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Based on observation and interview, the facility did not provide and maintain the required building construction type with structural support steel covered with rated fire proofing. This deficiency occurred in 4 of the 26 smoke compartments, and had the potential to affect 25 staff that were working in those smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 10:00 am surveyor #18107 observed in the 6B smoke compartment on the 6th floor in the Elevator Equipment Room, that fire proofing was missing from the structural steel beam. Elevator hoistway was observed not separated at floor below. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/26/2012 at 8:30 am surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Chiller Equipment Room #80B, that fire proofing was missing from the structural steel beam. Observed location is at ceiling near middle garage door. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 11:43 am surveyor #18107 observed in the 3B & 3C smoke compartments on the 3rd floor in the Mechanical Room, that fire proofing was missing from the structural steel at structural steel supports in Mechanical Room that is part of the overall building. This Mechanical Room addition was added to house the new AHU for the MRI Suite. The space is not separated from the rest of the structure and adjoining Mechanical Room. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

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 corridor ceiling (in a sprinkled smoke zone), and smoke detection in spaces that are open to the corridor. This deficiency occurred in 7 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/25/2012 at 1:15 pm surveyor #18107 observed in the 1A, 1B, 1E smoke compartments on the 1st floor in the Corridors at Imaging, PT/OT/Rehab & both Main Elevator Lobbies, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included openings around the perimeter of light fixtures greater than 1/2 inch, the light fixtures themselves were 12" x 48" two bulb light fixtures that allow smoke and hot gases to penetrate the ceiling membrane used as a horizontal surface to stop smoke. The walls along all these corridors were not all smoke-tight to the rooms above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/25/2012 at 2:31 pm surveyor #18107 observed in the 2E smoke compartment on the 2nd floor in the Surgery Scheduling Control Room, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included two sets of slide-by glass panels without appropriate smoke-tight gasketing at the vertical edges of the glass panels. The panels were about 42 inches in height starting at 38 inches above finished floor (AFF) to about 80 inches AFF. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/25/2012 at 4:00 pm surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Corridors around #5 Plant Operations, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included openings around the perimeter of light fixtures greater than 1/2 inch, the light fixtures themselves were 12" x 48" two bulb light fixtures that allow smoke and hot gases to penetrate the ceiling membrane used as a horizontal surface to stop smoke. The walls along all these corridors were not all smoke-tight to the rooms above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/26/2012 at 10:47 am surveyor #18107 observed in the 0B smoke compartment on the Ground floor in the Data Room #1H, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 1/2 inch hole in the corridor wall from the Data Room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/26/2012 at 10:50 am surveyor #18107 observed in the 0B smoke compartment on the Ground floor in the Data Room #1C, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 1/2 inch hole in the corridor wall from the Data Room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/25/2012 at 2:40 pm surveyor #18107 observed in the 1D smoke compartment on the 1st floor in the Reception Desk Room at the Emergency Entry, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. The vertical slide-by glass panels did not have a smoke-tight seal. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware, and doors that would close when pushed or pulled. This deficiency occurred in 2 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/26/2012 at 10:08 am surveyor #18107 observed in the 0A smoke compartment on the Ground floor in the Kitchen Dish Room #44, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This is the door that accesses the Cafeteria, which is part of a required corridor and exit access route. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/25/2012 at 2:10 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Cath. Lab Waiting Room, that the door to the corridor was held open with a chair. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with compliant vertical opening, doors with positive-latching hardware, sealed wall penetrations, and rated wall construction. This deficiency occurred in 11 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 11:53 am surveyor #18107 observed in the 3B & 3C smoke compartment on the 3rd floor in the Mechanical Room over Emergency Department Addition, that the vertical shaft wall was not compliant. Observed a sprinkler pipe penetrating a shaft that did not use the shaft and the installer took a short cut and ran the pipe through the shaft wall or the shaft was created after the pipe was already installed. Only items that use the shaft are allowed to penetrate the shaft per the 2002, 2006 & 2009 IBC requirements. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/26/2012 at 11:15 am surveyor #18107 observed in the 0A smoke compartment on the Ground floor in the Exit Passageway at Stairwell #3, that the door in the vertical opening would not positively self-latch when released. When pressure was applied to the door, without turning the latch or pushing on the panic push bar, the latch would not hold the door in the latched position. One of the access door's would not stay latched as part of the double door set leading into a Exit Passageway at Corridor #5. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 12:08 pm surveyor #18107 observed in the 3B & 3C smoke compartment on the 3rd floor in the Mechanical Room over Emergency Department Addition, that penetration(s) in a vertical shaft were not sealed according to an approved method. The deficiency included two pipe penetrations, one 3" diameter and the other a 1-1/2" diameter pipe not fire-stopped through the floor assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/24/2012 at 3:46 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Mechanical Shaft at #2008, that penetration(s) in a vertical shaft were not sealed according to an approved method. The deficiency included several openings in shaft wall that were not smoke tight. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/25/2012 at 10:29 am surveyor #18107 observed in the 1F smoke compartment on the 1st floor in the Exit Passageway at Stairwell #4, that penetration(s) in a vertical shaft were not sealed according to an approved method. The deficiency included a penetration in the 'fire barrier' separating the Exit Passageway from the vertical Stairwell. This wall was not sealed to the required 2-hours for a vertical shaft of Type I (332) for a building higher than 4-stories. A linear opening was observed at top of wall between these two spaces. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/25/2012 at 10:48 am surveyor #18107 observed in the 1A, 1B, 1E smoke compartments on the 1st floor in the Mechanical Shaft behind Public Elevators, that penetration(s) in a vertical shaft were not sealed according to an approved method. The deficiency included a open horizontal line at each floor where the concrete block meets the floor slab. Over the years since 1977, the concrete mortar has dried and left an opening between the floor slabs and the vertical concrete wall in this shaft. This shaft touches all three of these smoke compartments at this floor alone. Observed horizontal openings at 1st, 2nd & 3rd Floors where it meets the upper floor deck within the shaft. Other smoke compartments affected are: 2B, 3B and 4B. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

