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Based on observation and interview, the facility did not provide corridor finishes with the appropriate rating. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/01/2016 at 3:20 PM, observation revealed on the Lobby level floor in the corridor near OR suite, that the facility could not confirm the corridor had an appropriate rating. Four 4'-0"x 3'-0" display boards with combustible papers were hung in corridor wall above 4 feet from finished floor. Staff A and B were unable to confirm the flame spread rating of the attached papers on the display board during survey. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/01/2016 at 2:15 PM, observation revealed on the 1st level floor in the Intensive care units, that the corridor door would not positively self-latch when pushed to a closed position. The life safety plan did not identify the intensive care units area as a suite and indicated exit route through the intensive care area from other parts of this floor. The pair of corridor doors in the intensive care rooms 1-6 did not latch because they were not equipped with positive latching hardware. At the same location, nurse server corridor doors in the intensive care rooms 1-6 did not latch either because they were also not equipped with positive latching hardware. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with compliant sized lettering on "no-exit" signs. The "no-exit" signs at that end may be confused as exits. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 12:30 PM, observation revealed on the 2nd level floor in the fire barrier door near the central stair, that the layout and lettering on the no exit sign did not meet the code requirements. The no exit sign was written as "NOT AN EXIT" with letter 3 inch high instead of code required, the word NO in letter 2 inch high with a stroke width of 3/8 inch and the word EXIT in letter 1 inch high, with the word EXIT below the word NO. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 12:45 PM, observation revealed on the 2nd level floor in the Vestibule, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. The door opening to the roof top garden permits viewing of the exterior and can be mistaken as an exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

3. On 02/01/2016 at 1:45 PM, observation revealed on the 2nd level floor in the Dining room, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. Doors leading to the roof terrace permits viewing of the exterior and can be mistaken as exits. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with rated windows. This deficiency occurred in 2 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/02/2016 at 10:30 am, observation revealed on the Lower level floor in the cross corridor smoke barrier doors near suite C, that vision panels consisting of fire rated glazing or wired glass panels were not provided in each cross corridor swinging doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.7. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, rated wall construction, and rated doors. This deficiency occurred in 2 of the 13 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 2:35 PM, observation revealed on the 1st level floor in the Staff room 1329, that the door would not self-close because the door was not equipped with an automatic or self closing device. Eighteen cardboard boxes full of combustible materials were stored inside the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 and 18.3.6.3.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 3:50 PM, observation revealed on the Lobby level floor in the Room 712 in the OR area, that the door in the hazard enclosure wall could not be verified as having at least a 45 minute rating. The room was used to store paper and plastic based combustible materials. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

3. On 02/01/2016 at 4:15 PM, observation revealed on the Lobby Level floor in the Prep & Pack room, that the door in the hazard enclosure wall could not be verified as having at least a 45 minute rating because seven combustible paper notice pages were taped on rated door. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 2 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 3:15 pm, observation revealed on the Lobby level floor in the corridor near OR suite, that a permanent writing desk with a chair was kept in the corridor that reduced corridor width to 7'-0". Corridors used by patients/residents are required to be at least 8'-0" vwide (6' in psychiatric units). This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff C (Facilities Engineer), and staff D (Director of Facilities & Operations Effectiveness).

2. On 02/01/2016 at 4:20 pm, observation revealed on the Lobby Level floor in the Surgery and Procedure center corridor, that the clear and unobstructed width of the corridor was 7 feet because sofas and chairs from waiting area were encroached to the corridor area also. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

Based on observation, interview and document review, the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure with adequate testing of emergency batteries. This deficiency occurred in 2 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:10 PM, observation revealed on the 2nd level floor in the C-Section operating room, that Staff B was unable to confirm the testing of 3 battery-powered emergency lights for 30 seconds each month and 90 minutes each year. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.9.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/02/2016 at 2:45 PM, during a review of facility documents, Staff B was unable to verify that the facility tested the battery-powered emergency lights for 30 seconds each month and 90 minutes each year located inside the operating rooms 1 to 6. This situation was not compliant with NFPA 101 (2000 ed.), 7.9.3. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on interview and record review, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 13 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/02/2016 at 2:50 PM, during review of the facility fire drill record for the past 12 months it was revealed that fire drills were not conducted at varied times. Drills were conducted in the same shift within an hour of each other. The facility's fire drill records from March 2015 to December 2015 indicated that 1st, 2nd, 3rd & 4th Quarters of the (four) 2nd-shift drills were held between 7:30 PM and 7:45 PM, and 2nd, 3rd & 4th Quarters of the (four) 3rd-shift drills were held between 2:00 am and 3:00 am. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements with non-sprinkled rooms that meet permitted exceptions . This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/02/2016 at 10:20 am, observation revealed on the Lower level floor in the Electrical room, that the room was not sprinkler protected, although the entire facility was required to be sprinkled. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but a 3' x 4' return air duct opening in the 2 hour rated wall was not protected with a fire damper. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception) and NFPA 13 (1999 ed.), 5-3.11. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25, sprinklers free of lint, and weekly tests of the fire pump. This deficiency occurred in 13 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 2:00 PM, observation revealed on the 2nd level floor in the Chute room, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

3. On 02/02/2016 at 2:30 PM, during a review of facility documents it was discovered, that the monthly wet sprinkler inspections were not performed as required by the code. There were no documents that showed valves were inspected monthly. This situation was not compliant with NFPA 25 (1998 ed.), 2-2, Table 2-1 and 9-4.1. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

4. On 02/02/2016 at 3:00 PM, during a review of the facility documents it could not verify the durations of the fire pump's 10 minute weekly churn test. This situation was not compliant with NFPA 25 (1998 ed.), 5-3.2. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96 with extinguisher operation instruction. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/01/2016 at 1:30 PM, observation revealed on the 2nd level floor in the Kitchen, that the placard to identify the use of the fire extinguisher as a secondary back up means to the automatic fire suppression system was not visible because it was covered with solid paper. This observed situation was not compliant with NFPA 96 (1998 ed.), Section 7-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash, and properly sized storage containers for soiled/trash. This deficiency occurred in 3 of the 13 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:40 PM, observation revealed on the 2nd level floor in the tray return area inside the dining room, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Four trash and recycle receptacles of 28 gallon size each were kept in a close proximity within a 64 square feet area. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 3:30 PM, observation revealed on the Lobby level floor in the OR number 1, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Two 32 gallon size soiled linen hampers with full of soiled linen were kept side by side in a very close poximity. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff C (Facilities Engineer), and staff D (Director of Facilities & Operations Effectiveness).

