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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 a properly constructed separation wall. This deficiency occurred in 6 of the 27 smoke compartments, and would affect 50 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1H smoke compartment in the Stair H that the separation doors would not positively self-latch when released because the west door on the north set of doors was out adjustment and would not self-latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. 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 11:15 am on Jan 6, 2010.

2. It was observed in the LH smoke compartment in the 566-Stair H exit passage that penetration(s) were not sealed according to approved UL designs. Penetrations included a 3/4" conduit in the south wall that was sealed with a gray compound that the facility could not confirm was a listed fire stop product. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. 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 9:35 am on Jan 7, 2010.

3. It was observed in the 3Q smoke compartment in the Corridor that the separation wall was not constructed to have a 2-hour fire resistance rating because the top of the wall was not sealed at the deck. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. 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 1:48 pm on Jan 4, 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 the proper fire rated structure, walls, and floors for the type of construction used and as required by the code.This deficiency occurred in 7 of the 27 smoke compartments, and would affect 50 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 3100-Corridor that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 1:36 pm on Jan 4, 2010.

2. It was observed in the 3Q smoke compartment in the Corridor that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 1:40 pm on Jan 4, 2010.

3. It was observed in the 3E smoke compartment in the 3200-Corridor that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 2:06 pm on Jan 4, 2010.

4. It was observed in the 2D smoke compartment in the Corridor E2400 near smoke barrier 2D and 2Y that fire proofing was missing from the structural steel beam. Six feet of fire proofing material was missing on the bottom flange of the beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 11:45 am on Jan 5, 2010.

5. It was observed in the 1A smoke compartment in the 1008-Exit Passageway that fire proofing was missing from the structural steel beam. A ten foot by 3 inch wide portion of the fire proofing material was missing on the bottom flange of a beam that was located in the air plenum above the ceiling in the south wall of the exit passage. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 12:45 pm on Jan 5, 2010.

6. It was observed in the 1F smoke compartment in the 1870-Exit Passageway that fire proofing was missing from the structural steel beam. There was 4 inches of fire proofing missing on the bottom of the beam flange near stair "F". This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 5, 2010.

7. It was observed in the LD smoke compartment in the 420-Human Resources Files that fire proofing was missing from the structural steel beam. There were two holes in the fire proof insulation near the bottom of the beam on the west wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 8:20 am on Jan 7, 2010.

8. It was observed in the 5E smoke compartment in the Penthouse that there were penetration(s) through the floor that were not fire stopped according to a UL design standard. Penetration(s) included an open electrical junction box with unsealed 2" and 1 1/2" conduits through 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. 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 12:23 pm on Jan 4, 2010.

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 walls that meet code requirements for protecting the corridor from non-corridor spaces.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 1R smoke compartment in the W1418-Triage that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 3' x 3' sliding glass reception window as well as a through the wall mail box which was 16" 28" located 36" above the finished floor, neither of which were smoke tight. 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), 18.3.6.2.1. 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 1:00 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 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 3E smoke compartment in the 3200-Waiting 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. A detector in the adjacent corridor was 25 feet from the far corner of the waiting room. For smooth ceilings, all points on the ceiling must have a detector within 21', per NFPA 72 (1999) section 2-3.4.5.1.2. 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 2:17 pm on Jan 4, 2010.

2. It was observed in the 1A smoke compartment in the 1833-Holter Scan that the area was not separated from the exit egress corridor by wall construction and was used for the treatment of patients. The space was used for holter scanning. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 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 8:10 am on Jan 6, 2010.

3. It was observed in the 2E smoke compartment in the 2004-Waiting 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.A detector in the adjacent corridor was 25 feet from the far corner of the waiting room. For smooth ceilings, all points on the ceiling must have a detector within 21', per NFPA 72 (1999) section 2-3.4.5.1.2. 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 11:10 am on Jan 5, 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 corridor door assemblies that meet code-requirements for protecting the corridor from non-corridor spaces.This deficiency occurred in 3 of the 27 smoke compartments, and would affect 15 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1E smoke compartment in the 1012-Gift Shop 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 full height glass door had a manual dead bolt at the bottom frame of the door. The door also did not resist the passage of smoke because there were no stops on the frame. The room did not have any smoke detection and could not be considered as a room open to 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) at 1:45 pm on Jan 5, 2010.

2. It was observed in the 1H smoke compartment in the 1590-OR #4 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 door hardware was out of adjustment. 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 11:20 am on Jan 6, 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 9 of the 14 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 6R smoke compartment in the W6500-Assisi Conference Center that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. There was no astragal at the double doors, the gap is greater than 1/8". This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 9:10 am on Jan 11, 2010.

2. It was observed in the 6Q smoke compartment in the W6402-Administraton Reception that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. There was no astragal at the double doors, the gap is 3/8". This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 9:20 am on Jan 11, 2010.

3. It was observed in the 6Q smoke compartment in the W6300-Canticl Room that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. There was no astragal at the double doors, the gap is greater than 1/8". This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 9:25 am on Jan 11, 2010.

4. It was observed in the Q and R smoke compartment in the all patient rooms that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 9:45 am on Jan 11, 2010.

5. It was observed in the 2Q smoke compartment in the W2200 and W2234 Cath Lab that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This was at a door leading into a suite. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 12:25 pm on Jan 11, 2010.

6. It was observed in the 2Q smoke compartment in the W2120-Operating Rooms that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 12:25 pm on Jan 11, 2010.

7. It was observed in the 2Q smoke compartment in the W2154-Bulk Stores that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 12:31 pm on Jan 11, 2010.

8. It was observed in the 1Q smoke compartment in the W1131-East Emergency Passage that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 12:35 pm on Jan 11, 2010.

9. It was observed in the 1R smoke compartment in the W1238-West Emergency Passage that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 12:55 pm on Jan 11, 2010.

10. It was observed in the 1R smoke compartment in the W1450-Emergency North that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The measured gap was 1/4". This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 12:55 pm on Jan 11, 2010.

11. It was observed in the LQ smoke compartment in the W0312-Cardio Pulmonary that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 1:33 pm on Jan 11, 2010.

12. It was observed in the 1Q smoke compartment in the W1160-Fire Control Room that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The door stays open, the closer upon inspection closes very slowly and is not labeled. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 12:40 pm on Jan 11, 2010.

13. It was observed in the 1Q smoke compartment in the W1358 and W1360-Patient Rooms that the corridor door would not positively self-latch when pushed to a closed position because the sliding doors would not latch when forced closed. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. 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 1:16 pm on Jan 11, 2010.