7. On 01/26/2012 at 11:27 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Shaft at Room #52A and behind Room #66, that penetration(s) in a vertical shaft were not sealed according to an approved method. The deficiency included a hole in the shaft. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

8. On 01/24/2012 at 1:06 pm surveyor #18107 observed in the 3A smoke compartment on the 3rd floor in the Shaft behind Elevators, that the shaft enclosure wall was not constructed to have a 2-hour fire resistance rating as required at the time it was built because rigid insulation was exposed within the wall construction and not encapsulated per its fire-rated assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage and exit signs when the egress path is not readily apparent. This deficiency occurred in 3 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/25/2012 at 1:59 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Cath. Lab Suite Passage #1140, that the path of egress in the corridor/aisle/pathway was not readily apparent and an exit sign was not provided near the end of the exit discharge where the passageway turns abruptly and the door seen is not the exit discharge door that could confuse someone in the event of a fire emergency. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/26/2012 at 8:25 am surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Boiler Room, that the path of egress in the corridor/aisle/pathway was not readily apparent and an exit sign was not provided near the dead-end side of the mezzanine above boilers leading to the only exit behind electrical panels. No clear direction was identified to exit egress the mezzanine. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/26/2012 at 10:00 am surveyor #18107 observed in the 0A smoke compartment on the Ground floor in the Kitchen Suite, that the path of egress in the corridor/aisle/pathway was not readily apparent and an exit sign was not provided near three exit egress doors out of the Kitchen Suite 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

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, and rated wall construction. This deficiency occurred in 10 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 10:50 am surveyor #18107 observed in the 4A smoke compartment on the 4th floor in the Corridor between smoke compartments 4A & 4B, that the smoke barrier wall was not compliant. The vertical wall between corridor wall and smoke barrier was not sufficient sealed at several locations to stop the spread of smoke. These observed situations were not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/24/2012 at 11:30 am surveyor #18107 observed in the 3B & 3C smoke compartment on the 3rd floor in the Corridor between smoke compartments 3A & 3B, that penetration(s) were not sealed according to an approved method. The deficiency included a 14" x 8" duct penetration was missing a certified fire/smoke assembly around the duct in the barrier to stop smoke and heat migration. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 3:27 pm surveyor #18107 observed in the 2A & 2B smoke compartment on the 2nd floor in the Corridors at smoke barrier between smoke compartments 2A & 2B, that penetration(s) were not sealed according to an approved method. The deficiency included a 1" diameter hole. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/25/2012 at 2:30 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Gift Shop Room, that a penetration was not sealed according to an approved method. The deficiency included a conduit penetrating the smoke barrier and not sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/25/2012 at 10:55 am surveyor #18107 observed in the 1B smoke compartment on the 1st floor in the Smoke Barrier running along side the Corridor outside MRI Suite near patient elevators, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the upper wall area is not sealed tight to floor deck above ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/25/2012 at 10:58 am surveyor #18107 observed in the 1A & 1B smoke compartment on the 1st floor in the Smoke Barrier running along side the Corridor outside Clinical Laboratory and next to the Imaging Department, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the upper wall area is not sealed tight to floor deck above ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

7. On 01/25/2012 at 12:05 pm surveyor #18107 observed in the 1B & 1C smoke compartment on the 1st floor in the Office Room #1026, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the smoke barrier did not extend to the outside building wall to stop the spread of smoke around the end wall condition. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with compliant smoke doors. This deficiency occurred in 6 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 10:41 am surveyor #18107 observed in the 5A smoke compartment on the 5th floor in the Corridor between smoke compartments 5A & 5C, that the smoke barrier doors were not compliant. The door labels were missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/24/2012 at 11:35 am surveyor #18107 observed in the 3B & 3C smoke compartment on the 3rd floor in the Corridor between smoke compartments 3A & 3B, that the smoke barrier doors were not compliant. The door labels were missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 3:35 pm surveyor #18107 observed in the 2A & 2B smoke compartment on the 2nd floor in the Corridor at Nurse Station, that the smoke barrier doors were not compliant. Doors are required to have a label per NFPA 80. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, a smoke-tight room enclosure (in a sprinkled smoke zone), doors with positive-latching hardware, and sealed wall penetrations. This deficiency occurred in 7 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 3:00 pm surveyor #18107 observed in the 2E smoke compartment on the 2nd floor in the Anesthesia Clean Supply Room #2066, that the door would not self-close because of a automatic door hold-open. Through documentation could not confirm door would close and latch upon activation of fire alarm. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/24/2012 at 10:34 am surveyor #18107 observed in the 5A smoke compartment on the 5th floor in the Soiled Utility Room #533, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included a portion of the fire caulking coming out of the original 3 inch hole. Facility could not show the listed assembly for this fire-rated closure withjsut fire caulk. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 3:53 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Genesis Clean Linen Storage Room #269, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included several 1/4 to 1/2 inch lineal openings around duct penetration at East fire-rated wall. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/24/2012 at 2:43 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Clean Break-out Room #299G, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door spring would not recoil and fit back into the hole of the door frame. The room was over 100 square feet and had combustible cardboard, collapsed from box break-downs. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/25/2012 at 11:25 am surveyor #18107 observed in the 1A smoke compartment on the 1st floor in the Clinical Lab Storage Room, that penetration(s) were not sealed according to an approved method. The deficiency included drywall seams not taped and screws not double mudded per listed and approved methods. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/26/2012 at 8:50 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Soiled Linen Chute Room #61, that penetration(s) were not sealed according to an approved method. The deficiency included 4 pipes at 3 inches in diameter. These observed situations were not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

7. On 01/26/2012 at 9:25 am surveyor #18107 observed in the 0E smoke compartment on the Ground floor in the Data & Electrical Room #87E, that penetration(s) were not sealed according to an approved method. The deficiency included 2 holes, one a 8" x 8" hole and the other a 3" x 24" hole. These observed situations were not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

