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Based on observation and staff interview the facility failed to provide corridor openings that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.3.1 as evidenced by the following item(s). This deficient practice could affect the patients in one of six smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 25th, 2014 at 10:15 am, it was observed that the pair of doors into the corridor from the ICU suite #124 (north opening) were not equipped with an astragal at the meeting edge of these doors to resist the passage of smoke.

2. On August 25th, 2014 at 10:35 am, it was observed that the pair of doors into the corridor from Electrical closet #114 were not equipped with an astragal at the meeting edge of these doors to resist the passage of smoke.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 [2000 Ed] Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in one of six smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 25th, 2014 at 9:34 am, it was observed that the Clean Utility #138 was indicated as a one-hour fire barrier on the floor plan of the hospital.
-The perimeter walls of this room were not enclosed with gypsum wallboard up to the roof deck above.
-All joints were not taped and fully embedded in joint compound around the perimeter (required on both sides of a wall assembly).
-Pipe/duct penetrations and the roof deck/wall intersection were not fire caulked to a one-hour rating.

2. On August 25th, 2014 at 9:55 am, it was observed that the Soiled Utility #168 was indicated as a one-hour fire barrier on the floor plan of the hospital.
-The perimeter walls of this room were not enclosed with gypsum wallboard up to the roof deck above.
-All joints were not taped and fully embedded in joint compound around the perimeter (required on both sides of a wall assembly).
-Pipe/duct penetrations and the roof deck/wall intersection were not fire caulked to a one-hour rating.

This deficient practice was confirmed by observation and interview with Staff E (Facilities
Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide a sprinkler system that was installed in accordance to NFPA 13 - Installation of Sprinkler Systems [1999 Ed] as evidenced by the following item(s). This deficient practice could affect the patients in six of the six smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 25th, 2014 at 11:45 am, within Electrical closet #061 it could not be determined whether this space was provided with a sprinkler head to comply with Sections 19.3.5.1 and 9.7.1.1 of NFPA 101 (2000 Ed) and Section 5.1.1 of NFPA 13 (1999 Ed).

2. On August 25th, 2014 at 1:41 pm, it was observed that the Main Electrical room #208 containing the normal and emergency main distribution gear was protected with a full sprinkler system. No non-combustible shields were found within this room to protect any of this gear from the discharge water of these sprinkler heads during a fire situation to comply with Sections 19.3.5.1 and 9.7.1.1 of NFPA 101 (2000 Ed) and Section 5.13.11 of NFPA 13 (1999 Ed).

3. On August 25th, 2014 at 3:04 pm, within Electrical closet #271 of the OB suite, it could not be determined whether this space was provided with a sprinkler head to comply with Sections 19.3.5.1 and 9.7.1.1 of NFPA 101 (2000 Ed) and Section 5.1.1 of NFPA 13 (1999 Ed).

4. On August 25th, 2014 at 3:06 pm, within Electrical closet #114, it could not be determined whether this space was provided with a sprinkler head to comply with Sections 19.3.5.1 and 9.7.1.1 of NFPA 101 (2000 Ed) and Section 5.1.1 of NFPA 13 (1999 Ed).

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide an Electrical system that was installed in compliance to NFPA 70 National Electrical Code as evidenced by the following item(s). This deficient practice could affect the patients in one of the six smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 25th, 2014 at 2:48 pm, it was observed that panel CLP-3A located within the Emergency Department was not locked.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide corridor openings that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.3.1 as evidenced by the following item(s). This deficient practice could affect the patients in one of six smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 25th, 2014 at 10:15 am, it was observed that the pair of doors into the corridor from the ICU suite #124 (north opening) were not equipped with an astragal at the meeting edge of these doors to resist the passage of smoke.

2. On August 25th, 2014 at 10:35 am, it was observed that the pair of doors into the corridor from Electrical closet #114 were not equipped with an astragal at the meeting edge of these doors to resist the passage of smoke.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide and maintain the one-hour rated enclosures with 45-minute rated doors into hazardous areas per NFPA 101 [2000 Ed] Section 19.3.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in one of six smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 25th, 2014 at 9:34 am, it was observed that the Clean Utility #138 was indicated as a one-hour fire barrier on the floor plan of the hospital.
-The perimeter walls of this room were not enclosed with gypsum wallboard up to the roof deck above.
-All joints were not taped and fully embedded in joint compound around the perimeter (required on both sides of a wall assembly).
-Pipe/duct penetrations and the roof deck/wall intersection were not fire caulked to a one-hour rating.

2. On August 25th, 2014 at 9:55 am, it was observed that the Soiled Utility #168 was indicated as a one-hour fire barrier on the floor plan of the hospital.
-The perimeter walls of this room were not enclosed with gypsum wallboard up to the roof deck above.
-All joints were not taped and fully embedded in joint compound around the perimeter (required on both sides of a wall assembly).
-Pipe/duct penetrations and the roof deck/wall intersection were not fire caulked to a one-hour rating.

This deficient practice was confirmed by observation and interview with Staff E (Facilities
Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide a sprinkler system that was installed in accordance to NFPA 13 - Installation of Sprinkler Systems [1999 Ed] as evidenced by the following item(s). This deficient practice could affect the patients in six of the six smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 25th, 2014 at 11:45 am, within Electrical closet #061 it could not be determined whether this space was provided with a sprinkler head to comply with Sections 19.3.5.1 and 9.7.1.1 of NFPA 101 (2000 Ed) and Section 5.1.1 of NFPA 13 (1999 Ed).

2. On August 25th, 2014 at 1:41 pm, it was observed that the Main Electrical room #208 containing the normal and emergency main distribution gear was protected with a full sprinkler system. No non-combustible shields were found within this room to protect any of this gear from the discharge water of these sprinkler heads during a fire situation to comply with Sections 19.3.5.1 and 9.7.1.1 of NFPA 101 (2000 Ed) and Section 5.13.11 of NFPA 13 (1999 Ed).

3. On August 25th, 2014 at 3:04 pm, within Electrical closet #271 of the OB suite, it could not be determined whether this space was provided with a sprinkler head to comply with Sections 19.3.5.1 and 9.7.1.1 of NFPA 101 (2000 Ed) and Section 5.1.1 of NFPA 13 (1999 Ed).

4. On August 25th, 2014 at 3:06 pm, within Electrical closet #114, it could not be determined whether this space was provided with a sprinkler head to comply with Sections 19.3.5.1 and 9.7.1.1 of NFPA 101 (2000 Ed) and Section 5.1.1 of NFPA 13 (1999 Ed).

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director) at the time of discovery.

Based on observation and staff interview the facility failed to provide an Electrical system that was installed in compliance to NFPA 70 National Electrical Code as evidenced by the following item(s). This deficient practice could affect the patients in one of the six smoke compartments, as well as an undetermined number of staff and visitors.

Findings include:
1. On August 25th, 2014 at 2:48 pm, it was observed that panel CLP-3A located within the Emergency Department was not locked.

This deficient practice was confirmed by observation and interview with Staff E (Facilities Director) at the time of discovery.