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Based on observation and staff interviews, while on tour of the facility with several of the facility staff between June 30th to July 2nd; it was observed that the facility failed to provide exit access corridor walls that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On July 1st, 2014 at 8:03 pm, it was observed that a 4" hole was found in the corridor wall of the exit access corridor inside of Room #1104.

This deficient practice was confirmed by observation and interview with Staff F (Facilities Director), Staff G (Construction Director), Staff I (Facilities Maintenance Specialist) and Staff H (Regional Safety Coordinator) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with several of the facility staff between June 30th to July 2nd, it was observed that the facility failed to provide and maintain the one-half hour fire-rating and smoke tightness of the smoke barrier walls in accordance to NFPA 101 Section 19.3.7.3 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On June 30th, 2014 at 1:06 pm it was observed that a 4" hole was found in the smoke wall of Kitchen #2504 (second floor). The one-half hour fire-rating and smoke tightness of this smoke compartment wall was circumvented by this item.

2. On June 30th, 2014 at 1:08 pm it was observed that telecom wires and a pneumatic tube penetrated the north side of the smoke wall in Corridor (second floor) and were not sealed with fire caulk to maintain the one-half hour fire-rating and smoke tightness of this smoke compartment wall.

3. On June 30th, 2014 at 1:10 pm it was observed that a 2" hole in the northside of the smoke wall of Proc/Treat #2515 (second floor). The one-half hour fire-rating and smoke tightness of this smoke compartment wall was circumvented by this item.

4. On June 30th, 2014 at 3:30 pm it was observed that telecom wires penetrated the north wall of Office #1304 (first floor) and were not sealed with fire caulk to maintain the one-half hour fire-rating and smoke tightness of this smoke compartment wall.

These deficient practices were confirmed by observation and interview with Staff F (Facilities Director), Staff G (Construction Director), Staff I (Facilities Maintenance Specialist) and Staff H (Regional Safety Coordinator) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with several of the facility staff between June 30th to July 2nd, it was observed that 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 all of the patients in the smoke compartment where these rooms were located, as well as an undetermined number of staff and visitors. This facility contains 7 smoke compartments.

Findings include:
1. On June 30th at 1:17 pm it was observed that Storage #2502 (second floor) was not taped and mudded to a one-hour fire barrier rating. This condition does not meet NFPA 101 Section 19.3.2.1.

2. On June 30th at 1:17 pm it was observed that Elevator equipment room (lower level) had a sprinkler line in the east wall that was not fire caulked to the hourly fire barrier rating of this room. This condition does not meet NFPA 101 Section 19.3.2.1.

3. On June 30th at 1:23 pm it was observed that a copper line in the west wall of the Boiler room (lower level) was not fire caulked to the hourly fire barrier rating of this room. This condition does not meet NFPA 101 Section 19.3.2.1.

3. On June 30th, 2014 at 1:53 pm it was observed that several polyvinyl chloride (PVC) plumbing lines, and several other utility lines penetrated the floor within the large Storage room (lower level) and were not fire caulked to a one hour fire barrier rating. The south wall of this space was not taped and mudded to a one-hour fire barrier rating. This condition does not meet NFPA 101 Section 19.3.2.1 for hazardous areas greater than 50 square feet.

4. On June 30th at 2:45 pm it was observed that Soiled Utility room #1316 (first floor) within the surgery department was not taped and mudded to a one-hour fire barrier rating, the two doors were not 45-minute labeled and no closer's were present on these doors. This condition does not meet NFPA 101 Section 19.3.2.1.

These deficient practices were confirmed by observation and interview with Staff F (Facilities Director), Staff G (Construction Director), Staff I (Facilities Maintenance Specialist) and Staff H (Regional Safety Coordinator) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with several of the facility staff between June 30th to July 2nd, it was observed that the facility failed to provide and maintain a sprinkler system that was installed in accordance to the Life Safety Code [2000 Ed] Sections 19.3.5.1 and 9.7.1.1 and NFPA 13 [1999 Ed] Section 5.1.1. The deficient practice could affect all the patients, staff and an undeterminable number of visitors within the 7 smoke compartments of this building.

Findings include:
1. On June 30th, 2014 at 1:20 pm, while on tour it was observed that a fusible link sprinkler head (212 degree) and a standard response (155 degree) head were in the same compartment of the south stair on the lower level. This condition does not meet NFPA 13 (1999 Ed).

