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Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficiency could affect 23 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/23/2012 at 9:28 am surveyor observed that the top of the two-hour fire barrier was not sealed to the roof/wall joint and fire caulked to a two-hour standard for this fire barrier. This violation occurred on both sides of the wall [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

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, sealed floor penetrations. This deficiency could affect all of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/18/2012 at 11:58 am surveyor observed on the 5th floor in the soiled utility in the O.B. area, that there were penetration(s) through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included 4' and 2' pipes Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

2. On 7/18/2012 at 12:23 pm surveyor observed on the 5th floor in the room 5-65, that there were penetration(s) through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included a 18" X 12" hole. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

3. On 7/18/2012 at 3:10 pm surveyor observed on the 5th floor in the room 5-29, that there were penetration(s) through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included the ceiling of plaster that is not 2 hour rated. The size is 12" X 6". Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

4. On 7/18/2012 at 4:25 pm surveyor observed on the 5th floor in the room 5-03G, that there were penetration(s) through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included the 8 inch pneumatic tube Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

5. On 7/19/2012 at 10:35 am surveyor observed on the basement floor in the room B 9, that there were penetration(s) through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included 3 pipes at the ceiling. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

6. On 7/19/2012 at 10:50 am surveyor observed on the basement floor in the room B13, that there were penetration(s) through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included 2 pipes. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

7. On 7/23/2012 at 11:05 am surveyor observed on the 1st floor in the electrical closet, 1-82A, that there were penetration(s) through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included plaster at the floor line instead of 2 hour rated floor. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

8. On 7/24/2012 at 11:35 am surveyor observed on the 2nd floor in the room 2-52B (electrical room), that there were penetration(s) through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included many conduits passing though the ceiling and floor. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

9. On 7/24/2012 at 11:38 am surveyor observed on the 2nd floor in the Room 2-51B, that fire proofing was missing from the structural steel at the beam and expansion joint . 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 YY (Admin. Support services) and staff DDD (Construction Specialist).

10. On 7/24/2012 at 11:39 am surveyor observed on the 2nd floor in the Room 2-51B, that there were penetration(s) through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included pipes and cabling that were not fire caulked. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

11. On 7/24/2012 at 11:45 am surveyor observed on the 2nd floor in the room 2-52B, that there were penetration(s) through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included 5 pipes. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

12. On 7/25/2012 at 10:02 am surveyor observed that the Mechanical shaft in Lab 3-47D did not have a 12" x 12" hole in the deck sealed to maintain the rating of this floor [3rd Floor /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview the facility did not provide room finishes with rated ceiling materials, rated wall finishes, and rated materials. This deficiency could affect 25 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 12:25 pm surveyor observed that a cotton wall hanging was on display in the lower level within the 'atrium' space of this building. No tag was present, and staff could not verify that this material met the Class A or B rating required for item [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

Based on observation and interview the facility did not provide room finishes with rated ceiling materials, rated wall finishes, and rated materials. This deficiency could affect 10 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/19/2012 at 8:30 am surveyor observed on the basement floor in the room B55, that the facility could not confirm the ceiling had an appropriate rating. The ceiling was finished with wood. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

2. On 7/23/2012 at 12:00 pm surveyor observed on the 1st floor in the room 107, that the facility could not confirm the wall had an appropriate rating. The room wall was finished with a plastic sheet. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

3. On 7/23/2012 at 1:00 pm surveyor observed on the 1st floor in the Gift shop, room 1-058, that the facility could not confirm the room had an appropriate rating. The facility did not provide the fame spread rating for the wood paneling on the wall in the gift shop. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

4. On 7/24/2012 at 2:00 pm surveyor observed on the 2nd floor in the room 2-61, Chapel, that the facility could not confirm the room had an appropriate rating. The facility did not provide the fame spread rating for the wood paneling on the wall in the Chapel. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight construction, no combustible material storage, and smoke detection and quick response sprinklers in corridors with spaces that are open to the corridor. This deficiency could affect 50 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 3:05 pm surveyor observed that Viewing L-52, Control L-63, and Control L-65 were open to the corridor and were not protected with smoke detectors for these spaces. These spaces are not staffed 24/7 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/19/2012 at 8:45 am surveyor observed that Nurse Office 1-85A is open to the corridor and not protected with a smoke detector for this space. This space are not staffed 24/7 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/19/2012 at 1:45 pm surveyor observed that the booths within Registration 1-12 are open to the corridor not protected with smoke detectors. The spaces are not staffed 24/7 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

