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Based on observation and interview, the facility did not provide a common separation wall with and rated doors. This deficiency occurred in 3 of the 22 smoke compartments, and had the potential to affect 22 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/11/13 at 13:34 pm surveyor #32724 & 28616 observed in the SC1-3 smoke compartment on the Third floor in Corridor-3398Y, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. A vinyl astragal was used to close a door gap in a 2 hour fire barrier wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

2. On 11/11/13 at 14:09 pm surveyor #32724 & 28616 observed in the SC4-3 smoke compartment on the Third floor in Corridor-3399W, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. A 90 minute door had a vinyl astragal. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

3. On 11/11/13 at 14:12 pm surveyor #32724 & 28616 observed in the SC5-2 smoke compartment on the Second floor in Corridor-2299W, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. A 90 minute door had a vinyl astragal. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing. This deficiency occurred in of the 22 smoke compartments, and had the potential to affect of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 13:42 pm surveyor #32724 & 28616 observed in the SC4-G smoke compartment on the Ground floor in Storage-G560B, that fire proofing was missing from the structural steel column. One layer of gypsum board was pulled away from a fire rated column enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor. This deficiency occurred in 1 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 9:23 am surveyor #32724 & 28616 observed in the SC5-1 smoke compartment on the First floor in Triage-1533, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have the code required "electrically supervised" automatic smoke detection system. The room was open to the corridor and did not have a smoke detector. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

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. This deficiency occurred in 1 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 12:38 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in Corridor-G699E, that the path of egress in the corridor was not readily apparent and an exit sign was not provided looking south. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, and sealed wall penetrations. This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/11/13 at 13:59 pm surveyor #32724 & 28616 observed in the SC2-3 smoke compartment on the Third floor in Storage-3317A, that the door would not self-close. 24 boxes on wire racks were stored in a room originally designated as a patient room and is now used as storage. The door to the corridor did not have a closer. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

2. On 11/12/13 at 12:00 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in the Linen Storage-G104A, that penetration(s) were not sealed according toaccording to an approved method. The deficiency included openings not fire sealed around a 1 1/2" pipe and a 2" hole. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not provide enclosures around exit stairs with and sealed wall penetrations. This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/11/13 at 14:48 pm surveyor #32724 & 28616 observed in the SC1-2 smoke compartment on the Second floor in Stair-STR2-2, that penetration(s) were not sealed according to an approved method. The deficiency included a 6" diameter, a 4" diameter, and (2) 2" diameter pipes running from the roof top. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director fo Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

2. On 11/11/13 at 14:57 pm surveyor #32724 & 28616 observed in the SC2-2 smoke compartment on the Second floor in Stair-STR1-2, that penetration(s) were not sealed according to an approved method. The deficiency included a 1" diameter pipe and (2) 1" copper pipes without fire calk. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director fo Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

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. egress lighting fed by emergency power, and adequate lighting of the egress path. This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect 16 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/12/13 at 10:55 am surveyor #32724 & 28616 observed in the SC1-1 smoke compartment on the First floor in the Cath Lab, that the facility was unable to verify that the lighting along the path of egress was powered from the emergency electrical system. The location of a battery backup emergency light could not be verified. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff QQ (Building Project Specialist).

2. On 11/12/13 at 9:32 am surveyor #32724 & 28616 observed in the SC5-1 smoke compartment on the First floor at the Exit Door, that there were no light fixtures along the path of discharge at this location. No exterior lights were at the exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, sprinkler gauges with the required maintenance, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, sprinklers free of lint. This deficiency occurred in 4 of the 22 smoke compartments, and had the potential to affect 42 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors..

