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Based on observation and interview, the facility did not provide and maintain the required building construction type that had support steel covered with rated fire proofing, and sealed floor penetrations. This deficiency occurred in 4 of the 36 smoke compartments, and would affect 35 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 6, 2010 at 11:30 am surveyor #18107 observed in the 42-B smoke compartment on the 2nd floor that in the Maintenance Area fire proofing was missing from the structural steel at the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

2. On May 4, 2010 at 9:00 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the Treatment Room there were penetration(s) through the floor that were not fire stopped according to a UL design standard. The deficiency included an open hole in the floor. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

3. On May 4, 2010 at 2:13 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #23-Electrical Closet there were penetration(s) through the floor that were not fire stopped according to a UL design standard. The deficiency included a non-sealed sleeve. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

4. On May 6, 2010 at 11:40 am surveyor #18107 observed in the 42-B smoke compartment on the 2nd floor that in the Maintenance Toilet Room there were penetration(s) through the floor that were not fire stopped according to a UL design standard. The deficiency included four (4) floor penetrations near the sink, urinal and lavatory. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

5. On May 6, 2010 at 4:34 pm surveyor #18107 observed in the 21-N smoke compartment on the 1st floor that in the #1025-Room there were penetration(s) through the floor that were not fire stopped according to a UL design standard. The deficiency included electrical conduit. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces that had a smoke-tight corridor ceiling (in a sprinkled smoke zone), and sealed wall penetrations. This deficiency occurred in 2 of the 36 smoke compartments, and would affect 20 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 6, 2010 at 8:39 am surveyor #18107 observed in the 43-H1 smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included an access panel that was missing in the ceiling. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

2. On May 3, 2010 at 2:50 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the Corridor, penetration(s) were not sealed according to approved UL designs. 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 sprinkler pipe with rock wool backing but no fire-rated sealant. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

3. On May 6, 2010 at 8:41 am surveyor #18107 observed in the 43-H1 smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier, penetration(s) were not sealed according to approved UL designs. 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 an unsealed sleeve with cabling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

4. On May 6, 2010 at 8:47 am surveyor #18107 observed in the 43-H1 smoke compartment on the 3rd floor that in the Corridor by Smoke Barrier, penetration(s) were not sealed according to approved UL designs. 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 an unsealed sleeve with cabling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

Based on observation and interview, the facility did not provide corridor separation doors that had positive-latching dutch doors, doors with positive-latching hardware, and doors that would close when pushed or pulled. This deficiency occurred in 5 of the 36 smoke compartments, and would affect 50 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 8:42 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2013-Intake Foyer the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

2. On May 4, 2010 at 9:30 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the 2124-Office the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

3. On May 4, 2010 at 9:45 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2112-Police Report Room the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. The door had a manual dead bolt. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

4. On May 7, 2010 at 10:36 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the #1007-Mail Room the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. The upper door had a deadbolt that did not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

5. On May 7, 2010 at 1:48 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1095-Office and Main Court Room the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. The upper door had a deadbolt that did not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

6. On May 3, 2010 at 2:25 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the #2329-Dishwashing Room the corridor door would not remain fully-closed if a force of 5 lbs were applied to the latch edge of the door. Positive latching was not possible because of mis-alignment. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

7. On May 7, 2010 at 11:55 am surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1084-Storage Room the door to the corridor was held open with a a door chuck. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

8. On May 11, 2010 at 9:18 am surveyor #18107 observed in the 42-A2 smoke compartment on the 2nd floor that in the #2208-Central Supply Room (Hardware Rm.) the door to the corridor was held open with a a patient lift. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

9. On May 11, 2010 at 2:30 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #23-Pantry the door to the corridor was held open with a food cart. There was a closer on the door. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations and rated wall construction. This deficiency occurred in 20 of the 36 smoke compartments, and would affect 90 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 3, 2010 at 2:16 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2301-Food Service penetration(s) were not sealed according to approved UL designs. The deficiency included an opening at the top of the wall above a 48"x 20" mechanical duct. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

2. On May 4, 2010 at 3:26 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the #13-Conference Room penetration(s) were not sealed according to approved UL designs. The deficiency included various penetrations. The smoke barrier wall was not fire-rated because the top of wall at the deck was not sealed and screws were not fully-covered with joint compound. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

3. On May 5, 2010 at 2:04 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier penetration(s) were not sealed according to approved UL designs. The deficiency included multiple pipes. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

4. On May 6, 2010 at 11:46 am surveyor #18107 observed in the 42-B smoke compartment on the 2nd floor that in the 2220-Corridor by Smoke Barrier penetration(s) were not sealed according to approved UL designs. The deficiency included multiple ducts, sleeves, and pipes. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

5. On May 3, 2010 at 2:10 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the #2314-Staff CC's Office the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the uppermost 6" of wall was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

6. On May 3, 2010 at 2:20 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the Corridor the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top of wall was not sealed at the deck above. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

7. On May 3, 2010 at 2:50 pm surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the 52A Corridor the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top of wall and both sides of the drywall wall were not sealed where they met the adjacent concrete block wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

8. On May 4, 2010 at 8:58 am surveyor #18107 observed in the 32-C1 smoke compartment on the 2nd floor that in the Corridor by Smoke Barrier, the smoke barrier wall was not constructed to a 30 minute fire resistance rating because screws were not covered with joint compound and the wall was not enclosed at the top of two (2) mechanical ducts. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

9. On May 4, 2010 at 2:58 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top of the wall at the deck above was not sealed. The vertical side joints and joint against door frame header were not sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

10. On May 6, 2010 at 11:10 am surveyor #18107 observed in the 43-F1 smoke compartment on the 3rd floor that in the Corridor by Smoke Barrier the smoke barrier wall was not constructed to a 30 minute fire resistance rating because seams in the drywall were not taped and multiple screws were not covered with joint compound. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

11. On May 7, 2010 at 2:21 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the Old Library Room the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the wall contained un-rated glass in the walls and door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

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 that had smoke-tight seals at meeting edges, and closers on all doors. This deficiency occurred in 6 of the 36 smoke compartments, and would affect 50 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 9:46 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the Corridor at Smoke Barrier the room had double smoke barrier doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The doors were warped. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

2. On May 5, 2010 at 3:26 pm surveyor #18107 observed in the 53-C smoke compartment on the 3rd floor that in the #3308-Smoke Barrier Corridor Doors the room had double smoke barrier doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