4. On 7/19/2012 at 2:41 pm surveyor observed that the penetration at the round duct in the south wall of Work room 1-03 was not sealed to resist the passage of smoke in this corridor wall [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/19/2012 at 2:51 pm surveyor observed that (4) penetrations in the west wall of Corridor 100-0 were not sealed to resist the passage of smoke in this corridor wall [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

6. On 7/19/2012 at 2:56 pm surveyor observed that (1) 3" hole and (2) stub conduits in the west wall of Decontamination 1-01B were not sealed to resist the passage of smoke in this corridor wall [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview the facility did not provide reliable corridor doors due to a lack of an astragal or latching hardware. This deficiency could affect 50 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 3:33 pm surveyor observed that the door into the ' Linac ' room is a door opening into a corridor system without positive latching [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/19/2012 at 7:25 am surveyor observed that a brush gasket was installed in lieu of a astragal at the pair of doors from Mechanical L-21 into the corridor system. This gasket will not maintain the smoke-tight integrity under a fire condition [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/23/2012 at 7:34 am surveyor observed that the paired set of doors from OR #2 did not positively latch, and no astragal was provided to maintain the smoke-tight quality Corridor 300-6 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

4. On 7/23/2012 at 7:58 am surveyor observed that the paired set of doors from OR#1, #3, #4, #5, #6, #7, #9 and #10 were not provided with astragals to maintain the smoke-tight quality in Corridor 300-5 and Corridor 300-6 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/23/2012 at 8:03 am surveyor observed that the paired set of doors from Supply 3-46 had a rubber astragal that was partially missing; this did not provide a smoke-tight quality for Corridor 300-12 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

6. On 7/23/2012 at 8:22 am surveyor observed that the Dutch doors from Workroom 3-07 did not positively latch independently, and no astragal was provided at the meeting edge of the upper and lower door to maintain the smoke-tight quality for Corridor 3-07 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

7. On 7/23/2012 at 8:45 am surveyor observed that the three sets of paired doors from Recovery and Passage into Corridor 300-10 and Corridor 300-6 did not have astragals. This did not provide a smoke-tight quality for Corridor 300-10 or 300-6. None of these sets of doors had positive latching [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

8. On 7/23/2012 at 8:48 am surveyor observed that the set of paired doors from Passage near Nurse Desk 3-24E into Corridor 300-10 did not have any latching hardware [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with non-compliant vertical openings and non-rated doors. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 11:33 am surveyor observed that a plastic membrane had been installed on the rated fire doors into the elevator shaft. The plastic material is not part of the rated doors as tested by UL standards [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/18/2012 at 12:05 am surveyor observed that a plastic membrane had been installed on the rated fire doors into the elevator shaft at 9 out of 10 locations. This material is not part of the rated doors as tested by UL standards [Lower Level /I-2 occupancy This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/19/2012 at 3:10 pm surveyor observed that the south and east walls of Mechanical 4-02 into Stairs 4-04 were open at the top of this two-hour wall [Penthouse Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficiency could affect all of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/19/2012 at 8:45 am surveyor observed on the basement floor in the stair 3, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

2. On 7/19/2012 at 11:40 am surveyor observed on the basement floor in the room B 86, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

3. On 7/23/2012 at 10:50 am surveyor observed on the 1st floor in the room 1-77, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

4. On 7/24/2012 at 8:15 am surveyor observed on the 2nd floor in the room 2-58L and 2-58K, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

5. On 7/24/2012 at 9:20 am surveyor observed on the 2nd floor in the room 2-140, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

6. On 7/25/2012 at 10:50 am surveyor observed on the 3rd floor in the connector to ST Anna, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

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, and "no-exit" signs at that may be confused as exits. This deficiency could affect 75 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/18/2012 at 11:16 am surveyor observed on the 5th floor in the corridor of the OB area, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near room 4. 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 YY (Admin. Support services) and staff CCC (Safety Officer).

2. On 7/23/2012 at 1:35 pm surveyor observed on the 1st floor in the exit passage way for Stair 6, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near door to vestible. 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 YY (Admin. Support services) and staff DDD (Construction Specialist).

3. On 7/24/2012 at 9:15 am surveyor observed on the 2nd floor in Room 2-05, 2nd floor patio, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near the stairs leading off of the patio. 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 YY (Admin. Support services) and staff DDD (Construction Specialist).

4. On 7/24/2012 at 12:16 pm surveyor observed on the 2nd floor in the exit 2-140, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near from the room 2-140 area. 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 YY (Admin. Support services) and staff DDD (Construction Specialist).