2. On June 30th, 2014 at 1:50 pm, while on tour it was observed that a standard response head and a quick response head were installed within the same compartment of the north stairwell. This condition does does not meet NFPA 13 (1999 Ed) Section 5-3.1.5.2.

3. On June 30th, 2014 at 1:57 pm, while on tour it was observed that the sprinkler head located at the west end of the Electrical room (lower level) had the discharge obstructed by a ventilation duct. This condition does does not meet NFPA 13 (1999 Ed) Section 5-6.5.1.2.

4. On June 30th, 2014 at 1:58 pm, while on tour it was observed that a standard response head and a quick response head were installed within the Electrical room (lower level). This condition does not meet NFPA 13 (1999 Ed) Section 5-3.1.5.2.

5. On June 30th, 2014 at 1:59 pm, while on tour it was observed that the sprinkler head located at the east end of the Electrical room (lower level) was greater than 1/2 the sprinkler spacing to the south wall of this space. This condition does does not meet NFPA 13 (1999 Ed) Section 5-5.3.2.

6. On June 30th, 2014 at 2:43 pm, while on tour it was observed that the sprinkler head located in the Air Handler room (first floor) was greater than 22" from the exposed structure of this space. This condition does does not meet NFPA 13 (1999 Ed) Section 5-6.4.1.2.

7. On June 30th, 2014 at 3:51 pm, while on tour it was observed that the sprinkler heads located at the intersection of Corridor #1351 and Corridor #1347 (first floor) were closer than 6'-0" to each other. This condition does does not meet NFPA 13 (1999 Ed) Section 5-6.3.4.

8. On July 1st, 2014 at 9:07 am, while on tour it was observed that the sprinkler head located in Storage #1127 (first floor) had the discharge obstructed by storage less than 18" below this head. This condition does does not meet NFPA 13 (1999 Ed) Section 5-6.5.2.1.

These deficient practices were confirmed by observation and interview with Staff F (Facilities Director), Staff G (Construction Director), Staff I (Facilities Maintenance Specialist) and Staff H (Regional Safety Coordinator) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with several of the facility staff between June 30th to July 2nd; it was observed that the facility failed to provide exit access corridor walls that were resistant to the passage of smoke in accordance to NFPA 101 Section 19.3.6.2.1 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On July 1st, 2014 at 8:03 pm, it was observed that a 4" hole was found in the corridor wall of the exit access corridor inside of Room #1104.

This deficient practice was confirmed by observation and interview with Staff F (Facilities Director), Staff G (Construction Director), Staff I (Facilities Maintenance Specialist) and Staff H (Regional Safety Coordinator) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with several of the facility staff between June 30th to July 2nd, it was observed that the facility failed to provide and maintain the one-half hour fire-rating and smoke tightness of the smoke barrier walls in accordance to NFPA 101 Section 19.3.7.3 as evidenced by the following item(s). This deficient practice could affect the patients in 2 of 7 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On June 30th, 2014 at 1:06 pm it was observed that a 4" hole was found in the smoke wall of Kitchen #2504 (second floor). The one-half hour fire-rating and smoke tightness of this smoke compartment wall was circumvented by this item.

2. On June 30th, 2014 at 1:08 pm it was observed that telecom wires and a pneumatic tube penetrated the north side of the smoke wall in Corridor (second floor) and were not sealed with fire caulk to maintain the one-half hour fire-rating and smoke tightness of this smoke compartment wall.

3. On June 30th, 2014 at 1:10 pm it was observed that a 2" hole in the northside of the smoke wall of Proc/Treat #2515 (second floor). The one-half hour fire-rating and smoke tightness of this smoke compartment wall was circumvented by this item.

4. On June 30th, 2014 at 3:30 pm it was observed that telecom wires penetrated the north wall of Office #1304 (first floor) and were not sealed with fire caulk to maintain the one-half hour fire-rating and smoke tightness of this smoke compartment wall.

These deficient practices were confirmed by observation and interview with Staff F (Facilities Director), Staff G (Construction Director), Staff I (Facilities Maintenance Specialist) and Staff H (Regional Safety Coordinator) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with several of the facility staff between June 30th to July 2nd, it was observed that 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 all of the patients in the smoke compartment where these rooms were located, as well as an undetermined number of staff and visitors. This facility contains 7 smoke compartments.