FINDINGS INCLUDE:
1. On 11/11/13 at 14:21 pm surveyor #32724 & 28616 observed in the SC4-2 smoke compartment on the Second floor in Storage 2427, 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. Storage was kept within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
2. On 11/12/13 at 11:58 am surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in Linen Storage G104A, 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. Linen was stacked within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems) and staff RR (Maintanance).
3. On 11/12/13 at 12:12 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in Central Storage G199C,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. Storage was kept within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
4. On 11/12/13 at 12:27 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in Central Storage G199C, walk-in cooler, 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. Food storage was kept within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
5. On 11/12/13 at 12:57 pm surveyor #32724 & 28616 observed in the SC1-G smoke compartment on the Ground floor at MRI Reception G600A,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. Cabinetry was kept within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
6. On 11/12/13 at 13:38 pm surveyor #32724 & 28616 observed in the SC4-G smoke compartment on the Ground floor at Storage G560B, 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. Shelving was kept within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
7. On 11/12/13 at 13:45 pm surveyor #32724 & 28616 observed in the SC4-G smoke compartment on the Ground floor at Storage G560B, 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. Stacked storage totally obstructed sprinkler heads. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, sprinkler gauges with the required maintenance, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, sprinklers free of lint. This deficiency occurred in 10 of the 22 smoke compartments, and had the potential to affect 42 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/12/13 at 12:06 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in the Alcove-G199C, that the escutcheon ring on the sprinkler was 1/2" below the ceiling tile. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

2. On 11/12/13 at 13:31 pm surveyor #32724 & 28616 observed in the SC3-G smoke compartment on the Ground floor in the FPS Room, that during a review of documents the facility could not verify that the sprinkler water pressure gauge had been replaced or calibrated within the last 5 years. The fire sprinkler gauges were not labeled or dated. This observed situation was not compliant with NFPA 25 (1998 edition), 2-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

3. On 11/11/13 at 12:56 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Electrical Closet-3421, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2" x 6" and a 3" x 3" hole in ceiling at conduit penetrations. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

4. On 11/11/13 at 13:52 pm surveyor #32724 & 28616 observed in the SC2-3 smoke compartment on the Third floor in the Electrical Closet-3352, that there was one or more unsealed holes near the ceiling. The hole(s) included a 3" x 6' opening where ceiling tile was missing at conduit locations. This opening would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

5. On 11/11/13 at 14:14 pm surveyor #32724 & 28616 observed in the SC4-2 smoke compartment on the Second floor in the Electrical Closet-2420, that there was one or more unsealed holes near the ceiling. The hole(s) included (6) holes in the ceiling tile. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

6. On 11/12/13 at 9:38 am surveyor #32724 & 28616 observed in the SC5-1 smoke compartment on the First floor in the Vestibule-1567A, that there was one or more unsealed holes near the ceiling. The hole(s) included 1/2" hole in the ceiling tile adjacent to the sprinkler head. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

7. On 11/12/13 at 9:47 am surveyor #32724 & 28616 observed in the SC5-1 smoke compartment on the First floor in the Housekeeping-1555, that there was one or more unsealed holes near the ceiling. The hole(s) included a broken ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

8. On 11/12/13 at 11:59 am surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in the Linen Storage-G104A, that there was one or more unsealed holes near the ceiling. The hole(s) included a 3' x 2' ceiling tile missing. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

9. On 11/12/13 at 12:42 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in the Laundry Room-G672B, that there was one or more unsealed holes near the ceiling. The hole(s) included a sprinkler where the concealed sprinkler head was missing a cover plate. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

10. On 11/12/13 at 13:18 pm surveyor #32724 & 28616 observed in the SC3-G smoke compartment on the Ground floor in the Telecommunication Room-G450, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2" x 4" & a 2" x 2" holes in the ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

11. On 11/11/13 at 12:58 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Doctor Dressing Room-3415A-A, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

12. On 11/11/13 at 13:09 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the OR-3416, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

13. On 11/11/13 at 13:26 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Stroage Room-3433, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. (3) sprinkler heads were full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