5. On 7/24/2012 at 3:50 pm surveyor observed on the 2nd floor in the corridor to clinic, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. A 'No Exit' sign is needed on the fall down fire shutter. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficiency could affect 50 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 2:25 pm surveyor observed that all of the east wall of Clean Utility L-70 and the west wall of Soiled Utility L-68 did not have all of the screw heads covered with joint compound, and 6 penetrations were not fire caulked [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/18/2012 at 2:40 pm surveyor observed that all of the west and north walls of Serenity L-81 did not have all of the screw heads covered with joint compound and a 3" sprinkler line was not fire caulked [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/18/2012 at 2:44 pm surveyor observed that all of the south side of the smoke compartment in the Passage east of Serenity L-81 did not have all of the screw heads covered with joint compound and the top of the wall was not sealed to a one-hour rating [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

4. On 7/18/2012 at 2:52 pm surveyor observed that the north wall of Conference L-79 did not have a hole in the gypsum wallboard sealed to a one-hour rating [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/18/2012 at 2:57 pm surveyor observed that the south side of the smoke compartment in Passage west of Clean Utility L-70 did not have all of the screw heads covered with joint compound to a one-hour rating [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

6. On 7/19/2012 at 8:45 am surveyor observed that the north side of the smoke compartment in Corridor 100-15 did not have an 8" round duct fire caulked to a one-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

7. On 7/19/2012 at 9:44 am surveyor observed that the north side of the smoke compartment in Corridor 100-10 did not have the ductwork fire caulked to a one-hour rating on the east and west sides [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

8. On 7/19/2012 at 12:39 pm surveyor observed that four (4) penetrations on the south side of the smoke compartment at the north end of Passage 100-02 were not fire caulked to a one-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

9. On 7/19/2012 at 12:48 pm surveyor observed that eight (8) penetrations in the west wall of the smoke compartment at the north end of Passage 100-02 were not fire caulked to a one-hour rating, and the screw heads were not covered with joint compound [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

10. On 7/19/2012 at 1:01 pm surveyor observed that four (4) penetrations and one 3" x 4" hole in the south side of the smoke compartment at the north end of Passage 100-05 were not fire caulked to a one-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

11. On 7/19/2012 at 1:48 am surveyor observed that two (2) penetrations in the north side of the smoke compartment within Reception 1-12 and one (1) penetration in the north side of the smoke compartment within Corridor 100-04 are not fire caulked to a one-hour rating. The screw heads were not mudded with joint compound along this one-hour wall [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

12. On 7/23/2012 at 7:25 am surveyor observed that one (1) penetration in the north side of the smoke compartment from Corridor 300-3 above the doors was not fire caulked [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

13. On 7/23/2012 at 8:52 am surveyor observed that one (1) hole was found in the east wall of Storage 3-32 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

14. On 7/23/2012 at 9:11 am surveyor observed that the penetration of the unistrut into the smoke compartment from Workroom 3-33 was not fire caulked. No pillows were installed within the cable tray that penetrated this wall. The screw heads were also not mudded at this rated wall [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier doors due to non-compliant door hardware. This deficiency could affect 50 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 11:36 am surveyor observed the meeting edge of the paired doors at the west end of Corridor #14 were covered with a brush gasket to prevent the passage of smoke for this smoke compartment. These nylon brushes are not tested as an "astragal" by Underwriters Laboratory (UL) and will not maintain the smoke integrity up to the 155 degree in temperature of the sprinkler head rating. These brushes melt at 134 degrees and can not be used in lieu of UL listed astragal door hardware [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/18/2012 at 12:05 pm surveyor observed the meeting edge of the paired doors at the east end of Corridor #16 were covered with a brush gasket to prevent the passage of smoke for this smoke compartment. Gaskets can not be used in lieu of an astragal. The nylon brushes are not tested nor listed as astragals by UL [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/18/2012 at 12:21 pm surveyor observed the meeting edge of the paired doors into Mechanical L-114 were covered with a brush gasket to prevent the passage of smoke for this smoke compartment/exit access door. Gaskets can not be used in lieu of an astragal. These nylon brushes are not tested nor listed as astragals by UL [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

4. On 7/18/2012 at 2:57 pm surveyor observed that the meeting edge of the paired doors into Suite #1 from Corridor #05 were covered with a brush gasket to prevent the passage of smoke for this smoke compartment/exit access door. These nylon brushes are not tested nor listed as astragals by UL [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/19/2012 at 8:39 am surveyor observed the meeting edge of the paired doors in the north wall of Lobby 1-120 were sealed with a rubber gasket to prevent the passage of smoke for this smoke compartment. These gaskets are not tested nor listed as astragals by UL [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