14. It was observed in the LR smoke compartment in the W0166-Mechanical that the corridor door would not positively self-latch when pushed to a closed position because the inactive door has a manual flush bolt. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. 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 2:02 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, 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 proper fire-rated wall assemblies to enclose vertical openings, such as shafts.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 1G smoke compartment in the Shaft across from 1018 that the door was in a vertical opening and would not self-close because the 2 foot access door was not properly aligned to fully close and latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2. 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 3:00 pm on Jan 5, 2010.

2. It was observed in the 1A smoke compartment in the 1008 Exit Passage that an opening in an exit enclosure was from an unoccupied space. The unoccupied space was Electrical Closet 1009. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). 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 12:40 pm on Jan 5, 2010.

3. It was observed in the 1A smoke compartment in the 1100-Exit Passageway that penetration(s) were not sealed according to approved UL designs. Penetration(s) included 2-3/4" conduits. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:00 pm on Jan 5, 2010.

4. It was observed in the 2B smoke compartment in the Shaft 2A/B that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there was a 6" gap in the drywall joint above the access door. The drywall joint was not taped and there was no fire stopping. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. 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 10:55 am on Jan 5, 2010.

5. It was observed in the 1A smoke compartment in the 1009-Exit Passageway that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there was non-rated 24" x 24" recessed service panel box in the exit passage wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. 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 1:00 pm on Jan 5, 2010.

6. It was observed in the 1B smoke compartment in the 1202-Exit Passageway that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there was a 2 foot by 4 foot cut out for a drinking fountain. The existing construction did not permit confirmation of the continuity of the rated construction. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. 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 1:15 pm on Jan 5, 2010.

7. It was observed in the 1B smoke compartment in the Stair A that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the transom is not constructed to the same rating as the wall; where as the transom is required to meet the construction of the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. 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 5, 2010.

8. It was observed in the 1F smoke compartment in the 1870-Exit Passageway that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the ceiling access panel was not self closing. The facility relies on the ceiling to maintain the 1-hour enclosure in lieu of the wall extending to the deck above. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. 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 2:20 pm on Jan 5, 2010.

______________________________________

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.

______________________________________

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 2 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 3Y smoke compartment in the E3813-Smoke Barrier between 3Y and 3AA that penetration(s) were not sealed according to approved UL designs. Penetrations included a sleeve that was full of cables and did not have any fire stop material. 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), Staff TT (Peds Clinical Mngr) at 11:00 pm on Jan 7, 2010.

2. It was observed in the 3Y smoke compartment in the E3805-Smoke Barrier between 3Y and 3AA that penetration(s) were not sealed according to approved UL designs. Penetrations included two 2" insulated chilled water pipes that were not sealed. 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), Staff TT (Peds Clinical Mngr) at 11:12 pm on Jan 7, 2010.

______________________________________

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 2 of the 14 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 2R smoke compartment in the W2434-Communication Room that penetration(s) were not sealed according to approved UL designs. Penetrations included a 4" sleeve with approximately 20 cables without fire stopping; only fiberglass stuffing. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. 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 12:15 pm on Jan 11, 2010.

______________________________________

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.

______________________________________

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 4 of the 52 smoke compartments, and would affect 40 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1Q smoke compartment in the W1242-Smoke Barrier between 1R and 1Q 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. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 12:50 pm on Jan 11, 2010.

2. It was observed in the LQ smoke compartment in the W0400-Cardiac Rehab 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. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:35 pm on Jan 11, 2010.

3. It was observed in the 1R smoke compartment in the W1234-Smoke Barrier between 1R and 1Q that the smoke barrier door was not self-closing because the fire shutter was blocked by a tape dispenser and papers. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.6 . 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 12:50 pm on Jan 11, 2010.

______________________________________

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 6 of the 27 smoke compartments, and would affect 50 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1G smoke compartment in the Smoke Barrier between 1H and 1G that 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. 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 10:00 am on Jan 6, 2010.

2. It was observed in the 3G smoke compartment in the 3700-Corridor that the smoke barrier door would not self-close because there was an imbalance of air from 3G. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . 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 8:10 am on Jan 4, 2010.

3. It was observed in the 3G smoke compartment in the Smoke Barrier between 3G and 3K that the smoke barrier door would not self-close because of an imbalance on either side of the smoke barrier door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . 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 9:30 am on Jan 5, 2010.

4. It was observed in the 1F smoke compartment in the 1905-Smoke Barrier between 1F and 1K that the smoke barrier door would not self-close because an air flow imbalance between the smoke barrier compartments. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . 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 9:25 am on Jan 6, 2010.

______________________________________

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.

______________________________________

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 4 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 2A smoke compartment in the 2115-Laundry that the door would not self-close because the door was misaligned to close fully. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 18.3.6.3.4. 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 9:30 am on Jan 12, 2010.

______________________________________

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 3 of the 11 smoke compartments, and would affect 10 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 3Y smoke compartment in the E3601-CPR Storage that the door would not self-close because the closer had been removed from the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 11:10 pm on Jan 7, 2010.

2. It was observed in the 1AA smoke compartment in the E1104-Business Office that the door would not self-close because there was no closer on the door. The room is considered hazardous because there is a 55 gallon recycling bin in the room. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 1:10 pm on Jan 7, 2010.

3. It was observed in the 1Y smoke compartment in the E1638-Former Dark Room that the door would not self-close because there was no closer on the door. The room is considered hazardous because there is a 51 gallon x-ray film recycling bin in the 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. 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 1:45 pm on Jan 7, 2010.

______________________________________

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 7 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 3B smoke compartment in the 3204-Clean Supply that the door would not self-close because there was no door closer on the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 2:03 pm on Jan 4, 2010.

2. It was observed in the 1F smoke compartment in the 1972-Equipment Room that the door would not self-close because there was no door closer on the door. 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. 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 8:55 am on Jan 6, 2010.

3. It was observed in the 1G smoke compartment in the 1701-Copy Room that the door would not self-close because there was no closer on the door. The room is considered hazardous because there is a recycling bin in the 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. 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 10:10 am on Jan 6, 2010.

4. It was observed in the 1D smoke compartment in the 1424-Clean Hold that the door would not self-close because a plugged in electrical cord to a computer on wheels was obstructing the door operation. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 10:47 am on Jan 6, 2010.

5. It was observed in the 1D smoke compartment in the E1718-Sterile Supply that the door would not self-close because the closer was not adjusted to permit full closure. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 10:48 am on Jan 6, 2010.

6. It was observed in the LE smoke compartment in the 910-Bulk Stores that the door would not self-close because the closure was inoperable. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 2:55 pm on Jan 6, 2010.

7. It was observed in the 1G smoke compartment in the 1719 X-Ray Tech Area that the door would not positively self-latch when released because the door to the Registration Area had push-pull hardware and would not latch. Also, the doors to the Registration and Corridor did not have a door closing device. The room was considered hazardous because a 55 gallon trash container was used to collect old X-ray films. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 9:50 am on Jan 6, 2010.