14. On 11/11/13 at 13:42 pm surveyor #32724 & 28616 observed in the SC1-3 smoke compartment on the Third floor in the Corridor, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. (2) sprinkler heads were full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
15. On 11/11/13 at 14:02 pm surveyor #32724 & 28616 observed in the SC2-3 smoke compartment on the Third floor in the Lounge 3340B, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
16. On 11/11/13 at 14:18 pm surveyor #32724 & 28616 observed in the SC3-2 smoke compartment on the Second floor in the PT Room 204, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
17. On 11/11/13 at 14:40 pm surveyor #32724 & 28616 observed in the SC1-2 smoke compartment on the Second floor in the Office 2278, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
18. On 11/12/13 at 9:18 am surveyor #32724 & 28616 observed in the SC4-1 smoke compartment on the First floor in the Pain Management Nurse Station, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
19. On 11/12/13 at 9:25 am surveyor #32724 & 28616 observed in the SC5-1 smoke compartment on the First floor in Triage 1533, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, sprinkler gauges with the required maintenance, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, sprinklers free of lint. This deficiency occurred in 10 of the 22 smoke compartments, and had the potential to affect 42 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 2:15 pm surveyor #32724 & 28616 observed in the lower level smoke compartment on the ground floor in the Storage Room, that there was one or more unsealed holes in the ceiling. The hole(s) included a 2' x 4' and a 10" diameter hole in ceiling. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff QQ (Building Project Specialist).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with accessible extinguisher. This deficiency occurred in 1 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 12:16 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in the Central Supply-G199C, that a fire extinguisher was not accessible for immediate use because a cart was blocking access to the fire extinguisher. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 edition) 1-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with oxygen cylinders restrained from falling. This deficiency occurred in 1 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 10:50 am surveyor #32724 & 28616 observed in the SC1-1 smoke compartment on the First floor in the Endo Scope Room-1740C, that a cylinder of oxygen in storage was not secured to keep it from falling. A door was held open with an oxygen tank. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 8-3.1.11. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff QQ (Building Project Specilaist).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, and fixed wiring rather than extension cords. This deficiency occurred in 4 of the 22 smoke compartments, and had the potential to affect 24 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/12/13 at 10:14 am surveyor #32724 & 28616 observed in the SC2-1 smoke compartment on the First floor in the Soiled Utility-1632B room, that access to electrical panel was less than 3'-0" clearance. (3) electrical panels were blocked by carts, a table, and a soiled laundry bin. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

2. On 11/11/13 at 12:50 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Supply Room-3428B, 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 charge phones. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

3. On 11/11/13 at 13:15 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Lactation Room-3410, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a radio, a refrigerator and a pump. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

4. On 11/11/13 at 13:21 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Family Lounge-3432, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a coffee machine and a water cooler. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

5. On 11/11/13 at 13:38 pm surveyor #32724 & 28616 observed in the SC1-3 smoke compartment on the Third floor in Offcie-3373, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. Two strip plugs were used to provide power to (2) power multiple items. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

6. On 11/12/13 at 9:07 am surveyor #32724 & 28616 observed in the SC4-1 smoke compartment on the First floor in the Break Room-1424, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a toaster and a microwave. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

7. On 11/12/13 at 9:10 am surveyor #32724 & 28616 observed in the SC4-1 smoke compartment on the First floor in Storage-1423, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was attached to a shelf and was used to power multiple equipment items. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

8. On 11/12/13 at 10:18 am surveyor #32724 & 28616 observed in the SC2-1 smoke compartment on the First floor in the Kitchen-1634, 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 charge several phones. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not provide a common separation wall with and rated doors. This deficiency occurred in 3 of the 22 smoke compartments, and had the potential to affect 22 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/11/13 at 13:34 pm surveyor #32724 & 28616 observed in the SC1-3 smoke compartment on the Third floor in Corridor-3398Y, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. A vinyl astragal was used to close a door gap in a 2 hour fire barrier wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