8. On 01/26/2012 at 10:16 am surveyor #18107 observed in the 0A smoke compartment on the Ground floor in the Gift Shop Storage Room #47, that penetration(s) were not sealed according to an approved method. The deficiency included 12" x 12" hole around a speaker. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide egress paths at all times, without travel interruption at stairs that go below the level of exit discharge, and level walking surfaces in the path of egress. This deficiency occurred in 3 of the 26 smoke compartments,
and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/26/2012 at 8:59 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Stair #9 at 1st Level landing, that the travel down the Stairwell was not interrupted by an effective means to prevent travel past the level of discharge. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/25/2012 at 11:38 am surveyor #18107 observed in the 1B smoke compartment on the 1st floor in the Fluoroscopy Room #1013, that a portion of the path of egress had an abrupt change in elevation of egress path within the room due to a 3/4 inch diameter cable recently installed in the room. Both the patient and staff must traverse this cable lying on the floor at times during procedures. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/26/2012 at 8:40 am surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the IT. Server Room , that a portion of the path of egress had an abrupt change in elevation of greater than 1/2 inch at two locations on the IT Server Floor. This would cause a trip hazard in the event of a fire emergency. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. And with egress lighting fed by emergency power. This deficiency occurred in 1 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
On 01/25/2012 at 3:56 pm surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Contractor/Vendor Entrance/Exit, that the facility was unable to verify that the lighting along the path of egress was powered from the emergency electrical system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The facility did not provide a sprinkler system with unobstructed water distribution, and sprinklers located the appropriate distance from the ceiling. This deficiency occurred in 3 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 3:05 pm surveyor #18107 observed in the 2E smoke compartment on the 2nd floor in the Clean Storage Room #2059, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a large full-height storage cabinet greater than 18 inches in depth that had combustibles within the cabinet. The door on the cabinet prevented the room sprinkler discharge to reach the contents within the cabinet. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/25/2012 at 10:40 am surveyor #18107 observed in the 1A smoke compartment on the 1st floor in the Nuclear Medicine Room #136A, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included two large storage cabinets holding combustible cushions that protect equipment templates. The cabinet doors prevent the sprinklers from protecting all areas of the room where combustibles are stored. There currently is no sprinkler coverage in the full-height cabinets. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/25/2012 at 11:14 am surveyor #18107 observed in the 1A smoke compartment on the 1st floor in the Clinical Lab Electrical Room, that a sprinkler was located greater than 18 inches from the ceiling and floor deck. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.4.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/24/2012 at 2:20 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Surgery Men's Locker Room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included center island lockers were less than 12 inches from the sprinkler head, blocking coverage to one side of the lockers. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have a complete annual inspection, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of paint or other spray material. This deficiency occurred in 12 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 2:18 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Surgery Men's Locker Room & Hallway between Women's Locker Room and Lounge, that the sprinkler system maintenance was not compliant. At Men's Locker area 5 ceiling tiles were observed ajar and open, and at the Hallway area 7 ceiling tiles were damaged and open. This observed situation was not compliant with NFPA 25 (998 edition), 2-2. and Table 2-1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/24/2012 at 1:43 pm surveyor #18107 observed in the 3A smoke compartment on the 3rd floor in the Pharmacy Room #307, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 1:59 pm surveyor #18107 observed in the 2E smoke compartment on the 2nd floor in the ICU Bio-hazardous Waste Room, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/25/2012 at 9:14 am surveyor #18107 observed in the 2C smoke compartment on the 2nd floor in the G.I. Nurses Station & Steris Cleaning Room, that the escutcheon ring on the sprinkler was not tight to ceiling. There were two defective escutcheon ring installations in each space. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/25/2012 at 11:00 am surveyor #18107 observed in the 1A smoke compartment on the 1st floor in the Clinical Lab Reception Room, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/25/2012 at 1:56 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Cath. Lab Clean Utility Room #1145, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

7. On 01/25/2012 at 3:58 pm surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Plant Operations Office & Corridor #49, that the escutcheon ring on the sprinkler was not tight to ceiling at corridor and a 24" x 24" tile was out next to speaker in the office. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

8. On 01/24/2012 at 3:55 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Office Room #271, that there was one or more unsealed holes near the ceiling. The hole(s) included 2 damaged ceiling tiles. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

9. On 01/25/2012 at 9:03 am surveyor #18107 observed in the 2A smoke compartment on the 2nd floor in the Nurses Lounge #207, that there was one or more unsealed holes near the ceiling. The hole(s) included damaged tile around sprinkler head. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

10. On 01/25/2012 at 11:48 am surveyor #18107 observed in the 1B smoke compartment on the 1st floor in the General Radiographic Room #1018, that there was one or more unsealed holes near the ceiling. The hole included a 24" x 24" ceiling tile missing near the door. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

11. On 01/25/2012 at 2:21 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Data Closet across from Admitting & Stairwell #7, that there was one or more unsealed holes near the ceiling. The hole(s) included several ceiling tiles were missing in data closet open to the underside of the structure above (not sprinkled) and unfinished walls around closet. Stairwell ceiling had one hole. These holes would reduce the response time of the sprinkler(s) in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

12. On 01/25/2012 at 2:38 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Stairwell #7, that there was one or more unsealed holes near the ceiling. The hole(s) included 4 ceiling panels ajar. These holes would reduce the response time of the sprinklers in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

13. On 01/25/2012 at 2:42 pm surveyor #18107 observed in the 1D smoke compartment on the 1st floor in the Triage Room #1113, that there was one or more unsealed holes near the ceiling. The hole included a 1" diameter hole next to the camera. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

14. On 01/26/2012 at 8:53 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Room #97A, that there was one or more unsealed holes near the ceiling. The holes included several 1" diameter holes. These holes would reduce the response time of the sprinklers in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

15. On 01/26/2012 at 11:00 am surveyor #18107 observed in the 0B smoke compartment on the Ground floor in the Linear Accelerator Closet & Central Sterile Processing Room (CSPR), that there was one or more unsealed holes near the ceiling. The holes included two 1" diameter holes in ceiling tile next to Linear Accelerator Control Room and two damaged tiles over clean sterilizers of CSPR. These holes would reduce the response time of the sprinklers in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