3. On 02/01/2016 at 4:00 PM, observation revealed on the Lobby level floor in the Or number 6, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Two 32 gallon size trash receptacles were kept side by side in a very close proximity. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff C (Facilities Engineer), and staff D (Director of Facilities & Operations Effectiveness).

4. On 02/02/2016 at 10:45 am, observation revealed on the Lower level floor in the Pharmacy room, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. A 64 gallon size trash receptacle was kept for trash collection. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide egress paths at all times with paths that are maintainable in all weather conditions, the sprinklers did not provide full coverage, and electrical extension cord were used instead of permanent wiring.

FINDINGS INCLUDE:

1. On 02/01/2016 at 8:30 AM, observation revealed on the 1st floor that the exit discharge path did not have a maintainable surface. The path was composed of gravel and grass. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.7.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/01/2016 at 8:45 AM, observation revealed on the 1st floor in the exterior of the building, that sprinkler protection was not provided at the overhand / canopy that extended more than 4 feet from the building and is made of combustible material. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

3. On 02/01/2016 at 8:45 AM, observation revealed on the 1st floor in the waiting room, 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 fish tank. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

Based on observation and interview, the facility did not provide proper exiting in accordance with NFPA 101, 39.2.4.

FINDINGS INCLUDE:

1. On 02/2/2016 at 11:30 AM, observation revealed on the basement floor that there is only one exit out of the basement. The common path of travel is 90 out of the basement and the distance to an exit is 106 feet, up a stairs and out through a break room, onto an unsprinkler 1st floor. The basement is fully sprinklered. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.2.4.2. The situation did not meet any of the exceptions for one exit. There is storage room, a shower and bath and a workout room for staff. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

Based on observation and interview, the facility did not provide proper exiting in accordance with NFPA 101, 39.2.4, hazardous area were not enclosed in hour fire rated construction or have sprinklers and there was exiting through a hazardous area.

FINDINGS INCLUDE:

1. On 02/2/2016 at 2:30 PM, observation revealed on the basement floor that there is only one exit out of the basement. The common path of travel is more than 100 feet out of the basement and, up a stairs and out through a back corridor. The building is not sprinklered. A second 'exit' did exist which is into a space occupied by a different tenant that had bars and dead bolt latches which preventing exiting. This second 'exit' is not an exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.2.4.2. The situation did not meet any of the exceptions for one exit. There is storage room, a break room and a furnace room. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

2. On 02/2/2016 at 2:33 PM, observation revealed on the basement floor that the exit from the staff lounge (a non hazardous room) is through the furnace room, a hazardous location. This observed situation was not compliant with NFPA 101 (2000 ed.) 7.5.1.7 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

3. On 2/2/2016 at 2:35 PM,observation revealed on the basement floor that the furnace and hot water heaters were not enclosed in a 1 hour rated walls and ceiling and the area that contained the furnaces and hot water heater were not sprinklered. This is considered a hazardous area. This observed situation was not compliant with NFPA 101 (2000 ed.) 39.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

Based on observation and interview, the facility did not provide proper sprinkler coverage, proper exiting, proper exit signage, adequate lighting of the egress path or proper electrical wiring installation.

FINDINGS INCLUDE:

1. On 02/2/2016 at 1:35 PM, observation revealed on the 1st floor in the PT area, full sprinkler coverage was not provided underneath the soffit. The soffit block the sprinkler coverage. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

2. On 02/2/2016 at 1:37 PM, observation revealed on the 1st floor that the 2nd exit from the PT area had two motions to open the door. This observed situation was not compliant with NFPA 101 (2000 ed.) 7.2.1.5.4 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

3. On 2/2/2016 at 1:40 PM,observation revealed on the 1st floor at mechanical room # 2, that the electrical panel breakers were not labeled to identify the loads they fed. The panel in the mechanical room #2 did not have the circuit breakers labeled. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

4. On 2/2/2016 at 1:45 PM,observation revealed an exit sign was missing out the door by PT.
This observed situation was not compliant with NFPA 101 (2000 ed.) 7.10.1.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

5. On 2/2/2016 at 1:50 PM,observation revealed on the 1st floor 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 the coffee maker. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

6. On 02/01/2016 at 1:55 PM, observation revealed on the 1st floor in the Ortho supply 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. 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 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).


7. On 02/01/2016 at 2:00 PM, observation revealed on the 1st floor in the exterior overhang, that sprinkler protection was not provided at the overhand / canopy that extended more than 4 feet from the building and is made of combustible material. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

8. On 02/01/2016 at 2:10 PM, observation revealed on the 1st floor in the corridor by med gas room, that there were no light fixtures along the path of egress at this location. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

9 On 02/01/2016 at 2:20 PM, observation revealed on the 1st floor in the ev1 utility room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K 15}
Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes with rated wall finishes.