3. On May 6, 2010 at 8:35 am surveyor #18107 observed in the 43-H1 smoke compartment on the 3rd floor that in the #3-04-Corridor near Women's Toilet the room had double smoke barrier doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The astragal on the door was damaged and was unable to provide a seal that resisted the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

4. On May 4, 2010 at 3:38 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier the smoke barrier door would not self-close because the door was broken. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, rated doors, doors with positive-latching hardware, and sealed wall penetrations. This deficiency occurred in 9 of the 36 smoke compartments, and would affect 70 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 9:29 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the Electrical Closet the door would not self-close because there was no closer. This room was used for the storage of oxygen. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

2. On May 4, 2010 at 1:41 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #5-Tub Room the door would not self-close because there was no closer. This room was used for storage. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

3. On May 4, 2010 at 1:44 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #6-Office the door would not self-close because there was no closer. This room was used for storage. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

4. On May 4, 2010 at 1:48 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #41-Storage the door would not self-close because there was no closer. This room was used for storage. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

5. On May 4, 2010 at 1:49 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #11-Storage the door would not self-close because there was no closer. This room was used for storage. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

6. On May 4, 2010 at 2:01 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #34-Office and #29-Office the doors would not self-close because there were no door closers. This rooms were used for storage. The rooms were considered hazardous because they 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

7. On May 7, 2010 at 11:05 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the #1039-1-Storage Room the door would not self-close because there was no closing device on the door. The door was not labeled. The wall was not constructed to a 1-hour fire resistance rating. The room was used to store two (2) large 90 gallon paper storage bins. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

8. On May 7, 2010 at 11:25 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the #1045-Storage Room the door would not self-close because the door was not provided with a closing device. The door did not have a label to confirm its rating. The walls were not 1-hour rated. The same deficiency was observed in #1050-Storage Room and #1048-Storage Room. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

9. On May 7, 2010 at 2:01 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1116-Storage Room and #1122-Medical Records Room the doors would not self-close because the closing devices were missing. The rooms were considered hazardous because they 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

10. On May 7, 2010 at 11:55 am surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1084-Storage Room the room was not sprinkled and the fire barrier door could not be verified to have the required rating. Two (2) walls were not constructed to a 1-hour fire rating. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

11. On May 3, 2010 at 3:11 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the #2330-Storage Room the door would not positively self-latch when released because of mis-alignment. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

12. On May 3, 2010 at 3:13 pm surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the #2337-Storage Room near loading dock the door would not positively self-latch when released because the doors were binding. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

13. On May 3, 2010 at 3:35 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2319-Materials Management Storeroom the door would not positively self-latch when released because of mis-alignment due to damage. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

14. On May 4, 2010 at 8:39 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2006-Storage Room the door would not positively self-latch when released because of mis-alignment. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

15. On May 3, 2010 at 12:00 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2312-Housekeeping Storage Room penetration(s) were not sealed according to approved UL designs. The deficiency included a 3"x 8" piece of wood embedded in the top of the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

16. On May 3, 2010 at 3:10 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the #2329-Housekeeping Storage Room penetration(s) were not sealed according to approved UL designs. The deficiency included two (3'x 18", 24"x 12") ducts at two (2) walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

17. On May 11, 2010 at 9:34 am surveyor #18107 observed in the 42-A2 smoke compartment on the 2nd floor that in the #2208-Central Supply Room (Hardware Rm.) penetration(s) were not sealed according to approved UL designs. The deficiency included a minimum of eight (8) penetrations observed in one of the 1-hour fire-rated walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

18. On May 11, 2010 at 11:38 am surveyor #18107 observed in the 52-B1 smoke compartment on the 2nd floor that in the #2307A & #2311- Patient Storage Room the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall had a duct penetration that was not sealed and fire caulked through the 1-hour concrete block wall assembly. The room was used to store patient clothing and shelves were filled from 4 inches above the floor to at least 8 feet above the floor. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide enclosures around exit stairs that were free of storage. This deficiency occurred in 2 of the 36 smoke compartments, and would affect 20 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 1:40 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the Stairwell #3-1 the stairwell was used for storage. Storage included a wood pallet at the bottom of the steps. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

2. On May 4, 2010 at 2:49 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the Stairwell #5-5 the stairwell was used for storage. Storage included a wood pallet. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide egress paths at all times that had doors that were unlockable in the egress path, no swinging door obstructions, doors that swing in the direction of egress, and level walking surfaces in the path of egress. This deficiency occurred in 9 of the 36 smoke compartments, and would affect 'ALL' of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 11:14 am surveyor #18107 observed in the 32-C1 smoke compartment on the 2nd floor that in the Stairwell #3-4 the door was locked from the egress side. The door has a manual deadbolt lock that was not positive self-latching. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

2. On May 4, 2010 at 1:58 pm surveyor #18107 observed in the 32-A2 smoke compartment on the 2nd floor that in the Stairwell #32-A2 the door was locked from the egress side. A deadbolt was installed on the door that was not positive latching. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

3. On May 4, 2010 at 8:35 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2003-Electrical Closet one or more doors swung outward into the exit path and obstructed the path because the fully-open doors extended more than 7" into the required egress width. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

4. On May 4, 2010 at 9:35 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the 2124-Office one or more doors swung outward into the exit path and obstructed the path because the fully open door extended more than 7" into the required egress width. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

5. On May 7, 2010 at 11:55 am surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1075-Electrical Room one or more doors swung outward into the exit path and obstructed the path because they extended more than 7" into the required egress width. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

6. On May 4, 2010 at 11:11 am surveyor #18107 observed in the 32-B1 smoke compartment on the 2nd floor that in the Stairwell #3-4 the door in the path of egress did not swing in the direction of egress travel and the occupancy load of the egress was estimated to be at least 50 persons. The gate that interrupts the travel past the exit discharge swings against the direction of egress from the lower floor. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

7. On May 3, 2010 at 2:21 pm surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the 52-A Stair Discharge a portion of the path of egress had an abrupt change in elevation of 4" to 5" between two (2) concrete slabs due to soil erosion. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

8. On May 5, 2010 at 3:00 pm surveyor #18107 observed in the 53-C smoke compartment on the 3rd floor that in the Staff Entrance a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