16. On 01/26/2012 at 11:21 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Autopsy Shower Room #83, that there was one or more unsealed holes near the ceiling. The hole included a 1 inch opening at the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

17. On 01/26/2012 at 11:30 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Soiled Linen Cart Storage Room #67, that there was one or more unsealed holes near the ceiling. The hole included one 1" diameter hole in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

18. On 01/24/2012 at 3:12 pm surveyor #18107 observed in the 2E smoke compartment on the 2nd floor in the Stairwell #7, that a sprinkler had paint on the head. Sprinkler is compromised by plaster spray or paint on the head, as well as the ceiling material is missing around the escutcheon ring. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with missing fire damper. This deficiency occurred in 1 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
On 01/25/2012 at 9:52 am surveyor #18107 observed in the 1A smoke compartment on the 1st floor in the Mechanical Shaft Room #132A, that a fire damper was not installed in an air duct that penetrated the fire rated wall. A duct of about 12" x 18" penetrated a 2-hour fire-rated barrier and was observed not to have a fire damper as required per NFPA 90A. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based upon observation and documentation review, the facility did not provide a properly enclosed linen/trash chute and appropriate collection rooms as with a latching, fire rated and labeled linen chute door. This deficiency occurred in 1 of the 26 smoke compartments, and had the potential to affect 20 staff that were working in the smoke compartment at the time of the survey.

FINDINGS INCLUDE:
On 01/26/2012 at 11:01 am surveyor #18107 observed in the 0B smoke compartment on the Ground floor in the Soiled Linen Chute Room, that the linen chute door that opened into the chute room did not have a 1-hour fire protection rating, because the chute door would not latch closed in the event of a fire. This observed situation was not compliant with NFPA 101 (2000 edition), 9.5.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as sprinkler obstruction with cubical curtains that permit the designed distribution of sprinkler water. This deficiency occurred in 1 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
On 01/25/2012 at 2:43 pm surveyor #18107 observed in the 1D smoke compartment on the 1st floor in the Doctors Lounge #1063 & Doctors Sleep Room #1062, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area and was not 18 inches from the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 Chapter 4, with separation of oxygen from combustibles. This deficiency occurred in 1 of the 26 smoke compartments, and had the potential to affect 15 staff that were working in this smoke compartment at the time of the survey.

FINDINGS INCLUDE:
On 01/25/2012 at 4:25 pm surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Medical Gas Storage Room, that combustible materials were stored too close to the storage site of cylinders of oxygen. Several Acetylene, Argon, CO2 & N2 cylinders were observed chain-ganged together in the same room and less than 5'-0" from O2 cylinders. The access path was not kept clear to gases "in-use" for CO2, N2O & MA. This observed situation was not compliant with NFPA 99 (1999 edition), 4-3.1.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide and maintain duct penetrations through smoke barrier walls with rated seals. This deficiency occurred in 2 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 10:49 am surveyor #18107 observed in the 4A smoke compartment on the 4th floor in the Corridor between smoke compartments 4A & 4B, that a duct penetrated a smoke barrier and was not sufficiently sealed around the duct to stop the spread of smoke between smoke compartments per a listed assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/24/2012 at 1:29 pm surveyor #18107 observed in the 3A smoke compartment on the 3rd floor in the Corridor at Smoke Barrier between 3A & 3C, that a duct penetrated a smoke barrier and was not sufficiently sealed at the top of the duct to stop the spread of smoke between smoke compartments per a listed assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code, fixed wiring rather than extension cords, and electrical panels with complete directories is the required installation. This deficiency occurred in 6 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/25/2012 at 11:46 am surveyor #18107 observed in the 1B smoke compartment on the 1st floor in the (Vacated) Catheterization Lab #4, that the electrical code was not followed. The wire raceway was left open at the walls and floor since the hospital relocated the Catheterization Lab #4 to its new location in smoke compartment 1C. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/25/2012 at 11:53 am surveyor #18107 observed in the 1B smoke compartment on the 1st floor in the Staff Lounge, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to appliances within the room without a ground fault protector. A strip plug with a surge protection feature may be used in non-patient areas for computers, but non-computer equipment cannot be plugged into it. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 10:39 am surveyor #18107 observed in the 5A smoke compartment on the 5th floor in the Soiled Utility Room #533, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #423, Breaker #12 was observed in the 'ON' position and noted as a 'spare' on the index sheet in the Panel. Staff could not identify what it was serving. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/24/2012 at 11:10 am surveyor #18107 observed in the 4A smoke compartment on the 4th floor in the Electrical Closet Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #433, Breakers within the electrical panel were not properly marked. Open spaces were left blank. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/25/2012 at 10:17 am surveyor #18107 observed in the 1F smoke compartment on the 1st floor in the Electrical Closet Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #379, Breakers (#41 & #42) were left in an 'ON' position, yet the index sheet within the electrical panel stated they were 'spares'. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/25/2012 at 3:15 pm surveyor #18107 observed in the 1D smoke compartment on the 1st floor in the Clean Equipment Holding Room #1128, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #EC?, for the Trauma Room #5, was showing several outlet breakers within the panel to be in the 'OFF' position for the ceiling mounted articulating arm. In talking with one ER staff person they stated they may use all the electrical outlets on the articulating arm and none of the outlets should be in a 'OFF' position. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

7. On 01/26/2012 at 10:37 am surveyor #18107 observed in the 0B smoke compartment on the Ground floor in the Room #18, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #1, Breaker #5 for the Surgical Air Compressor #1 was incorrectly tag. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide and maintain the required building construction type with structural support steel covered with rated fire proofing. This deficiency occurred in 4 of the 26 smoke compartments, and had the potential to affect 25 staff that were working in those smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 10:00 am surveyor #18107 observed in the 6B smoke compartment on the 6th floor in the Elevator Equipment Room, that fire proofing was missing from the structural steel beam. Elevator hoistway was observed not separated at floor below. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/26/2012 at 8:30 am surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Chiller Equipment Room #80B, that fire proofing was missing from the structural steel beam. Observed location is at ceiling near middle garage door. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 11:43 am surveyor #18107 observed in the 3B & 3C smoke compartments on the 3rd floor in the Mechanical Room, that fire proofing was missing from the structural steel at structural steel supports in Mechanical Room that is part of the overall building. This Mechanical Room addition was added to house the new AHU for the MRI Suite. The space is not separated from the rest of the structure and adjoining Mechanical Room. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