6. On 7/19/2012 at 9:44 am surveyor observed that the meeting edge of the paired doors in the smoke compartment wall from Corridor 100-10 were covered with a brush gasket to prevent the passage of smoke for this smoke compartment/exit access door. These nylon brushes are not tested nor listed as astragals by UL. [First Level /I-2 occupancy] This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

7. On 7/19/2012 at 10:05 am surveyor observed that the cover plate for the door lock was not installed at the leaf for the smoke door [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

8. On 7/23/2012 at 7:27 am surveyor observed that the meeting edge of the paired doors in the smoke compartment wall from Corridor 300-3 were covered with a brush gasket to prevent the passage of smoke for this smoke compartment/exit access door. These nylon brushes are not tested nor listed as astragals by UL. [Third Level /I-2 occupancy] This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not enclose hazardous rooms with closer's on all doors, doors with positive-latching hardware, closer's on all doors, sealed wall penetrations, closer's on all doors, rated doors, and rated walls in a non-sprinkled hazardous room. This deficiency could affect 50 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 11:58 am surveyor observed that all of the perimeter walls of Housekeeping L-113 did not have all of the tape fully embedded in joint compound to a one-hour standard [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/18/2012 at 1:48 pm surveyor observed within Electrical L-116 that the one-hour fire resistant walls did not have all of the penetrations sealed to a one-hour rating at the wood panel, 24x24 duct, and the beam at the west wall. The door did not have a fire label and no door closer was installed [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/18/2012 at 2:24 pm surveyor observed that all of the perimeter walls of Soiled Utility L-68 and Clean Utility L-70 did not have all of the screw heads covered with joint compound to a one-hour standard for all of these walls [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

4. On 7/18/2012 at 3:15 pm surveyor observed that Shell Space L-64 was greater than 100 square feet and used for storage of combustible materials. The wall from this space into Corridor 07 had only one layer of gypsum wallboard on one side of metal studs (not a one-hour assembly) [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/19/2012 at 7:15 am surveyor observed that one (1) ¾" and one (1) 1" electrical conduits were not fire caulked in the south wall of Storage L-29 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

6. On 7/19/2012 at 7:25 am surveyor observed that a door label was not installed at either of the paired doors from Mechanical L-21 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

7. On 7/19/2012 at 8:45 am surveyor observed that three (3) 3/4" conduits and one (1) 10" round duct were not fire caulked to a one-hour standard in Clean Utility 1-86 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

8. On 7/19/2012 at 8:49 am surveyor observed that a gypsum wallboard offset in this wall was not taped and mudded to a one-hour standard in the corridor for the west wall of Clean Utility 1-86 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

9. On 7/19/2012 at 8:58 am surveyor observed that two (2) penetrations in the west wall and one (1) penetration in the south wall were not fire caulked to a one-hour standard in Clean Utility 1-82 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

10. On 7/19/2012 at 9:01 am surveyor observed that one (1) penetration in the north wall and one (1) penetration in the south wall were not fire caulked to a one-hour standard in Soiled Utility 1-84 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

11. On 7/19/2012 at 9:44 am surveyor observed that the screw heads within the one-hour wall of Electrical 1-131 were not mudded [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

12. On 7/19/2012 at 10:12 am surveyor observed that a 12" x 12" opening was found in the south wall, a sprinkler pipe was not fire caulked to a one-hour and the door was not labeled at 45 minutes within Communications 1-138A [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

13. On 7/19/2012 at 10:55 am surveyor observed that one (1) penetration in the west wall and two (2) penetrations in the south wall were not fire caulked to a one-hour standard in Clean Utility 1-34 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

14. On 7/19/2012 at 11:24 am surveyor observed that a 2" x 3" hole in the north wall was not sealed to a one-hour standard in Soiled Utility 1-39 [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

15. On 7/19/2012 at 1:31 pm surveyor observed that both doors into Communications 1-81 and Storage 1-83 were not 45-min labeled doors. Additionally, four (4) penetrations into the walls were not fire caulked [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

16. On 7/19/2012 at 7:49 am surveyor observed that six (6) holes in the north wall of Corridor 100-01 at the two-hour wall were not fire caulked to a two-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

17. On 7/19/2012 at 2:39 pm surveyor observed that one (1) hole in the north wall of Workroom 1-03 at the two-hour wall was not fire caulked to a two-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

18. On 7/19/2012 at 2:52 pm surveyor observed that four (4) penetrations in the north wall of Office 1-03A at the two-hour wall was not fire caulked to a two-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

