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Based on observation and interview, the facility did not provide a common separation wall that had sealed wall penetrations, rated doors, smoke-tight seals at meeting edges, and rated wall construction. This deficiency occurred in 7 of the 83 smoke compartments, and had the potential to affect 27 of the 450 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 11:10 am surveyor #14105 observed in the B4/5 smoke compartment on the 4th floor in the Core Space, that the separation wall was not constructed to have a 2-hour fire resistance rating because the wall to pod B6/5 was not fire sealed above the doors. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

2. On 10/4/2010 at 12:02 pm surveyor #28616 observed in the L5/B smoke compartment on the basement floor in the 100K-Corridor, that penetration(s) were not sealed according to approved UL designs. The deficiency included a conduit where the original fire stop sealant failed and no longer provided a valid fire stop. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

3. On 10/5/2010 at 9:10 am surveyor #28616 observed in the F6/2 smoke compartment on the 2nd floor in the 276-Waiting Room, that penetration(s) were not sealed according to approved UL designs. The deficiency included two 1-1/2" conduits. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

4. On 10/6/2010 at 10:32 am surveyor #14105 observed in the E7/3 smoke compartment on the 3rd floor in the Space #FA001512, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating.The left door had a 45 minute label. No astragal was installed on this door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

5. On 10/6/2010 at 10:36 am surveyor #14105 observed in the E7/3 smoke compartment on the 3rd floor in the Space # FA001513, that the pair of fire barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

6. On 10/6/2010 at 9:53 am surveyor #14105 observed in the G5/3 smoke compartment on the 3rd floor in the G5 Core, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating.The right door from the G7 pod had a 45 minute label. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4 and 8.2.3.2.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

7. On 10/7/2010 at 10:13 am surveyor #14105 observed in the E5/3 smoke compartment on the 3rd floor in the Space #FA30705, that the pair of fire barrier doors had a gap greater than 1/8" at their meeting edges that was not sealed with an effective astragal to resist the passage of smoke. This situation was also observed at doors FA001692, 1693, 702, and 706. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

8. On 10/7/2010 at 10:57 am surveyor #14105 observed in the E5/3 smoke compartment on the 3rd floor in the Room #305, that the separation wall was not constructed to have a 2-hour fire resistance rating because the angled wall had patches in the gypsum wall board that were not taped and covered with joint compound. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

9. On 10/7/2010 at 2:06 pm surveyor #14105 observed in the E5/3 smoke compartment on the 3rd floor in the Room #316, that penetration(s) were not sealed according to approved UL designs. The deficiency included a 1" conduit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

10. On 10/7/2010 at 2:29 pm surveyor #14105 observed in the C5/3 smoke compartment on the 3rd floor in the Room #300L, that penetration(s) were not sealed according to approved UL designs. The deficiency included a pneumatic tube, and 3 electrical conduits that were not fire stopped at a drywall patch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

11. On 10/7/2010 at 2:41 pm surveyor #14105 observed in the E5/3 smoke compartment on the 3rd floor in the Room #307, that the separation wall was not constructed to have a 2-hour fire resistance rating because there was a 12"x10" open hole in the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

12. On 10/4/2010 at 12:50 pm surveyor #28616 observed in the L5/B smoke compartment on the basement floor in the B39-Shell Space, that the separation wall was not constructed to have a 2-hour fire resistance rating because the vertical wall seal and perimeter floor seal between the basement and 1st floor had a 3" wide joint that was not sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

Based on observation and interview, the facility did not provide and maintain the required building construction type, including support steel covered with rated fire proofing, and sealed floor penetrations. This deficiency would affect 3 of the 14 smoke compartments, and had the potential to affect 16 of the 61 inpatients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 1:10 pm surveyor #22219 observed in the 1-North smoke compartment on the 1st floor in the 1169-1st Floor Shell, that fire proofing was missing from the structural steel at the bottoms of the southwest and southeast columns. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr. Mechanic), and staff aa (Director, Plant Engineering).