9. On May 5, 2010 at 3:06 pm surveyor #18107 observed in the 53-C smoke compartment on the 3rd floor that in the Stair #5-1 a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

10. On May 6, 2010 at 9:33 am surveyor #18107 observed in the 43-C2 smoke compartment on the 3rd floor that in the Stair #4-3-Exit Discharge a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

11. On May 6, 2010 at 11:54 am surveyor #18107 observed in the 42-A1 smoke compartment on the 2nd floor that in the Stair #4-2 Exit Discharge a portion of the path of egress had an abrupt change in elevation were 8 panels of sidewalk that were broken and this created an un-level egress path to a public way. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

12. On May 6, 2010 at 2:35 pm surveyor #18107 observed in the 43-B1 smoke compartment on the 5th floor that in the Stair #4-5 Exit Discharge a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

13. On May 6, 2010 at 4:09 pm surveyor #18107 observed in the 43-A1 smoke compartment on the 3rd floor that in the Stair #4-1 Exit Discharge a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

14. On May 7, 2010 at 10:59 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the Stair #3-1 a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide and maintain multiple light 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 and the egress paths would be walk-able with redundant lighting. This deficiency occurred in 7 of the 36 smoke compartments, and would affect 90 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 3, 2010 at 2:20 pm till 4 pm surveyor #18107 observed in the smoke compartment on the 1st, 2nd & 3rd floors that in the various Stairwells the path of egress was illuminated by a single light 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 condition was observed at various times in a number of Stairwells , including, but not limited to, the following examples:
43-H2: Stair #4-15 Exit Discharge;
43-C1: Stair #4-14 Exit Discharge;
43-C2: Stair #4-3 Exit Discharge;
43-D2: Exit Discharge;
52-A2: Stair #52A Exit Discharge;
52-B: Stair #52B D Exit Discharge;
53-A1: Stair #5-3 Exit Discharge;
53-C: Stair #5-1 Exit Discharge;
This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

2. On May 11, 2010 at 2:45 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the Stair #5-2 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. The light was burnt-out and the space was dark, come night. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system that had visible alarm notification devices. This deficiency occurred in 1 of the 36 smoke compartments, and would affect 0 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
On May 11, 2010 at 9:25 am surveyor #18107 observed in the 42-A2 smoke compartment on the 2nd floor that in the #2208-Central Supply Room (Hardware Rm.) a visual fire alarm notification device was obstructed so it was not viewable from all areas of the space. The fire alarm visual device located on one of the walls was blocked for viewing by all areas of the room. This observed situation was not compliant with NFPA 72 (1999 edition), 4-4.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a sprinkler system that had sprinklers free of obstructions near the ceiling, all rooms sprinkled when the code required sprinkling, and Stairwells with sprinklers. This deficiency occurred in 10 of the 36 smoke compartments, and would affect 'ALL' of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 8:36 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2003-Storage Closet, items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included items on shelves. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

2. On May 11, 2010 at 9:13 am surveyor #18107 observed in the 42-B2 smoke compartment on the 2nd floor that in the #2308-Central Supply/General Distribution Room, items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included multiple storage shelves in the middle of the room with materials stored less than 12 inches below the sprinkler heads. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

3. On May 7, 2010 at 2:30 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the Data Room where Halon was the source of fire-suppression, the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The room was equipped with a Halon extinguishing system, but was not considered effective because the mechanical ducts were not smoke-dampered to contain the gas within the room upon activation. This observed situation was not compliant with NFPA 101 (2000 edition). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

4. On May 6, 2010 at 10:58 am surveyor #18107 observed in the various smoke compartment on the lowest floor that in the Stairwells the stairwell did not have a sprinkler at the first landing above the bottom of the shaft. The surveyor observed this deficiency in Stairwells #4-10, #4-3, #4-2, #3-2, #3-3, #3-4, and #4-3. This observed situation was not compliant with NFPA 13 (1999 edition), 5-13.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

5. On May 3, 2010 at 2:35 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2318-Materials Management Store Room, the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included boxes and various materials stacked on the top of three (3) center aisle shelving units and the tops were less than 12" below the height of the sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

6. On May 3, 2010 at 2:40 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2318-Materials Management Storeroom, the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

7. On May 4, 2010 at 8:38 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2005-Storage Closet, the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included items on shelves. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

8. On May 4, 2010 at 9:20 am surveyor #18107 observed in the 32-C1 smoke compartment on the 2nd floor that in the #1-Storage Closet, the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included materials stored on shelves. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

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 intact escutcheon rings, and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 10 of the 36 smoke compartments, and would affect 90 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 6, 2010 at 9:36 am surveyor #18107 observed in the smoke compartment on the 3rd and every other floor that in the occupied spaces the escutcheon ring on the sprinkler was missing, ajar, or damaged. This was observed throughout the facility at various times and in various smoke compartments, including, but not limited to the following examples:
43-B1: in #23-Electrical Closet, #37-Sleeping Room, #8 Toilet, #7-Sleeping Room, and #4-Tub Room;
43-C1: in #29-Seclusion Room, #3-Janitor Closet, #4-Shower Room, #10-Laundry Room, #35-Sleep Room, #40-Toilet Room, #13-Conference Room, and #24-Conference Room;
43-D: in Corridor, #2-Sleep Room, and #7-Sleep Room;
43-H1: in corridor #3208;#3-04-Women's Toilet;
21-N: in the French Quarter;
31-A: in the Reception, Vestibule, #1039-2, #1039-3, #1039-4, and #1039-5-Offices;
31-B: in #1121-Suite, #1010-Gathering Room, Medical Records Room, Corridor by Janitor Closet, and #1110-Suite Aisles;
32-D1: in the Corridor by Room 2116, Room #2120, #2109-Waiting;
32-C1: in #2132-8-Toilet Room, #3132-16-Consult Room,
32-B1: in the Corridor, #30-Room
32-A1: in #2102-31-Office
53-B1: in #6-Inpatient Room, #12-Dayroom, #40-Inpatient Room, Corridor by Room #40, #40A-Toilet Room;
53-C: in the Corridor by #3-Office This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

