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Based on observation and interview, the facility did not provide a common separation wall with sealed wall penetrations. This deficiency occurred in 2 of the 21 smoke compartments, and had the potential to affect 16 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/30/2012 at 9:24 am surveyor #28616 & 30964 observed in the ED smoke compartment on the 1st floor in the corridor, that penetration(s) were not sealed according to an approved method. The deficiency included a 12" x 12" hole and a 4" diameter pipe with no fire resistive material at the penetration. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/30/2012 at 11:17 am surveyor #28616 & 30964 observed in the Birthing Center smoke compartment on the 3rd floor in the corridor, that penetration(s) were not sealed according to an approved method. The deficiency included a 2" x 12" and a 2" x 6" hole in the concrete masonry wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes with rated wall finishes. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 16 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/30/2012 at 10:24 am surveyor #28616 & 30964 observed in the Med Surg 2 smoke compartment on the 2nd floor in the electrical/communication closet, that the facility could not confirm the wall had an appropriate rating. The room wall was finished with plywood wall panels that were not represented as being fire resistive rated. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling (in a sprinkled smoke zone), and sealed wall penetrations. This deficiency occurred in 3 of the 21 smoke compartments, and had the potential to affect 8 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/29/2012 at 1:10 pm surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the corridor at room #1235, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 1/2" flexible conduit penetration without a fire resistive seal. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/30/2012 at 11:27 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the janitor closet room #324, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 12" x 12" hole. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

3. On 5/30/2012 at 11:29 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the corridor at room #322, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included (5) 1" x 1/2" and a 2" x 3" hole. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

4. On 5/30/2012 at 11:11 am surveyor #28616 & 30964 observed in the Cafeteria smoke compartment on the 2nd floor in the corridor, that penetration(s) were not sealed according to an approved method. The corridor was not within a fully sprinkled smoke compartment and the separation wall was required to have a 30 minute fire resistance rating, including all penetrations. Penetrations included a conduit penetration that was not sealed with fire resistive material. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

5. On 5/30/2012 at 11:23 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the corridor at room #319, that penetration(s) were not sealed according to an approved method. The corridor was not within a fully sprinkled smoke compartment and the separation wall was required to have a 30 minute fire resistance rating, including all penetrations. Penetrations included (2) 2" x 4" holes. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 5 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/30/2012 at 9:45 am surveyor #28616 & 30964 observed in the Diagnostic Imaging smoke compartment on the 1st floor in the x-ray room #1438, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 10 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/29/2012 at 12:30 pm surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the corridor, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist fire and the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not enclose hazardous rooms with a smoke-tight room enclosure (in a sprinkled smoke zone), and rated walls in a non-sprinkled hazardous room. This deficiency occurred in 7 of the 21 smoke compartments, and had the potential to affect 55 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/29/2012 at 12:57 pm surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the hyperbaric room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included a 2" diameter hole and the top track of the wall did not have a fire resistive seal. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/29/2012 at 3:04 pm surveyor #28616 & 30964 observed in the Ambulatory Health Care smoke compartment on the 1st floor in the storage room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included the top track of the wall which was not sealed with fire resistive material. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

3. On 5/30/2012 at 9:22 am surveyor #28616 & 30964 observed in the Admitting smoke compartment on the 1st floor in the storage room #1214, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included the top track of the wall which was not sealed with fire resistive material. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

4. On 5/30/2012 at 11:41 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the corridor at staff lounge, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included a 1/2" annular space around the fire protection sprinkler pipe, a 3" diameter hole, a 1" diameter hole, (2) 3" holes and the top track was not sealed to the deck above. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

5. On 5/29/2012 at 2:15 pm surveyor #28616 & 30964 observed in the Lab smoke compartment on the 1st floor in the lab storage room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall had a 2' x 1' and a 6" x 12" hole as well as the gypsum board on one side stopped above the ceiling tile and did not extend to the deck above. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

6. On 5/29/2012 at 2:17 pm surveyor #28616 & 30964 observed in the Lab smoke compartment on the 1st floor in the lab storage room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall did not have gypsum board that extended to the deck above on one side above the ceiling tile. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

