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Based on observation and interview, the facility failed to provide and maintain a properly a constructed separation wall. This deficiency occurred in 2 of the 4 smoke compartments, and would affect 30 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 3C smoke compartment in the 3322-PHP Group Room that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. In addition, the door was equipped with a deadbolt that did not positively self-latch. The door had waiting room furniture in front of it and would be required to have the same 120 minute rating as the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4 and 8.2.3.2.3. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 8:20 am on Jan 12, 2010.

2. It was observed in the 3C smoke compartment in the 3318-Corridor that the separation wall was not constructed to a 2-hour fire rating because the wall above the ceiling was open and pipe penetrations were not sealed. The door was not rated. The wall was not constructed to a 2-hour rating in all locations it was inspected. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 8:10 am on Jan 12, 2010.

3. It was observed in the 2C smoke compartment in the 2351-Corridor that the separation wall was not constructed to a 2-hour fire rating because the wall above the ceiling was open and pipe penetrations were not sealed. The door was not rated. The wall was not constructed to a 2-hour rating in all locations it was inspected. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 9:45 am on Jan 12, 2010.

4. It was observed in the 2C smoke compartment in the 2318-Psych Office that the separation wall was not constructed to a 2-hour fire rating because the wall above the ceiling was open and pipe penetrations were not sealed. The door was not rated. The wall was not constructed to a 2-hour rating in all locations it was inspected. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 9:55 am on Jan 12, 2010.

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Based on observation and interview, the facility failed to provide and maintain the proper fire rated structure, walls, and floors for the type of construction used and as required by the code.This deficiency occurred in 3 of the 14 smoke compartments, and would affect 20 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 6R smoke compartment in the W6204-Storage that fire proofing was missing from the structural steel at the top flange on the south side of the central beam there is a 4" x 3" area of missing fire protection. Also confirm the fire protection on the underside of the 4" x 4" electrical raceway.. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6.2. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 8:25 am on Jan 11, 2010.

2. It was observed in the 5Q smoke compartment in the W5102-Electrical Room that fire proofing was missing from the structural steel at the bottom where the measured thickness is only 3/4". This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6.2. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 9:40 am on Jan 11, 2010.

3. It was observed in the LR smoke compartment in the W0200-Comminication Room that fire proofing was missing from the structural steel at the beam above the ceiling is thin in two locations. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6.2. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 2:15 pm on Jan 11, 2010.

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Based on observation and interview, the facility failed to provide and maintain corridor walls that meet code requirements for protecting the corridor from non-corridor spaces.This deficiency occurred in 1 of the 11 smoke compartments, and would affect 5 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1Z smoke compartment in the E1323-Microscope Room that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:25 pm on Jan 7, 2010.

2. It was observed in the 1Z smoke compartment in the E1444-Waiting Room that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative.The waiting space was 6'x8' in size. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:32 pm on Jan 7, 2010.

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Based on observation and interview, the facility failed to provide and maintain corridor door assemblies that meet code-requirements for protecting the corridor from non-corridor spaces.This deficiency occurred in 3 of the 11 smoke compartments, and would affect 20 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1Z smoke compartment in the E1334-Pamphlet Storage that the room had double corridor 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. Both the south and north set of corridor doors had 1/4" gaps at their meeting edges. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:30 pm on Jan 7, 2010.

2. It was observed in the LY smoke compartment in the E0600G-Auditorium that the room had double corridor 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.Both the south and north set of corridor doors had 1/4" gaps at their meeting edges. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.1. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 2:00 pm on Jan 7, 2010.

3. It was observed in the 3AA smoke compartment in the E3108, E3109 and E3113 Patient Rooms that 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 misajustment. The 24"x30" doors were located on nurse server compartments below windows in the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager), Staff TT (Peds Clinical Mngr) at 10:15 pm on Jan 7, 2010.

4. It was observed in the LY smoke compartment in the E0400-Rehab Reception that 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 the aluminum door had a manually operated latch that was retracted during administrative day. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 2:10 pm on Jan 7, 2010.

5. It was observed in the 1Z smoke compartment in the E1321-Clean Supply that the door to the corridor was held open with a wooden wedge.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. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:25 pm on Jan 7, 2010.

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Based on observation and interview, the facility failed to provide and maintain the proper fire-rated wall assemblies to enclose vertical openings, such as shafts. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 30 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 3C smoke compartment in the 3238-Equipment Room that penetration(s) were not sealed according to approved UL designs. Penetration(s) included a 2" x 3/4" on the west wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 8:50 am on Jan 12, 2010.

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Based on observation and interview, the facility failed to provide and maintain the fire-rating and smoke tightness of smoke barrier walls required by the code.This deficiency occurred in 14 of the 27 smoke compartments, and would affect 100 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 3A smoke compartment in the 3024-Smoke Barrier between 3A and 3E that penetration(s) were not sealed according to approved UL designs. Penetrations included an unsealed cable through a sleeve. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:23 pm on Jan 4, 2010.