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 corridor ceiling (in a sprinkled smoke zone), and smoke detection in spaces that are open to the corridor. This deficiency occurred in 7 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/25/2012 at 1:15 pm surveyor #18107 observed in the 1A, 1B, 1E smoke compartments on the 1st floor in the Corridors at Imaging, PT/OT/Rehab & both Main Elevator Lobbies, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included openings around the perimeter of light fixtures greater than 1/2 inch, the light fixtures themselves were 12" x 48" two bulb light fixtures that allow smoke and hot gases to penetrate the ceiling membrane used as a horizontal surface to stop smoke. The walls along all these corridors were not all smoke-tight to the rooms above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/25/2012 at 2:31 pm surveyor #18107 observed in the 2E smoke compartment on the 2nd floor in the Surgery Scheduling Control Room, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included two sets of slide-by glass panels without appropriate smoke-tight gasketing at the vertical edges of the glass panels. The panels were about 42 inches in height starting at 38 inches above finished floor (AFF) to about 80 inches AFF. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/25/2012 at 4:00 pm surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Corridors around #5 Plant Operations, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included openings around the perimeter of light fixtures greater than 1/2 inch, the light fixtures themselves were 12" x 48" two bulb light fixtures that allow smoke and hot gases to penetrate the ceiling membrane used as a horizontal surface to stop smoke. The walls along all these corridors were not all smoke-tight to the rooms above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/26/2012 at 10:47 am surveyor #18107 observed in the 0B smoke compartment on the Ground floor in the Data Room #1H, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 1/2 inch hole in the corridor wall from the Data Room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/26/2012 at 10:50 am surveyor #18107 observed in the 0B smoke compartment on the Ground floor in the Data Room #1C, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 1/2 inch hole in the corridor wall from the Data Room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/25/2012 at 2:40 pm surveyor #18107 observed in the 1D smoke compartment on the 1st floor in the Reception Desk Room at the Emergency Entry, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. The vertical slide-by glass panels did not have a smoke-tight seal. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware, and doors that would close when pushed or pulled. This deficiency occurred in 2 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/26/2012 at 10:08 am surveyor #18107 observed in the 0A smoke compartment on the Ground floor in the Kitchen Dish Room #44, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This is the door that accesses the Cafeteria, which is part of a required corridor and exit access route. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/25/2012 at 2:10 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Cath. Lab Waiting Room, that the door to the corridor was held open with a chair. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings with compliant vertical opening, doors with positive-latching hardware, sealed wall penetrations, and rated wall construction. This deficiency occurred in 11 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 11:53 am surveyor #18107 observed in the 3B & 3C smoke compartment on the 3rd floor in the Mechanical Room over Emergency Department Addition, that the vertical shaft wall was not compliant. Observed a sprinkler pipe penetrating a shaft that did not use the shaft and the installer took a short cut and ran the pipe through the shaft wall or the shaft was created after the pipe was already installed. Only items that use the shaft are allowed to penetrate the shaft per the 2002, 2006 & 2009 IBC requirements. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/26/2012 at 11:15 am surveyor #18107 observed in the 0A smoke compartment on the Ground floor in the Exit Passageway at Stairwell #3, that the door in the vertical opening would not positively self-latch when released. When pressure was applied to the door, without turning the latch or pushing on the panic push bar, the latch would not hold the door in the latched position. One of the access door's would not stay latched as part of the double door set leading into a Exit Passageway at Corridor #5. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 12:08 pm surveyor #18107 observed in the 3B & 3C smoke compartment on the 3rd floor in the Mechanical Room over Emergency Department Addition, that penetration(s) in a vertical shaft were not sealed according to an approved method. The deficiency included two pipe penetrations, one 3" diameter and the other a 1-1/2" diameter pipe not fire-stopped through the floor assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/24/2012 at 3:46 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Mechanical Shaft at #2008, that penetration(s) in a vertical shaft were not sealed according to an approved method. The deficiency included several openings in shaft wall that were not smoke tight. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/25/2012 at 10:29 am surveyor #18107 observed in the 1F smoke compartment on the 1st floor in the Exit Passageway at Stairwell #4, that penetration(s) in a vertical shaft were not sealed according to an approved method. The deficiency included a penetration in the 'fire barrier' separating the Exit Passageway from the vertical Stairwell. This wall was not sealed to the required 2-hours for a vertical shaft of Type I (332) for a building higher than 4-stories. A linear opening was observed at top of wall between these two spaces. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/25/2012 at 10:48 am surveyor #18107 observed in the 1A, 1B, 1E smoke compartments on the 1st floor in the Mechanical Shaft behind Public Elevators, that penetration(s) in a vertical shaft were not sealed according to an approved method. The deficiency included a open horizontal line at each floor where the concrete block meets the floor slab. Over the years since 1977, the concrete mortar has dried and left an opening between the floor slabs and the vertical concrete wall in this shaft. This shaft touches all three of these smoke compartments at this floor alone. Observed horizontal openings at 1st, 2nd & 3rd Floors where it meets the upper floor deck within the shaft. Other smoke compartments affected are: 2B, 3B and 4B. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

7. On 01/26/2012 at 11:27 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Shaft at Room #52A and behind Room #66, that penetration(s) in a vertical shaft were not sealed according to an approved method. The deficiency included a hole in the shaft. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