19. On 7/19/2012 at 2:53 pm surveyor observed that one (1) penetration in the north wall of Decontamination 1-01B was not fire caulked to a two-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

20. On 7/19/2012 at 2:56 pm surveyor observed that two (2) stub conduits and three (3) conduit penetrations in the north wall of LT 1-01A were not fire caulked to a two-hour rating [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

21. On 7/19/2012 at 3:53 pm surveyor observed that the door and frame into Electrical 3-48 were not labeled [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

22. On 7/23/2012 at 8:16 am surveyor observed that the door into Trash 3-04 was not labeled [Third Level/I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

23. On 7/23/2012 at 8:39 am surveyor observed that the southeast and southwest corners were not taped and mudded to a one-hour rating in Soiled Utility 3-14C [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide enclosures around exit stairs with exit stairwells without openings to unoccupied rooms. This deficiency could affect 50 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1) On 7/19/2012 at 10:00 am surveyor observed on the basement floor in the stairs 7, that there is an opening into an exit enclosure was from a mechanical room, which is an non habitable room. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

2) On 7/23/2012 at 3:30 pm surveyor observed on the 1st floor in Stair 1, that the stairwell was not compliant. An elevator opened directly into a stairway. An elevator is not a corrisor or habitable room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.3 and 7.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide egress paths at all times with doors that opened with under 50 pounds of force, doors that were unlockable in the egress path, doors that swing in the direction of egress, compliant egress path, doors that were unlockable in the egress path, and paths with sufficient headroom. This deficiency could affect all of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/18/2012 at 11:12 am surveyor observed on the 5th floor in the corridor that goes through OB, that the door in the path of egress would not open when a force of 50 lbs pounds was applied, which exceeded the maximum 50 pounds needed to open an existing exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ccc (Safety Office).

2. On 7/18/2012 at 12:10 pm surveyor observed on the 5th floor in the corridor by stairs 6, that the door was locked from the egress side. The stair doors are locked when a baby bracelet is near the door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ccc (Safety Office).

3. On 7/18/2012 at 4:20 pm surveyor observed on the 5th floor in the elevator lobby door, that the door was locked from the egress side. The stair doors are locked when a baby bracelet is near the door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ccc (Safety Office).

4. On 7/19/2012 at 8:25 am surveyor observed on the basement floor in the room B50, that the door was locked from the egress side. The door could be locked from the corridor side and one could be unable to exit the room. This is an old refrigerator door without the safety release from the inside. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ccc (Safety Office).

5. On 7/19/2012 at 9:00 am surveyor observed on the basement floor in the room B31, that the door was locked from the egress side. The door could be locked from the corridor side and one could be unable to exit the room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ccc (Safety Office).

6. On 7/19/2012 at 1:22 pm surveyor observed on the 4th floor in the room 403C, that the door in the path of egress would not open when a force of 100 pounds was applied, which exceeded the maximum 50 pounds needed to open an existing exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist), staff ccc (Safety Office), and staff ddd (Construction Specialist).

7. On 7/23/2012 at 12:10 pm surveyor observed on the 1st floor in the former ED area, that the door was locked from the egress side. Magnetic locks prevented egress from the area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).

8. On 7/23/2012 at 2:40 pm surveyor observed on the 1st floor in the Hall 78, that the egress path was not compliant. The exit access path was 36" wide between chairs. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).

9. On 7/23/2012 at 3:10 pm surveyor observed on the 1st floor in the room 1-62, that the door in the path of egress did not swing in the direction of egress travel and the occupancy load of the egress was estimated to be at least 50 persons. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).

10. On 7/23/2012 at 3:17 pm surveyor observed on the 1st floor in the corridor by stair 1, that the headroom was six feet. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).

11. On 7/23/2012 at 3:40 pm surveyor observed on the 1st floor in the stair 1, that the egress path was not compliant. There was not a safe path to a public way. As one leaves the door from stair 1, one passes in front of an intake/exhaust louver that is not protected with a fire damper. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).

12. On 7/24/2012 at 10:55 am surveyor observed on the 2nd floor in the room 2-170E and F (Bay5), that the egress path was not compliant. The sliding door did not break open. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).

13. On 7/25/2012 at 10:00 am surveyor observed on the 3rd floor in the PAB Connector, that the door was locked from the egress side. The doors to the hospital can not be locked from the PAB. A magnetic lock is activated at night. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).

14. On 7/25/2012 at 4:00 pm surveyor observed on the basement floor in the maintenance shop office suite, that the headroom was less than 6'-8". This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ddd (Construction Specialist).