2. It was observed in the 3C smoke compartment in the 3300-Smoke Barrier between 3C and 3E that penetration(s) were not sealed according to approved UL designs. Penetrations included conduits passing through the wall with multiple communication wires where the fire putty is falling out or was not properly installed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 2:27 pm on Jan 4, 2010.

3. It was observed in the 3D smoke compartment in the 3400-Corridor that penetration(s) were not sealed according to approved UL designs. Penetrations included an 1/8" wire where the through hole was not fire stopped. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 2:45 pm on Jan 4, 2010.

4. It was observed in the 2A smoke compartment in the Smoke Barrier between 2A and 2E that penetration(s) were not sealed according to approved UL designs. Penetrations included 1-2" sleeve with cables that were not fire stopped and 1-2" "Fire stop Pro SP-2" that did not have any fire stopping. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 10:45 am on Jan 5, 2010.

5. It was observed in the 2B smoke compartment in the Smoke Barrier between 2B and Core that penetration(s) were not sealed according to approved UL designs. Penetrations included a 2" sleeve where the annular space was not sealed at the top resulting in a 1/2" gap. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 11:00 am on Jan 5, 2010.

6. It was observed in the 1G smoke compartment in the 1905-Smoke Barrier between 1F and 1G that penetration(s) were not sealed according to approved UL designs. Penetrations included 2" sleeve with about 15 cables that did not have any fire stop sealant. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 9:15 am on Jan 6, 2010.

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Based on observation and interview, the facility failed to provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments.This deficiency occurred in 2 of the 4 smoke compartments, and would affect 20 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 3C smoke compartment in the 3179-Smoke Barrier between 3A and 3C that the pair of smoke barrier doors did not resist the passage of smoke because they did not have an effective astragal at their meeting edge. There was a 5/8" gap at the astragal at the top of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.6 and 8.3.4. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 9:07 am on Jan 12, 2010.

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Based on observation and interview, the facility failed to provide protection of the facility from the contents of hazardous room by using construction methods required by the code. This deficiency occurred in 1 of the 14 smoke compartments, and would affect 5 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the LR smoke compartment in the W0162-Storage that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 2:00 pm on Jan 11, 2010.

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Based on observation and interview, the facility failed to provide and maintain the proper fire-rated wall assemblies to enclose vertical openings used for exiting, such as stairs and exit passages. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 3 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 2C smoke compartment in the 2274-Stair D that the door would not positively self-latch when released because the latch stayed retracted. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 10:05 am on Jan 12, 2010.

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Based on observation and interview, the facility failed to provide and maintain the exit capacity width required for the number of persons in the facility.This deficiency occurred in 1 of the 27 smoke compartments, and would affect 10 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1B smoke compartment in the 1220-Medical Records Passageway that the exit width was 27" at the north exit door and 26" at an internal partition; where as the minimum width of 36" is required in accordance with NFPA 101 (2000 edition) 7.3.4.1 exception 3. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.1 and 7.3. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:30 pm on Jan 5, 2010.

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Based on observation and interview, the facility failed to ensure that all means of egress were readily available at all times. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 3 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1C smoke compartment in the Stair D first floor that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge.The exterior exit door did not have a window to view the actual outside and there was no exit sign to the exterior door or gate or other interrupting means to prevent continued downward travel. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7.3. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 10:10 am on Jan 12, 2010.

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Based on observation and interview, the facility failed to provide and maintain patient spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress.This deficiency occurred in 2 of the 27 smoke compartments, and would affect 30 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 3G smoke compartment in the 3602-corridor that the delayed egress lock (DEL) release process did not begin following 3 seconds of pushing the release mechanism. It was observed that the delayed egress lock did not have the required signage on the Stair G door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 8:50 am on Jan 5, 2010.

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Based on observation and interview, the facility failed to provide and maintain multiple fixtures or lamps in the interior and exterior means of egress so the path would still be illuminated if any single fixture or bulb failed.This deficiency occurred in 2 of the 4 smoke compartments, and would affect 30 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1A smoke compartment in the Stair A that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 10:20 am on Jan 12, 2010.

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Based on observation and interview, the facility failed to provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 3 of the 4 smoke compartments, and would affect 10 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1C smoke compartment in the Stair D exit discharge that the path of egress to the public way was not provided with any light fixtures to provide egress lighting. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 10:05 am on Jan 12, 2010.

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Based on observation and interview, the facility failed to provide and maintain emergency illumination of exit and directional signs.This deficiency occurred in 3 of the 11 smoke compartments, and would affect 50 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1AA smoke compartment in the 3001-Stair AA that the path of egress in the corridor was not readily apparent and an exit sign was not provided near the egress path within Stair AA that was visible from the stairs and 1st floor landing. The existing exit light was located at about 8' above the floor and view was blocked by a concrete header in the path of egress. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 2:30 pm on Jan 7, 2010.