8. On 01/24/2012 at 1:06 pm surveyor #18107 observed in the 3A smoke compartment on the 3rd floor in the Shaft behind Elevators, that the shaft enclosure wall was not constructed to have a 2-hour fire resistance rating as required at the time it was built because rigid insulation was exposed within the wall construction and not encapsulated per its fire-rated assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage and exit signs when the egress path is not readily apparent. This deficiency occurred in 3 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/25/2012 at 1:59 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Cath. Lab Suite Passage #1140, that the path of egress in the corridor/aisle/pathway was not readily apparent and an exit sign was not provided near the end of the exit discharge where the passageway turns abruptly and the door seen is not the exit discharge door that could confuse someone in the event of a fire emergency. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/26/2012 at 8:25 am surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Boiler Room, that the path of egress in the corridor/aisle/pathway was not readily apparent and an exit sign was not provided near the dead-end side of the mezzanine above boilers leading to the only exit behind electrical panels. No clear direction was identified to exit egress the mezzanine. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/26/2012 at 10:00 am surveyor #18107 observed in the 0A smoke compartment on the Ground floor in the Kitchen Suite, that the path of egress in the corridor/aisle/pathway was not readily apparent and an exit sign was not provided near three exit egress doors out of the Kitchen Suite 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

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, and rated wall construction. This deficiency occurred in 10 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 10:50 am surveyor #18107 observed in the 4A smoke compartment on the 4th floor in the Corridor between smoke compartments 4A & 4B, that the smoke barrier wall was not compliant. The vertical wall between corridor wall and smoke barrier was not sufficient sealed at several locations to stop the spread of smoke. These observed situations were not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/24/2012 at 11:30 am surveyor #18107 observed in the 3B & 3C smoke compartment on the 3rd floor in the Corridor between smoke compartments 3A & 3B, that penetration(s) were not sealed according to an approved method. The deficiency included a 14" x 8" duct penetration was missing a certified fire/smoke assembly around the duct in the barrier to stop smoke and heat migration. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 3:27 pm surveyor #18107 observed in the 2A & 2B smoke compartment on the 2nd floor in the Corridors at smoke barrier between smoke compartments 2A & 2B, that penetration(s) were not sealed according to an approved method. The deficiency included a 1" diameter hole. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/25/2012 at 2:30 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Gift Shop Room, that a penetration was not sealed according to an approved method. The deficiency included a conduit penetrating the smoke barrier and not sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/25/2012 at 10:55 am surveyor #18107 observed in the 1B smoke compartment on the 1st floor in the Smoke Barrier running along side the Corridor outside MRI Suite near patient elevators, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the upper wall area is not sealed tight to floor deck above ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/25/2012 at 10:58 am surveyor #18107 observed in the 1A & 1B smoke compartment on the 1st floor in the Smoke Barrier running along side the Corridor outside Clinical Laboratory and next to the Imaging Department, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the upper wall area is not sealed tight to floor deck above ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

7. On 01/25/2012 at 12:05 pm surveyor #18107 observed in the 1B & 1C smoke compartment on the 1st floor in the Office Room #1026, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because the smoke barrier did not extend to the outside building wall to stop the spread of smoke around the end wall condition. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with compliant smoke doors. This deficiency occurred in 6 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 10:41 am surveyor #18107 observed in the 5A smoke compartment on the 5th floor in the Corridor between smoke compartments 5A & 5C, that the smoke barrier doors were not compliant. The door labels were missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/24/2012 at 11:35 am surveyor #18107 observed in the 3B & 3C smoke compartment on the 3rd floor in the Corridor between smoke compartments 3A & 3B, that the smoke barrier doors were not compliant. The door labels were missing. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 3:35 pm surveyor #18107 observed in the 2A & 2B smoke compartment on the 2nd floor in the Corridor at Nurse Station, that the smoke barrier doors were not compliant. Doors are required to have a label per NFPA 80. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not enclose hazardous rooms with closers on all doors, a smoke-tight room enclosure (in a sprinkled smoke zone), doors with positive-latching hardware, and sealed wall penetrations. This deficiency occurred in 7 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 3:00 pm surveyor #18107 observed in the 2E smoke compartment on the 2nd floor in the Anesthesia Clean Supply Room #2066, that the door would not self-close because of a automatic door hold-open. Through documentation could not confirm door would close and latch upon activation of fire alarm. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/24/2012 at 10:34 am surveyor #18107 observed in the 5A smoke compartment on the 5th floor in the Soiled Utility Room #533, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included a portion of the fire caulking coming out of the original 3 inch hole. Facility could not show the listed assembly for this fire-rated closure withjsut fire caulk. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 3:53 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Genesis Clean Linen Storage Room #269, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included several 1/4 to 1/2 inch lineal openings around duct penetration at East fire-rated wall. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/24/2012 at 2:43 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Clean Break-out Room #299G, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The door spring would not recoil and fit back into the hole of the door frame. The room was over 100 square feet and had combustible cardboard, collapsed from box break-downs. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/25/2012 at 11:25 am surveyor #18107 observed in the 1A smoke compartment on the 1st floor in the Clinical Lab Storage Room, that penetration(s) were not sealed according to an approved method. The deficiency included drywall seams not taped and screws not double mudded per listed and approved methods. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/26/2012 at 8:50 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Soiled Linen Chute Room #61, that penetration(s) were not sealed according to an approved method. The deficiency included 4 pipes at 3 inches in diameter. These observed situations were not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

7. On 01/26/2012 at 9:25 am surveyor #18107 observed in the 0E smoke compartment on the Ground floor in the Data & Electrical Room #87E, that penetration(s) were not sealed according to an approved method. The deficiency included 2 holes, one a 8" x 8" hole and the other a 3" x 24" hole. These observed situations were not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