2. On 11/11/13 at 14:09 pm surveyor #32724 & 28616 observed in the SC4-3 smoke compartment on the Third floor in Corridor-3399W, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. A 90 minute door had a vinyl astragal. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

3. On 11/11/13 at 14:12 pm surveyor #32724 & 28616 observed in the SC5-2 smoke compartment on the Second floor in Corridor-2299W, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. A 90 minute door had a vinyl astragal. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not provide and maintain the required building construction type with support steel covered with rated fire proofing. This deficiency occurred in of the 22 smoke compartments, and had the potential to affect of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 13:42 pm surveyor #32724 & 28616 observed in the SC4-G smoke compartment on the Ground floor in Storage-G560B, that fire proofing was missing from the structural steel column. One layer of gypsum board was pulled away from a fire rated column enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with smoke detection in spaces that are open to the corridor. This deficiency occurred in 1 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 9:23 am surveyor #32724 & 28616 observed in the SC5-1 smoke compartment on the First floor in Triage-1533, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have the code required "electrically supervised" automatic smoke detection system. The room was open to the corridor and did not have a smoke detector. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

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. This deficiency occurred in 1 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 12:38 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in Corridor-G699E, that the path of egress in the corridor was not readily apparent and an exit sign was not provided looking south. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, and sealed wall penetrations. This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/11/13 at 13:59 pm surveyor #32724 & 28616 observed in the SC2-3 smoke compartment on the Third floor in Storage-3317A, that the door would not self-close. 24 boxes on wire racks were stored in a room originally designated as a patient room and is now used as storage. The door to the corridor did not have a closer. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

2. On 11/12/13 at 12:00 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in the Linen Storage-G104A, that penetration(s) were not sealed according toaccording to an approved method. The deficiency included openings not fire sealed around a 1 1/2" pipe and a 2" hole. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not provide enclosures around exit stairs with and sealed wall penetrations. This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/11/13 at 14:48 pm surveyor #32724 & 28616 observed in the SC1-2 smoke compartment on the Second floor in Stair-STR2-2, that penetration(s) were not sealed according to an approved method. The deficiency included a 6" diameter, a 4" diameter, and (2) 2" diameter pipes running from the roof top. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director fo Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

2. On 11/11/13 at 14:57 pm surveyor #32724 & 28616 observed in the SC2-2 smoke compartment on the Second floor in Stair-STR1-2, that penetration(s) were not sealed according to an approved method. The deficiency included a 1" diameter pipe and (2) 1" copper pipes without fire calk. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director fo Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

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. egress lighting fed by emergency power, and adequate lighting of the egress path. This deficiency occurred in 2 of the 22 smoke compartments, and had the potential to affect 16 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/12/13 at 10:55 am surveyor #32724 & 28616 observed in the SC1-1 smoke compartment on the First floor in the Cath Lab, that the facility was unable to verify that the lighting along the path of egress was powered from the emergency electrical system. The location of a battery backup emergency light could not be verified. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff QQ (Building Project Specialist).

2. On 11/12/13 at 9:32 am surveyor #32724 & 28616 observed in the SC5-1 smoke compartment on the First floor at the Exit Door, that there were no light fixtures along the path of discharge at this location. No exterior lights were at the exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, sprinkler gauges with the required maintenance, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, sprinklers free of lint. This deficiency occurred in 4 of the 22 smoke compartments, and had the potential to affect 42 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors..