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Based on observation and interview, the facility failed to provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, including the exceptions for not sprinkling a space. Full sprinkler protection is required to satisfy the exceptions permitted when a building is fully sprinkled, such as for the reduced rating of corridor walls doors and frames, reduced rating of corridor windows, reduced ratings of interior finishes, rooms open to corridors, storing recycle containers in non-rated rooms, and eliminating smoke dampers in smoke barriers. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 3 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 2C smoke compartment in the 2268-Passage that the space was equipped with both quick response and standard response sprinklers.The space had 3 lead links and 2 quick response heads. This observed situation was not compliant with NFPA 13 (1999 edition), 5-3.1.5.2. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 10:10 am on Jan 12, 2010.

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Based on observation and interview and a review of documents, the facility failed to maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. This deficiency occurred in 2 of the 11 smoke compartments, and would affect 5 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 3Z smoke compartment in the E3313A-Clinical Engineering Closet that there were three unsealed holes near the ceiling. The hole(s) included the top of the wall that was not sealed at the deck on three sides of the room. 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. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager), Staff TT (Peds Clinical Mngr) at 10:30 am on Jan 7, 2010.

2. It was observed in the 3Z smoke compartment in the E3306B-Storage that there was one or more unsealed holes near the ceiling. The hole(s) included a missing 2"x24" portion of the ceiling tile. 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. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager), Staff TT (Peds Clinical Mngr) at 10:35 am on Jan 7, 2010.

3. It was observed in the 2Z smoke compartment in the E2445-Clinical Engineering Equipment that there was one or more unsealed holes near the ceiling. The hole(s) included four 1"x3-1/4" openings in the ceiling tile. 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. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager), Staff XX (Womens and Childrens Clinical Mngr) at 12:30 pm on Jan 7, 2010.

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Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes.This deficiency occurred in 1 of the 14 smoke compartments, and would affect 3 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1Q smoke compartment in the W1156-Garage Corridor that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area.Three blue soiled linen bins, approximately 20 gallons each, were stored in the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.6. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 12:45 pm on Jan 11, 2010.

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Based on observation and interview, the facility failed to provide the safe storage and use of medical gases, as required by NFPA 99.This deficiency occurred in 1 of the 27 smoke compartments, and would affect 10 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1D smoke compartment in the E1620-GYN Equipment that combustible materials were stored too close to the storage site of cylinders of oxygen. Items stored included items on a medical supply cart located 6" from 5 exposed oxygen tanks. This observed situation was not compliant with NFPA 99 (1999 edition), 4-3.1.1.2. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 10:51 am on Jan 6, 2010.

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A. EGRESS ILLUMINATION REQUIREMENT: Emergency lighting of at least 1? hour duration is provided in accordance with NFPA 101 (2000 edition) 7-9

Based on observation and interview, the facility failed to provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure.

FINDINGS INCLUDE:
1. It was observed in the #1 smoke compartment in the Stair #1 & #2 exit discharges that the path of egress to the public way had no light fixtures at the exit discharge door and the facility was unable to confirm that the street light fixtures were powered from the emergency electrical system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:20 pm on Jan 6, 2010.

2. It was observed in the #1 smoke compartment in the Stair #1 & #2 that the facility was unable to provide documentation that the battery-powered emergency lights in the stairwells were tested for 30 seconds each month or 90 minutes each year. This observed situation was not compliant with NFPA 101 (2000 edition), 7.9.3. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:25 pm on Jan 6, 2010.
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B. SPRINKLER REQUIREMENT: If there is an automatic sprinkler system, it must be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. NFPA 13 (1999 Edition) 5-1.

Based on observation and interview, the facility failed to provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements.

FINDINGS INCLUDE:
It was observed in the #1 smoke compartment in the 210-Electrical Room that a sprinkler was located over 18" below the ceiling deck. Sprinklers can be a maximum of 12" below an unobstructed ceiling. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.4.1.1. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:30 pm on Jan 6, 2010.
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Based on observation and interview, the facility failed to provide the appropriate space used for the transferring of oxygen, as required by the code. This deficiency occurred in 1 of the 14 smoke compartments, and would affect 10 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the LQ smoke compartment in the W0350-Oxygen Transfer that designated interior room for transferring of liquid oxygen did not have the required precautionary no smoking sign posted for a liquid oxygen transferring location. This observed situation was not compliant with NFPA 99 (1999 edition) 8-6.2.5.2(c). This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:35 pm on Jan 11, 2010.

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Based upon observation the facility failed to provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code. This deficiency occurred in 1 of the 11 smoke compartments, and would affect 0 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the 1AA smoke compartment in the E1112-Registration that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a refrigerator and coffee pot. The multi-gage device was a brown light-gauge extension cord that did not appear to be UL listed for the amperage of the devices that were plugged into it.. A strip plug with a surge protection feature may be used in non-patient areas for computers, but non-computer equipment cannot be plugged into it. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8 and 517-18. This deficiency was observed and verified by surveyor 22219 and 28616, Staff K (Dir of Facilities), Staff M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:10 pm on Jan 7, 2010.

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