FINDINGS INCLUDE:
On 02/01/2016 at 2:19 PM, observation revealed on the lower level floor in the PT room, that the facility could not confirm the wall had the appropriate flame spread rating. The room wall was finished with a pink finish that did not have a labeling information about its construction. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K20}
Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated doors and rated wall construction.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:15 PM, observation revealed on the 1st, 2nd & 3rd floor in the Atrium that the fire shutters on the 2nd and 3rd floors did not close and the Won door on the first floor does not close in the fire barrier wall. They have been disabled. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.3.1, 8.2.5.4, 8.2.5.5 and 8.2.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/01/2016 at 1:55 PM, observation revealed on the 1st floor in the Atrium door to exit passage way, that the door in the fire barrier wall could not be verified of having the required rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.1.1, and 8.2.5.4, 8.2.5.5 and 8.2.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

3. On 02/01/2016 at 2:00 PM, observation revealed on the 1st floor in the Stair to the north by the main entrance which has it's own exit passageway that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because above the ceiling is not rated nor the wall to the back side of the Won door at the bottom of the stairs. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

4. On 02/03/2016 at 9:51 AM, observation revealed in the 1970 building in room south of EVS30 on 4th floor, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there is a 12" by 2" hole next to the fire damper in the wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

5. On 02/01/2016 at 2:15 PM, observation revealed on the lower level floor in the electrical closet by stair 2, that the duct passing through the ceiling/floor assembly could not be verified of having a fire damper. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K22}
Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent.
FINDINGS INCLUDE:

1. On 02/01/2016 at 12:15 PM, observation revealed on the 5th floor in the walkway conference room, IT offices, and room 369 , that the path of egress was not readily apparent and an exit sign was not provided. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/01/2016 at 1:30 PM, observation revealed on the floor in the corridor by PT waiting, that the path of egress was not readily apparent and an exit sign was not provided. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

3. On 02/01/2016 at 1:45 PM, observation revealed on the 1st floor in the from stair #1 over the door to the west, that the path of egress was not readily apparent and an exit sign was not provided. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

4. On 02/03/2016 at 1:10 PM, observation revealed in the Old OR area, that the path of egress was not readily apparent and an exit sign was not provided. Exits signs are missing guiding one out to an exit from the Old OR Area. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K29}
Based on observation and interview, the facility did not enclose hazardous rooms with rated walls and doors or have a sprinkler in the room.

FINDINGS INCLUDE:

1. On 02/01/2016 at 12:50 PM, observation revealed on the 5th floor in room 551, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/03/2016 at 8:30 AM, observation revealed in the room 8 of the old ICU, 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 ed.), 38.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

3. On 02/03/2016 at 12:00 PM, observation revealed in the dialysis storage area, room 12, 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 ed.), 38.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K37}
Based on observation and interview, the facility did not ensure that corridors did not have excessively long dead-ends as permitted by the code with too long of dead end corridors.

FINDINGS INCLUDE:

On 02/03/2016 at 3:25 PM, observation revealed on the 5th floor in the west end of 1970 building, that a dead end corridor is 30 feet This observed situation was not compliant with NFPA 101 (2000 ed.), 38.2.5.2 which allow a dead end corridor of 20 feet since the building is not sprinkler throughout . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K38}
Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path and with door hardware that operated with a single release motion.
FINDINGS INCLUDE:

1. On 02/01/2016 at 2:10 PM, observation revealed on the 1st floor in the main entrance, that the door was locked from the egress side. The main exit out of the building is locked at night. However, there are outpatients sleeping in the building for the sleep study program throughout the night. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.2.2.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/03/2016 at 9:17 AM, observation revealed on the door to stair #4, it was locked from the egress side, i.e. entering the stair. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

3. On 02/03/2016 at 1:25 PM, observation revealed in the Old Imaging, south of EV15 room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a electrical push button on the wall to unlock the magnetic lock. The door could then be pushed open This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K46}
Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure.
FINDINGS INCLUDE:

On 02/01/2016 at 1:50 PM, observation revealed on the 1st floor in the exit passage way from stair 1, that the egress lighting was not compliant. The lights are metal halide which takes about 10 minutes before light is restored after an interruption in the electrical source of power. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K56}
Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with no obstructions near the sprinkler. In addition, the facility did not provide a fully sprinklered building.
FINDINGS INCLUDE:

1. On 02/03/2016 at 1:45 PM, observation revealed on the 1st floor in the Imaging records area, 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 high density shelving 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 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/02/2016 at 2:45 PM, observation revealed that the Saint Clare Clinic building was not totally sprinklered throughout. Sprinklers were missing in about 1/2 of the building. This observed situation was not compliant with NFPA 101 (2000 ed.), 28.3.5.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).


{K62}
Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat.
FINDINGS INCLUDE:

1. On 02/03/2016 at 1:29 PM, observation revealed in the skills lab, that there was one or more unsealed holes near the ceiling. The holes included holes in the lab in the closets 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 ed.), 1-11.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/03/2016 at 3:20 PM, observation revealed the Patient Accounts area, that there was one or more unsealed holes near the ceiling. The holes included open 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 ed.), 1-11.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K 67}
Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance.

FINDINGS INCLUDE:

On 02/01/2016 at 12:40 PM, observation revealed that during a review of documents it was discovered that all required maintenance procedures were not performed. Dampers were not exercised every 4 years. The dampers were last exercised December 2009. They are required to be exercised every 4 years. The Life Safety Code, section 9.2.1 permits existing ventilation systems to remain in service only when specifically approved by the authority having jurisdiction (AHJ). CMS directs their inspectors to use NFPA 90A as the guideline that should be followed in all existing facilities. Thus, the Life Safety Code supersedes NFPA 90A (1999 ed.) 1-3.3, which notes that the code is not normally intended to be applied retroactively. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7. . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K 147}
Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels with complete directories, with proper use of extension cords, .

FINDINGS INCLUDE:

1. On 02/01/2016 at 12:25 PM, observation revealed on the 5th floor in the corridor of the 1970 building, that electrical panel breaker(s) were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/03/2016 at 1:37 PM, observation in the Debriefing room, 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 equipment other than computers. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

3. On 02/03/2016 at 3:00 PM, observation revealed in the New Glarus room, 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 video machine This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

4. On 02/03/2016 at 3:15 PM, observation revealed in the Patient Accounts, 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 toaster This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).


29942

{K29}
Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetration.

FINDINGS INCLUDE:

On 02/03/2016 at 2:20 PM, observation revealed on the Lobby Level floor in the Boiler room, that penetration was not sealed according to an approved method. The deficiency included a 12 inch diameter unsealed hole with pipe penetration in the wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.2.1. and 8.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

{K38}
Based on observation and interview, the facility did not provide egress paths at all times with door hardware that operated with a single release motion.

FINDINGS INCLUDE:

On 02/03/2016 at 2:45 PM, observation revealed on the Lobby level floor in the Kitchen room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead bolt installed 1 foot above the door handle. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.2.1 & 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

{K47}
Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent.