FINDINGS INCLUDE:
1. On 11/11/13 at 14:21 pm surveyor #32724 & 28616 observed in the SC4-2 smoke compartment on the Second floor in Storage 2427, 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. Storage was kept within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
2. On 11/12/13 at 11:58 am surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in Linen Storage G104A, 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. Linen was stacked within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems) and staff RR (Maintanance).
3. On 11/12/13 at 12:12 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in Central Storage G199C,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. Storage was kept within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
4. On 11/12/13 at 12:27 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in Central Storage G199C, walk-in cooler, 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. Food storage was kept within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
5. On 11/12/13 at 12:57 pm surveyor #32724 & 28616 observed in the SC1-G smoke compartment on the Ground floor at MRI Reception G600A,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. Cabinetry was kept within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
6. On 11/12/13 at 13:38 pm surveyor #32724 & 28616 observed in the SC4-G smoke compartment on the Ground floor at Storage G560B, 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. Shelving was kept within 18" of a sprinkler head. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
7. On 11/12/13 at 13:45 pm surveyor #32724 & 28616 observed in the SC4-G smoke compartment on the Ground floor at Storage G560B, 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. Stacked storage totally obstructed sprinkler heads. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, sprinkler gauges with the required maintenance, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, sprinklers free of lint. This deficiency occurred in 10 of the 22 smoke compartments, and had the potential to affect 42 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/12/13 at 12:06 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in the Alcove-G199C, that the escutcheon ring on the sprinkler was 1/2" below the ceiling tile. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

2. On 11/12/13 at 13:31 pm surveyor #32724 & 28616 observed in the SC3-G smoke compartment on the Ground floor in the FPS Room, that during a review of documents the facility could not verify that the sprinkler water pressure gauge had been replaced or calibrated within the last 5 years. The fire sprinkler gauges were not labeled or dated. This observed situation was not compliant with NFPA 25 (1998 edition), 2-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

3. On 11/11/13 at 12:56 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Electrical Closet-3421, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2" x 6" and a 3" x 3" hole in ceiling at conduit penetrations. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

4. On 11/11/13 at 13:52 pm surveyor #32724 & 28616 observed in the SC2-3 smoke compartment on the Third floor in the Electrical Closet-3352, that there was one or more unsealed holes near the ceiling. The hole(s) included a 3" x 6' opening where ceiling tile was missing at conduit locations. This opening would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

5. On 11/11/13 at 14:14 pm surveyor #32724 & 28616 observed in the SC4-2 smoke compartment on the Second floor in the Electrical Closet-2420, that there was one or more unsealed holes near the ceiling. The hole(s) included (6) holes in the ceiling tile. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

6. On 11/12/13 at 9:38 am surveyor #32724 & 28616 observed in the SC5-1 smoke compartment on the First floor in the Vestibule-1567A, that there was one or more unsealed holes near the ceiling. The hole(s) included 1/2" hole in the ceiling tile adjacent to the sprinkler head. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

7. On 11/12/13 at 9:47 am surveyor #32724 & 28616 observed in the SC5-1 smoke compartment on the First floor in the Housekeeping-1555, that there was one or more unsealed holes near the ceiling. The hole(s) included a broken ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

8. On 11/12/13 at 11:59 am surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in the Linen Storage-G104A, that there was one or more unsealed holes near the ceiling. The hole(s) included a 3' x 2' ceiling tile missing. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

9. On 11/12/13 at 12:42 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in the Laundry Room-G672B, that there was one or more unsealed holes near the ceiling. The hole(s) included a sprinkler where the concealed sprinkler head was missing a cover plate. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

10. On 11/12/13 at 13:18 pm surveyor #32724 & 28616 observed in the SC3-G smoke compartment on the Ground floor in the Telecommunication Room-G450, that there was one or more unsealed holes near the ceiling. The hole(s) included a 2" x 4" & a 2" x 2" holes in the ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

11. On 11/11/13 at 12:58 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Doctor Dressing Room-3415A-A, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

12. On 11/11/13 at 13:09 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the OR-3416, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

13. On 11/11/13 at 13:26 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Stroage Room-3433, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. (3) sprinkler heads were full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