7. On 5/30/2012 at 9:36 am surveyor #28616 & 30964 observed in the ED smoke compartment on the 1st floor in the soiled utility, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall had a 1 1/2" diameter pipe penetration with a 1" unsealed annular space. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

8. On 5/30/2012 at 10:27 am surveyor #28616 & 30964 observed in the Med Surg 2 smoke compartment on the 2nd floor in the equipment storage across from room #206, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

9. On 5/30/2012 at 11:05 am surveyor #28616 & 30964 observed in the Cafeteria smoke compartment on the 2nd floor in the reperatory therapy #255, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

10. On 5/30/2012 at 11:53 am surveyor #28616 & 30964 observed in the Med Surg 3 South smoke compartment on the 3rd floor in the storage room #303, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide egress paths at all times with and paths that are maintainable in all weather conditions . This deficiency occurred in 2 of the 21 smoke compartments, and had the potential to affect 15 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/29/2012 at 12:42 pm surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the exterior exit door, that the exit discharge path did not have a maintainable surface. The path was composed of grass leading to the open yard surrounding the hospital. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/29/2012 at 2:55 pm surveyor #28616 & 30964 observed in the Ambulatory Health Care smoke compartment on the 1st floor in the exterior exit door, that the exit discharge path did not have a maintainable surface. The path was composed of grass leading to the open yard surrounding the hospital. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

3. On 5/30/2012 at 9:18 am surveyor #28616 & 30964 observed in the Admitting smoke compartment on the 1st floor in the exterior exit door, that the exit discharge path did not have a maintainable surface. The path was composed of grass leading to the open yard surrounding the hospital. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress with and a fully sprinkled building when using delayed egress locks. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 8 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/30/2012 at 11:35 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the exit stair enclosure, that a delayed egress lock (DEL) was installed in a building that was not fully sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/30/2012 at 11:38 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the egress door from corridor, that a delayed egress lock (DEL) was installed in a building that was not fully sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps in the interior and exterior means of egress so the path would still be illuminated if any single fixture or bulb failed with egress paths with redundant lighting. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 10 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/29/2012 at 12:44 pm surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the exterior exit door, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat. This deficiency occurred in of the 21 smoke compartments, and had the potential to affect of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/30/2012 at 2:00 pm surveyor #28616 & 30964 observed in the clinic space smoke compartment on the 1st floor in the electrical/communication closet, that there was one or more unsealed holes near the ceiling. The hole(s) included all the ceiling tile being removed from the space. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have sprinkler gauges with the required maintenance, and the appropriate quantity of spare sprinklers. This deficiency occurred in 2 of the 21 smoke compartments, and had the potential to affect 8 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/30/2012 at 9:26 am surveyor #28616 & 30964 observed in the ED smoke compartment on the 1st floor in the exit stair enclosure, that during a review of documents the facility could not verify that the sprinkler water pressure gauge had been replaced or calibrated within the last 5 years. This observed situation was not compliant with NFPA 25 (1998 edition), 2-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/30/2012 at 10:07 am surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the fire protection sprinkler riser room, that the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that were observed in the facility. Spare sprinklers were not provided for a number of sprinkler head types identified during the survey. This observed situation was not compliant with NFPA 25 (1998 edition), 2-4.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with generator with a remote stop. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 71 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/29/2012 at 1:45 pm surveyor #28616 & 30964 observed in the Lab smoke compartment on the 1st floor in the boiler room, that the three emergency generators were not provided with a remote stop switch. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide alcohol based hand rub dispensers that were installed and located as permitted by the code with and compliant installation. This deficiency occurred in 2 of the 21 smoke compartments, and had the potential to affect 16 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/29/2012 at 1:50 pm surveyor #28616 & 30964 observed in the Lab smoke compartment on the 1st floor in the central processing, that the alcohol based hand rub (ABHR) dispenser was directly above the soap dispenser containers where ABHR accumulation on the floor will not be detected; the building was not fully sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.7 and 42 CFR 403.744. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/30/2012 at 10:16 am surveyor #28616 & 30964 observed in the Med Surg 2 smoke compartment on the 2nd floor in the corridor at nurse station, that an alcohol based hand rub (ABHR) dispenser was installed in a corridor that was less than the minimum 6' width and the building was not fully sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.7 and 42 CFR 403.744. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide a common separation wall with sealed wall penetrations. This deficiency occurred in 2 of the 21 smoke compartments, and had the potential to affect 16 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/30/2012 at 9:24 am surveyor #28616 & 30964 observed in the ED smoke compartment on the 1st floor in the corridor, that penetration(s) were not sealed according to an approved method. The deficiency included a 12" x 12" hole and a 4" diameter pipe with no fire resistive material at the penetration. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/30/2012 at 11:17 am surveyor #28616 & 30964 observed in the Birthing Center smoke compartment on the 3rd floor in the corridor, that penetration(s) were not sealed according to an approved method. The deficiency included a 2" x 12" and a 2" x 6" hole in the concrete masonry wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4; and 8.2.3.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes with rated wall finishes. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 16 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/30/2012 at 10:24 am surveyor #28616 & 30964 observed in the Med Surg 2 smoke compartment on the 2nd floor in the electrical/communication closet, that the facility could not confirm the wall had an appropriate rating. The room wall was finished with plywood wall panels that were not represented as being fire resistive rated. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling (in a sprinkled smoke zone), and sealed wall penetrations. This deficiency occurred in 3 of the 21 smoke compartments, and had the potential to affect 8 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/29/2012 at 1:10 pm surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the corridor at room #1235, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 1/2" flexible conduit penetration without a fire resistive seal. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/30/2012 at 11:27 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the janitor closet room #324, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 12" x 12" hole. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