8. On 01/26/2012 at 10:16 am surveyor #18107 observed in the 0A smoke compartment on the Ground floor in the Gift Shop Storage Room #47, that penetration(s) were not sealed according to an approved method. The deficiency included 12" x 12" hole around a speaker. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide egress paths at all times, without travel interruption at stairs that go below the level of exit discharge, and level walking surfaces in the path of egress. This deficiency occurred in 3 of the 26 smoke compartments,
and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/26/2012 at 8:59 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Stair #9 at 1st Level landing, that the travel down the Stairwell was not interrupted by an effective means to prevent travel past the level of discharge. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/25/2012 at 11:38 am surveyor #18107 observed in the 1B smoke compartment on the 1st floor in the Fluoroscopy Room #1013, that a portion of the path of egress had an abrupt change in elevation of egress path within the room due to a 3/4 inch diameter cable recently installed in the room. Both the patient and staff must traverse this cable lying on the floor at times during procedures. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/26/2012 at 8:40 am surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the IT. Server Room , that a portion of the path of egress had an abrupt change in elevation of greater than 1/2 inch at two locations on the IT Server Floor. This would cause a trip hazard in the event of a fire emergency. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.6 and 7.1.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. And with egress lighting fed by emergency power. This deficiency occurred in 1 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
On 01/25/2012 at 3:56 pm surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Contractor/Vendor Entrance/Exit, that the facility was unable to verify that the lighting along the path of egress was powered from the emergency electrical system. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide a sprinkler system that was installed according to NFPA 13 as required by the Life Safety Code, section 9.7.1.1. The facility did not provide a sprinkler system with unobstructed water distribution, and sprinklers located the appropriate distance from the ceiling. This deficiency occurred in 3 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 3:05 pm surveyor #18107 observed in the 2E smoke compartment on the 2nd floor in the Clean Storage Room #2059, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included a large full-height storage cabinet greater than 18 inches in depth that had combustibles within the cabinet. The door on the cabinet prevented the room sprinkler discharge to reach the contents within the cabinet. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/25/2012 at 10:40 am surveyor #18107 observed in the 1A smoke compartment on the 1st floor in the Nuclear Medicine Room #136A, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item . The obstruction included two large storage cabinets holding combustible cushions that protect equipment templates. The cabinet doors prevent the sprinklers from protecting all areas of the room where combustibles are stored. There currently is no sprinkler coverage in the full-height cabinets. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/25/2012 at 11:14 am surveyor #18107 observed in the 1A smoke compartment on the 1st floor in the Clinical Lab Electrical Room, that a sprinkler was located greater than 18 inches from the ceiling and floor deck. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.4.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/24/2012 at 2:20 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Surgery Men's Locker Room, that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included center island lockers were less than 12 inches from the sprinkler head, blocking coverage to one side of the lockers. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have a complete annual inspection, intact escutcheon rings, ceilings sealed above the sprinklers to collect heat, and sprinklers free of paint or other spray material. This deficiency occurred in 12 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 2:18 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Surgery Men's Locker Room & Hallway between Women's Locker Room and Lounge, that the sprinkler system maintenance was not compliant. At Men's Locker area 5 ceiling tiles were observed ajar and open, and at the Hallway area 7 ceiling tiles were damaged and open. This observed situation was not compliant with NFPA 25 (998 edition), 2-2. and Table 2-1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/24/2012 at 1:43 pm surveyor #18107 observed in the 3A smoke compartment on the 3rd floor in the Pharmacy Room #307, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 1:59 pm surveyor #18107 observed in the 2E smoke compartment on the 2nd floor in the ICU Bio-hazardous Waste Room, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/25/2012 at 9:14 am surveyor #18107 observed in the 2C smoke compartment on the 2nd floor in the G.I. Nurses Station & Steris Cleaning Room, that the escutcheon ring on the sprinkler was not tight to ceiling. There were two defective escutcheon ring installations in each space. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/25/2012 at 11:00 am surveyor #18107 observed in the 1A smoke compartment on the 1st floor in the Clinical Lab Reception Room, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/25/2012 at 1:56 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Cath. Lab Clean Utility Room #1145, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

7. On 01/25/2012 at 3:58 pm surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Plant Operations Office & Corridor #49, that the escutcheon ring on the sprinkler was not tight to ceiling at corridor and a 24" x 24" tile was out next to speaker in the office. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

8. On 01/24/2012 at 3:55 pm surveyor #18107 observed in the 2B smoke compartment on the 2nd floor in the Office Room #271, that there was one or more unsealed holes near the ceiling. The hole(s) included 2 damaged ceiling tiles. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

9. On 01/25/2012 at 9:03 am surveyor #18107 observed in the 2A smoke compartment on the 2nd floor in the Nurses Lounge #207, that there was one or more unsealed holes near the ceiling. The hole(s) included damaged tile around sprinkler head. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

10. On 01/25/2012 at 11:48 am surveyor #18107 observed in the 1B smoke compartment on the 1st floor in the General Radiographic Room #1018, that there was one or more unsealed holes near the ceiling. The hole included a 24" x 24" ceiling tile missing near the door. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

11. On 01/25/2012 at 2:21 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Data Closet across from Admitting & Stairwell #7, that there was one or more unsealed holes near the ceiling. The hole(s) included several ceiling tiles were missing in data closet open to the underside of the structure above (not sprinkled) and unfinished walls around closet. Stairwell ceiling had one hole. These holes would reduce the response time of the sprinkler(s) in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

12. On 01/25/2012 at 2:38 pm surveyor #18107 observed in the 1C smoke compartment on the 1st floor in the Stairwell #7, that there was one or more unsealed holes near the ceiling. The hole(s) included 4 ceiling panels ajar. These holes would reduce the response time of the sprinklers in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

13. On 01/25/2012 at 2:42 pm surveyor #18107 observed in the 1D smoke compartment on the 1st floor in the Triage Room #1113, that there was one or more unsealed holes near the ceiling. The hole included a 1" diameter hole next to the camera. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

14. On 01/26/2012 at 8:53 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Room #97A, that there was one or more unsealed holes near the ceiling. The holes included several 1" diameter holes. These holes would reduce the response time of the sprinklers in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

15. On 01/26/2012 at 11:00 am surveyor #18107 observed in the 0B smoke compartment on the Ground floor in the Linear Accelerator Closet & Central Sterile Processing Room (CSPR), that there was one or more unsealed holes near the ceiling. The holes included two 1" diameter holes in ceiling tile next to Linear Accelerator Control Room and two damaged tiles over clean sterilizers of CSPR. These holes would reduce the response time of the sprinklers in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