8. It was observed in the 1D smoke compartment in the E1717-Soiled Hold that the door would not positively self-latch when released because the hardware was out of adjustment. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 10:51 am on Jan 6, 2010.

9. It was observed in the 1H smoke compartment in the 1678-Soiled Hold that the door would not positively self-latch when released because the hardware was out of adjustment. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 11:10 am on Jan 6, 2010.

10. It was observed in the LA smoke compartment in the 808-Environmental Services Storage that penetration(s) were not sealed according to approved UL designs. Penetration(s) included a cable tray that had openings that were not filled with fire stop material. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. 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 2:35 pm on Jan 6, 2010.

11. It was observed in the 3G smoke compartment in the 3744-Soiled Hold that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall had a 6" hole above the ceiling on the south side. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials that was considered hazardous by the authority having jurisdiction at the time of the survey. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. 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 5, 2010.

______________________________________

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.

______________________________________

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 4 of the 14 smoke compartments, and would affect 40 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the LR smoke compartment in the W0002-Stair R that the door was not equipped with a door closer. of an imbalance on either side a the smoke barrier door. This observed situation was not compliant with NFPA 101, 18.3.1.1; 8.2.5.4, and 8.2.3.2. 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 1:46 pm on Jan 11, 2010.

______________________________________

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.

______________________________________

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.

______________________________________

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 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 travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge.The "No Exit" signs at the stairs leading to the lower level are not an effective means of preventing travel past the 1st floor exit discharge, which is not directly visible. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 2:30 pm on Jan 7, 2010.

______________________________________

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 3 of the 27 smoke compartments, and would affect 50 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 3724-corridor that the door was locked from the egress side. There was a pair of doors locked with a magnetic lock with a push button for secondary release but no sensor for automatic release as required by NFPA 101(2000 edition), 7.2.1.6.2(a). This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. 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 9:10 am on Jan 5, 2010.

2. It was observed in the 3G smoke compartment in the 3739-corridor that the door was locked from the egress side. There was a pair of doors locked with a magnetic lock with a push button for secondary release but no sensor for automatic release as required by NFPA 101(2000 edition), 7.2.1.6.2(a). This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. 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 9:20 am on Jan 5, 2010.

3. It was observed in the 3K smoke compartment in the Stair K that one or more doors swung outward into the exit path and obstructed the path because the 33" door swung into a 42" landing and obstructed the clear width down to 15.5" where as the required minimum clear width is 22". Stair K is a required exit from the adjacent health care occupancy on the 1st and 2nd floors. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.4. 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 10:00 am on Jan 5, 2010.

4. It was observed in the 3K smoke compartment in the North skywalk door that the door in the path of egress did not swing in the direction of egress travel The occupancy load of the egress was estimated to be at least 50 persons. The egress path is from smoke compartment 3G is into the skywalk and the single egress pair of doors swung into the 3G space. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.2. 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 5, 2010.

______________________________________

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.

______________________________________

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 3 of the 11 smoke compartments, and would affect 50 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 3AA smoke compartment in the 3001-Stair AA that a delayed egress lock (DEL) did not activate within 3 seconds of pushing the release mechanism. the delayed egress lock (DEL) activated after 4 seconds (maximum 3 seconds permitted) and released after 21 seconds (maximum of 15 seconds permitted). 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), Staff TT (Peds Clinical Mngr) at 10:00 am on Jan 7, 2010.

2. It was observed in the 2Z smoke compartment in the E2002-3Z Stairs that a delayed egress lock (DEL) did not activate within 3 seconds of pushing the release mechanism. the delayed egress lock (DEL) released after 17 seconds (maximum of 15 seconds permitted). The door also required more than 30 pounds of force to operate. 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), Staff XX (Womens and Childrens Clinical Mngr) at 12:15 pm on Jan 7, 2010.

3. It was observed in the 2Y smoke compartment in the E2003-Stair Y that a delayed egress lock (DEL) did not release within 15 seconds of activation. The delayed egress lock (DEL) released after 16 seconds (maximum of 15 seconds permitted). The door also required more than 30 pounds of force to operate. 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), Staff XX (Womens and Childrens Clinical Mngr) at 12:42 pm on Jan 7, 2010.

______________________________________

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.

______________________________________

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.

_________________________________________

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.

______________________________________

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 14 smoke compartments, and would affect 80 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the LR smoke compartment in the W0002-Stair R that the change in direction in the path of egress was not readily apparent and an exit sign with an arrow was not provided. When exiting from the Cardiac Rehab area a turn to the right is needed to enter the 'R' stairwell and there was no exit sign with an arrow provided. 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 1:48 pm on Jan 11, 2010.

2. It was observed in the 5Q smoke compartment in the W5038-Corridor that an exit sign was installed over the door to a 6 foot wide side corridor for inpatient units with a 36 inch wide door. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 9:55 am on Jan 11, 2010.

3. It was observed in the 3Q smoke compartment in the W3368-Corridor that an exit sign was installed over the door to a 6 foot wide side corridor for inpatient units with a 36 inch wide door. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 11:15 am on Jan 11, 2010.

4. It was observed in the 5Q smoke compartment in the W5038-Corridor that an exit sign was installed over the door to a 6 foot wide side corridor for inpatient units with a 36 inch wide door. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 9:55 am on Jan 11, 2010.

______________________________________

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 27 smoke compartments, and would affect 50 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 3100-Corridor that an exit sign was installed over the door to the Cardio-Vascular Institute building which was only accessible with an access card. An egress stair "A" was immediately adjacent. The facility staff confirmed that the doors leading to the Cardio-Vascular Institute building were not an egress path. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 1:38 pm on Jan 4, 2010.

2. It was observed in the 2A smoke compartment in the Smoke Barrier between 2A and 2R that an exit sign was installed over the door to the Cardio-Vascular Institute building which was only accessible with an access card. Egress stair "A" was immediately adjacent. The facility staff confirmed that the doors leading to the Cardio-Vascular Institute building were not an egress path. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 10:50 am on Jan 5, 2010.

3. It was observed in the 3G smoke compartment in the 3745-Corridor that an exit sign was installed over the door to corridor 3745, which was equipped with a magnetic lock. Corridor 3745 was not a required exit because egress was available through corridor 3739. Also, exit sign #342 directed exit toward corridor 3739 which was 6 feet wide and represented a narrowing of the egress path from the 8 foot wide corridor 3745. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 8:45 am on Jan 5, 2010.