FINDINGS INCLUDE:
On 02/03/2016 at 2:40 PM, observation revealed on the Lobby level floor in the Kitchen room, that the egress path signage was not compliant. Exit signage illuminating light bulb inside the exit light was flashing intermittently. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.2.1.1 & 7.10.5.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with ducts in rated walls with fire dampers, and taped joints on rated walls. The facility did not ensure the path of egress clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent and the facility did not provide egress paths at all times with travel interruption at stairs that go below the level of exit discharge. The facility did not enclose hazardous rooms with closers on all doors. The facility did not provide sprinkler protection inside the elevator equipment room and the facility did not maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, and closed electrical raceways.

FINDINGS INCLUDE:

1. On 02/03/2016 at 11:15 am, observation revealed on the 1st level floor in the HVAC shaft, that one or more air ducts penetrated the shaft enclosure and could not be confirmed to have a properly installed fire damper. The duct a had fire damper with fire caulking seal in the interior surface of duct and fire damper. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.3.1.1 & NFPA 90A (1999 ed.), 3-3.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

2. On 02/03/2016 at 11:20 am, observation revealed on the 1st level floor in the HVAC shaft , that the enclosing shaft wall was not constructed to the required fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.3.1.1 & 8.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W(Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

3. On 02/03/2016 at 11:05 am, observation revealed on the Lobby level floor in the south stair well, that the exit signage was not provided on the exit door that was located at the landing between lobby level and 1st level whereas the stair was still continued toward downstairs to the lower level. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.2.1.1 & 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

4. On 02/03/2016 at 11:00 am, observation revealed on the 1st level floor in the storage room , that the door would not self-close because the door was not equipped with an automatic or self closing device. The room was considered hazardous because it contained a quantity of stored combustible materials considered hazardous. 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 ed.), 39.3.2.1. and 8.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

5. On 02/03/2016 at 11:45 am, observation revealed on the lobby level floor in the billing office, that the door would not self-close because the door was not equipped with a self or automatic closing device. Seven cardboard boxes with full of combustible papers and a 64 gallon size trash receptacle were stored inside 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 ed.), 39.3.2.1. and 8.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

6. On 02/03/2016 at 11:10 am, observation revealed on the lobby level floor in the south stair well, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.2.1.1 & 7.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

7. On 02/02/2016 at 3:15 PM, observation revealed on the lower level floor in the elevator equipment room, that the room was not sprinkled. Some portion of this building remodeled on 2015. Access to exit through corridors in this building did not have 1 hour fire resistance rating so all areas in this building shall be protected with sprinklers. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

8. On 02/03/2016 at 10:00 am, observation revealed on the 2nd level floor in the EVS Room C6, that access to electrical panel was less than 3'-0" clearance. Two 32 gallon capacity trash receptacles, vacuum cleaners, and other unused old machines were stored in fornt of the electrical panels 2LD and 2LC. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 & NFPA 70 (1999 ed.), 110-26. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

9. On 02/03/2016 at 10:30 am, observation revealed on the 1st level floor in the EVS Room near the stair, that access to electrical panel was less than 3'-0" clearance. Unused chairs were stored in front of the electrical panel 1LB. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 & NFPA 70 (1999 ed.), 110-26This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

10. On 02/03/2016 at 10:45 am, observation revealed on the 1st level floor in the EVS Room near the elevators, that access to electrical panel was less than 3'-0" clearance. Two large trash receptacles and two trash carts were stored in front of the electrical panels TLL and TLD. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 & NFPA 70 (1999 ed.), 110-26. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

11. On 02/03/2016 at 3:00 pm, observation revealed on the penthouse level floor in the mechanical room, that a 4"x4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 & NFPA 70 (1999 ed.), 517-12. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not install the emergency electrical generator in accordance with the codes by having a generator with a remote stop and emergency battery powered lighting. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/02/2016 at 10:00 am, observation revealed in the exterior generator enclosure, that the emergency generators were provided with remote stop switches on the exterior of the generator enclosure wall near the enclosure door. Per code the remote stop switch shall be located elsewhere on the premises where the prime mover is located outside the building. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/02/2016 at 10:15 am, observation revealed in the exterior generator enclosure, that the battery powered emergency lighting inside the generator enclosure was powered with the same prime mover starter batteries. The emergency lighting charging system shall be supplied from the load side of the transfer switch. This observed situation was not compliant with NFPA 110 (1999 ed.), 5.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels having complete directories. This deficiency occurred in 3 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:20 PM, observation revealed on the 2nd level floor in the Electrical room, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 1-33 and 43-47 inside the panel B2/ Q2LA were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 2:45 PM, observation revealed on the 1st level floor in the Data Room 1538, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 1-16 inside the panel 1N/ UPSA were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

3. On 02/02/2016 at 9:30 am, observation revealed on the Lower level floor in the room CUP 103, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers inside the panel BILL/ INV were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

4. On 02/02/2016 at 11:00 am, observation revealed on the Lower level floor in the Electrical Room LL224, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 1-12 inside the panel BLL/ Q2LB and circuit breakers 11, 14, 17, 31 inside the panel ALL/ CLC were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide corridor finishes with the appropriate rating. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/01/2016 at 3:20 PM, observation revealed on the Lobby level floor in the corridor near OR suite, that the facility could not confirm the corridor had an appropriate rating. Four 4'-0"x 3'-0" display boards with combustible papers were hung in corridor wall above 4 feet from finished floor. Staff A and B were unable to confirm the flame spread rating of the attached papers on the display board during survey. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