2. On 10/4/2010 at 2:53 pm surveyor #12316 observed in the 4A-North smoke compartment on the 4Ath floor in the M003-Mechanical Room, that fire proofing was missing from the structural steel at the column on the south side of Stair #2. and exposed a 4" long section of metal. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

3. On 10/5/2010 at 11:43 am surveyor #12316 observed in the 4-North smoke compartment on the 4th floor in the 4209-IT room, that there were penetration(s) through the floor that were not fire stopped according to a UL design standard. Penetration(s) included a cable sleeve (1 of 6). Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

Based on observation, interview, and a review of facility flame spread documents, the facility did not provide room finishes that had rated wall finishes. This deficiency occurred in 1 of the 83 smoke compartments, and had the potential to affect 15 of the 1000 staff that were working.

FINDINGS INCLUDE:
On 10/4/2010 at 2:36 pm surveyor #28616 observed in the F6/1 smoke compartment on the 1st floor in the 25A-Small Robot Room, that the facility could not confirm the wall finish had an appropriate rating.. The room wall was finished with 4" thick foam sound insulation. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces that had no combusitible material storage. This deficiency occurred in 1 of the 83 smoke compartments, and had the potential to affect 20 of the 1000 staff that were working.

FINDINGS INCLUDE:
On 10/6/2010 at 10:57 am surveyor #14105 observed in the E7/3 smoke compartment on the 3rd floor in the 300K-Corridor, that the corridor space was used for storage, and was not separated by a wall from the corridor. Storage included over 100 sq. ft. of combustible materials. This quantity of materials was deemed hazardous for storage in a corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 , and 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

Based on observation and interview, the facility did not provide compliant corridor separation doors, including sliding doors that satisfied corridor requirements, self-latching inactive doors, doors with positive-latching hardware, and corridor doors that would close when pushed or pulled. This deficiency would affect 6 of the 14 smoke compartments, and had the potential to affect 21 of the 61 inpatients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:

1. On 10/4/2010 at 2:15 pm surveyor #22219 observed in the 1-East smoke compartment on the 1st floor in the 1335-Community Room, that the inacitve door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it did not have an automatic flush bolt. The inactive door had a manual latch bolt that would not engage without human intervention. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5, exception 4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Building Trade Supervisor), and staff aa (Director, Plant Engineering).

2. On 10/4/2010 at 11:30 am surveyor #22219 observed in the Bsmt-South smoke compartment on the Basement floor in the B033-Mechanical Room, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it did not have an automatic flush bolt. The inactive door had a manual latch bolt that would not engage without human intervention. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5, exception 4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Building Trade Supervisor), and staff aa (Director, Plant Engineering).

3. On 10/4/2010 at 1:33 pm surveyor #22219 observed in the 1-East smoke compartment on the 1st floor in the 1023-Passage, that the corridor door would not positively self-latch when pushed to a closed position. The west leaf of a pair of doors was mechanically prevented from latching. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Building Trade Supervisor), and staff aa (Director, Plant Engineering).

4. On 10/4/2010 at 2:49 pm surveyor #22219 observed in the 2-North smoke compartment on the 2nd floor in the 2125-Audiology Booths, that the corridor door would not positively self-latch when pushed to a closed position. Eight doors had manual dead-bolt latches. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Building Trade Supervisor), and staff aa (Director, Plant Engineering).

5. On 10/5/2010 at 7:52 am surveyor #22219 observed in the 3-South smoke compartment on the 3rd floor in the 3122-28-Negative/Positive Pressure Rooms, that a manual horizontal sliding door was used in a corridor and would not break-a-way when the manual jamb-latch was in the up-position. When the manual jamb-latch was in the down-position the door would break-a-way, but there was a 1/4" gap between the doors and they would not resist the passage of smoke. The door would not operate when a force of 15 pounds was applied in the direction of egress travel. This situation was typical of all five of the negative and positive pressure rooms (#3122 through #3128) in the corridor. Room #3128 also would not break-a-way until a force of more than 30 pounds were pushed on the latch end of the door in the direction of egress travel. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.2.9 and 7.2.1.14. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Building Trade Supervisor), and staff aa (Director, Plant Engineering).