2. On May 6, 2010 at 9:04 am surveyor #18107 observed in the smoke compartment on the 1st, 2nd & 3rd floor that in the occupied areas there was one or more unsealed holes near the ceiling. The hole(s) included mis-aligned ceiling tile joints and gaps caused by damaged, out-of-place, or missing ceiling tiles or unsealed penetrations. This situation was observed throughout the facility, including but not limited to:
43-D1: in the Corridor by room #18, Nurse Station, #24-Office, and #13-Conference Room;
43-C1: in the corridor;
43-G1: in #3234-Music Therapy Room, and in the corridor by the Smoke Barrier;
43-B1: in #23-Electrical Closet;
43-H1: in #3-Office
21-N: in #3-Office
53-B1: in #24-Electrical Closet, #13-Conference Room
31-A1: in the entry vestibule to the Day Hospital;
31-B1: in #1120-suite; #2a-Court Room;
32-A1: #14-Office
32-D1: in #2013-Intake Foyer, Corridor by #2126-Office, #2126-Office
53-A1: in #24-Electrical Closet
53-C: in #3310-Staffing Suite Passage;
These holes 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. These observed situations were not compliant with NFPA 25 (1998 edition), 1-11.1. The deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

3. On May 11, 2010 at 2:47 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #3322-7-Inpatient Toilet Room there was one or more unsealed holes near the ceiling. The hole(s) included an opening in the valance light fixture because is was missing a lens. The fixture was located above the mirror at the handwashing lavatory. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide a means of egress that was free of impediments, including corridors free of materials that obstruct egress. This deficiency occurred in 1 of the 36 smoke compartments, and would affect 15 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
On May 3, 2010 at 3:17 pm surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the #52A Stair Discharge materials were stored in the exit access pathway, including a chair in the outside smoking area blocked the exit path. The materials were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 6), and 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the code that had properly sized storage containers for soiled/trash materials. This deficiency occurred in 1 of the 36 smoke compartments, and would affect 0 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
On May 5, 2010 at 3:36 pm surveyor #18107 observed in the 43-H1 smoke compartment on the 3rd floor that in the #3204-Office Suite mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Two (2) large 32 gallon waste containers were next to each, along with other large volumes of paper supplies in the office. This quantity of combustible materials must be enclosed with walls and doors that are appropriate for a hazardous space. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code that had working clearances at electrical panels, GFIC outlets, closed electrical raceways, and electrical panels with complete directories. This deficiency occurred in 13 of the 36 smoke compartments, and would affect 40 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 3, 2010 at 2:30 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2317-Loading Dock access to electrical panel was less than 3'-0" clearance. A 32 gallon cart was parked in front of two electrical panels. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

2. On May 4, 2010 at 9:14 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #7-Electrical Panel Room access to electrical panel was less than 3'-0" clearance. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

3. On May 4, 2010 at 10:40 am surveyor #18107 observed in the 32-C1 smoke compartment on the 2nd floor that in the #19-Storage Closet access to electrical panel was less than 3'-0" clearance. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

4. On May 6, 2010 at 9:42 am surveyor #18107 observed in the 43-C1 smoke compartment on the 3rd floor that in the #19-Clean Supply Store Room access to electrical panel was less than 3'-0" clearance. Access to the electrical panel was blocked by a clean supply cart. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

5. On May 6, 2010 at 9:59 am surveyor #18107 observed in the 43-D1 smoke compartment on the 3rd floor that in the #19-Clean Supply Store Room access to electrical panel was less than 3'-0" clearance. Access to the electrical panel was blocked by a clean supply cart. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

6. On May 6, 2010 at 3:06 pm surveyor #18107 observed in the 43-B1 smoke compartment on the 3rd floor that in the #9-Closet access to electrical panel was less than 3'-0" clearance. Access to the electrical panel was blocked by a clean supply cart. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

7. On May 11, 2010 at 9:21 am surveyor #18107 observed in the 42-A2 smoke compartment on the 2nd floor that in the #2208-Central Supply Room (Hardware Rm.) access to electrical panel was less than 3'-0" clearance. The electrical panel was blocked by several boxes and a cart parked in front of the electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

8. On May 11, 2010 at 2:25 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #20-Storage Closet access to electrical panel was less than 3'-0" clearance. Storage shelves where placed in front of the electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

9. On May 4, 2010 at 1:53 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #28-Pantry an outlet within 4' of a sink was not equipped with a ground fault circuit interruption device. A toaster was plugged into the outlet. This observed situation was not compliant with NFPA 70 (1999 edition), 210-8. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

10. On May 6, 2010 at 11:10 am surveyor #18107 observed in the 43-F1 smoke compartment on the 3rd floor that in the Corridor by Smoke Barrier a 4" x 4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

11. On May 6, 2010 at 11:20 am surveyor #18107 observed in the 42-H1 smoke compartment on the 2nd floor that in the Electrical Switchgear Room a 4" x 4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

12. On May 7, 2010 at 11:01 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the #1039-Infection Control Office a two (2) gang electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

13. On May 7, 2010 at 2:42 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1038-6-Court Room a 4"x4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

14. On May 11, 2010 at 9:23 am surveyor #18107 observed in the 42-A2 smoke compartment on the 2nd floor that in the #2208-Central Supply Room (Hardware Rm.) a duplex electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

15. On May 11, 2010 at 2:22 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #31- Pantry and #17- Inpatient Art Supplies Room a double gang electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

16. On May 4, 2010 at 9:15 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #7-Electrical Panel Room electrical panel breaker(s) were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

17. On May 4, 2010 at 2:09 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #19-Clean Supply Store Room and #23-Electrical Closet electrical panel breaker(s) were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

18. On May 4, 2010 at 3:18 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the #24-Electrical Closet electrical panel breaker(s) were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide and maintain the required building construction type that had support steel covered with rated fire proofing, and sealed floor penetrations. This deficiency occurred in 4 of the 36 smoke compartments, and would affect 35 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 6, 2010 at 11:30 am surveyor #18107 observed in the 42-B smoke compartment on the 2nd floor that in the Maintenance Area fire proofing was missing from the structural steel at the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

2. On May 4, 2010 at 9:00 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the Treatment Room there were penetration(s) through the floor that were not fire stopped according to a UL design standard. The deficiency included an open hole in the floor. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

3. On May 4, 2010 at 2:13 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #23-Electrical Closet there were penetration(s) through the floor that were not fire stopped according to a UL design standard. The deficiency included a non-sealed sleeve. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