Findings include:
1. On June 30th at 1:17 pm it was observed that Storage #2502 (second floor) was not taped and mudded to a one-hour fire barrier rating. This condition does not meet NFPA 101 Section 19.3.2.1.

2. On June 30th at 1:17 pm it was observed that Elevator equipment room (lower level) had a sprinkler line in the east wall that was not fire caulked to the hourly fire barrier rating of this room. This condition does not meet NFPA 101 Section 19.3.2.1.

3. On June 30th at 1:23 pm it was observed that a copper line in the west wall of the Boiler room (lower level) was not fire caulked to the hourly fire barrier rating of this room. This condition does not meet NFPA 101 Section 19.3.2.1.

3. On June 30th, 2014 at 1:53 pm it was observed that several polyvinyl chloride (PVC) plumbing lines, and several other utility lines penetrated the floor within the large Storage room (lower level) and were not fire caulked to a one hour fire barrier rating. The south wall of this space was not taped and mudded to a one-hour fire barrier rating. This condition does not meet NFPA 101 Section 19.3.2.1 for hazardous areas greater than 50 square feet.

4. On June 30th at 2:45 pm it was observed that Soiled Utility room #1316 (first floor) within the surgery department was not taped and mudded to a one-hour fire barrier rating, the two doors were not 45-minute labeled and no closer's were present on these doors. This condition does not meet NFPA 101 Section 19.3.2.1.

These deficient practices were confirmed by observation and interview with Staff F (Facilities Director), Staff G (Construction Director), Staff I (Facilities Maintenance Specialist) and Staff H (Regional Safety Coordinator) at the time of discovery.

Based on observation and staff interviews, while on tour of the facility with several of the facility staff between June 30th to July 2nd, it was observed that the facility failed to provide and maintain a sprinkler system that was installed in accordance to the Life Safety Code [2000 Ed] Sections 19.3.5.1 and 9.7.1.1 and NFPA 13 [1999 Ed] Section 5.1.1. The deficient practice could affect all the patients, staff and an undeterminable number of visitors within the 7 smoke compartments of this building.

Findings include:
1. On June 30th, 2014 at 1:20 pm, while on tour it was observed that a fusible link sprinkler head (212 degree) and a standard response (155 degree) head were in the same compartment of the south stair on the lower level. This condition does not meet NFPA 13 (1999 Ed).

2. On June 30th, 2014 at 1:50 pm, while on tour it was observed that a standard response head and a quick response head were installed within the same compartment of the north stairwell. This condition does does not meet NFPA 13 (1999 Ed) Section 5-3.1.5.2.

3. On June 30th, 2014 at 1:57 pm, while on tour it was observed that the sprinkler head located at the west end of the Electrical room (lower level) had the discharge obstructed by a ventilation duct. This condition does does not meet NFPA 13 (1999 Ed) Section 5-6.5.1.2.

4. On June 30th, 2014 at 1:58 pm, while on tour it was observed that a standard response head and a quick response head were installed within the Electrical room (lower level). This condition does not meet NFPA 13 (1999 Ed) Section 5-3.1.5.2.

5. On June 30th, 2014 at 1:59 pm, while on tour it was observed that the sprinkler head located at the east end of the Electrical room (lower level) was greater than 1/2 the sprinkler spacing to the south wall of this space. This condition does does not meet NFPA 13 (1999 Ed) Section 5-5.3.2.

6. On June 30th, 2014 at 2:43 pm, while on tour it was observed that the sprinkler head located in the Air Handler room (first floor) was greater than 22" from the exposed structure of this space. This condition does does not meet NFPA 13 (1999 Ed) Section 5-6.4.1.2.

7. On June 30th, 2014 at 3:51 pm, while on tour it was observed that the sprinkler heads located at the intersection of Corridor #1351 and Corridor #1347 (first floor) were closer than 6'-0" to each other. This condition does does not meet NFPA 13 (1999 Ed) Section 5-6.3.4.

8. On July 1st, 2014 at 9:07 am, while on tour it was observed that the sprinkler head located in Storage #1127 (first floor) had the discharge obstructed by storage less than 18" below this head. This condition does does not meet NFPA 13 (1999 Ed) Section 5-6.5.2.1.

These deficient practices were confirmed by observation and interview with Staff F (Facilities Director), Staff G (Construction Director), Staff I (Facilities Maintenance Specialist) and Staff H (Regional Safety Coordinator) at the time of discovery.