6. On 10/5/2010 at 8:50 am surveyor #22219 observed in the 3-North smoke compartment on the 3rd floor in the 3025A-Electrical Closet, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it did not have an automatic flush bolt. The inactive door had a manual latch bolt that would not engage without human intervention. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5, exception 4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff aa (Director, Plant Engineering).

7. On 10/5/2010 at 11:08 am surveyor #12316 observed in the 4-South smoke compartment on the 4th floor in the 4401-Family/Visitor Room, that the door to the corridor was held open with a cart full of books.The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

8. On 10/5/2010 at 11:18 am surveyor #12316 observed in the 4-South smoke compartment on the 4th floor in the 4416 and 4418 Patient Rooms, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it did not have an automatic flush bolt. The inactive door had a manual latch bolt that would not engage without human intervention. The inactive leaf had manual latching hardware and was observed in the unlatched position. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5, exception 4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

9. On 10/5/2010 at 11:24 am surveyor #12316 observed in the 4-South smoke compartment on the 4th floor in the 4436-Patient Room, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it did not have an automatic flush bolt. The inactive door had a manual latch bolt that would not engage without human intervention. The inactive leaf had manual latching hardware and was observed in the unlatched position. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.3.5, exception 4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings that had rated wall construction and sealed wall penetrations. This deficiency occurred in 8 of the 83 smoke compartments, and had the potential to affect 66 of the 450 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 1:10 pm surveyor #14105 observed in the A6/4 smoke compartment on the 4th floor in the 400A-Stairwell, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the corridor wall and wall behind the door were not fire sealed at the top of the wall (near room 401). This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

2. On 10/4/2010 at 1:20 pm surveyor #14105 observed in the D4/4 smoke compartment on the 4th floor in the 428A-Patient Room, that penetration(s) were not sealed according to approved UL designs. The deficiency included 2 conduits at the patient head wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

3. On 10/4/2010 at 10:00 am surveyor #14105 observed in the B4/4 smoke compartment on the 4th floor in the 453-End Lobby, that penetration(s) were not sealed according to approved UL designs. The deficiency included a 1" flexible conduit into the B4/454 shaft. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

4. On 10/4/2010 at 10:10 am surveyor #14105 observed in the B4/4 smoke compartment on the 4th floor in the 454-Shaft, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the shaft was not fire stopped under the beam at the top of three walls. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

5. On 10/4/2010 at 10:15 am surveyor #14105 observed in the A4/4 smoke compartment on the 4th floor in the 401-Shaft, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the shaft was not fire stopped to the upper concrete deck along the entire shaft. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

6. On 10/4/2010 at 10:20 am surveyor #14105 observed in the A4/4 smoke compartment on the 4th floor in the 401-Shaft, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the shaft was not fire stopped on the gypsum wall board to the upper deck along the entire shaft. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

7. On 10/4/2010 at 10:30 am surveyor #14105 observed in the A4/4 smoke compartment on the 4th floor in the Stairwell, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because two slots in the gypsum wallboard were not fire sealed above the ceiling (behind the door). This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

8. On 10/4/2010 at 12:50 pm surveyor #14105 observed in the C6/4 smoke compartment on the 4th floor in the 400A-Stairwell, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the corridor wall and wall behind the door were not fire sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

9. On 10/4/2010 at 2:30 pm surveyor #14105 observed in the E5/4 smoke compartment on the 4th floor in the 410-Resident Room, that penetration(s) were not sealed according to approved UL designs. The deficiency included two holes in the wall located opposite the door where pipes were removed. There were also a 1/4" hole in the wall on the wall left of the door. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

10. On 10/5/2010 at 1:18 am surveyor #14105 observed in the F4/4 smoke compartment on the 4th floor in the 481-Room, that penetration(s) were not sealed according to approved UL designs. The deficiency included two heating pipes and an open hole. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

