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Based on observation and interview the facility failed to provide exit access corridor walls that were at least 1/2 hour rated and resistant to the passage of smoke in accordance to NFPA 101 section 19.3.6.3.1, and were not in compliance as evidenced by the following items. This deficiency could affect all of the patients on these levels of the facility, as well as an undetermined number of staff and visitors.

Findings Include:

1. On January 15th, 2014 at 10:23 AM, during the walk-through of the Behavioral Health unit, observation revealed that the Dutch doors from Staff Observation room #3426 into the Corridor were not smoke-tight. A visible gap was present at the meeting edges between the upper leaf and the lower leaf of this Dutch door. This observed condition was not compliant to NFPA 101 (2000 ED) section 19.3.6.3.6.

2. On January 15th, 2014 at 11:35 AM, during the walk-through of the Fourth floor inpatient unit, observation revealed that the door from Physical Therapy room #3426 into the Corridor was not provided with positive latching hardware. This observed condition was not compliant to NFPA 101 (2000 ED) section 19.3.6.3.2.

3. On January 16th, 2014 at 10:10 AM, during the walk-through of the Kitchen observation revealed that the paired doors from Kitchen Storage room #B115 into the Corridor were not smoke-tight. A visible gap was present at the meeting edges of these doors and no astragal was installed on the doors. This observed condition was not compliant to NFPA 101 (2000 ED) section 19.3.6.3.6.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview the facility failed to provide corridor doors that were resistant to the passage of smoke in accordance to the 2000 Edition of NFPA 101 section 18.3.6.3 Corridor Doors; and are not in compliance as evidenced by the following items. This deficiency could affect all of the patients, staff and and undetermined number of visitors within one of the four smoke compartments on this floor of the hospital.

Findings Include:

1. On January 14th, 2014 at 9:21 AM, during the walk-through of the Second floor of the Luther building; observation revealed that two sets of paired doors from the Special Care Nursery #21020 into the Corridor were not smoke-tight. A visible gap was found at the meeting edges of these doors and no astragal was installed on the doors. This observed condition was not compliant to Subsection 18.3.6.3.1 of NFPA 101 [2000 Ed.].

2. On January 15th, 2014 at 3:30 PM, during the walk-through of the Lower Level of the Luther building; observation revealed that two sets of paired doors from the Auditorium room #3105 into the Corridor were not smoke-tight. A visible gap at the meeting edges of these doors was present and no astragal was installed on the doors. This observed condition was not compliant to Subsection 18.3.6.3.1 of NFPA 101 [2000 Ed.].

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview the facility failed to provide smoke compartment doors that were resistant to the passage of smoke in accordance to the 2000 Edition of NFPA 101 section 18.3.7.8; and are not in compliance as evidenced by the following items. This deficiency could affect all of the patients, staff and and undetermined number of visitors within this two of the four smoke compartments on this floor of the hospital.

Findings Include:

1. On January 14th, 2014 at 10:14 AM, during the walk-through of the Third floor of the Luther building; observation revealed that one set of paired doors #31051 of the smoke compartment were not smoke-tight. A visible gap was found at the meeting edges of these doors and no astragal was installed on the doors. This observed condition was not compliant to Subsection 18.3.7.8 of NFPA 101 [2000 Ed.].

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview the facility failed to provide exit components (such as exit passageway doors) that were resistant to the passage of smoke in accordance to the 2000 Edition of NFPA 101 sections 18.3.1.1 and 8.2.5; and were not in compliance as evidenced by the following items. This deficiency could affect all of the patients, staff and and undetermined number of visitors within this one of the four smoke compartments on this floor of the hospital.

Findings Include:

1. On January 15th, 2014 at 8:21 AM, during the walk-through of the Lower Level of the Luther building; observation revealed that two sets of paired doors from the exit passageway into the Corridor were not smoke-tight. A visible gap was found at the meeting edges of these doors and no astragal was installed on the doors. This observed condition was not compliant to Subsections 18.3.1.1 and 8.2.5 of NFPA 101 [2000 Ed.].

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview, the facility did not provide egress to the exits through a door that had hardware which operated with a single release motion. This deficiency occurred in 20 rooms within one of the 12 smoke compartments on this floor; and had the potential to affect the inpatients, staff and visitors within this smoke compartment.

Findings Include:

1. On January 16th, 2014 at 1:30 PM, during the walk-through of the CCU/ICU of the Northeast additions; observation revealed that a push pad was installed within the shared inpatient bathrooms of these units. A test was conducted of the pad in several locations of these units and it was discovered that the pads were inoperable. The presence of the pads cause confusion for any occupant who may egress from this room. This observed condition was not compliant to NFPA 101 [2000 Ed.] Section 18.2.2.2.2, Section 7.2.1 and subsection 7.2.1.5.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and staff interview, the facility failed to maintain exit access to 1 of 4 stairwell exits due to obstruction caused by a delayed egress exit access door that did not conform to NFPA 101 section 18.2.2. Means of Egress components. This deficient practice could affect all patients, staff, and visitors in two of the four smoke compartments on this floor.