14. On 11/11/13 at 13:42 pm surveyor #32724 & 28616 observed in the SC1-3 smoke compartment on the Third floor in the Corridor, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. (2) sprinkler heads were full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
15. On 11/11/13 at 14:02 pm surveyor #32724 & 28616 observed in the SC2-3 smoke compartment on the Third floor in the Lounge 3340B, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
16. On 11/11/13 at 14:18 pm surveyor #32724 & 28616 observed in the SC3-2 smoke compartment on the Second floor in the PT Room 204, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
17. On 11/11/13 at 14:40 pm surveyor #32724 & 28616 observed in the SC1-2 smoke compartment on the Second floor in the Office 2278, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
18. On 11/12/13 at 9:18 am surveyor #32724 & 28616 observed in the SC4-1 smoke compartment on the First floor in the Pain Management Nurse Station, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).
19. On 11/12/13 at 9:25 am surveyor #32724 & 28616 observed in the SC5-1 smoke compartment on the First floor in Triage 1533, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. A sprinkler head was full of lint. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Systems), staff QQ (Building Project Specialist) and staff RR (Maintanance).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings, sprinkler gauges with the required maintenance, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, ceilings sealed above the sprinklers to collect heat, sprinklers free of lint. This deficiency occurred in 10 of the 22 smoke compartments, and had the potential to affect 42 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 2:15 pm surveyor #32724 & 28616 observed in the lower level smoke compartment on the ground floor in the Storage Room, that there was one or more unsealed holes in the ceiling. The hole(s) included a 2' x 4' and a 10" diameter hole in ceiling. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff QQ (Building Project Specialist).

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with accessible extinguisher. This deficiency occurred in 1 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 12:16 pm surveyor #32724 & 28616 observed in the SC2-G smoke compartment on the Ground floor in the Central Supply-G199C, that a fire extinguisher was not accessible for immediate use because a cart was blocking access to the fire extinguisher. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 edition) 1-6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 with oxygen cylinders restrained from falling. This deficiency occurred in 1 of the 22 smoke compartments, and had the potential to affect 12 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 11/12/13 at 10:50 am surveyor #32724 & 28616 observed in the SC1-1 smoke compartment on the First floor in the Endo Scope Room-1740C, that a cylinder of oxygen in storage was not secured to keep it from falling. A door was held open with an oxygen tank. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 8-3.1.11. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff QQ (Building Project Specilaist).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, and fixed wiring rather than extension cords. This deficiency occurred in 4 of the 22 smoke compartments, and had the potential to affect 24 of the 95 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 11/12/13 at 10:14 am surveyor #32724 & 28616 observed in the SC2-1 smoke compartment on the First floor in the Soiled Utility-1632B room, that access to electrical panel was less than 3'-0" clearance. (3) electrical panels were blocked by carts, a table, and a soiled laundry bin. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

2. On 11/11/13 at 12:50 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Supply Room-3428B, 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 charge phones. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

3. On 11/11/13 at 13:15 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Lactation Room-3410, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a radio, a refrigerator and a pump. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

4. On 11/11/13 at 13:21 pm surveyor #32724 & 28616 observed in the SC3-3 smoke compartment on the Third floor in the Family Lounge-3432, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a coffee machine and a water cooler. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

5. On 11/11/13 at 13:38 pm surveyor #32724 & 28616 observed in the SC1-3 smoke compartment on the Third floor in Offcie-3373, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. Two strip plugs were used to provide power to (2) power multiple items. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

6. On 11/12/13 at 9:07 am surveyor #32724 & 28616 observed in the SC4-1 smoke compartment on the First floor in the Break Room-1424, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a toaster and a microwave. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

7. On 11/12/13 at 9:10 am surveyor #32724 & 28616 observed in the SC4-1 smoke compartment on the First floor in Storage-1423, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was attached to a shelf and was used to power multiple equipment items. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).

8. On 11/12/13 at 10:18 am surveyor #32724 & 28616 observed in the SC2-1 smoke compartment on the First floor in the Kitchen-1634, 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 charge several phones. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff PP (Director of Integrated Services), staff QQ (Building Project Specialist) and staff RR (Maintenance).