4. It was observed in the 1F smoke compartment in the 1870-Exit Passageway that the path of travel toward the double doors leading to corridor 1860 was likely to be mistaken as an exit and a "NO Exit" sign was not provided. This path was in a straight line with the normal direction of travel, and the double doors in the direct path appeared to be an exit because the exterior was visible through a window in the doors. 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 2:10 pm on Jan 5, 2010.

______________________________________

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.

______________________________________

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 3 of the 14 smoke compartments, and would affect 10 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 2Q smoke compartment in the W2300-Reception that 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 a 23 1/2" deep soffit. 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. 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 12:10 pm on Jan 11, 2010.

2. It was observed in the LR smoke compartment in the W0458-Storage #3 that 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 shelving units that had the top shelf located 10" below the sprinkler deflector.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. 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 1:44 pm on Jan 11, 2010.

3. It was observed in the LQ smoke compartment in the W0124-Locker Room that 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 Materials were placed on top of metal lockers so they were approximately 15" below the sprinkler deflector.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. 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 11, 2010.

______________________________________

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 3 of the 27 smoke compartments, and would affect 10 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the LA smoke compartment in the 102-Gift Shop Storage that 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 various gift shop sales items. The sprinkler was installed directly above shelving located on the perimeter walls.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. 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 8:05 am on Jan 7, 2010.

2. It was observed in the 3E smoke compartment in the 3009-Nurse Station that a sprinkler was located 16" below the finished hard ceiling surface where a lay-in decorative parabolic ceiling was installed. 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 2:15 pm on Jan 4, 2010.

3. It was observed in the 3C smoke compartment in the 3302-Electrical Room that a sprinkler was located estimated to be 24" below the deck above which is not permitted for upright heads. 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 2:24 pm on Jan 4, 2010.

______________________________________

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.

______________________________________

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 14 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 1Q smoke compartment in the W1156-Garage Corridor that there was one or more unsealed holes near the ceiling. The hole(s) included 2 ceiling tile were ajar. 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) at 12:45 pm on Jan 11, 2010.

2. It was observed in the LQ smoke compartment in the W0140-Chemical Storage that there was one or more unsealed holes near the ceiling. The hole(s) included an 8" PVC tube through the ceiling with a 3/4" gap. The cap on the sprinkler was not tight to the ceiling. 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) at 1:55 pm on Jan 11, 2010.

______________________________________

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 4 smoke compartments, and would affect 15 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 2C smoke compartment in the 2306-Toilet that the escutcheon ring on the sprinkler was missing in this location. 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 . 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.

2. It was observed in the 2C smoke compartment in the 2311-Pain Management Passage that the escutcheon ring on the sprinkler was missing in this location. 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 . 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 9:58 am on Jan 12, 2010.

3. It was observed in the LA smoke compartment in the 102-Pump Room that the cabinet of spare sprinklers did not contain a wrench that would fit the heads in the cabinet. The wrench for the suicide resistant sprinkler heads was missing. This observed situation was not compliant with NFPA 25 (1998 edition), 2-4.1.4. 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 10:50 am on Jan 12, 2010.

4. It was observed in the 3C smoke compartment in the 3268-Telecommunication Room that there was one or more unsealed holes near the ceiling. The hole(s) included a cable bundle through the ceiling and a 1/2" gap. 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 UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 8:30 am on Jan 12, 2010.

______________________________________

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 6 of the 27 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 1A smoke compartment in the 1848-Woman's Locker that the escutcheon ring on the sprinkler was missing. 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 . 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 8:05 am on Jan 6, 2010.

2. It was observed in the LA smoke compartment in the 916-Telecommunications Closet that the escutcheon ring on the sprinkler was missing in this location. 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 . 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 2:55 pm on Jan 6, 2010.

3. It was observed in the LD smoke compartment in the 539-Cold Production that the sprinkler showed signs of corrosion. This observed situation was not compliant with NFPA 25 (998 edition), 2-2.1 .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 9:15 am on Jan 7, 2010.

4. It was observed in the 3A smoke compartment in the 3102-Clean Supply that there was one or more unsealed holes near the ceiling. The hole(s) included six broken and/or mis-cut ceiling tiles. 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) at 1:55 pm on Jan 4, 2010.

5. It was observed in the 1A smoke compartment in the 1115-Communications Closet that there was one or more unsealed holes near the ceiling. The hole(s) included a 2 1/2", a 2" x 6" and a 1" x 3" hole. 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) at 2:25 pm on Jan 5, 2010.

6. It was observed in the LD smoke compartment in the 426-Decontamination Mens Locker that there was one or more unsealed holes near the ceiling. The hole(s) included a 3"x3" triangular portion of missing ceiling tile material. 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) at 8:38 am on Jan 7, 2010.

7. It was observed in the LD smoke compartment in the 634-Catering Room that there was one or more unsealed holes near the ceiling. The hole(s) included a 8"x3" gap in the ceiling tile where a bundle of syrup tubing penetrated the surface. 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) at 9:25 am on Jan 7, 2010.

8. It was observed in the 1F smoke compartment in the 1972-Equipment Room that there was one or more unsealed holes near the ceiling. The hole(s) included a 8"x6" hole 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) at 8:55 am on Jan 6, 2010.

9. It was observed in the 1F smoke compartment in the 1955-Mechanical Room that the wall did not fully enclose the room up to the ceiling/floor above. The wall was open for 6" at the deck. This opening 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) at 8:50 am on Jan 6, 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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Based upon observation the facility failed to provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code. This deficiency occurred in 5 of the 27 smoke compartments, and would affect 15 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 3D smoke compartment in the 3303-Staff Restroom that a 30" x 30" 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. 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 4, 2010.

2. It was observed in the 3D smoke compartment in the 3400-Corridor that a 4" x 4" alarm junction 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. 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 2:46 pm on Jan 4, 2010.

3. It was observed in the 3G smoke compartment in the Soiled Hold that a single 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. 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 8:20 am on Jan 5, 2010.

4. It was observed in the 1A smoke compartment in the 1742-EMG and 1743-EEG that 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. 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 8:20 am on Jan 6, 2010.

5. It was observed in the 1F smoke compartment in the 1917-Former Ultra-Sound Processing that a 4"x4" and single 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. 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 9:10 am on Jan 6, 2010.

6. It was observed in the 3G smoke compartment in the 3602-corridor that access to the electrical panel was not restricted to authorized use only, because panel 3G2L was not locked and was in a public corridor. This observed situation was not compliant with NFPA 70 (1999 edition), Article 110-31?. 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 9:00 am on Jan 5, 2010.

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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 a properly constructed separation wall. This deficiency occurred in 6 of the 27 smoke compartments, and would affect 50 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1H smoke compartment in the Stair H that the separation doors would not positively self-latch when released because the west door on the north set of doors was out adjustment and would not self-latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. 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 11:15 am on Jan 6, 2010.