Based on observation and interview, the facility did not provide corridor separation doors with doors with positive-latching hardware. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/01/2016 at 2:15 PM, observation revealed on the 1st level floor in the Intensive care units, that the corridor door would not positively self-latch when pushed to a closed position. The life safety plan did not identify the intensive care units area as a suite and indicated exit route through the intensive care area from other parts of this floor. The pair of corridor doors in the intensive care rooms 1-6 did not latch because they were not equipped with positive latching hardware. At the same location, nurse server corridor doors in the intensive care rooms 1-6 did not latch either because they were also not equipped with positive latching hardware. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.6.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with compliant sized lettering on "no-exit" signs. The "no-exit" signs at that end may be confused as exits. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 12:30 PM, observation revealed on the 2nd level floor in the fire barrier door near the central stair, that the layout and lettering on the no exit sign did not meet the code requirements. The no exit sign was written as "NOT AN EXIT" with letter 3 inch high instead of code required, the word NO in letter 2 inch high with a stroke width of 3/8 inch and the word EXIT in letter 1 inch high, with the word EXIT below the word NO. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 12:45 PM, observation revealed on the 2nd level floor in the Vestibule, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. The door opening to the roof top garden permits viewing of the exterior and can be mistaken as an exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

3. On 02/01/2016 at 1:45 PM, observation revealed on the 2nd level floor in the Dining room, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. Doors leading to the roof terrace permits viewing of the exterior and can be mistaken as exits. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.8.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with rated windows. This deficiency occurred in 2 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/02/2016 at 10:30 am, observation revealed on the Lower level floor in the cross corridor smoke barrier doors near suite C, that vision panels consisting of fire rated glazing or wired glass panels were not provided in each cross corridor swinging doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.7.7. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, rated wall construction, and rated doors. This deficiency occurred in 2 of the 13 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 2:35 PM, observation revealed on the 1st level floor in the Staff room 1329, that the door would not self-close because the door was not equipped with an automatic or self closing device. Eighteen cardboard boxes full of combustible materials were stored inside the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1 and 18.3.6.3.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 3:50 PM, observation revealed on the Lobby level floor in the Room 712 in the OR area, that the door in the hazard enclosure wall could not be verified as having at least a 45 minute rating. The room was used to store paper and plastic based combustible materials. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

3. On 02/01/2016 at 4:15 PM, observation revealed on the Lobby Level floor in the Prep & Pack room, that the door in the hazard enclosure wall could not be verified as having at least a 45 minute rating because seven combustible paper notice pages were taped on rated door. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficiency occurred in 2 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 3:15 pm, observation revealed on the Lobby level floor in the corridor near OR suite, that a permanent writing desk with a chair was kept in the corridor that reduced corridor width to 7'-0". Corridors used by patients/residents are required to be at least 8'-0" vwide (6' in psychiatric units). This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff C (Facilities Engineer), and staff D (Director of Facilities & Operations Effectiveness).

2. On 02/01/2016 at 4:20 pm, observation revealed on the Lobby Level floor in the Surgery and Procedure center corridor, that the clear and unobstructed width of the corridor was 7 feet because sofas and chairs from waiting area were encroached to the corridor area also. Corridors used by patients/residents are required to be at least 8'-0" wide (6' in psychiatric units). This observed situation was not compliant with NFPA 101 (2000 ed.), 18.2.3.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

Based on observation, interview and document review, the facility did not provide and maintain emergency illumination of the interior means of egress for at least 90 minutes after a power failure with adequate testing of emergency batteries. This deficiency occurred in 2 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:10 PM, observation revealed on the 2nd level floor in the C-Section operating room, that Staff B was unable to confirm the testing of 3 battery-powered emergency lights for 30 seconds each month and 90 minutes each year. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.9.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/02/2016 at 2:45 PM, during a review of facility documents, Staff B was unable to verify that the facility tested the battery-powered emergency lights for 30 seconds each month and 90 minutes each year located inside the operating rooms 1 to 6. This situation was not compliant with NFPA 101 (2000 ed.), 7.9.3. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on interview and record review, the facility did not conduct fire drills as required by the code to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency occurred in 13 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/02/2016 at 2:50 PM, during review of the facility fire drill record for the past 12 months it was revealed that fire drills were not conducted at varied times. Drills were conducted in the same shift within an hour of each other. The facility's fire drill records from March 2015 to December 2015 indicated that 1st, 2nd, 3rd & 4th Quarters of the (four) 2nd-shift drills were held between 7:30 PM and 7:45 PM, and 2nd, 3rd & 4th Quarters of the (four) 3rd-shift drills were held between 2:00 am and 3:00 am. This situation was not compliant with NFPA 101 (2000 ed.), 18.7.1.2. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements with non-sprinkled rooms that meet permitted exceptions . This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/02/2016 at 10:20 am, observation revealed on the Lower level floor in the Electrical room, that the room was not sprinkler protected, although the entire facility was required to be sprinkled. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but a 3' x 4' return air duct opening in the 2 hour rated wall was not protected with a fire damper. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.5.1 (exception) and NFPA 13 (1999 ed.), 5-3.11. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25, sprinklers free of lint, and weekly tests of the fire pump. This deficiency occurred in 13 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 2:00 PM, observation revealed on the 2nd level floor in the Chute room, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. This observed situation was not compliant with NFPA 25 (1998 ed.), 2-2.1.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

3. On 02/02/2016 at 2:30 PM, during a review of facility documents it was discovered, that the monthly wet sprinkler inspections were not performed as required by the code. There were no documents that showed valves were inspected monthly. This situation was not compliant with NFPA 25 (1998 ed.), 2-2, Table 2-1 and 9-4.1. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

4. On 02/02/2016 at 3:00 PM, during a review of the facility documents it could not verify the durations of the fire pump's 10 minute weekly churn test. This situation was not compliant with NFPA 25 (1998 ed.), 5-3.2. This condition was confirmed at the time of discovery by a concurrent record review and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96 with extinguisher operation instruction. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 02/01/2016 at 1:30 PM, observation revealed on the 2nd level floor in the Kitchen, that the placard to identify the use of the fire extinguisher as a secondary back up means to the automatic fire suppression system was not visible because it was covered with solid paper. This observed situation was not compliant with NFPA 96 (1998 ed.), Section 7-2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash, and properly sized storage containers for soiled/trash. This deficiency occurred in 3 of the 13 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:40 PM, observation revealed on the 2nd level floor in the tray return area inside the dining room, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Four trash and recycle receptacles of 28 gallon size each were kept in a close proximity within a 64 square feet area. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 3:30 PM, observation revealed on the Lobby level floor in the OR number 1, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Two 32 gallon size soiled linen hampers with full of soiled linen were kept side by side in a very close poximity. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff C (Facilities Engineer), and staff D (Director of Facilities & Operations Effectiveness).