Findings Include:

1. On January 14th, 2014 at 9:30 PM, during the walk-through of the Second floor of the Luther building; observation revealed that a delayed egress mechanism was present on the door into Stair #3. This observed condition was not compliant to NFPA 101 [2000 Ed.] section 18.2.2.2, Section 18.2.2.4 Exception #2 and Section 7.2.1.6.1; since no signage was installed at the door to assist any occupant who would use this door in an emergency. Signage should comply with Section 7.2.1.6.1 for proper size and language for this delayed locking mechanism.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview, the facility did not provide a sprinkler system that was installed in accordance to NFPA 13 as required by the Life Safety Code [2000 Ed] sections 19.5.1 and 9.7.1.1. The facility did not provide a sprinkler system with unobstructed water distribution. The deficient practice could affect all the patients, staff and an undeterminable number of visitors on this floor.

Findings include:

1. On January 14th, 2014 at 1:15 PM, observation revealed that boxes were stacked above the 18" clear plane of the sprinkler system within the EVS Storage room #B377; this condition obstructed the proper discharge of the pendent sprinkler heads. The minimum clearance of 18" was not provided below the deflectors of these heads to an obstruction below.

2. On January 15th, 2014 at 2:34 PM, observation revealed that the upper shelf within each of the closets of the Staff Breakroom #4007 on the fourth floor obstructed the proper discharge of the pendent sprinkler heads. The minimum clearance of 18" was not provided below the deflector of the head to the shelf below.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview, the facility did not provide a sprinkler system that was installed in accordance to NFPA 13 as required by the Life Safety Code, sections 19.5.1 and 9.7.1.1. The deficient practice could affect all the patients of the floor and an undeterminable number of staff and visitors within this smoke compartment of the floor.

Findings include:

1. On January 14th, 2014 at 3:34 PM, observation revealed that an electrical extension cord was supported by the sprinkler system in several locations of the Shell space #B1213 in the basement level of the Luther building. The sprinkler system shall not be used to support any other utilities, whether permanent or temporary.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview the facility failed to provide electrical wiring and equipment in accordance to NFPA 70 section 9.1.2 and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients, staff as well as an undetermined number of visitors within this building served by the electrical system.

Findings include:

1. On January 15th, 2014 at 1:30 PM, observation revealed that combustible storage was being kept in both the Normal Electrical Distribution room and Emergency Electrical Distribution rooms (#B1024E and #B1029E) of the lower level within the Luther building.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview the facility failed to provide exit access corridor walls that were at least 1/2 hour rated and resistant to the passage of smoke in accordance to NFPA 101 section 19.3.6.3.1, and were not in compliance as evidenced by the following items. This deficiency could affect all of the patients on these levels of the facility, as well as an undetermined number of staff and visitors.

Findings Include:

1. On January 15th, 2014 at 10:23 AM, during the walk-through of the Behavioral Health unit, observation revealed that the Dutch doors from Staff Observation room #3426 into the Corridor were not smoke-tight. A visible gap was present at the meeting edges between the upper leaf and the lower leaf of this Dutch door. This observed condition was not compliant to NFPA 101 (2000 ED) section 19.3.6.3.6.

2. On January 15th, 2014 at 11:35 AM, during the walk-through of the Fourth floor inpatient unit, observation revealed that the door from Physical Therapy room #3426 into the Corridor was not provided with positive latching hardware. This observed condition was not compliant to NFPA 101 (2000 ED) section 19.3.6.3.2.

3. On January 16th, 2014 at 10:10 AM, during the walk-through of the Kitchen observation revealed that the paired doors from Kitchen Storage room #B115 into the Corridor were not smoke-tight. A visible gap was present at the meeting edges of these doors and no astragal was installed on the doors. This observed condition was not compliant to NFPA 101 (2000 ED) section 19.3.6.3.6.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview the facility failed to provide corridor doors that were resistant to the passage of smoke in accordance to the 2000 Edition of NFPA 101 section 18.3.6.3 Corridor Doors; and are not in compliance as evidenced by the following items. This deficiency could affect all of the patients, staff and and undetermined number of visitors within one of the four smoke compartments on this floor of the hospital.

Findings Include:

1. On January 14th, 2014 at 9:21 AM, during the walk-through of the Second floor of the Luther building; observation revealed that two sets of paired doors from the Special Care Nursery #21020 into the Corridor were not smoke-tight. A visible gap was found at the meeting edges of these doors and no astragal was installed on the doors. This observed condition was not compliant to Subsection 18.3.6.3.1 of NFPA 101 [2000 Ed.].

2. On January 15th, 2014 at 3:30 PM, during the walk-through of the Lower Level of the Luther building; observation revealed that two sets of paired doors from the Auditorium room #3105 into the Corridor were not smoke-tight. A visible gap at the meeting edges of these doors was present and no astragal was installed on the doors. This observed condition was not compliant to Subsection 18.3.6.3.1 of NFPA 101 [2000 Ed.].