4. On May 6, 2010 at 11:40 am surveyor #18107 observed in the 42-B smoke compartment on the 2nd floor that in the Maintenance Toilet Room there were penetration(s) through the floor that were not fire stopped according to a UL design standard. The deficiency included four (4) floor penetrations near the sink, urinal and lavatory. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

5. On May 6, 2010 at 4:34 pm surveyor #18107 observed in the 21-N smoke compartment on the 1st floor that in the #1025-Room there were penetration(s) through the floor that were not fire stopped according to a UL design standard. The deficiency included electrical conduit. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces that had a smoke-tight corridor ceiling (in a sprinkled smoke zone), and sealed wall penetrations. This deficiency occurred in 2 of the 36 smoke compartments, and would affect 20 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 6, 2010 at 8:39 am surveyor #18107 observed in the 43-H1 smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included an access panel that was missing in the ceiling. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

2. On May 3, 2010 at 2:50 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the Corridor, penetration(s) were not sealed according to approved UL designs. 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 sprinkler pipe with rock wool backing but no fire-rated sealant. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

3. On May 6, 2010 at 8:41 am surveyor #18107 observed in the 43-H1 smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier, penetration(s) were not sealed according to approved UL designs. 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 an unsealed sleeve with cabling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

4. On May 6, 2010 at 8:47 am surveyor #18107 observed in the 43-H1 smoke compartment on the 3rd floor that in the Corridor by Smoke Barrier, penetration(s) were not sealed according to approved UL designs. 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 an unsealed sleeve with cabling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

Based on observation and interview, the facility did not provide corridor separation doors that had positive-latching dutch doors, doors with positive-latching hardware, and doors that would close when pushed or pulled. This deficiency occurred in 5 of the 36 smoke compartments, and would affect 50 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 8:42 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2013-Intake Foyer the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

2. On May 4, 2010 at 9:30 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the 2124-Office the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

3. On May 4, 2010 at 9:45 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2112-Police Report Room the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. The door had a manual dead bolt. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

4. On May 7, 2010 at 10:36 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the #1007-Mail Room the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. The upper door had a deadbolt that did not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

5. On May 7, 2010 at 1:48 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1095-Office and Main Court Room the door to the corridor was split in the middle to form a "dutch door". The upper door would not positively self-latch to the bottom door or the frame. The upper door had a deadbolt that did not positively self-latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

6. On May 3, 2010 at 2:25 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the #2329-Dishwashing Room the corridor door would not remain fully-closed if a force of 5 lbs were applied to the latch edge of the door. Positive latching was not possible because of mis-alignment. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

7. On May 7, 2010 at 11:55 am surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1084-Storage Room the door to the corridor was held open with a a door chuck. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

8. On May 11, 2010 at 9:18 am surveyor #18107 observed in the 42-A2 smoke compartment on the 2nd floor that in the #2208-Central Supply Room (Hardware Rm.) the door to the corridor was held open with a a patient lift. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

9. On May 11, 2010 at 2:30 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #23-Pantry the door to the corridor was held open with a food cart. There was a closer on the door. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls that had sealed wall penetrations and rated wall construction. This deficiency occurred in 20 of the 36 smoke compartments, and would affect 90 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 3, 2010 at 2:16 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2301-Food Service penetration(s) were not sealed according to approved UL designs. The deficiency included an opening at the top of the wall above a 48"x 20" mechanical duct. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

2. On May 4, 2010 at 3:26 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the #13-Conference Room penetration(s) were not sealed according to approved UL designs. The deficiency included various penetrations. The smoke barrier wall was not fire-rated because the top of wall at the deck was not sealed and screws were not fully-covered with joint compound. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

3. On May 5, 2010 at 2:04 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier penetration(s) were not sealed according to approved UL designs. The deficiency included multiple pipes. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

4. On May 6, 2010 at 11:46 am surveyor #18107 observed in the 42-B smoke compartment on the 2nd floor that in the 2220-Corridor by Smoke Barrier penetration(s) were not sealed according to approved UL designs. The deficiency included multiple ducts, sleeves, and pipes. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

5. On May 3, 2010 at 2:10 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the #2314-Staff CC's Office the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the uppermost 6" of wall was missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

6. On May 3, 2010 at 2:20 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the Corridor the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top of wall was not sealed at the deck above. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

7. On May 3, 2010 at 2:50 pm surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the 52A Corridor the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top of wall and both sides of the drywall wall were not sealed where they met the adjacent concrete block wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

8. On May 4, 2010 at 8:58 am surveyor #18107 observed in the 32-C1 smoke compartment on the 2nd floor that in the Corridor by Smoke Barrier, the smoke barrier wall was not constructed to a 30 minute fire resistance rating because screws were not covered with joint compound and the wall was not enclosed at the top of two (2) mechanical ducts. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

9. On May 4, 2010 at 2:58 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the top of the wall at the deck above was not sealed. The vertical side joints and joint against door frame header were not sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

10. On May 6, 2010 at 11:10 am surveyor #18107 observed in the 43-F1 smoke compartment on the 3rd floor that in the Corridor by Smoke Barrier the smoke barrier wall was not constructed to a 30 minute fire resistance rating because seams in the drywall were not taped and multiple screws were not covered with joint compound. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

11. On May 7, 2010 at 2:21 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the Old Library Room the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the wall contained un-rated glass in the walls and door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

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 that had smoke-tight seals at meeting edges, and closers on all doors. This deficiency occurred in 6 of the 36 smoke compartments, and would affect 50 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 9:46 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the Corridor at Smoke Barrier the room had double smoke barrier doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The doors were warped. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

2. On May 5, 2010 at 3:26 pm surveyor #18107 observed in the 53-C smoke compartment on the 3rd floor that in the #3308-Smoke Barrier Corridor Doors the room had double smoke barrier doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

3. On May 6, 2010 at 8:35 am surveyor #18107 observed in the 43-H1 smoke compartment on the 3rd floor that in the #3-04-Corridor near Women's Toilet the room had double smoke barrier doors with a gap greater than 1/8" at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The astragal on the door was damaged and was unable to provide a seal that resisted the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

4. On May 4, 2010 at 3:38 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the Corridor at Smoke Barrier the smoke barrier door would not self-close because the door was broken. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, rated doors, doors with positive-latching hardware, and sealed wall penetrations. This deficiency occurred in 9 of the 36 smoke compartments, and would affect 70 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 9:29 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the Electrical Closet the door would not self-close because there was no closer. This room was used for the storage of oxygen. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.) .