15. On 7/23/2012 at 4:10 pm surveyor observed on the 1st floor in the corridor by room 37, that a dead end corridor of 41 feet was observed. The surveyor observed that it would be practical and feasible to alter the layout to provide a corridor without a dead end. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.10. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).



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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 could affect 30 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/18/2012 at 11:17 am surveyor observed on the 5th floor in the corridor by room 4, that the clear and unobstructed width of the corridor was 5 feet because a gurney was located there. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

2. On 7/23/2012 at 11:55 am surveyor observed on the 1st floor in the corridor by room 103, that the clear and unobstructed width of the corridor was less than four feet because one door was in the 8 foot wide corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

3. On 7/24/2012 at 3:30 pm surveyor observed on the 2nd floor in the corridor by room 2-115, that the clear and unobstructed width of the corridor was 6 feet because 5 chairs stuck out into the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide egress with a maximum of two intervening rooms or within required travel distance limits. This deficiency could affect 100 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/25/2012 at 7:59 am surveyor observed that a door located in Passage, west of Storage 3-51J, created three intervening rooms for some of the occupants of this suite [3rd Floor /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/23/2012 at 12:35 pm surveyor observed on the 1st floor in the room 129B, that the travel distance of 78 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

3. On 7/23/2012 at 1:25 pm surveyor observed on the 1st floor in the room 130B, that the travel distance of 75 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

4. On 7/24/2012 at 12:35 pm surveyor observed on the 2nd floor in the room 2-139I, that the travel distance of 99 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

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Based on observation and interview, the facility did not provide all spaces with the required signage for a delayed egress device. This deficiency could affect 25 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/24/2012 at 9:25 am surveyor observed on the 2nd floor in the room 2-140, that a delayed egress lock (DEL) did not did not have the required signage on the door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

2. On 7/24/2012 at 12:15 pm surveyor observed on the 2nd floor in the exit 2-140, that a delayed egress lock (DEL) did not did not have the required signage on the door. There was no sign on the door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with smoke detectors installed per listing requirements and did not install notification devices in all public spaces. This deficiency could affect all patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/19/2012 at 8:54 am surveyor observed that Nurse Office 1-85A was permanently occupied by two or more occupants and no visible appliance were installed in this room. This room was not manned 24/7 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 1-5.2.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/19/2012 at 7:29 am surveyor observed that smoke detector in UPS room L-11A was not mounted to the ceiling [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 1-5.2.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/19/2012 at 9:12 am surveyor observed that Workroom 1-108 was permanently occupied by two or more occupants and no visible appliance were installed in this room [First Level/I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 1-5.2.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

4. On 7/19/2012 at 12:55 am surveyor observed that Workroom 1-26 was permanently occupied by two or more occupants and no visible appliance were installed in this room [First Level/I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 1-5.2.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/19/2012 at 1:23 am surveyor observed that the fire alarm purge panel was not locked or secured within Communications 1-81 [First Level/I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), Chapter 1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation, interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements with compliant fire alarm testing. This deficiency could affect all of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 7/25/2012 at 3:50 pm surveyor observed that the fire alarm maintenance was not compliant. Repair to the fire alarm system was identified within the facility fire alarm testing reports, but there was no information that substantiated that the repair was completed. Examples of items not tested: initiating devices L2D30, L2D20 and L1-D94. Additionally 14 out of 18 batteries in the fire alarm panel were indicated to have failed. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.7 and NFPA 72 (1999 edition), Chapter 7-3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with all rooms sprinkled when the code required full sprinkle coverage. This deficiency could affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 1:48 pm surveyor observed within Electrical L-116 that the sprinkler head was not located less than 22 inches below the exposed ceiling of this space [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/18/2012 at 1:54 pm surveyor observed that no sprinkler head was located below the monumental stair landing, which was greater than 4 feet in width [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/18/2012 at 2:10 pm surveyor observed that no sprinkler heads were located within the raised soffit areas along the east and south walls of Waiting L-120. The elevation of the ceiling of the soffit was greater than 22" above most of the ceiling within this room [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

4. On 7/18/2012 at 2:46 pm surveyor observed that a gap was present around the sprinkler head escutcheon in Storage L-80 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/18/2012 at 3:39 pm surveyor observed that storage obstructed the discharge of the sprinkler heads in Storage rooms L53 and L55 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

6. On 7/18/2012 at 3:47 pm surveyor observed that walls within Changing L-47 obstructed the discharge of the sprinkler heads [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

7. On 7/18/2012 at 4:15 pm surveyor observed that the main switchgear located within Electrical L-25 was not shielded from the discharge of the sprinkler heads and sprinkler branch lines were located above this equipment [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