11. On 10/5/2010 at 1:22 pm surveyor #14105 observed in the B4/5 smoke compartment on the 5th floor in the Stairwell, that penetration(s) were not sealed according to approved UL designs. The deficiency included a conduit above the door. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

12. On 10/5/2010 at 1:40 pm surveyor #14105 observed in the B4/5 smoke compartment on the 5th floor in the B4/5 (at B5/5), that penetration(s) were not sealed according to approved UL designs. The deficiency included numerous pipes and holes. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

13. On 10/5/2010 at 1:44 pm surveyor #14105 observed in the B4/5 smoke compartment on the 5th floor in the 505-Resident On-Call Room, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because there were open holes at the top of the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

14. On 10/5/2010 at 1:53 pm surveyor #14105 observed in the B5/5 smoke compartment on the 5th floor in the 503-Lactation Room, that penetration(s) were not sealed according to approved UL designs. The deficiency included a flexible conduit. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

Based on observation and interview, the facility did not provide hold-open devices on doors in rated walls that included an adjacent smoke detector. This deficiency occurred in 2 of the 83 smoke compartments, and had the potential to affect 16 of the 450 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/6/2010 at 10:23 am surveyor #14105 observed in the F8/3 smoke compartment on the 3rd floor in the Room #329, that the fire barrier door was magnetically held open and did not have a smoke detector. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls, including sealed wall penetrations. This deficiency would affect 1 of the 14 smoke compartments, and had the potential to affect 10 of the 155 facility-estimated number of outpatients that the building served at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/4/2010 at 2:30 pm surveyor #22219 observed in the 1-East smoke compartment on the 1st floor in the 1034-Corridor, that penetration(s) were not sealed according to approved UL designs. The deficiency included four 1" diameter holes that were not sealed and a 1"x2" slot with a 1" conduit. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr. Mechanic), and staff aa (Director, Plant Engineering).

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 that had an adjacent smoke detector, and approved window frames. This deficiency would affect 6 of the 14 smoke compartments, and had the potential to affect 61 of the 61 inpatients that the facility was licensed to serve, as well as an undeterminal number of outpatients, staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 1:37 pm surveyor #22219 observed in the 1-West smoke compartment on the 1st floor in the 1205-Diagosis Waiting Room, that the smoke barrier door was magnetically held open and did not have a local smoke detector to activate the alarm system. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 and 8.4.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr. Mechanic), and staff aa (Director, Plant Engineering).

2. On 10/4/2010 at 1:00 pm surveyor #12316 observed in the 6-North smoke compartment on the 6th floor in the 6001-Shell Space, that the wired glass vision panels of smoke barrier doors could not be confirmed to be installed in approved frames. The information was not available to confirm that the wired glass vision panel was installed in approved frame and tested with the door as a door assembly. There were two sets of smoke barrier doors. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

3. On 10/4/2010 at 9:20 am and on10/5/2010 at 11:30 am, surveyor #12316 observed in the 4th and 5th floors that the wired glass vision panels of smoke barrier doors were installed in wood frames. Information was not available to confirm that the wired glass vision panels were installed in approved frames and tested as a door assembly. There were two sets of smoke barrier doors in each floor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.7. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

Based on observation and interview, the facility did not enclose hazardous rooms that had rated doors, doors with positive-latching hardware, sealed wall penetrations, rated ceiling construction, and closers on all doors. This deficiency occurred in 8 of the 83 smoke compartments, and had the potential to affect 55 of the 450 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 1:18 pm surveyor #28616 observed in the K4/B smoke compartment on the basement floor in the B100MJ4-Mechanical/Boiler Room, that the room was not sprinkled and the fire barrier door could not be verified to have the required rating. The door was not labeled. The space was considered a hazardous space and was remodeled since 2007 and is required to satisfy new construction requirements 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

2. On 10/4/2010 at 1:31 pm surveyor #28616 observed in the K4/B smoke compartment on the basement floor in the B49(4)-Shell Space, that the enclosing wall was not constructed to a 1-hour fire resistance rating. There were about 4 missing gypsum wall board panels on the inside surface of the wall. The space was considered a hazardous space and was remodeled since 2007 and is required to satisfy new construction requirements. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