3. On 5/30/2012 at 11:29 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the corridor at room #322, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included (5) 1" x 1/2" and a 2" x 3" hole. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

4. On 5/30/2012 at 11:11 am surveyor #28616 & 30964 observed in the Cafeteria smoke compartment on the 2nd floor in the corridor, that penetration(s) were not sealed according to an approved method. The corridor was not within a fully sprinkled smoke compartment and the separation wall was required to have a 30 minute fire resistance rating, including all penetrations. Penetrations included a conduit penetration that was not sealed with fire resistive material. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

5. On 5/30/2012 at 11:23 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the corridor at room #319, that penetration(s) were not sealed according to an approved method. The corridor was not within a fully sprinkled smoke compartment and the separation wall was required to have a 30 minute fire resistance rating, including all penetrations. Penetrations included (2) 2" x 4" holes. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 5 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/30/2012 at 9:45 am surveyor #28616 & 30964 observed in the Diagnostic Imaging smoke compartment on the 1st floor in the x-ray room #1438, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with smoke-tight seals at meeting edges. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 10 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/29/2012 at 12:30 pm surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the corridor, that the pair of cross-corridor smoke barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist fire and the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not enclose hazardous rooms with a smoke-tight room enclosure (in a sprinkled smoke zone), and rated walls in a non-sprinkled hazardous room. This deficiency occurred in 7 of the 21 smoke compartments, and had the potential to affect 55 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/29/2012 at 12:57 pm surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the hyperbaric room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included a 2" diameter hole and the top track of the wall did not have a fire resistive seal. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/29/2012 at 3:04 pm surveyor #28616 & 30964 observed in the Ambulatory Health Care smoke compartment on the 1st floor in the storage room, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included the top track of the wall which was not sealed with fire resistive material. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

3. On 5/30/2012 at 9:22 am surveyor #28616 & 30964 observed in the Admitting smoke compartment on the 1st floor in the storage room #1214, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included the top track of the wall which was not sealed with fire resistive material. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

4. On 5/30/2012 at 11:41 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the corridor at staff lounge, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included a 1/2" annular space around the fire protection sprinkler pipe, a 3" diameter hole, a 1" diameter hole, (2) 3" holes and the top track was not sealed to the deck above. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

5. On 5/29/2012 at 2:15 pm surveyor #28616 & 30964 observed in the Lab smoke compartment on the 1st floor in the lab storage room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall had a 2' x 1' and a 6" x 12" hole as well as the gypsum board on one side stopped above the ceiling tile and did not extend to the deck above. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