2. It was observed in the LH smoke compartment in the 566-Stair H exit passage that penetration(s) were not sealed according to approved UL designs. Penetrations included a 3/4" conduit in the south wall that was sealed with a gray compound that the facility could not confirm was a listed fire stop product. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. 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 9:35 am on Jan 7, 2010.

3. It was observed in the 3Q smoke compartment in the Corridor that the separation wall was not constructed to have a 2-hour fire resistance rating because the top of the wall was not sealed at the deck. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. 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 1:48 pm on Jan 4, 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 the proper fire rated structure, walls, and floors for the type of construction used and as required by the code.This deficiency occurred in 7 of the 27 smoke compartments, and would affect 50 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 3100-Corridor that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 1:36 pm on Jan 4, 2010.

2. It was observed in the 3Q smoke compartment in the Corridor that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 1:40 pm on Jan 4, 2010.

3. It was observed in the 3E smoke compartment in the 3200-Corridor that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 2:06 pm on Jan 4, 2010.

4. It was observed in the 2D smoke compartment in the Corridor E2400 near smoke barrier 2D and 2Y that fire proofing was missing from the structural steel beam. Six feet of fire proofing material was missing on the bottom flange of the beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 11:45 am on Jan 5, 2010.

5. It was observed in the 1A smoke compartment in the 1008-Exit Passageway that fire proofing was missing from the structural steel beam. A ten foot by 3 inch wide portion of the fire proofing material was missing on the bottom flange of a beam that was located in the air plenum above the ceiling in the south wall of the exit passage. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 12:45 pm on Jan 5, 2010.

6. It was observed in the 1F smoke compartment in the 1870-Exit Passageway that fire proofing was missing from the structural steel beam. There was 4 inches of fire proofing missing on the bottom of the beam flange near stair "F". This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 5, 2010.

7. It was observed in the LD smoke compartment in the 420-Human Resources Files that fire proofing was missing from the structural steel beam. There were two holes in the fire proof insulation near the bottom of the beam on the west wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. 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 8:20 am on Jan 7, 2010.

8. It was observed in the 5E smoke compartment in the Penthouse that there were penetration(s) through the floor that were not fire stopped according to a UL design standard. Penetration(s) included an open electrical junction box with unsealed 2" and 1 1/2" conduits through 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. 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 12:23 pm on Jan 4, 2010.

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 walls that meet code requirements for protecting the corridor from non-corridor spaces.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 1R smoke compartment in the W1418-Triage that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 3' x 3' sliding glass reception window as well as a through the wall mail box which was 16" 28" located 36" above the finished floor, neither of which were smoke tight. 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), 18.3.6.2.1. 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 1:00 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 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 3E smoke compartment in the 3200-Waiting 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. A detector in the adjacent corridor was 25 feet from the far corner of the waiting room. For smooth ceilings, all points on the ceiling must have a detector within 21', per NFPA 72 (1999) section 2-3.4.5.1.2. 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 2:17 pm on Jan 4, 2010.

2. It was observed in the 1A smoke compartment in the 1833-Holter Scan that the area was not separated from the exit egress corridor by wall construction and was used for the treatment of patients. The space was used for holter scanning. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 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 8:10 am on Jan 6, 2010.

3. It was observed in the 2E smoke compartment in the 2004-Waiting 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.A detector in the adjacent corridor was 25 feet from the far corner of the waiting room. For smooth ceilings, all points on the ceiling must have a detector within 21', per NFPA 72 (1999) section 2-3.4.5.1.2. 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 11:10 am on Jan 5, 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 corridor door assemblies that meet code-requirements for protecting the corridor from non-corridor spaces.This deficiency occurred in 3 of the 27 smoke compartments, and would affect 15 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1E smoke compartment in the 1012-Gift Shop 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 full height glass door had a manual dead bolt at the bottom frame of the door. The door also did not resist the passage of smoke because there were no stops on the frame. The room did not have any smoke detection and could not be considered as a room open to 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) at 1:45 pm on Jan 5, 2010.

2. It was observed in the 1H smoke compartment in the 1590-OR #4 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 door hardware was out of adjustment. 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 11:20 am on Jan 6, 2010.

______________________________________

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 9 of the 14 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 6R smoke compartment in the W6500-Assisi Conference Center that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. There was no astragal at the double doors, the gap is greater than 1/8". This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 9:10 am on Jan 11, 2010.

2. It was observed in the 6Q smoke compartment in the W6402-Administraton Reception that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. There was no astragal at the double doors, the gap is 3/8". This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 9:20 am on Jan 11, 2010.

3. It was observed in the 6Q smoke compartment in the W6300-Canticl Room that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. There was no astragal at the double doors, the gap is greater than 1/8". This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 9:25 am on Jan 11, 2010.

4. It was observed in the Q and R smoke compartment in the all patient rooms that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 9:45 am on Jan 11, 2010.

5. It was observed in the 2Q smoke compartment in the W2200 and W2234 Cath Lab that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. This was at a door leading into a suite. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 12:25 pm on Jan 11, 2010.

6. It was observed in the 2Q smoke compartment in the W2120-Operating Rooms that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 12:25 pm on Jan 11, 2010.

7. It was observed in the 2Q smoke compartment in the W2154-Bulk Stores that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 12:31 pm on Jan 11, 2010.

8. It was observed in the 1Q smoke compartment in the W1131-East Emergency Passage that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 12:35 pm on Jan 11, 2010.

9. It was observed in the 1R smoke compartment in the W1238-West Emergency Passage that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 12:55 pm on Jan 11, 2010.

10. It was observed in the 1R smoke compartment in the W1450-Emergency North that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The measured gap was 1/4". This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 12:55 pm on Jan 11, 2010.

11. It was observed in the LQ smoke compartment in the W0312-Cardio Pulmonary that the room had double corridor doors with a gap 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), 18.2.3.5-exception 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 1:33 pm on Jan 11, 2010.

12. It was observed in the 1Q smoke compartment in the W1160-Fire Control Room that the room had double corridor doors with a gap at their meeting edges that was not sealed with an astragal to resist the passage of smoke. The door stays open, the closer upon inspection closes very slowly and is not labeled. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5-exception 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 12:40 pm on Jan 11, 2010.

13. It was observed in the 1Q smoke compartment in the W1358 and W1360-Patient Rooms that the corridor door would not positively self-latch when pushed to a closed position because the sliding doors would not latch when forced closed. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. 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 1:16 pm on Jan 11, 2010.

14. It was observed in the LR smoke compartment in the W0166-Mechanical that the corridor door would not positively self-latch when pushed to a closed position because the inactive door has a manual flush bolt. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. 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 2:02 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, 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.