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview the facility failed to provide smoke compartment doors that were resistant to the passage of smoke in accordance to the 2000 Edition of NFPA 101 section 18.3.7.8; and are not in compliance as evidenced by the following items. This deficiency could affect all of the patients, staff and and undetermined number of visitors within this two of the four smoke compartments on this floor of the hospital.

Findings Include:

1. On January 14th, 2014 at 10:14 AM, during the walk-through of the Third floor of the Luther building; observation revealed that one set of paired doors #31051 of the smoke compartment were not smoke-tight. A visible gap was found at the meeting edges of these doors and no astragal was installed on the doors. This observed condition was not compliant to Subsection 18.3.7.8 of NFPA 101 [2000 Ed.].

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview the facility failed to provide exit components (such as exit passageway doors) that were resistant to the passage of smoke in accordance to the 2000 Edition of NFPA 101 sections 18.3.1.1 and 8.2.5; and were not in compliance as evidenced by the following items. This deficiency could affect all of the patients, staff and and undetermined number of visitors within this one of the four smoke compartments on this floor of the hospital.

Findings Include:

1. On January 15th, 2014 at 8:21 AM, during the walk-through of the Lower Level of the Luther building; observation revealed that two sets of paired doors from the exit passageway into the Corridor were not smoke-tight. A visible gap was found at the meeting edges of these doors and no astragal was installed on the doors. This observed condition was not compliant to Subsections 18.3.1.1 and 8.2.5 of NFPA 101 [2000 Ed.].

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview, the facility did not provide egress to the exits through a door that had hardware which operated with a single release motion. This deficiency occurred in 20 rooms within one of the 12 smoke compartments on this floor; and had the potential to affect the inpatients, staff and visitors within this smoke compartment.

Findings Include:

1. On January 16th, 2014 at 1:30 PM, during the walk-through of the CCU/ICU of the Northeast additions; observation revealed that a push pad was installed within the shared inpatient bathrooms of these units. A test was conducted of the pad in several locations of these units and it was discovered that the pads were inoperable. The presence of the pads cause confusion for any occupant who may egress from this room. This observed condition was not compliant to NFPA 101 [2000 Ed.] Section 18.2.2.2.2, Section 7.2.1 and subsection 7.2.1.5.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and staff interview, the facility failed to maintain exit access to 1 of 4 stairwell exits due to obstruction caused by a delayed egress exit access door that did not conform to NFPA 101 section 18.2.2. Means of Egress components. This deficient practice could affect all patients, staff, and visitors in two of the four smoke compartments on this floor.

Findings Include:

1. On January 14th, 2014 at 9:30 PM, during the walk-through of the Second floor of the Luther building; observation revealed that a delayed egress mechanism was present on the door into Stair #3. This observed condition was not compliant to NFPA 101 [2000 Ed.] section 18.2.2.2, Section 18.2.2.4 Exception #2 and Section 7.2.1.6.1; since no signage was installed at the door to assist any occupant who would use this door in an emergency. Signage should comply with Section 7.2.1.6.1 for proper size and language for this delayed locking mechanism.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview, the facility did not provide a sprinkler system that was installed in accordance to NFPA 13 as required by the Life Safety Code [2000 Ed] sections 19.5.1 and 9.7.1.1. The facility did not provide a sprinkler system with unobstructed water distribution. The deficient practice could affect all the patients, staff and an undeterminable number of visitors on this floor.

Findings include:

1. On January 14th, 2014 at 1:15 PM, observation revealed that boxes were stacked above the 18" clear plane of the sprinkler system within the EVS Storage room #B377; this condition obstructed the proper discharge of the pendent sprinkler heads. The minimum clearance of 18" was not provided below the deflectors of these heads to an obstruction below.

2. On January 15th, 2014 at 2:34 PM, observation revealed that the upper shelf within each of the closets of the Staff Breakroom #4007 on the fourth floor obstructed the proper discharge of the pendent sprinkler heads. The minimum clearance of 18" was not provided below the deflector of the head to the shelf below.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview, the facility did not provide a sprinkler system that was installed in accordance to NFPA 13 as required by the Life Safety Code, sections 19.5.1 and 9.7.1.1. The deficient practice could affect all the patients of the floor and an undeterminable number of staff and visitors within this smoke compartment of the floor.

Findings include:

1. On January 14th, 2014 at 3:34 PM, observation revealed that an electrical extension cord was supported by the sprinkler system in several locations of the Shell space #B1213 in the basement level of the Luther building. The sprinkler system shall not be used to support any other utilities, whether permanent or temporary.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).

Based on observation and interview the facility failed to provide electrical wiring and equipment in accordance to NFPA 70 section 9.1.2 and was not in compliance as evidenced by the following items. This deficiency could affect all of the patients, staff as well as an undetermined number of visitors within this building served by the electrical system.

Findings include:

1. On January 15th, 2014 at 1:30 PM, observation revealed that combustible storage was being kept in both the Normal Electrical Distribution room and Emergency Electrical Distribution rooms (#B1024E and #B1029E) of the lower level within the Luther building.

This condition was confirmed at the time of discovery by a concurrent observation and interview with Staff PP (Facilities Director), Staff OO (Project Manager).