16. On 01/26/2012 at 11:21 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Autopsy Shower Room #83, that there was one or more unsealed holes near the ceiling. The hole included a 1 inch opening at the ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

17. On 01/26/2012 at 11:30 am surveyor #18107 observed in the 0D smoke compartment on the Ground floor in the Soiled Linen Cart Storage Room #67, that there was one or more unsealed holes near the ceiling. The hole included one 1" diameter hole in ceiling. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

18. On 01/24/2012 at 3:12 pm surveyor #18107 observed in the 2E smoke compartment on the 2nd floor in the Stairwell #7, that a sprinkler had paint on the head. Sprinkler is compromised by plaster spray or paint on the head, as well as the ceiling material is missing around the escutcheon ring. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with missing fire damper. This deficiency occurred in 1 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
On 01/25/2012 at 9:52 am surveyor #18107 observed in the 1A smoke compartment on the 1st floor in the Mechanical Shaft Room #132A, that a fire damper was not installed in an air duct that penetrated the fire rated wall. A duct of about 12" x 18" penetrated a 2-hour fire-rated barrier and was observed not to have a fire damper as required per NFPA 90A. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based upon observation and documentation review, the facility did not provide a properly enclosed linen/trash chute and appropriate collection rooms as with a latching, fire rated and labeled linen chute door. This deficiency occurred in 1 of the 26 smoke compartments, and had the potential to affect 20 staff that were working in the smoke compartment at the time of the survey.

FINDINGS INCLUDE:
On 01/26/2012 at 11:01 am surveyor #18107 observed in the 0B smoke compartment on the Ground floor in the Soiled Linen Chute Room, that the linen chute door that opened into the chute room did not have a 1-hour fire protection rating, because the chute door would not latch closed in the event of a fire. This observed situation was not compliant with NFPA 101 (2000 edition), 9.5.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as sprinkler obstruction with cubical curtains that permit the designed distribution of sprinkler water. This deficiency occurred in 1 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
On 01/25/2012 at 2:43 pm surveyor #18107 observed in the 1D smoke compartment on the 1st floor in the Doctors Lounge #1063 & Doctors Sleep Room #1062, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower area and was not 18 inches from the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 Chapter 4, with separation of oxygen from combustibles. This deficiency occurred in 1 of the 26 smoke compartments, and had the potential to affect 15 staff that were working in this smoke compartment at the time of the survey.

FINDINGS INCLUDE:
On 01/25/2012 at 4:25 pm surveyor #18107 observed in the 0C smoke compartment on the Ground floor in the Medical Gas Storage Room, that combustible materials were stored too close to the storage site of cylinders of oxygen. Several Acetylene, Argon, CO2 & N2 cylinders were observed chain-ganged together in the same room and less than 5'-0" from O2 cylinders. The access path was not kept clear to gases "in-use" for CO2, N2O & MA. This observed situation was not compliant with NFPA 99 (1999 edition), 4-3.1.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide and maintain duct penetrations through smoke barrier walls with rated seals. This deficiency occurred in 2 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/24/2012 at 10:49 am surveyor #18107 observed in the 4A smoke compartment on the 4th floor in the Corridor between smoke compartments 4A & 4B, that a duct penetrated a smoke barrier and was not sufficiently sealed around the duct to stop the spread of smoke between smoke compartments per a listed assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/24/2012 at 1:29 pm surveyor #18107 observed in the 3A smoke compartment on the 3rd floor in the Corridor at Smoke Barrier between 3A & 3C, that a duct penetrated a smoke barrier and was not sufficiently sealed at the top of the duct to stop the spread of smoke between smoke compartments per a listed assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.3.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code, fixed wiring rather than extension cords, and electrical panels with complete directories is the required installation. This deficiency occurred in 6 of the 26 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:
1. On 01/25/2012 at 11:46 am surveyor #18107 observed in the 1B smoke compartment on the 1st floor in the (Vacated) Catheterization Lab #4, that the electrical code was not followed. The wire raceway was left open at the walls and floor since the hospital relocated the Catheterization Lab #4 to its new location in smoke compartment 1C. 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 C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

2. On 01/25/2012 at 11:53 am surveyor #18107 observed in the 1B smoke compartment on the 1st floor in the Staff Lounge, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to appliances within the room without a ground fault protector. A strip plug with a surge protection feature may be used in non-patient areas for computers, but non-computer equipment cannot be plugged into it. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

3. On 01/24/2012 at 10:39 am surveyor #18107 observed in the 5A smoke compartment on the 5th floor in the Soiled Utility Room #533, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #423, Breaker #12 was observed in the 'ON' position and noted as a 'spare' on the index sheet in the Panel. Staff could not identify what it was serving. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

4. On 01/24/2012 at 11:10 am surveyor #18107 observed in the 4A smoke compartment on the 4th floor in the Electrical Closet Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #433, Breakers within the electrical panel were not properly marked. Open spaces were left blank. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

5. On 01/25/2012 at 10:17 am surveyor #18107 observed in the 1F smoke compartment on the 1st floor in the Electrical Closet Room, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #379, Breakers (#41 & #42) were left in an 'ON' position, yet the index sheet within the electrical panel stated they were 'spares'. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

6. On 01/25/2012 at 3:15 pm surveyor #18107 observed in the 1D smoke compartment on the 1st floor in the Clean Equipment Holding Room #1128, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #EC?, for the Trauma Room #5, was showing several outlet breakers within the panel to be in the 'OFF' position for the ceiling mounted articulating arm. In talking with one ER staff person they stated they may use all the electrical outlets on the articulating arm and none of the outlets should be in a 'OFF' position. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).

7. On 01/26/2012 at 10:37 am surveyor #18107 observed in the 0B smoke compartment on the Ground floor in the Room #18, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #1, Breaker #5 for the Surgical Air Compressor #1 was incorrectly tag. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Director Plant / Facilities), staff D (Analysis Quality), staff E (Director Safety), and staff F (Manager Facilities Srvcs.).