3. On 10/4/2010 at 1:40 pm surveyor #28616 observed in the K4/B smoke compartment on the basement floor in the B41-Storage Room, that the door would not self-close because a 10'x10' ceiling access panel that failed to also self-close, in the rated gypsum ceiling assembly above, blocked the door from closing. The space was considered a hazardous space and was remodeled since 2007 and is required to satisfy new construction requirements. The room was considered hazardous because it exceeded 100 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

4. On 10/4/2010 at 1:40 pm surveyor #14105 observed in the D4/4 smoke compartment on the 4th floor in the 415-Equipment Storage, that the room was not sprinkled and the fire barrier door could not be verified to have the required rating. The room was considered hazardous because it exceeded 100 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

5. On 10/4/2010 at 11:00 am surveyor #14105 observed in the B4/4 smoke compartment on the 4th floor in the 463-Clean Supply Room, that penetration(s) were not sealed according to approved UL designs. The deficiency included a flexible conduit and 2 small holes in the corridor wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

6. On 10/4/2010 at 11:35 am surveyor #28616 observed in the K5/B smoke compartment on the basement floor in the 07-Storage Room, that the door would not positively self-latch when released because of maladjustment. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

7. On 10/4/2010 at 12:43 pm surveyor #28616 observed in the L5/B smoke compartment on the basement floor in the B39-Shell Space, that penetration(s) were not sealed according to approved UL designs. The deficiency included three 3" conduits and an 8" cable tray. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

8. On 10/5/2010 at 10:01 am surveyor #14105 observed in the F8/4 smoke compartment on the 4th floor in the 422-Storeroom, that the enclosing wall was not constructed to a 1-hour fire resistance rating. Joints were not taped or coated with joint compound. Several conduits were not fire stopped. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

9. On 10/5/2010 at 10:14 am surveyor #14105 observed in the F8/4 smoke compartment on the 4th floor in the 427-Soiled Holding Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating, since the joint where the wall met the upper deck was not firesafed. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

10. On 10/5/2010 at 10:23 am surveyor #14105 observed in the F8/4 smoke compartment on the 4th floor in the 461-Clean Utility, that the enclosing wall was not constructed to a 1-hour fire resistance rating, since the joint where the wall met an adjacent beam was not firesafed. Five electrical and four sprinkler penetrations were not fire stopped. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

11. On 10/5/2010 at 11:26 am surveyor #14105 observed in the F4/4 smoke compartment on the 4th floor in the 472-Clean Supply Room, that penetration(s) were not sealed according to approved UL designs. The deficiency included two conduits that were not firesafed to a one-hour standard. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

12. On 10/5/2010 at 2:49 pm surveyor #14105 observed in the E5/5 smoke compartment on the 5th floor in the 577-Soiled Room, that the ceiling was not constructed to a 60 minute fire resistance rating. The room was open to the interstitial space; no enclosing walls were extended to the roof deck. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

13. On 10/5/2010 at 2:56 pm surveyor #14105 observed in the E5/5 smoke compartment on the 5th floor in the 525-Clean Room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall common to the locker room does not extend to the roof deck; therefore, this room is open to the interstitial space. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

14. On 10/5/2010 at 9:26 am surveyor #28616 observed in the F6/2 smoke compartment on the 2nd floor in the 220-Supply Room, that the door would not self-close because there was no closer installed on the door and the tray of an ice cube machine in the room extended into the door swing space and prevented the door from fully closing and self-latching. The room was considered hazardous because it exceeded 100 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

Based on observation and interview, the facility did not provide egress paths at all times and doors that were unlockable in the egress path. This deficiency would affect 1 of the 14 smoke compartments, and had the potential to affect 21 of the 61 inpatients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/5/2010 at 9:10 am surveyor #12316 observed in the 4-South smoke compartment on the 4th floor in the 4043-East Corridor, that the door was locked from the egress side. The west smoke barrier door near patient room #4442 was locked via a magnetic lock and would not provide ready access to the egress path. The locking was part of the security measures to restrict access into the Peds ICU. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