8. On 7/19/2012 at 7:29 am surveyor observed that openings were present within the ceiling system in UPS room L-11A and Data Center L-11. These openings will not allow the sprinkler systems to activate in the allotted time frame for these sprinklers [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

9. On 7/19/2012 at 7:37 am surveyor observed that one (1) 1" hole was found in the ceiling of Linen L-07 [Lower Level /I-2 occupancy]. Ceilings in all sprinkler spaces require reliable and continuous ceiling membrane to ensure prompt sprinkler response. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

10. On 7/19/2012 at 7:43 pm surveyor observed that a ceiling light and the rubbish chute door obstructed the discharge of the sprinkler head in Trash L-05 [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

11. On 7/19/2012 at 7:55 am surveyor observed that within Switchgear L-01 the main switchgear was not shielded from the discharge of the sprinkler heads and sprinkler branch lines were located above this equipment [Lower Level /I-2 occupancy] This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

12. On 7/19/2012 at 8:36 am surveyor observed that no sprinkler heads were located within the raised soffit areas along the north and south walls of Lobby 1-120. The elevation of the ceiling of the soffit was greater than 22" above most of the ceiling within this room [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

13. On 7/19/2012 at 10:55 am surveyor observed that holes within the ceiling of Clean Utility 1-34 are not sealed to a smoke-tight quality for timely sprinkler system discharge [First Level/ I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

14. On 7/19/2012 at 1:31 pm surveyor observed that the sprinkler head into Storage 1-83 was greater than 22" from the exposed deck [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

15. On 7/23/2012 at 8:05 am surveyor observed that storage obstructed the discharge of a sprinkler head in Supply 3-46 [Third Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

16. On 7/23/2012 at 8:38 am surveyor observed that ceiling tiles were missing in Clean Utility 3-14B [Third Level/ I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

17. On 7/23/2012 at 8:54 am surveyor observed that holes within the ceiling of Frozen Lab 3-40 are not sealed to a smoke-tight quality for timely sprinkler system discharge [Third Level/ I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A. 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). The Wisconsins Department of Health Services and Centers for Medicare Services directs inspectors to use NFPA 90A when evaluating the ventilation system in both new and existing facilties. Thus, the Life Safey Code supercedes NFPA 90A (1999 edition) 1-3.3. This deficiency could affect 75 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/23/2012 at 2:51 pm surveyor observed that within 6-34B a dryer vent was installed using flexible ductwork into a vertical shaft and did not use hard pipe ductwork, which is the minimum standard for this installation [6th Floor/I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/24/2012 at 9:58 am surveyor observed within Custodial 8-28B the ductwork from the shaft just north of this room terminated in this room without a fire damper [8th Floor /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/24/2012 at 2:09 pm surveyor observed that the ductwork from Mechanical 9-22B did not have fire dampers installed in the ducts that left the shaft [9th Floor /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

4. On 7/24/2012 at 9:05 am surveyor observed that the duct from Mechanical 8-22B that served Clerical 8-22 was not equipped with a fire damper [8th Floor/I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

5. On 7/19/2012 at 11:05 am surveyor observed on the basement floor in the rooms B 67 and B 69, that airflow between the corridor and this room was not neutral. The air flow was from the receiving room to the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

6. On 7/23/2012 at 11:00 am surveyor observed on the 1st floor in Room 1-78, that the space was not provided with compliant ventilation. It was observed that there were no flanges for the fire dampers This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

7. On 7/24/2012 at 12:20 pm surveyor observed on the 2nd floor in Room 2-132, that the space was not provides with compliant ventilation. It was observed that the top of the duct containing the fire damper did not have a flange. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

8. On 7/25/2012 at 10:35 am surveyor observed on the 3rd floor in Room 3-20, that airflow between the corridor and this room was not neutral. The air flow was into the room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview the facility did not provide rubbish and linen chute enclosures installed to minimum standards. This deficiency could affect 25 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/19/2012 at 11:05 am surveyor observed that the linen chute located within Soiled Utility 1-39 was not equipped with a chute door that automatically closed [First Level/I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 9.5 and 8.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/23/2012 at 8:16 am surveyor observed that the rubbish chute located in Trash 3-04 was not equipped with a chute door that automatically closed [Third Level/I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 9.5 and 8.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles within density limitations. This deficiency could affect 50 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/23/2012 at 2:30 pm surveyor #12187 observed on the 1st floor in the room 1-017A (Suite5), that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There are 2 trash containers next to each other. One is 30 gallons and the other is 20 gallons. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