______________________________________

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 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 1G smoke compartment in the Shaft across from 1018 that the door was in a vertical opening and would not self-close because the 2 foot access door was not properly aligned to fully close and latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2. 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 3:00 pm on Jan 5, 2010.

2. It was observed in the 1A smoke compartment in the 1008 Exit Passage that an opening in an exit enclosure was from an unoccupied space. The unoccupied space was Electrical Closet 1009. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). 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 12:40 pm on Jan 5, 2010.

3. It was observed in the 1A smoke compartment in the 1100-Exit Passageway that penetration(s) were not sealed according to approved UL designs. Penetration(s) included 2-3/4" conduits. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:00 pm on Jan 5, 2010.

4. It was observed in the 2B smoke compartment in the Shaft 2A/B that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there was a 6" gap in the drywall joint above the access door. The drywall joint was not taped and there was no fire stopping. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. 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 10:55 am on Jan 5, 2010.

5. It was observed in the 1A smoke compartment in the 1009-Exit Passageway that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there was non-rated 24" x 24" recessed service panel box in the exit passage wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. 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 1:00 pm on Jan 5, 2010.

6. It was observed in the 1B smoke compartment in the 1202-Exit Passageway that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there was a 2 foot by 4 foot cut out for a drinking fountain. The existing construction did not permit confirmation of the continuity of the rated construction. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. 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 1:15 pm on Jan 5, 2010.

7. It was observed in the 1B smoke compartment in the Stair A that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the transom is not constructed to the same rating as the wall; where as the transom is required to meet the construction of the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. 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 5, 2010.

8. It was observed in the 1F smoke compartment in the 1870-Exit Passageway that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the ceiling access panel was not self closing. The facility relies on the ceiling to maintain the 1-hour enclosure in lieu of the wall extending to the deck above. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. 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 2:20 pm on Jan 5, 2010.

______________________________________

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.

______________________________________

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 2 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 3Y smoke compartment in the E3813-Smoke Barrier between 3Y and 3AA that penetration(s) were not sealed according to approved UL designs. Penetrations included a sleeve that was full of cables and did not have any fire stop material. 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), Staff TT (Peds Clinical Mngr) at 11:00 pm on Jan 7, 2010.

2. It was observed in the 3Y smoke compartment in the E3805-Smoke Barrier between 3Y and 3AA that penetration(s) were not sealed according to approved UL designs. Penetrations included two 2" insulated chilled water pipes that were not sealed. 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), Staff TT (Peds Clinical Mngr) at 11:12 pm on Jan 7, 2010.

______________________________________

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 2 of the 14 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 2R smoke compartment in the W2434-Communication Room that penetration(s) were not sealed according to approved UL designs. Penetrations included a 4" sleeve with approximately 20 cables without fire stopping; only fiberglass stuffing. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. 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 12:15 pm on Jan 11, 2010.

______________________________________

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.

______________________________________

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 4 of the 52 smoke compartments, and would affect 40 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1Q smoke compartment in the W1242-Smoke Barrier between 1R and 1Q 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. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 12:50 pm on Jan 11, 2010.

2. It was observed in the LQ smoke compartment in the W0400-Cardiac Rehab 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. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 1:35 pm on Jan 11, 2010.

3. It was observed in the 1R smoke compartment in the W1234-Smoke Barrier between 1R and 1Q that the smoke barrier door was not self-closing because the fire shutter was blocked by a tape dispenser and papers. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.6 . 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 12:50 pm on Jan 11, 2010.

______________________________________

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 6 of the 27 smoke compartments, and would affect 50 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 1G smoke compartment in the Smoke Barrier between 1H and 1G that 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. 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 10:00 am on Jan 6, 2010.

2. It was observed in the 3G smoke compartment in the 3700-Corridor that the smoke barrier door would not self-close because there was an imbalance of air from 3G. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . 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 8:10 am on Jan 4, 2010.

3. It was observed in the 3G smoke compartment in the Smoke Barrier between 3G and 3K that the smoke barrier door would not self-close because of an imbalance on either side of the smoke barrier door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . 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 9:30 am on Jan 5, 2010.

4. It was observed in the 1F smoke compartment in the 1905-Smoke Barrier between 1F and 1K that the smoke barrier door would not self-close because an air flow imbalance between the smoke barrier compartments. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . 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 9:25 am on Jan 6, 2010.

______________________________________

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.

______________________________________

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 4 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 2A smoke compartment in the 2115-Laundry that the door would not self-close because the door was misaligned to close fully. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 18.3.6.3.4. 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 9:30 am on Jan 12, 2010.

______________________________________

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 3 of the 11 smoke compartments, and would affect 10 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 3Y smoke compartment in the E3601-CPR Storage that the door would not self-close because the closer had been removed from the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 11:10 pm on Jan 7, 2010.

2. It was observed in the 1AA smoke compartment in the E1104-Business Office that the door would not self-close because there was no closer on the door. The room is considered hazardous because there is a 55 gallon recycling bin in the room. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 1:10 pm on Jan 7, 2010.

3. It was observed in the 1Y smoke compartment in the E1638-Former Dark Room that the door would not self-close because there was no closer on the door. The room is considered hazardous because there is a 51 gallon x-ray film recycling bin in the 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. 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 1:45 pm on Jan 7, 2010.

______________________________________

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 7 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 3B smoke compartment in the 3204-Clean Supply that the door would not self-close because there was no door closer on the door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 2:03 pm on Jan 4, 2010.

2. It was observed in the 1F smoke compartment in the 1972-Equipment Room that the door would not self-close because there was no door closer on the door. 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. 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 8:55 am on Jan 6, 2010.

3. It was observed in the 1G smoke compartment in the 1701-Copy Room that the door would not self-close because there was no closer on the door. The room is considered hazardous because there is a recycling bin in the 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. 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 10:10 am on Jan 6, 2010.

4. It was observed in the 1D smoke compartment in the 1424-Clean Hold that the door would not self-close because a plugged in electrical cord to a computer on wheels was obstructing the door operation. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 10:47 am on Jan 6, 2010.

5. It was observed in the 1D smoke compartment in the E1718-Sterile Supply that the door would not self-close because the closer was not adjusted to permit full closure. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 10:48 am on Jan 6, 2010.

6. It was observed in the LE smoke compartment in the 910-Bulk Stores that the door would not self-close because the closure was inoperable. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous by the authority having jurisdiction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. 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 2:55 pm on Jan 6, 2010.

