deficient practice could affect patients, staff, and visitors in the hospital because the hospital staff may not be properly prepared for a fire emergency if fire drills are not conducted properly.

Findings include:

On 01/22/19 at 12:56pm, while accompanied by the DFO, document review determined that fire drills are not conducted under varying conditions, as required by 19.7.1.6, because the fire drills for the shifts and quarters listed below were all conducted at similar times. This condition was found as listed:

A. Second Shift:

1. January 25, 2018: 4:00 PM.

2. April 26, 2018: 2:45 PM.

3. July 26, 2018: 3:02 PM.

4. November 5, 2018: 4:53 PM.

B. Third Shift:

1. January 25, 2018: 4:24 AM.

2. April 26, 2018: 4:15 AM.

3. July 26, 2018: 4:04 AM.

4. October 30, 2018: 4:18 AM.

Based on document review, the facility failed to conduct periodic fire drills as required. This deficient practice could affect patients, staff, and visitors in the hospital because the hospital staff may not be properly prepared for a fire emergency if fire drills are not conducted properly.

Findings include:

On 01/22/19 at 1:00pm, while accompanied by the CRDFO, document review determined that fire drills are not conducted under varying conditions, as required by 19.7.1.6, because the fire drills for the shifts and quarters listed below were all conducted at similar times. This condition was found as listed:

A. Second Shift:

1. January 25, 2018: 3:44 PM.

2. April 26, 2018: 2:34 PM.

3. July 26, 2018: 3:11 PM.

4. December 13, 2018: 3:20 PM.

B. Third Shift:

1. January 25, 2018: 4:10 AM.

2. April 26, 2018: 4:07 AM.

3. July 26, 2018: 4:11 AM.

4. November 29, 2018: 4:31 AM.

Based on document review, the facility failed to conduct periodic fire drills as required. This deficient practice could affect patients, staff, and visitors in the hospital because the hospital staff may not be properly prepared for a fire emergency if fire drills are not conducted properly.

Findings include:

On 01/22/19 at 1:02 PM while accompanied by the CRDFO, document review determined that fire drills are not conducted under varying conditions, as required by 19.7.1.6, because the fire drills for the shifts and quarters listed below were all conducted at similar times. This condition was found as listed:

A. Second Shift:

1. March 14, 2018: 4:02 PM.

2. June 28, 2018: 4:01 PM.

3. September 27, 2018: 3:04 PM.

4. December 19, 2018: 3:54 PM.

B. Third Shift:

1. January 25, 2018: 3:12 AM.

2. June 28, 2018: 4:31 AM.

3. September 27, 2018: 4:41 AM.

4. December 12, 2018: 4:04 AM.

Based on observation, not all electrical receptacles are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the rooms because electrical equipment required for their care may fail to operate under emergency conditions if the electrical receptacles are not properly installed and maintained.

The finding is:

On 01/23/19 at 11:15am while accompanied by the VPF and the BOM, observation determined that critical care patient beds lack electrical receptacles served by normal power to comply with NFPA 70 2011 517-19(A).

Location observed: Third floor Operating Room #4.

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. Failure to provide GFCI protection can result in electrical shock hazards to occupants.

Findings include:

On 01/22/19 at 1:00pm while in the company of the FM & EHSM, it was observed that receptacles within 6'-0" of sink fixtures were not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(6) at the 7th floor Conference room Kitchenette.

Based upon observation, oxygen storage rooms are not maintained in accordance with Code requirements. Failure to maintain oxygen storage in accordance with Code requirements can result in occupant exposure to hazardous conditions that contribute to a fire.

Findings include:

A. On 01/23/19 while in the company of the FM & PM, it was observed that typical oxygen tank storage rooms lacked identification/precautionary signage in accordance with NFPA 99-2012, 11.3.4. Example locations observed include the following:

1. At 10:00am at the 4th floor Tank Room 4240.

2. At 10:20am at 3rd floor Tank Room.