3. On 02/01/2016 at 4:00 PM, observation revealed on the Lobby level floor in the Or number 6, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Two 32 gallon size trash receptacles were kept side by side in a very close proximity. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff C (Facilities Engineer), and staff D (Director of Facilities & Operations Effectiveness).

4. On 02/02/2016 at 10:45 am, observation revealed on the Lower level floor in the Pharmacy room, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. A 64 gallon size trash receptacle was kept for trash collection. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.7.5.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide egress paths at all times with paths that are maintainable in all weather conditions, the sprinklers did not provide full coverage, and electrical extension cord were used instead of permanent wiring.

FINDINGS INCLUDE:

1. On 02/01/2016 at 8:30 AM, observation revealed on the 1st floor that the exit discharge path did not have a maintainable surface. The path was composed of gravel and grass. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.7.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/01/2016 at 8:45 AM, observation revealed on the 1st floor in the exterior of the building, that sprinkler protection was not provided at the overhand / canopy that extended more than 4 feet from the building and is made of combustible material. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

3. On 02/01/2016 at 8:45 AM, observation revealed on the 1st floor in the waiting room, 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 fish tank. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

Based on observation and interview, the facility did not provide proper exiting in accordance with NFPA 101, 39.2.4.

FINDINGS INCLUDE:

1. On 02/2/2016 at 11:30 AM, observation revealed on the basement floor that there is only one exit out of the basement. The common path of travel is 90 out of the basement and the distance to an exit is 106 feet, up a stairs and out through a break room, onto an unsprinkler 1st floor. The basement is fully sprinklered. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.2.4.2. The situation did not meet any of the exceptions for one exit. There is storage room, a shower and bath and a workout room for staff. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

Based on observation and interview, the facility did not provide proper exiting in accordance with NFPA 101, 39.2.4, hazardous area were not enclosed in hour fire rated construction or have sprinklers and there was exiting through a hazardous area.

FINDINGS INCLUDE:

1. On 02/2/2016 at 2:30 PM, observation revealed on the basement floor that there is only one exit out of the basement. The common path of travel is more than 100 feet out of the basement and, up a stairs and out through a back corridor. The building is not sprinklered. A second 'exit' did exist which is into a space occupied by a different tenant that had bars and dead bolt latches which preventing exiting. This second 'exit' is not an exit. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.2.4.2. The situation did not meet any of the exceptions for one exit. There is storage room, a break room and a furnace room. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

2. On 02/2/2016 at 2:33 PM, observation revealed on the basement floor that the exit from the staff lounge (a non hazardous room) is through the furnace room, a hazardous location. This observed situation was not compliant with NFPA 101 (2000 ed.) 7.5.1.7 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

3. On 2/2/2016 at 2:35 PM,observation revealed on the basement floor that the furnace and hot water heaters were not enclosed in a 1 hour rated walls and ceiling and the area that contained the furnaces and hot water heater were not sprinklered. This is considered a hazardous area. This observed situation was not compliant with NFPA 101 (2000 ed.) 39.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

Based on observation and interview, the facility did not provide proper sprinkler coverage, proper exiting, proper exit signage, adequate lighting of the egress path or proper electrical wiring installation.

FINDINGS INCLUDE:

1. On 02/2/2016 at 1:35 PM, observation revealed on the 1st floor in the PT area, full sprinkler coverage was not provided underneath the soffit. The soffit block the sprinkler coverage. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

2. On 02/2/2016 at 1:37 PM, observation revealed on the 1st floor that the 2nd exit from the PT area had two motions to open the door. This observed situation was not compliant with NFPA 101 (2000 ed.) 7.2.1.5.4 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

3. On 2/2/2016 at 1:40 PM,observation revealed on the 1st floor at mechanical room # 2, that the electrical panel breakers were not labeled to identify the loads they fed. The panel in the mechanical room #2 did not have the circuit breakers labeled. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

4. On 2/2/2016 at 1:45 PM,observation revealed an exit sign was missing out the door by PT.
This observed situation was not compliant with NFPA 101 (2000 ed.) 7.10.1.2 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

5. On 2/2/2016 at 1:50 PM,observation revealed on the 1st floor 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 the coffee maker. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

6. On 02/01/2016 at 1:55 PM, observation revealed on the 1st floor in the Ortho supply 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. 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 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).


7. On 02/01/2016 at 2:00 PM, observation revealed on the 1st floor in the exterior overhang, that sprinkler protection was not provided at the overhand / canopy that extended more than 4 feet from the building and is made of combustible material. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-13.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facility Engineer) and staff X (Director of Facilities).

8. On 02/01/2016 at 2:10 PM, observation revealed on the 1st floor in the corridor by med gas room, that there were no light fixtures along the path of egress at this location. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

9 On 02/01/2016 at 2:20 PM, observation revealed on the 1st floor in the ev1 utility room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K 15}
Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes with rated wall finishes.

FINDINGS INCLUDE:
On 02/01/2016 at 2:19 PM, observation revealed on the lower level floor in the PT room, that the facility could not confirm the wall had the appropriate flame spread rating. The room wall was finished with a pink finish that did not have a labeling information about its construction. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K20}
Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with rated doors and rated wall construction.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:15 PM, observation revealed on the 1st, 2nd & 3rd floor in the Atrium that the fire shutters on the 2nd and 3rd floors did not close and the Won door on the first floor does not close in the fire barrier wall. They have been disabled. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.3.1, 8.2.5.4, 8.2.5.5 and 8.2.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/01/2016 at 1:55 PM, observation revealed on the 1st floor in the Atrium door to exit passage way, that the door in the fire barrier wall could not be verified of having the required rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.1.1, and 8.2.5.4, 8.2.5.5 and 8.2.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

3. On 02/01/2016 at 2:00 PM, observation revealed on the 1st floor in the Stair to the north by the main entrance which has it's own exit passageway that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because above the ceiling is not rated nor the wall to the back side of the Won door at the bottom of the stairs. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