2. On 10/5/2010 at 9:30 am surveyor #12316 observed in the 4-South smoke compartment on the 4th floor in the 4040-West Corridor, that the door was locked from the egress side. The west smoke barrier door near patient room #4402 was locked via a magnetic lock and would not provide ready access to the egress path. The locking was part of the security measures to restrict access into the Peds ICU. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

Based on observation and interview, the facility did not provide and maintain emergency illumination of exit and directional signs, including exit signs when the egress path is not readily apparent. This deficiency occurred in 1 of the 83 smoke compartments, and had the potential to affect 10 of the 1000 staff that were working.

FINDINGS INCLUDE:
On 10/5/2010 at 11:24 am surveyor #28616 observed in the E3/2 smoke compartment on the 2nd floor in the 221-Gyn-Rehab, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near a location that could be viewed from all areas of the room. The room contained multiple doors, one of which had an exit sign, but was located in a recessed alcove. The single exit sign could not be seen from all areas of the room and the path of egress was not readily apparent. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 that had protected notification circuits, and an alert tone prior to relocation messages. This deficiency would affect all of the 14 smoke compartments, and had the potential to affect all of the 61 inpatients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/6/2010 at 4:30 pm surveyor #12187 observed that the wiring in the notification circuits of the fire alarm system were not 2-hour protected from the alarm panel to the notification zone. The building evacuation plan includes relocation of occupants. The circuit wires were not listed as being fire rated for an alarm system and were installed in standard conduit. The facility was unable to provide documentation that the wire and conduit were listed as an assembly to comply with sustainability requirements in a fire alarm system. This observed situation was not compliant with NFPA 72 (1999 edition), 3-8.4.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

2. On 10/6/2010 at 4:30 pm surveyor #12187 observed that the fire alarm system did not automatically sound a continuous alert tone (3-10 duration) prior to the emergency voice relocation message. This observed situation was not compliant with NFPA 72 (1999 edition), 3-8.4.1.3.5.3.1(b). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

Based on observation, interview and a review of documents, the facility did not maintain the fire alarm system according to NFPA 70 and 72 requirements that included adequate strobe coverage. This deficiency occurred in 2 of the 83 smoke compartments, and had the potential to affect 24 of the 450 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 10:40 am surveyor #14105 observed in the B4/4 smoke compartment on the 4th floor in the 419-Office, that the coverage of fire notification strobe lights was not adequate for a private mode notification because the common room contained multiple occupants and was not provided with a notification device. This also occurred in Room #423. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.7 and NFPA 72 (1999 edition), Chapter 4-5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

2. On 10/4/2010 at 10:50 am surveyor #14105 observed in the B4/4 smoke compartment on the 4th floor in the 413-Office, that the coverage of fire notification strobe lights was not adequate for a private mode notification because the common room contained two or more staff and was not provided with a notification device. This also occurred in all multiple occupant rooms in this compartment. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.7 and NFPA 72 (1999 edition), Chapter 4-5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

3. On 10/5/2010 at 3:11 pm surveyor #14105 observed in the E5/5 smoke compartment on the 5th floor in the 584-Conference Room, that the coverage of fire notification strobe lights was not adequate for a private mode notification because there was no strobe in the room. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.7 and NFPA 72 (1999 edition), Chapter 4-5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, including no obstructions near the sprinkler, and sprinklers with the appropriate temperature rating. This deficiency would affect 2 of the 14 smoke compartments, and had the potential to affect 12 of the 61 inpatients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 2:23 pm surveyor #12316 observed in the 5-South smoke compartment on the 5th floor in the 5334-Electrical Room, that horizontal conduit support track(s) near the ceiling obstructed the water discharge from one sprinkler head located within a few inches of the obstruction. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

