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Based on surveyor observations, the facility failed to maintain smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

1. Observation on 11/16/2011 of the one-hour/smoke barrier wall located on the ground floor, adjacent to the exterior courtyard, revealed an approximate 6 " X 5 " penetration of the wall located above the double smoke compartment doors (above the ceiling tiles).

Based on surveyor observations, the facility failed to maintain smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

1. Observation on 11/16/2011 of the two-hour building separation/smoke barrier wall located on the ground floor entrance to the " Waiting Area " , revealed (4) 2 " diameter penetrations of the wall located above the double smoke compartment doors (above the ceiling tiles).

2. Observation on 11/16/2011 of the two-hour building separation/smoke barrier wall located on the ground floor entrance to the " Borda " building (in corridor outside of the PACU), revealed a 6 " diameter penetration of the wall located above the double smoke compartment doors (above the ceiling tiles).

Based on surveyor observations, the facility failed to maintain the smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

1. Observation on 11/16/2011 of the two-hour building separation/smoke barrier wall located on the ground floor entrance and the corridor to the " Waiting Area " (located in the Surgical Pavilion Building), revealed a 5 " diameter penetration of the wall located above the double smoke compartment doors (above the ceiling tiles) and a 12 " diameter penetration of the corridor wall (above the ceiling tiles).

Based on surveyor observations, the facility failed to maintain the smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

1. Observation on 11/16/2011 of the two-hour building separation/smoke barrier wall located on the ground floor entrance to the " Read " building (located in the corridor separating the " Read " building and the Sturges building), revealed a 4 " diameter penetration of the wall located above the double smoke compartment doors (above the ceiling tiles).

Based on surveyors ' observations, it was determined that the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 13 Section 5-5.6.

NFPA 101 Section 19.3.5.3 requires the provision of complete sprinkler coverage for all portions of the building.

1. Observation on 11/16/11 at 10:00AM, in the presence of the Director of Facilities Management Services, of the environmental services closet, located on the ground floor of the East Addition building, revealed no sprinkler protection.

Based on surveyors ' observations, it was determined that the facility has failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 13 Section 5-5.6.

NFPA 101 Section 19.3.5.3 requires the provision of complete sprinkler coverage for all portions of the building.

Findings are as follows:

1. Observation on 11/16/11 at 10:30AM, in the presence of the Director of Facilities Management Services, revealed the " 1969 " room / old radiology room (approximately 200 square feet) in the Borda building, lacked sprinkler protection.

Based on surveyor observations, the facility failed to maintain smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

1. Observation on 11/16/2011 of the one-hour/smoke barrier wall located on the ground floor, adjacent to the exterior courtyard, revealed an approximate 6 " X 5 " penetration of the wall located above the double smoke compartment doors (above the ceiling tiles).

Based on surveyor observations, the facility failed to maintain smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

1. Observation on 11/16/2011 of the two-hour building separation/smoke barrier wall located on the ground floor entrance to the " Waiting Area " , revealed (4) 2 " diameter penetrations of the wall located above the double smoke compartment doors (above the ceiling tiles).

2. Observation on 11/16/2011 of the two-hour building separation/smoke barrier wall located on the ground floor entrance to the " Borda " building (in corridor outside of the PACU), revealed a 6 " diameter penetration of the wall located above the double smoke compartment doors (above the ceiling tiles).

Based on surveyor observations, the facility failed to maintain the smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

1. Observation on 11/16/2011 of the two-hour building separation/smoke barrier wall located on the ground floor entrance and the corridor to the " Waiting Area " (located in the Surgical Pavilion Building), revealed a 5 " diameter penetration of the wall located above the double smoke compartment doors (above the ceiling tiles) and a 12 " diameter penetration of the corridor wall (above the ceiling tiles).

Based on surveyor observations, the facility failed to maintain the smoke barriers in accordance with NFPA 101 Section 8.3.

Findings are as follows:

1. Observation on 11/16/2011 of the two-hour building separation/smoke barrier wall located on the ground floor entrance to the " Read " building (located in the corridor separating the " Read " building and the Sturges building), revealed a 4 " diameter penetration of the wall located above the double smoke compartment doors (above the ceiling tiles).

Based on surveyors ' observations, it was determined that the facility failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 13 Section 5-5.6.

NFPA 101 Section 19.3.5.3 requires the provision of complete sprinkler coverage for all portions of the building.

1. Observation on 11/16/11 at 10:00AM, in the presence of the Director of Facilities Management Services, of the environmental services closet, located on the ground floor of the East Addition building, revealed no sprinkler protection.

Based on surveyors ' observations, it was determined that the facility has failed to provide protection throughout by an approved, supervised automatic sprinkler system in accordance with NFPA 13 Section 5-5.6.

NFPA 101 Section 19.3.5.3 requires the provision of complete sprinkler coverage for all portions of the building.

Findings are as follows:

1. Observation on 11/16/11 at 10:30AM, in the presence of the Director of Facilities Management Services, revealed the " 1969 " room / old radiology room (approximately 200 square feet) in the Borda building, lacked sprinkler protection.