4. On 02/03/2016 at 9:51 AM, observation revealed in the 1970 building in room south of EVS30 on 4th floor, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there is a 12" by 2" hole next to the fire damper in the wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 8.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

5. On 02/01/2016 at 2:15 PM, observation revealed on the lower level floor in the electrical closet by stair 2, that the duct passing through the ceiling/floor assembly could not be verified of having a fire damper. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K22}
Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent.
FINDINGS INCLUDE:

1. On 02/01/2016 at 12:15 PM, observation revealed on the 5th floor in the walkway conference room, IT offices, and room 369 , that the path of egress was not readily apparent and an exit sign was not provided. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/01/2016 at 1:30 PM, observation revealed on the floor in the corridor by PT waiting, that the path of egress was not readily apparent and an exit sign was not provided. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

3. On 02/01/2016 at 1:45 PM, observation revealed on the 1st floor in the from stair #1 over the door to the west, that the path of egress was not readily apparent and an exit sign was not provided. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

4. On 02/03/2016 at 1:10 PM, observation revealed in the Old OR area, that the path of egress was not readily apparent and an exit sign was not provided. Exits signs are missing guiding one out to an exit from the Old OR Area. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K29}
Based on observation and interview, the facility did not enclose hazardous rooms with rated walls and doors or have a sprinkler in the room.

FINDINGS INCLUDE:

1. On 02/01/2016 at 12:50 PM, observation revealed on the 5th floor in room 551, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/03/2016 at 8:30 AM, observation revealed in the room 8 of the old ICU, 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 ed.), 38.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

3. On 02/03/2016 at 12:00 PM, observation revealed in the dialysis storage area, room 12, 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 ed.), 38.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K37}
Based on observation and interview, the facility did not ensure that corridors did not have excessively long dead-ends as permitted by the code with too long of dead end corridors.

FINDINGS INCLUDE:

On 02/03/2016 at 3:25 PM, observation revealed on the 5th floor in the west end of 1970 building, that a dead end corridor is 30 feet This observed situation was not compliant with NFPA 101 (2000 ed.), 38.2.5.2 which allow a dead end corridor of 20 feet since the building is not sprinkler throughout . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K38}
Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path and with door hardware that operated with a single release motion.
FINDINGS INCLUDE:

1. On 02/01/2016 at 2:10 PM, observation revealed on the 1st floor in the main entrance, that the door was locked from the egress side. The main exit out of the building is locked at night. However, there are outpatients sleeping in the building for the sleep study program throughout the night. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.2.2.1 This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/03/2016 at 9:17 AM, observation revealed on the door to stair #4, it was locked from the egress side, i.e. entering the stair. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.2.1.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

3. On 02/03/2016 at 1:25 PM, observation revealed in the Old Imaging, south of EV15 room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a electrical push button on the wall to unlock the magnetic lock. The door could then be pushed open This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K46}
Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure.
FINDINGS INCLUDE:

On 02/01/2016 at 1:50 PM, observation revealed on the 1st floor in the exit passage way from stair 1, that the egress lighting was not compliant. The lights are metal halide which takes about 10 minutes before light is restored after an interruption in the electrical source of power. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.8.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K56}
Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with no obstructions near the sprinkler. In addition, the facility did not provide a fully sprinklered building.
FINDINGS INCLUDE:

1. On 02/03/2016 at 1:45 PM, observation revealed on the 1st floor in the Imaging records area, 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 high density shelving 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 ed.), 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/02/2016 at 2:45 PM, observation revealed that the Saint Clare Clinic building was not totally sprinklered throughout. Sprinklers were missing in about 1/2 of the building. This observed situation was not compliant with NFPA 101 (2000 ed.), 28.3.5.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).


{K62}
Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have ceilings sealed above the sprinklers to collect heat.
FINDINGS INCLUDE:

1. On 02/03/2016 at 1:29 PM, observation revealed in the skills lab, that there was one or more unsealed holes near the ceiling. The holes included holes in the lab in the closets 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 ed.), 1-11.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/03/2016 at 3:20 PM, observation revealed the Patient Accounts area, that there was one or more unsealed holes near the ceiling. The holes included open 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 ed.), 1-11.1 . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K 67}
Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with required damper maintenance.

FINDINGS INCLUDE:

On 02/01/2016 at 12:40 PM, observation revealed that during a review of documents it was discovered that all required maintenance procedures were not performed. Dampers were not exercised every 4 years. The dampers were last exercised December 2009. They are required to be exercised every 4 years. The Life Safety Code, section 9.2.1 permits existing ventilation systems to remain in service only when specifically approved by the authority having jurisdiction (AHJ). CMS directs their inspectors to use NFPA 90A as the guideline that should be followed in all existing facilities. Thus, the Life Safety Code supersedes NFPA 90A (1999 ed.) 1-3.3, which notes that the code is not normally intended to be applied retroactively. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.5.2; 9.2.1; and NFPA 90A (1999 ed.), 3-4.7. . This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

{K 147}
Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels with complete directories, with proper use of extension cords, .

FINDINGS INCLUDE:

1. On 02/01/2016 at 12:25 PM, observation revealed on the 5th floor in the corridor of the 1970 building, that electrical panel breaker(s) were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

2. On 02/03/2016 at 1:37 PM, observation in the Debriefing room, 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 equipment other than computers. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

3. On 02/03/2016 at 3:00 PM, observation revealed in the New Glarus room, 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 video machine This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).

4. On 02/03/2016 at 3:15 PM, observation revealed in the Patient Accounts, 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 toaster This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff W (Facilities Engineer) and staff X (Director of Facilities).


29942

{K29}
Based on observation and interview, the facility did not enclose hazardous rooms with sealed wall penetration.

FINDINGS INCLUDE:

On 02/03/2016 at 2:20 PM, observation revealed on the Lobby Level floor in the Boiler room, that penetration was not sealed according to an approved method. The deficiency included a 12 inch diameter unsealed hole with pipe penetration in the wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.2.1. and 8.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

{K38}
Based on observation and interview, the facility did not provide egress paths at all times with door hardware that operated with a single release motion.