7. It was observed in the 1G smoke compartment in the 1719 X-Ray Tech Area that the door would not positively self-latch when released because the door to the Registration Area had push-pull hardware and would not latch. Also, the doors to the Registration and Corridor did not have a door closing device. The room was considered hazardous because a 55 gallon trash container was used to collect old X-ray films. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 9:50 am on Jan 6, 2010.

8. It was observed in the 1D smoke compartment in the E1717-Soiled Hold that the door would not positively self-latch when released because the hardware was out of adjustment. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 10:51 am on Jan 6, 2010.

9. It was observed in the 1H smoke compartment in the 1678-Soiled Hold that the door would not positively self-latch when released because the hardware was out of adjustment. 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 M (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 11:10 am on Jan 6, 2010.

10. It was observed in the LA smoke compartment in the 808-Environmental Services Storage that penetration(s) were not sealed according to approved UL designs. Penetration(s) included a cable tray that had openings that were not filled with fire stop material. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. 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 2:35 pm on Jan 6, 2010.

11. It was observed in the 3G smoke compartment in the 3744-Soiled Hold that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was not sprinkled. The wall had a 6" hole above the ceiling on the south side. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials that was considered hazardous by the authority having jurisdiction at the time of the survey. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. 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 5, 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 proper fire-rated wall assemblies to enclose vertical openings used for exiting, such as stairs and exit passages. This deficiency occurred in 4 of the 14 smoke compartments, and would affect 40 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed in the LR smoke compartment in the W0002-Stair R that the door was not equipped with a door closer. of an imbalance on either side a the smoke barrier door. This observed situation was not compliant with NFPA 101, 18.3.1.1; 8.2.5.4, and 8.2.3.2. 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 1:46 pm on Jan 11, 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 ensure that all means of egress were readily available at all times. 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 travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge.The "No Exit" signs at the stairs leading to the lower level are not an effective means of preventing travel past the 1st floor exit discharge, which is not directly visible. 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 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 ensure that all means of egress were readily available at all times. This deficiency occurred in 3 of the 27 smoke compartments, and would affect 50 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 3724-corridor that the door was locked from the egress side. There was a pair of doors locked with a magnetic lock with a push button for secondary release but no sensor for automatic release as required by NFPA 101(2000 edition), 7.2.1.6.2(a). This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. 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 9:10 am on Jan 5, 2010.

2. It was observed in the 3G smoke compartment in the 3739-corridor that the door was locked from the egress side. There was a pair of doors locked with a magnetic lock with a push button for secondary release but no sensor for automatic release as required by NFPA 101(2000 edition), 7.2.1.6.2(a). This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. 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 9:20 am on Jan 5, 2010.

3. It was observed in the 3K smoke compartment in the Stair K that one or more doors swung outward into the exit path and obstructed the path because the 33" door swung into a 42" landing and obstructed the clear width down to 15.5" where as the required minimum clear width is 22". Stair K is a required exit from the adjacent health care occupancy on the 1st and 2nd floors. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.4. 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 10:00 am on Jan 5, 2010.

4. It was observed in the 3K smoke compartment in the North skywalk door that the door in the path of egress did not swing in the direction of egress travel The occupancy load of the egress was estimated to be at least 50 persons. The egress path is from smoke compartment 3G is into the skywalk and the single egress pair of doors swung into the 3G space. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.2. 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 5, 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 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 3 of the 11 smoke compartments, and would affect 50 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 3AA smoke compartment in the 3001-Stair AA that a delayed egress lock (DEL) did not activate within 3 seconds of pushing the release mechanism. the delayed egress lock (DEL) activated after 4 seconds (maximum 3 seconds permitted) and released after 21 seconds (maximum of 15 seconds permitted). 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), Staff TT (Peds Clinical Mngr) at 10:00 am on Jan 7, 2010.

2. It was observed in the 2Z smoke compartment in the E2002-3Z Stairs that a delayed egress lock (DEL) did not activate within 3 seconds of pushing the release mechanism. the delayed egress lock (DEL) released after 17 seconds (maximum of 15 seconds permitted). The door also required more than 30 pounds of force to operate. 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), Staff XX (Womens and Childrens Clinical Mngr) at 12:15 pm on Jan 7, 2010.

3. It was observed in the 2Y smoke compartment in the E2003-Stair Y that a delayed egress lock (DEL) did not release within 15 seconds of activation. The delayed egress lock (DEL) released after 16 seconds (maximum of 15 seconds permitted). The door also required more than 30 pounds of force to operate. 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), Staff XX (Womens and Childrens Clinical Mngr) at 12:42 pm on Jan 7, 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 and maintain emergency illumination of exit and directional signs.This deficiency occurred in 3 of the 14 smoke compartments, and would affect 80 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the LR smoke compartment in the W0002-Stair R that the change in direction in the path of egress was not readily apparent and an exit sign with an arrow was not provided. When exiting from the Cardiac Rehab area a turn to the right is needed to enter the 'R' stairwell and there was no exit sign with an arrow provided. 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 1:48 pm on Jan 11, 2010.

2. It was observed in the 5Q smoke compartment in the W5038-Corridor that an exit sign was installed over the door to a 6 foot wide side corridor for inpatient units with a 36 inch wide door. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 9:55 am on Jan 11, 2010.

3. It was observed in the 3Q smoke compartment in the W3368-Corridor that an exit sign was installed over the door to a 6 foot wide side corridor for inpatient units with a 36 inch wide door. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 11:15 am on Jan 11, 2010.

4. It was observed in the 5Q smoke compartment in the W5038-Corridor that an exit sign was installed over the door to a 6 foot wide side corridor for inpatient units with a 36 inch wide door. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 9:55 am on Jan 11, 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 27 smoke compartments, and would affect 50 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 3100-Corridor that an exit sign was installed over the door to the Cardio-Vascular Institute building which was only accessible with an access card. An egress stair "A" was immediately adjacent. The facility staff confirmed that the doors leading to the Cardio-Vascular Institute building were not an egress path. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 1:38 pm on Jan 4, 2010.

2. It was observed in the 2A smoke compartment in the Smoke Barrier between 2A and 2R that an exit sign was installed over the door to the Cardio-Vascular Institute building which was only accessible with an access card. Egress stair "A" was immediately adjacent. The facility staff confirmed that the doors leading to the Cardio-Vascular Institute building were not an egress path. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 10:50 am on Jan 5, 2010.

3. It was observed in the 3G smoke compartment in the 3745-Corridor that an exit sign was installed over the door to corridor 3745, which was equipped with a magnetic lock. Corridor 3745 was not a required exit because egress was available through corridor 3739. Also, exit sign #342 directed exit toward corridor 3739 which was 6 feet wide and represented a narrowing of the egress path from the 8 foot wide corridor 3745. The facility indicated this door was not an official exit because it did not meet all the requirements of an exit. Exiting can not be directed toward a non-compliant egress path from the facility. 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 8:45 am on Jan 5, 2010.

