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Based on observation and staff interviews, while on tour of the facility with Staff M and Staff N between May 12th and May 13th; it was observed that the facility failed to provide exit access corridor openings that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.3.1 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 4 smoke compartments on this floor, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 13th, 2014 at 9:00 am, it was observed that the paired doors into the OR suite between Corridor #1003 and #1004 were not smoke tight; no astragal was installed at this paired door opening.

This deficient practice was confirmed by observation and interview with Staff N at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with Staff M and Staff N between May 12th and May 13th, it was observed that the facility failed to provide and maintain the one-half hour fire-rating and smoke tightness of the smoke barrier walls in accordance to NFPA 101 Section 19.3.7.3 and Section 8.3 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 13th, 2014 at 7:30 am, it was observed that the paired doors from the Radiology suite were not equipped with an astragal that prevented the passage of smoke.

This deficient practice was confirmed by observation and interview with Staff N at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with Staff M and Staff N between May 12th and May 13th, it was observed that the facility failed to provide and maintain openings in smoke barriers that resists fire for not less than 20 minutes in accordance to NFPA 101 Section 19.3.7.5 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 13th, 2014 at 7:30 am, it was observed that the paired doors into Waiting #1709 from the Main Lobby were not provided with a Underwriters Laboratory (UL) label on either of these leafs.

2. On May 13th, 2014 at 7:50 am, it was observed that the paired doors between Corridor #1003 and #1004 were not provided with a UL label on either of these leafs.

This deficient practice was confirmed by observation and interview with Staff N at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with Staff M and Staff N between May 12th and May 13th, it was observed that the facility failed to provide and maintain a sprinkler system that was installed in accordance to the Life Safety Code [2000 Ed] Sections 19.5.1 and 9.1.2 and NFPA 13 [1999 Ed] Section 5.13.11. The deficient practice could affect all the patients, staff and an undeterminable number of visitors within this building.

Findings include:

1. On May 13th, 2014 at 9:33 am, it was observed that the sprinkler heads installed in the Electrical Distribution/Generator room were not provided with shields to prevent direct discharge of water onto the Main Electrical distribution gear.

This deficient practice was confirmed by observation and interview with Staff N at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with Staff M and Staff N between May 12th and May 13th; it was observed that the facility failed to provide exit access corridor openings that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.3.1 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 4 smoke compartments on this floor, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 13th, 2014 at 9:00 am, it was observed that the paired doors into the OR suite between Corridor #1003 and #1004 were not smoke tight; no astragal was installed at this paired door opening.

This deficient practice was confirmed by observation and interview with Staff N at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with Staff M and Staff N between May 12th and May 13th, it was observed that the facility failed to provide and maintain the one-half hour fire-rating and smoke tightness of the smoke barrier walls in accordance to NFPA 101 Section 19.3.7.3 and Section 8.3 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 13th, 2014 at 7:30 am, it was observed that the paired doors from the Radiology suite were not equipped with an astragal that prevented the passage of smoke.

This deficient practice was confirmed by observation and interview with Staff N at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with Staff M and Staff N between May 12th and May 13th, it was observed that the facility failed to provide and maintain openings in smoke barriers that resists fire for not less than 20 minutes in accordance to NFPA 101 Section 19.3.7.5 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:

1. On May 13th, 2014 at 7:30 am, it was observed that the paired doors into Waiting #1709 from the Main Lobby were not provided with a Underwriters Laboratory (UL) label on either of these leafs.

2. On May 13th, 2014 at 7:50 am, it was observed that the paired doors between Corridor #1003 and #1004 were not provided with a UL label on either of these leafs.

This deficient practice was confirmed by observation and interview with Staff N at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with Staff M and Staff N between May 12th and May 13th, it was observed that the facility failed to provide and maintain a sprinkler system that was installed in accordance to the Life Safety Code [2000 Ed] Sections 19.5.1 and 9.1.2 and NFPA 13 [1999 Ed] Section 5.13.11. The deficient practice could affect all the patients, staff and an undeterminable number of visitors within this building.

Findings include:

1. On May 13th, 2014 at 9:33 am, it was observed that the sprinkler heads installed in the Electrical Distribution/Generator room were not provided with shields to prevent direct discharge of water onto the Main Electrical distribution gear.

This deficient practice was confirmed by observation and interview with Staff N at the time of discovery.