2. On May 4, 2010 at 1:41 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #5-Tub Room the door would not self-close because there was no closer. This room was used for storage. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.) .

3. On May 4, 2010 at 1:44 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #6-Office the door would not self-close because there was no closer. This room was used for storage. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

4. On May 4, 2010 at 1:48 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #41-Storage the door would not self-close because there was no closer. This room was used for storage. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

5. On May 4, 2010 at 1:49 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #11-Storage the door would not self-close because there was no closer. This room was used for storage. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

6. On May 4, 2010 at 2:01 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #34-Office and #29-Office the doors would not self-close because there were no door closers. This rooms were used for storage. The rooms were considered hazardous because they 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

7. On May 7, 2010 at 11:05 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the #1039-1-Storage Room the door would not self-close because there was no closing device on the door. The door was not labeled. The wall was not constructed to a 1-hour fire resistance rating. The room was used to store two (2) large 90 gallon paper storage bins. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

8. On May 7, 2010 at 11:25 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the #1045-Storage Room the door would not self-close because the door was not provided with a closing device. The door did not have a label to confirm its rating. The walls were not 1-hour rated. The same deficiency was observed in #1050-Storage Room and #1048-Storage Room. 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

9. On May 7, 2010 at 2:01 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1116-Storage Room and #1122-Medical Records Room the doors would not self-close because the closing devices were missing. The rooms were considered hazardous because they 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 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

10. On May 7, 2010 at 11:55 am surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1084-Storage Room the room was not sprinkled and the fire barrier door could not be verified to have the required rating. Two (2) walls were not constructed to a 1-hour fire rating. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

11. On May 3, 2010 at 3:11 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the #2330-Storage Room the door would not positively self-latch when released because of mis-alignment. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

12. On May 3, 2010 at 3:13 pm surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the #2337-Storage Room near loading dock the door would not positively self-latch when released because the doors were binding. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

13. On May 3, 2010 at 3:35 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2319-Materials Management Storeroom the door would not positively self-latch when released because of mis-alignment due to damage. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

14. On May 4, 2010 at 8:39 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2006-Storage Room the door would not positively self-latch when released because of mis-alignment. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

15. On May 3, 2010 at 12:00 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2312-Housekeeping Storage Room penetration(s) were not sealed according to approved UL designs. The deficiency included a 3"x 8" piece of wood embedded in the top of the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

16. On May 3, 2010 at 3:10 pm surveyor #18107 observed in the 52-A1 smoke compartment on the 2nd floor that in the #2329-Housekeeping Storage Room penetration(s) were not sealed according to approved UL designs. The deficiency included two (3'x 18", 24"x 12") ducts at two (2) walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

17. On May 11, 2010 at 9:34 am surveyor #18107 observed in the 42-A2 smoke compartment on the 2nd floor that in the #2208-Central Supply Room (Hardware Rm.) penetration(s) were not sealed according to approved UL designs. The deficiency included a minimum of eight (8) penetrations observed in one of the 1-hour fire-rated walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

18. On May 11, 2010 at 11:38 am surveyor #18107 observed in the 52-B1 smoke compartment on the 2nd floor that in the #2307A & #2311- Patient Storage Room the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall had a duct penetration that was not sealed and fire caulked through the 1-hour concrete block wall assembly. The room was used to store patient clothing and shelves were filled from 4 inches above the floor to at least 8 feet above the floor. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide enclosures around exit stairs that were free of storage. This deficiency occurred in 2 of the 36 smoke compartments, and would affect 20 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 1:40 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the Stairwell #3-1 the stairwell was used for storage. Storage included a wood pallet at the bottom of the steps. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

2. On May 4, 2010 at 2:49 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the Stairwell #5-5 the stairwell was used for storage. Storage included a wood pallet. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide egress paths at all times that had doors that were unlockable in the egress path, no swinging door obstructions, doors that swing in the direction of egress, and level walking surfaces in the path of egress. This deficiency occurred in 9 of the 36 smoke compartments, and would affect 'ALL' of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 11:14 am surveyor #18107 observed in the 32-C1 smoke compartment on the 2nd floor that in the Stairwell #3-4 the door was locked from the egress side. The door has a manual deadbolt lock that was not positive self-latching. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

2. On May 4, 2010 at 1:58 pm surveyor #18107 observed in the 32-A2 smoke compartment on the 2nd floor that in the Stairwell #32-A2 the door was locked from the egress side. A deadbolt was installed on the door that was not positive latching. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

3. On May 4, 2010 at 8:35 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2003-Electrical Closet one or more doors swung outward into the exit path and obstructed the path because the fully-open doors extended more than 7" into the required egress width. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

4. On May 4, 2010 at 9:35 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the 2124-Office one or more doors swung outward into the exit path and obstructed the path because the fully open door extended more than 7" into the required egress width. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

5. On May 7, 2010 at 11:55 am surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1075-Electrical Room one or more doors swung outward into the exit path and obstructed the path because they extended more than 7" into the required egress width. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

6. On May 4, 2010 at 11:11 am surveyor #18107 observed in the 32-B1 smoke compartment on the 2nd floor that in the Stairwell #3-4 the door in the path of egress did not swing in the direction of egress travel and the occupancy load of the egress was estimated to be at least 50 persons. The gate that interrupts the travel past the exit discharge swings against the direction of egress from the lower floor. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

7. On May 3, 2010 at 2:21 pm surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the 52-A Stair Discharge a portion of the path of egress had an abrupt change in elevation of 4" to 5" between two (2) concrete slabs due to soil erosion. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

8. On May 5, 2010 at 3:00 pm surveyor #18107 observed in the 53-C smoke compartment on the 3rd floor that in the Staff Entrance a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

9. On May 5, 2010 at 3:06 pm surveyor #18107 observed in the 53-C smoke compartment on the 3rd floor that in the Stair #5-1 a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

10. On May 6, 2010 at 9:33 am surveyor #18107 observed in the 43-C2 smoke compartment on the 3rd floor that in the Stair #4-3-Exit Discharge a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

11. On May 6, 2010 at 11:54 am surveyor #18107 observed in the 42-A1 smoke compartment on the 2nd floor that in the Stair #4-2 Exit Discharge a portion of the path of egress had an abrupt change in elevation were 8 panels of sidewalk that were broken and this created an un-level egress path to a public way. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