2. On 10/4/2010 at 3:30 pm surveyor #12316 observed in the 4A-North and South smoke compartments on the 4Ath floor in the M003-Mechanical Room, that the sprinkler heads were intermediate temperature-rated and not ordinary temperature-rated with red color glass bulbs. The temperature rating was not consistent with the ceiling temperature of the room in which it was located. The space is considered a light hazard sprinkler occupancy and the ceiling temperatures were not expected to exceed 150° F to warrant a intermediate temperature bulb. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3.3. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

Based on observation and interview the facility did not maintain the sprinkler system in a reliable operating condition, including a complete inspection program as required by NFPA 25. The sprinkler inspection program did not ensure that ceiling holes were sealed so heat would collect and activate the sprinkler. This deficiency would affect 2 of the 14 smoke compartments, and had the potential to affect 10 of the 155 facility-estimated number of outpatients that the building served at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 1:50 pm surveyor #22219 observed in the 1-West smoke compartment on the 1st floor in the 1202-IT Room, that there was one or more unsealed holes near the ceiling. The hole(s) included two 3" conduits through the ceiling, with gaps up to 1/4" between the ceiling pipes. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr. Mechanic), and staff aa (Director, Plant Engineering).

2. On 10/4/2010 at 2:00 pm surveyor #22219 observed in the 1-South smoke compartment on the 1st floor in the 1420-Family Resource Storeroom, that there was one or more unsealed holes near the ceiling. The hole(s) included six ceiling tiles that were missing from the grid system. There were also two water stained tiles in the grid. 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 deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr. Mechanic), and staff aa (Director, Plant Engineering).

Based on observation and interview, the facility did not provide a ventilation system in accordance that had manufacturer specifications and NFPA 90A. This deficiency occurred in 3 of the 83 smoke compartments, and had the potential to affect 16 of the 450 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/5/2010 at 10:50 am surveyor #14105 observed in the F8/4 smoke compartment on the 4th floor in the 450-Shaft, that the space was not provided with compliant ventilation. It was observed that three major ducts that served the 4th floor ICU and 3rd floor Surgery were not installed in a 2 hr rated shaft and did not have fire dampers. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

2. On 10/5/2010 at 8:33 am surveyor #14105 observed in the E4/4 smoke compartment on the 4th floor in the 492-Okagaki Conference Room, that the space was not provided with compliant ventilation. It was observed that foam-insulation was installed on a water pipe and the facility was not able to validate that it was rated for plenum use. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

3. On 10/5/2010 at 9:30 am surveyor #14105 observed in the E5/4 smoke compartment on the 4th floor in the 406-Room, that the space was not provided with compliant ventilation. It was observed that foam-insulation was installed on two pipes and the facility was not able to validate that it was rated for plenum use. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

Based on observation and interview, the facility did not maintain a safe and available egress path, including corridors that were free of materials that obstructed egress. This deficiency would affect 2 of the 14 smoke compartments, and had the potential to affect 13 of the 155 facility-estimated number of outpatients that the building served at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:

1. On 10/4/2010 at 11:35 am surveyor #12316 observed in the 6-North smoke compartment on the 6th floor in the 6001-Shell Space, that items were stored in the exit access pathway, including stored equipment such as a medical gas boom and operating light. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 and 18.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

2. On 10/4/2010 at 1:30 pm surveyor #22219 observed in the 1-North smoke compartment on the 1st floor in the 1010-Corridor, that items were stored in the exit access pathway, including a vacant bed. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 and 18.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr. Mechanic), and staff aa (Director, Plant Engineering).