FINDINGS INCLUDE:

On 02/03/2016 at 2:45 PM, observation revealed on the Lobby level floor in the Kitchen room, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead bolt installed 1 foot above the door handle. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.2.1 & 7.2.1.5.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

{K47}
Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent.

FINDINGS INCLUDE:
On 02/03/2016 at 2:40 PM, observation revealed on the Lobby level floor in the Kitchen room, that the egress path signage was not compliant. Exit signage illuminating light bulb inside the exit light was flashing intermittently. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.2.1.1 & 7.10.5.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with ducts in rated walls with fire dampers, and taped joints on rated walls. The facility did not ensure the path of egress clearly identified by appropriate exit signage with exit signs when the egress path is not readily apparent and the facility did not provide egress paths at all times with travel interruption at stairs that go below the level of exit discharge. The facility did not enclose hazardous rooms with closers on all doors. The facility did not provide sprinkler protection inside the elevator equipment room and the facility did not maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, and closed electrical raceways.

FINDINGS INCLUDE:

1. On 02/03/2016 at 11:15 am, observation revealed on the 1st level floor in the HVAC shaft, that one or more air ducts penetrated the shaft enclosure and could not be confirmed to have a properly installed fire damper. The duct a had fire damper with fire caulking seal in the interior surface of duct and fire damper. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.3.1.1 & NFPA 90A (1999 ed.), 3-3.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

2. On 02/03/2016 at 11:20 am, observation revealed on the 1st level floor in the HVAC shaft , that the enclosing shaft wall was not constructed to the required fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.3.1.1 & 8.2.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W(Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

3. On 02/03/2016 at 11:05 am, observation revealed on the Lobby level floor in the south stair well, that the exit signage was not provided on the exit door that was located at the landing between lobby level and 1st level whereas the stair was still continued toward downstairs to the lower level. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.2.1.1 & 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

4. On 02/03/2016 at 11:00 am, observation revealed on the 1st level floor in the storage room , that the door would not self-close because the door was not equipped with an automatic or self closing device. The room was considered hazardous because it contained a quantity of stored combustible materials considered hazardous. 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 ed.), 39.3.2.1. and 8.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

5. On 02/03/2016 at 11:45 am, observation revealed on the lobby level floor in the billing office, that the door would not self-close because the door was not equipped with a self or automatic closing device. Seven cardboard boxes with full of combustible papers and a 64 gallon size trash receptacle were stored inside 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 ed.), 39.3.2.1. and 8.4.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

6. On 02/03/2016 at 11:10 am, observation revealed on the lobby level floor in the south stair well, that the travel down the stairwell was not interrupted by an effective means to prevent travel past the level of discharge. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.2.1.1 & 7.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach), staff B (Maintenance Coach), staff W (Facilities Engineer), and staff X (Director of Facilities & Operations Effectiveness).

7. On 02/02/2016 at 3:15 PM, observation revealed on the lower level floor in the elevator equipment room, that the room was not sprinkled. Some portion of this building remodeled on 2015. Access to exit through corridors in this building did not have 1 hour fire resistance rating so all areas in this building shall be protected with sprinklers. This observed situation was not compliant with NFPA 101 (2000 ed.), 38.3.6.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

8. On 02/03/2016 at 10:00 am, observation revealed on the 2nd level floor in the EVS Room C6, that access to electrical panel was less than 3'-0" clearance. Two 32 gallon capacity trash receptacles, vacuum cleaners, and other unused old machines were stored in fornt of the electrical panels 2LD and 2LC. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 & NFPA 70 (1999 ed.), 110-26. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

9. On 02/03/2016 at 10:30 am, observation revealed on the 1st level floor in the EVS Room near the stair, that access to electrical panel was less than 3'-0" clearance. Unused chairs were stored in front of the electrical panel 1LB. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 & NFPA 70 (1999 ed.), 110-26This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

10. On 02/03/2016 at 10:45 am, observation revealed on the 1st level floor in the EVS Room near the elevators, that access to electrical panel was less than 3'-0" clearance. Two large trash receptacles and two trash carts were stored in front of the electrical panels TLL and TLD. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 & NFPA 70 (1999 ed.), 110-26. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

11. On 02/03/2016 at 3:00 pm, observation revealed on the penthouse level floor in the mechanical room, that a 4"x4" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 101 (2000 ed.), 39.5.1 & NFPA 70 (1999 ed.), 517-12. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not install the emergency electrical generator in accordance with the codes by having a generator with a remote stop and emergency battery powered lighting. This deficiency occurred in 1 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/02/2016 at 10:00 am, observation revealed in the exterior generator enclosure, that the emergency generators were provided with remote stop switches on the exterior of the generator enclosure wall near the enclosure door. Per code the remote stop switch shall be located elsewhere on the premises where the prime mover is located outside the building. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/02/2016 at 10:15 am, observation revealed in the exterior generator enclosure, that the battery powered emergency lighting inside the generator enclosure was powered with the same prime mover starter batteries. The emergency lighting charging system shall be supplied from the load side of the transfer switch. This observed situation was not compliant with NFPA 110 (1999 ed.), 5.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with electrical panels having complete directories. This deficiency occurred in 3 of the 13 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 02/01/2016 at 1:20 PM, observation revealed on the 2nd level floor in the Electrical room, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 1-33 and 43-47 inside the panel B2/ Q2LA were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

2. On 02/01/2016 at 2:45 PM, observation revealed on the 1st level floor in the Data Room 1538, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 1-16 inside the panel 1N/ UPSA were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

3. On 02/02/2016 at 9:30 am, observation revealed on the Lower level floor in the room CUP 103, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers inside the panel BILL/ INV were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).

4. On 02/02/2016 at 11:00 am, observation revealed on the Lower level floor in the Electrical Room LL224, that electrical panel breakers were not labeled to identify the loads they fed. Circuit breakers 1-12 inside the panel BLL/ Q2LB and circuit breakers 11, 14, 17, 31 inside the panel ALL/ CLC were not identified for the loads they were feeding. This observed situation was not compliant with NFPA 70 (1999 ed.), Section 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Plant Operations Coach) and staff B (Maintenance Coach).