12. On May 6, 2010 at 2:35 pm surveyor #18107 observed in the 43-B1 smoke compartment on the 5th floor that in the Stair #4-5 Exit Discharge a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

13. On May 6, 2010 at 4:09 pm surveyor #18107 observed in the 43-A1 smoke compartment on the 3rd floor that in the Stair #4-1 Exit Discharge a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

14. On May 7, 2010 at 10:59 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the Stair #3-1 a portion of the path of egress had an abrupt change in elevation of greater than 1/2" between the slab panels of the sidewalk. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide and maintain multiple light 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 and the egress paths would be walk-able with redundant lighting. This deficiency occurred in 7 of the 36 smoke compartments, and would affect 90 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 3, 2010 at 2:20 pm till 4 pm surveyor #18107 observed in the smoke compartment on the 1st, 2nd & 3rd floors that in the various Stairwells the path of egress was illuminated by a single light 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 condition was observed at various times in a number of Stairwells , including, but not limited to, the following examples:
43-H2: Stair #4-15 Exit Discharge;
43-C1: Stair #4-14 Exit Discharge;
43-C2: Stair #4-3 Exit Discharge;
43-D2: Exit Discharge;
52-A2: Stair #52A Exit Discharge;
52-B: Stair #52B D Exit Discharge;
53-A1: Stair #5-3 Exit Discharge;
53-C: Stair #5-1 Exit Discharge;
This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

2. On May 11, 2010 at 2:45 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the Stair #5-2 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. The light was burnt-out and the space was dark, come night. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a fire alarm system that had visible alarm notification devices. This deficiency occurred in 1 of the 36 smoke compartments, and would affect 0 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
On May 11, 2010 at 9:25 am surveyor #18107 observed in the 42-A2 smoke compartment on the 2nd floor that in the #2208-Central Supply Room (Hardware Rm.) a visual fire alarm notification device was obstructed so it was not viewable from all areas of the space. The fire alarm visual device located on one of the walls was blocked for viewing by all areas of the room. This observed situation was not compliant with NFPA 72 (1999 edition), 4-4.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The Wisconsin Department of Health Services and Centers for Medicare Services have not identified any exceptions to permit non-compliance with NFPA 13 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities, since patients are incapable of self preservation and rely on a highly reliable sprinkler system to defend in place. This is consistent with NFPA 13 (1999 edition) 1-3, which notes that while NFPA 13 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. The facility did not provide a sprinkler system that had sprinklers free of obstructions near the ceiling, all rooms sprinkled when the code required sprinkling, and Stairwells with sprinklers. This deficiency occurred in 10 of the 36 smoke compartments, and would affect 'ALL' of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 4, 2010 at 8:36 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2003-Storage Closet, items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included items on shelves. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

2. On May 11, 2010 at 9:13 am surveyor #18107 observed in the 42-B2 smoke compartment on the 2nd floor that in the #2308-Central Supply/General Distribution Room, items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included multiple storage shelves in the middle of the room with materials stored less than 12 inches below the sprinkler heads. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

3. On May 7, 2010 at 2:30 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the Data Room where Halon was the source of fire-suppression, the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The room was equipped with a Halon extinguishing system, but was not considered effective because the mechanical ducts were not smoke-dampered to contain the gas within the room upon activation. This observed situation was not compliant with NFPA 101 (2000 edition). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

4. On May 6, 2010 at 10:58 am surveyor #18107 observed in the various smoke compartment on the lowest floor that in the Stairwells the stairwell did not have a sprinkler at the first landing above the bottom of the shaft. The surveyor observed this deficiency in Stairwells #4-10, #4-3, #4-2, #3-2, #3-3, #3-4, and #4-3. This observed situation was not compliant with NFPA 13 (1999 edition), 5-13.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

5. On May 3, 2010 at 2:35 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2318-Materials Management Store Room, the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included boxes and various materials stacked on the top of three (3) center aisle shelving units and the tops were less than 12" below the height of the sprinkler deflector. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

6. On May 3, 2010 at 2:40 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2318-Materials Management Storeroom, the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

7. On May 4, 2010 at 8:38 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #2005-Storage Closet, the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included items on shelves. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

8. On May 4, 2010 at 9:20 am surveyor #18107 observed in the 32-C1 smoke compartment on the 2nd floor that in the #1-Storage Closet, the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included materials stored on shelves. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

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 intact escutcheon rings, and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 10 of the 36 smoke compartments, and would affect 90 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 6, 2010 at 9:36 am surveyor #18107 observed in the smoke compartment on the 3rd and every other floor that in the occupied spaces the escutcheon ring on the sprinkler was missing, ajar, or damaged. This was observed throughout the facility at various times and in various smoke compartments, including, but not limited to the following examples:
43-B1: in #23-Electrical Closet, #37-Sleeping Room, #8 Toilet, #7-Sleeping Room, and #4-Tub Room;
43-C1: in #29-Seclusion Room, #3-Janitor Closet, #4-Shower Room, #10-Laundry Room, #35-Sleep Room, #40-Toilet Room, #13-Conference Room, and #24-Conference Room;
43-D: in Corridor, #2-Sleep Room, and #7-Sleep Room;
43-H1: in corridor #3208;#3-04-Women's Toilet;
21-N: in the French Quarter;
31-A: in the Reception, Vestibule, #1039-2, #1039-3, #1039-4, and #1039-5-Offices;
31-B: in #1121-Suite, #1010-Gathering Room, Medical Records Room, Corridor by Janitor Closet, and #1110-Suite Aisles;
32-D1: in the Corridor by Room 2116, Room #2120, #2109-Waiting;
32-C1: in #2132-8-Toilet Room, #3132-16-Consult Room,
32-B1: in the Corridor, #30-Room
32-A1: in #2102-31-Office
53-B1: in #6-Inpatient Room, #12-Dayroom, #40-Inpatient Room, Corridor by Room #40, #40A-Toilet Room;
53-C: in the Corridor by #3-Office This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