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, as required by NFPA 99 that had sealed wall penetrations, and rated ceiling construction. This deficiency occurred in 2 of the 83 smoke compartments, and had the potential to affect 16 of the 450 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/5/2010 at 10:30 am surveyor #14105 observed in the F8/4 smoke compartment on the 4th floor in the 431-Gas room, that penetration(s) were not sealed according to approved UL designs. The deficiency included an electrical conduit. A drywall patch was not properly fire sealed. This room was used to store greater than 3,000 cubic feet of oxygen and was required to be enclosed with 1-hour rated construction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 8-3.1.11. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

2. On 10/5/2010 at 10:50 am surveyor #28616 observed in the E3/2 smoke compartment on the 2nd floor in the 280-Gas Manifold Room, that the ceiling was not constructed to a 60 minute fire resistance rating because a 10'x10' ceiling access panel did not self-close. The room contained about 18 "H"-size cylinders of oxygen. This room was used to store greater than 3,000 cubic feet of oxygen and was required to be enclosed with 1-hour rated construction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 8-3.1.11. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99. This deficiency occurred in 16 of the 83 smoke compartments, and had the potential to affect 61 of the 450 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/6/2010 at 11:00 am surveyor #12316 observed in the H6/B smoke compartment on the basement floor in the Mechanical Room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included a missing low pressure sensor and pressure gauge downstream of the source valve on the branch of the medical vacuum piping that fed the American Family Children's Hospital. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Figure 4-3.2.1.10. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr Mechanic).

Based on observation and interview, the facility did not provide a code compliant environment that had a generator with a remote stop, and medical gas maintenance. This deficiency occurred in 42 of the 83 smoke compartments, and had the potential to affect all of the 450 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/6/2010 at 3:33 pm surveyor #12316 observed that the facility did not have a regular preventive maintenance schedule for testing the station inlet terminals on the medical vacuum system. This observed situation was not compliant with NFPA 110 (1999 edition), 4-3.5.6.1(c). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff oo (Mechanical Trades Supervisor).

2. On 10/6/2010 at 4:00 pm surveyor #12187 observed in the D4/1 smoke compartment on the 1st floor in the 163-Control Room, that the facility emergency generators did not have a compliant remote annunciator panel. The alarms for generators #1, 3, 4, 5, 6, 8, 9, and 11 were connected to the Metis building management system and did not sound in a continuously occupied location. There was no generator annunciator panel in the control room. This observed situation was not compliant with NFPA 110 (1999 edition), 3-4.1.1.15. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ll (Mechanic).

Based on observation and interview, the facility did not provide oxygen transfer space that had a ceramic or concrete floor. This deficiency occurred in 1 of the 83 smoke compartments, and had the potential to affect 20 of the 450 patients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/6/2010 at 11:04 am surveyor #14105 observed in the E7/3 smoke compartment on the 3rd floor in the 370-Oxygen Store Room, that the floor had a non-concrete or ceramic tile finish. The floor finish was a rubber material. The room contained cylinders of liquid oxygen. This observed situation was not compliant with NFPA 99 (1999 edition) 8-6.2.5.2(b). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff dd (Construction Manager).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code, including closed electrical raceways. This deficiency would affect 2 of the 14 smoke compartments, and had the potential to affect 15 of the 155 facility-estimated number of outpatients that the building served at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 2:10 pm surveyor #22219 observed in the 1-South smoke compartment on the 1st floor in the 1424-Family Resource Gift Shop, that a 15"x15" electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr. Mechanic), and staff aa (Director, Plant Engineering).

2. On 10/4/2010 at 3:00 pm surveyor #22219 observed in the 2-North smoke compartment on the 2nd floor in the 2242-IT Room, that a 1-1/2" LB electrical box did not have a cover so the raceway system was not enclosed. This observed situation was not compliant with NFPA 70 (1999 edition), 517-12. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr. Mechanic), and staff aa (Director, Plant Engineering).

Based on observation and interview, the facility did not provide alcohol based hand rub dispensers that were installed and located as permitted by the code. This deficiency would affect 1 of the 14 smoke compartments, and had the potential to affect 6 of the 61 inpatients that the facility was licensed to serve, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/5/2010 at 7:55 am surveyor #22219 observed in the 3-North smoke compartment on the 3rd floor in the 3126 Positive Pressure Rooms, that an alcohol based hand rub (ABHR) dispenser was located 3" from an electrical switch that could arc. This situation was also observed in Room #3128, and about 40% of the 30 patient rooms in the Pre-Op suite. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.7 and CFR 403.744. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff aa (Director, Plant Engineering).