6. On 5/29/2012 at 2:17 pm surveyor #28616 & 30964 observed in the Lab smoke compartment on the 1st floor in the lab storage room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall did not have gypsum board that extended to the deck above on one side above the ceiling tile. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

7. On 5/30/2012 at 9:36 am surveyor #28616 & 30964 observed in the ED smoke compartment on the 1st floor in the soiled utility, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall had a 1 1/2" diameter pipe penetration with a 1" unsealed annular space. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

8. On 5/30/2012 at 10:27 am surveyor #28616 & 30964 observed in the Med Surg 2 smoke compartment on the 2nd floor in the equipment storage across from room #206, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

9. On 5/30/2012 at 11:05 am surveyor #28616 & 30964 observed in the Cafeteria smoke compartment on the 2nd floor in the reperatory therapy #255, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

10. On 5/30/2012 at 11:53 am surveyor #28616 & 30964 observed in the Med Surg 3 South smoke compartment on the 3rd floor in the storage room #303, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide egress paths at all times with and paths that are maintainable in all weather conditions . This deficiency occurred in 2 of the 21 smoke compartments, and had the potential to affect 15 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/29/2012 at 12:42 pm surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the exterior exit door, that the exit discharge path did not have a maintainable surface. The path was composed of grass leading to the open yard surrounding the hospital. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/29/2012 at 2:55 pm surveyor #28616 & 30964 observed in the Ambulatory Health Care smoke compartment on the 1st floor in the exterior exit door, that the exit discharge path did not have a maintainable surface. The path was composed of grass leading to the open yard surrounding the hospital. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

3. On 5/30/2012 at 9:18 am surveyor #28616 & 30964 observed in the Admitting smoke compartment on the 1st floor in the exterior exit door, that the exit discharge path did not have a maintainable surface. The path was composed of grass leading to the open yard surrounding the hospital. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress with and a fully sprinkled building when using delayed egress locks. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 8 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/30/2012 at 11:35 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the exit stair enclosure, that a delayed egress lock (DEL) was installed in a building that was not fully sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/30/2012 at 11:38 am surveyor #28616 & 30964 observed in the Birthday Center smoke compartment on the 3rd floor in the egress door from corridor, that a delayed egress lock (DEL) was installed in a building that was not fully sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps in the interior and exterior means of egress so the path would still be illuminated if any single fixture or bulb failed with egress paths with redundant lighting. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 10 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/29/2012 at 12:44 pm surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the exterior exit door, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat. This deficiency occurred in of the 21 smoke compartments, and had the potential to affect of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/30/2012 at 2:00 pm surveyor #28616 & 30964 observed in the clinic space smoke compartment on the 1st floor in the electrical/communication closet, that there was one or more unsealed holes near the ceiling. The hole(s) included all the ceiling tile being removed from the space. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have sprinkler gauges with the required maintenance, and the appropriate quantity of spare sprinklers. This deficiency occurred in 2 of the 21 smoke compartments, and had the potential to affect 8 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 5/30/2012 at 9:26 am surveyor #28616 & 30964 observed in the ED smoke compartment on the 1st floor in the exit stair enclosure, that during a review of documents the facility could not verify that the sprinkler water pressure gauge had been replaced or calibrated within the last 5 years. This observed situation was not compliant with NFPA 25 (1998 edition), 2-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

2. On 5/30/2012 at 10:07 am surveyor #28616 & 30964 observed in the 1929-Business 1 smoke compartment on the 1st floor in the fire protection sprinkler riser room, that the cabinet of spare sprinklers did not contain two spare heads for the each type of sprinkler that were observed in the facility. Spare sprinklers were not provided for a number of sprinkler head types identified during the survey. This observed situation was not compliant with NFPA 25 (1998 edition), 2-4.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).

Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with generator with a remote stop. This deficiency occurred in 1 of the 21 smoke compartments, and had the potential to affect 71 of the 71 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 5/29/2012 at 1:45 pm surveyor #28616 & 30964 observed in the Lab smoke compartment on the 1st floor in the boiler room, that the three emergency generators were not provided with a remote stop switch. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Mngr. of Fac. Op.), staff G (Dir. Of Fac. Op.-North) and staff GG (Dir. Of Fac. Operations).