2. On May 6, 2010 at 9:04 am surveyor #18107 observed in the smoke compartment on the 1st, 2nd & 3rd floor that in the occupied areas there was one or more unsealed holes near the ceiling. The hole(s) included mis-aligned ceiling tile joints and gaps caused by damaged, out-of-place, or missing ceiling tiles or unsealed penetrations. This situation was observed throughout the facility, including but not limited to:
43-D1: in the Corridor by room #18, Nurse Station, #24-Office, and #13-Conference Room;
43-C1: in the corridor;
43-G1: in #3234-Music Therapy Room, and in the corridor by the Smoke Barrier;
43-B1: in #23-Electrical Closet;
43-H1: in #3-Office
21-N: in #3-Office
53-B1: in #24-Electrical Closet, #13-Conference Room
31-A1: in the entry vestibule to the Day Hospital;
31-B1: in #1120-suite; #2a-Court Room;
32-A1: #14-Office
32-D1: in #2013-Intake Foyer, Corridor by #2126-Office, #2126-Office
53-A1: in #24-Electrical Closet
53-C: in #3310-Staffing Suite Passage;
These holes 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. These observed situations were not compliant with NFPA 25 (1998 edition), 1-11.1. The deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

3. On May 11, 2010 at 2:47 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #3322-7-Inpatient Toilet Room there was one or more unsealed holes near the ceiling. The hole(s) included an opening in the valance light fixture because is was missing a lens. The fixture was located above the mirror at the handwashing lavatory. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide a means of egress that was free of impediments, including corridors free of materials that obstruct egress. This deficiency occurred in 1 of the 36 smoke compartments, and would affect 15 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
On May 3, 2010 at 3:17 pm surveyor #18107 observed in the 52-A2 smoke compartment on the 2nd floor that in the #52A Stair Discharge materials were stored in the exit access pathway, including a chair in the outside smoking area blocked the exit path. The materials were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 6), and 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the code that had properly sized storage containers for soiled/trash materials. This deficiency occurred in 1 of the 36 smoke compartments, and would affect 0 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
On May 5, 2010 at 3:36 pm surveyor #18107 observed in the 43-H1 smoke compartment on the 3rd floor that in the #3204-Office Suite mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Two (2) large 32 gallon waste containers were next to each, along with other large volumes of paper supplies in the office. This quantity of combustible materials must be enclosed with walls and doors that are appropriate for a hazardous space. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code that had working clearances at electrical panels, GFIC outlets, closed electrical raceways, and electrical panels with complete directories. This deficiency occurred in 13 of the 36 smoke compartments, and would affect 40 of the 120 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On May 3, 2010 at 2:30 pm surveyor #18107 observed in the 52-B smoke compartment on the 2nd floor that in the #2317-Loading Dock access to electrical panel was less than 3'-0" clearance. A 32 gallon cart was parked in front of two electrical panels. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

2. On May 4, 2010 at 9:14 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #7-Electrical Panel Room access to electrical panel was less than 3'-0" clearance. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

3. On May 4, 2010 at 10:40 am surveyor #18107 observed in the 32-C1 smoke compartment on the 2nd floor that in the #19-Storage Closet access to electrical panel was less than 3'-0" clearance. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

4. On May 6, 2010 at 9:42 am surveyor #18107 observed in the 43-C1 smoke compartment on the 3rd floor that in the #19-Clean Supply Store Room access to electrical panel was less than 3'-0" clearance. Access to the electrical panel was blocked by a clean supply cart. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

5. On May 6, 2010 at 9:59 am surveyor #18107 observed in the 43-D1 smoke compartment on the 3rd floor that in the #19-Clean Supply Store Room access to electrical panel was less than 3'-0" clearance. Access to the electrical panel was blocked by a clean supply cart. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

6. On May 6, 2010 at 3:06 pm surveyor #18107 observed in the 43-B1 smoke compartment on the 3rd floor that in the #9-Closet access to electrical panel was less than 3'-0" clearance. Access to the electrical panel was blocked by a clean supply cart. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

7. On May 11, 2010 at 9:21 am surveyor #18107 observed in the 42-A2 smoke compartment on the 2nd floor that in the #2208-Central Supply Room (Hardware Rm.) access to electrical panel was less than 3'-0" clearance. The electrical panel was blocked by several boxes and a cart parked in front of the electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

8. On May 11, 2010 at 2:25 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #20-Storage Closet access to electrical panel was less than 3'-0" clearance. Storage shelves where placed in front of the electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

9. On May 4, 2010 at 1:53 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #28-Pantry an outlet within 4' of a sink was not equipped with a ground fault circuit interruption device. A toaster was plugged into the outlet. This observed situation was not compliant with NFPA 70 (1999 edition), 210-8. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

10. On May 6, 2010 at 11:10 am surveyor #18107 observed in the 43-F1 smoke compartment on the 3rd floor that in the Corridor by Smoke Barrier a 4" x 4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

11. On May 6, 2010 at 11:20 am surveyor #18107 observed in the 42-H1 smoke compartment on the 2nd floor that in the Electrical Switchgear Room a 4" x 4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

12. On May 7, 2010 at 11:01 am surveyor #18107 observed in the 31-A smoke compartment on the 1st floor that in the #1039-Infection Control Office a two (2) gang electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

13. On May 7, 2010 at 2:42 pm surveyor #18107 observed in the 31-B smoke compartment on the 1st floor that in the #1038-6-Court Room a 4"x4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

14. On May 11, 2010 at 9:23 am surveyor #18107 observed in the 42-A2 smoke compartment on the 2nd floor that in the #2208-Central Supply Room (Hardware Rm.) a duplex electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

15. On May 11, 2010 at 2:22 pm surveyor #18107 observed in the 53-A1 smoke compartment on the 3rd floor that in the #31- Pantry and #17- Inpatient Art Supplies Room a double gang electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

16. On May 4, 2010 at 9:15 am surveyor #18107 observed in the 32-D1 smoke compartment on the 2nd floor that in the #7-Electrical Panel Room electrical panel breaker(s) were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.), and Staff C (Crisis Dir.).

17. On May 4, 2010 at 2:09 pm surveyor #18107 observed in the 32-A1 smoke compartment on the 2nd floor that in the #19-Clean Supply Store Room and #23-Electrical Closet electrical panel breaker(s) were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).

18. On May 4, 2010 at 3:18 pm surveyor #18107 observed in the 53-B1 smoke compartment on the 3rd floor that in the #24-Electrical Closet electrical panel breaker(s) were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff CC (Mech.Util.Engr.), Staff DD (Oper.& Maint.Sprvsr.).