4. It was observed in the 1F smoke compartment in the 1870-Exit Passageway that the path of travel toward the double doors leading to corridor 1860 was likely to be mistaken as an exit and a "NO Exit" sign was not provided. This path was in a straight line with the normal direction of travel, and the double doors in the direct path appeared to be an exit because the exterior was visible through a window in the doors. 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 2:10 pm on Jan 5, 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, 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 3 of the 14 smoke compartments, and would affect 10 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 2Q smoke compartment in the W2300-Reception that 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 a 23 1/2" deep soffit. 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. 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 12:10 pm on Jan 11, 2010.

2. It was observed in the LR smoke compartment in the W0458-Storage #3 that 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 shelving units that had the top shelf located 10" below the sprinkler deflector.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. 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 1:44 pm on Jan 11, 2010.

3. It was observed in the LQ smoke compartment in the W0124-Locker Room that 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 Materials were placed on top of metal lockers so they were approximately 15" below the sprinkler deflector.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. 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 11, 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 3 of the 27 smoke compartments, and would affect 10 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the LA smoke compartment in the 102-Gift Shop Storage that 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 various gift shop sales items. The sprinkler was installed directly above shelving located on the perimeter walls.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. 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 8:05 am on Jan 7, 2010.

2. It was observed in the 3E smoke compartment in the 3009-Nurse Station that a sprinkler was located 16" below the finished hard ceiling surface where a lay-in decorative parabolic ceiling was installed. 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 2:15 pm on Jan 4, 2010.

3. It was observed in the 3C smoke compartment in the 3302-Electrical Room that a sprinkler was located estimated to be 24" below the deck above which is not permitted for upright heads. 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 2:24 pm on Jan 4, 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 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 14 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 1Q smoke compartment in the W1156-Garage Corridor that there was one or more unsealed holes near the ceiling. The hole(s) included 2 ceiling tile were ajar. 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) at 12:45 pm on Jan 11, 2010.

2. It was observed in the LQ smoke compartment in the W0140-Chemical Storage that there was one or more unsealed holes near the ceiling. The hole(s) included an 8" PVC tube through the ceiling with a 3/4" gap. The cap on the sprinkler was not tight to the ceiling. 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) at 1:55 pm on Jan 11, 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 4 smoke compartments, and would affect 15 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 2C smoke compartment in the 2306-Toilet that the escutcheon ring on the sprinkler was missing in this location. 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 . 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.

2. It was observed in the 2C smoke compartment in the 2311-Pain Management Passage that the escutcheon ring on the sprinkler was missing in this location. 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 . 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 9:58 am on Jan 12, 2010.

3. It was observed in the LA smoke compartment in the 102-Pump Room that the cabinet of spare sprinklers did not contain a wrench that would fit the heads in the cabinet. The wrench for the suicide resistant sprinkler heads was missing. This observed situation was not compliant with NFPA 25 (1998 edition), 2-4.1.4. 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 10:50 am on Jan 12, 2010.

4. It was observed in the 3C smoke compartment in the 3268-Telecommunication Room that there was one or more unsealed holes near the ceiling. The hole(s) included a cable bundle through the ceiling and a 1/2" gap. 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 UU (Maintenance Group Leader), Staff N (VP of Facilities), and Staff O (Safety Manager) at 8:30 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 6 of the 27 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 1A smoke compartment in the 1848-Woman's Locker that the escutcheon ring on the sprinkler was missing. 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 . 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 8:05 am on Jan 6, 2010.

2. It was observed in the LA smoke compartment in the 916-Telecommunications Closet that the escutcheon ring on the sprinkler was missing in this location. 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 . 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 2:55 pm on Jan 6, 2010.

3. It was observed in the LD smoke compartment in the 539-Cold Production that the sprinkler showed signs of corrosion. This observed situation was not compliant with NFPA 25 (998 edition), 2-2.1 .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 9:15 am on Jan 7, 2010.

4. It was observed in the 3A smoke compartment in the 3102-Clean Supply that there was one or more unsealed holes near the ceiling. The hole(s) included six broken and/or mis-cut ceiling tiles. 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) at 1:55 pm on Jan 4, 2010.

5. It was observed in the 1A smoke compartment in the 1115-Communications Closet that there was one or more unsealed holes near the ceiling. The hole(s) included a 2 1/2", a 2" x 6" and a 1" x 3" hole. 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) at 2:25 pm on Jan 5, 2010.

6. It was observed in the LD smoke compartment in the 426-Decontamination Mens Locker that there was one or more unsealed holes near the ceiling. The hole(s) included a 3"x3" triangular portion of missing ceiling tile material. 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) at 8:38 am on Jan 7, 2010.

7. It was observed in the LD smoke compartment in the 634-Catering Room that there was one or more unsealed holes near the ceiling. The hole(s) included a 8"x3" gap in the ceiling tile where a bundle of syrup tubing penetrated the surface. 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) at 9:25 am on Jan 7, 2010.

8. It was observed in the 1F smoke compartment in the 1972-Equipment Room that there was one or more unsealed holes near the ceiling. The hole(s) included a 8"x6" hole 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) at 8:55 am on Jan 6, 2010.

9. It was observed in the 1F smoke compartment in the 1955-Mechanical Room that the wall did not fully enclose the room up to the ceiling/floor above. The wall was open for 6" at the deck. This opening 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) at 8:50 am on Jan 6, 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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Based upon observation the facility failed to provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code. This deficiency occurred in 5 of the 27 smoke compartments, and would affect 15 of the patients in the facility on the day of the survey.

FINDINGS INCLUDE:
1. It was observed in the 3D smoke compartment in the 3303-Staff Restroom that a 30" x 30" 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. 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 4, 2010.

2. It was observed in the 3D smoke compartment in the 3400-Corridor that a 4" x 4" alarm junction 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. 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 2:46 pm on Jan 4, 2010.

3. It was observed in the 3G smoke compartment in the Soiled Hold that a single 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. 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 8:20 am on Jan 5, 2010.

4. It was observed in the 1A smoke compartment in the 1742-EMG and 1743-EEG that 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. 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 8:20 am on Jan 6, 2010.

5. It was observed in the 1F smoke compartment in the 1917-Former Ultra-Sound Processing that a 4"x4" and single 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. 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 9:10 am on Jan 6, 2010.

6. It was observed in the 3G smoke compartment in the 3602-corridor that access to the electrical panel was not restricted to authorized use only, because panel 3G2L was not locked and was in a public corridor. This observed situation was not compliant with NFPA 70 (1999 edition), Article 110-31?. 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 9:00 am on Jan 5, 2010.

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