2. On 7/23/2012 at 3:50 pm surveyor observed on the 1st floor in the room 37, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. The room contained three trash containers that are 3' X 3' X 2' in size by the dish machine. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

3. On 7/23/2012 at 5:00 pm surveyor observed on the 1st floor in the by corridor 1-106 , that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There were three 2' X 3" X 2.5' carts of storage. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

4. On 7/24/2012 at 10:30 am surveyor observed on the 2nd floor in the room 2-149, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There were two 32 gallon trash cans next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

5. On 7/24/2012 at 1:15 pm surveyor observed on the 2nd floor in the room 2-119, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. A 16 gallon, a 32 gallon sharps, and dirty linen containers were grouped together. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

6. On 7/25/2012 at 11:23 am surveyor observed that (5) soiled linen carts were being stored in the west corridor for staff usage near Nurse Station 3-03D. The volume of these carts exceeded the maximum 32 gallon capacity for soiled outside of a protected room [3rd Floor/I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide a medical gas system that was installed to the minimums standards established in NFPA 99. This deficiency could affect 25 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/18/2012 at 3:38 pm surveyor observed that zone valve box for the medical gases was incorrectly labeled. The valve box was located in the south wall of Corridor #06 near Control L-63. The rooms served were not reflected on the label within this box [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 9.5 and 8.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/19/2012 at 10:52 am surveyor observed that five (5) zone valve boxes for the medical gases within the Emergency Department were not labeled within the valve box. The common room names were not reflected on the labels for these boxes. Staff did not know where the valve boxes were and which boxes served what particular rooms. [Lower Level /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 9.5 and 8.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials. This deficiency could affect 5 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/19/2012 at 7:30 am surveyor observed on the basement floor in the telephone operators room, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

2. On 7/19/2012 at 10:05 am surveyor observed on the basement floor in the mechanical room B 140, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. The wall was constructed with wood next to a ramp down a stair inside of the room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff CCC (Safety Officer).

3. On 7/23/2012 at 1:31 pm surveyor observed on the 1st floor in the room 131B, that a wall was made with combustible materials, which is not permitted in non-combustible types of building construction. The wall was constructed with wood. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide alarms, emergency communication systems, and generator illumination with required generator and alarms powered by the emergency electrical system. This deficiency could affect all of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 7/19/2012 at 7:15 am surveyor observed on the basement floor in the maintenance shop, that the CAMs generator annuciation only when to the maintance shop. The maintenance shop is not a 24 hour location. There not a battery powered alarm signal that went to a 24 hour location. This observed situation was not compliant with NFPA 101 (1999 edition), 9.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff yy (Administrator, support services), staff xx (Construction Specialist) and staff ccc (Safety Office).

Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies, including stairs that continue more than one-half story beyond the level of discharge that are not interrupted at the level of exit discharge by partitions, doors or other effective means. This deficiency could affect 20 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 07/23/2012 at 10:20 am surveyor observed on the 1st floor in stair 8 that the stair traveled more than 1/2 story beyond the level of discharge and are not interrupted at the level of exit discharge by partitions, doors or other effective means. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).

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14105

Based on observation and interview, the facility did not provide a code compliant environment for a plumbing fixuture that requires a sanitary drain. This deficiency could affect 10 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 7/25/2012 at 9:53 am surveyor observed a shower was provided in Lab 3-47D without a plumbing drain [3rd Floor /I-2 occupancy]. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on observation and interview, the facility did not provide medical gas alarms as required by NFPA 99 with a medical gas panel in required locations. This deficiency could affect 5 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 7/23/2012 at 11:50 am surveyor observed on the 1st floor in the Former ED nurse station, that the facility had anesthetizing locations and did not have a compliant alarm panel for the medical gas system. There was no one near the alarm panel to hear it. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 4.3.1.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff YY (Admin. Support services) and staff DDD (Construction Specialist).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with secured electrical panels, fixed wiring rather than extension cords, and ground fault receptacles at sinks. This deficiency could affect 10 of the 195 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

Findings include:
1. On 7/19/2012 at 9:42 am surveyor observed that an outlet was within 6 feet to the edge of a sink in Lounge 1-56 and not protected with a GFCI device [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 70 (1999 edition), 210-8. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

2. On 7/19/2012 at 9:44 am surveyor observed that a junction box in Electrical 1-131 was open [First Level /I-2 occupancy] This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

3. On 7/19/2012 at 1:33 pm surveyor observed that three ladders were padlocked in place within the required clearance of an electrical panel within Electrical 1-60A [First Level /I-2 occupancy]. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).