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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 and maintain wall construction to protect the corridor from non-corridor spaces, including compliance with requirements for spaces that were open to the corridors. This deficiency would affect 1 of the 14 smoke compartments, and had the potential to affect 8 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 8:42 am surveyor #22219 observed in the 3-North smoke compartment on the 3rd floor in the 3203-OR Control Station, that the area had a sliding window that did not positively latch, and would not resist the passage of smoke so the room 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 are open to the corridor. The space did not have a smoke detector and was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff aa (Director, Plant Engineering).

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 enclosures around multi-floor vertical openings, including closers on all doors, and doors with positive-latching hardware. This deficiency would affect 3 of the 14 smoke compartments, and had the potential to affect 31 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 3:15 pm surveyor #22219 observed in the 2-South smoke compartment on the 2nd floor in the 2650-Lab Passage, that the door was in a vertical opening and would not self-close because the closure spring was not attached to the access fire door into a mechanical shaft. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.1.1, and 8.2.5.4, and 8.2.3.2. The 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 11:15 am surveyor #22219 observed in the Bsmt-West smoke compartment on the Basement floor in the B230-Main Electrical Room, that the door in the vertical opening and would not positively self-latch because the inactive door had a manual latch bolt that would not engage without manual operation. The room was open to the bottom of a 3-story electrical riser shaft and was required to be enclosed the same rating as a shaft. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.1.1, and 8.2.5.4, and 8.2.3.2. The 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 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 provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments that had smoke-tight seals at meeting edges. This deficiency occurred in 2 of the 83 smoke compartments, and had the potential to affect 32 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 10:10 am surveyor #14105 observed in the F8/3 smoke compartment on the 3rd floor in the Space #FA001497, that the cross-corridor double smoke 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), 19.3.7.6 and 8.3.4. 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 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 properly enclose hazardous rooms, including rated doors. 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 9:07 am surveyor #22219 observed in the 3-North smoke compartment on the 3rd floor in the 3312-Anesthesia Work Room, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The room was 24' x 20' in size and contained 2 large supply carts full of combustible materials and 40 linear feet of floor to ceiling shelving with combustible materials. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff aa (Director, Plant Engineering).

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 and maintain emergency illumination of exit and directional signs, including provision of exit signs when the egress path was not readily apparent. 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 11:30 am surveyor #12316 observed in the 6-North smoke compartment on the 6th floor in the 6001-Shell Space, that the path of egress was not readily apparent due to lack of an exit sign near the door in the temporary wall between the 6001-Shell Space and the exit stair #3. 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 cc (Building Trade Supervisor).

2. On 10/5/2010 at 10:50 am surveyor #12316 observed in the 4-North smoke compartment on the 4th floor in the 4013-Corridor, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near the south side of the cross-corridor doors near patient room #4133. 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 cc (Building Trade Supervisor).

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 and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The facility did not provide a fire alarm system that had smoke detectors at required locations. This deficiency occurred in 2 of the 83 smoke compartments, and had the potential to affect 18 of the 1000 staff that were working.

FINDINGS INCLUDE:
1. 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 smoke detector was not located in accordance with NFPA 72 requirements. The detector was located less than 3' from a supply air grill and the velocity of air flow exceeded the permitted limit for smoke detectors. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 2-2. 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 9:53 am surveyor #14105 observed in the G5/3 smoke compartment on the 3rd floor in the G5 Core, that the smoke detector was not located in accordance with NFPA 72 requirements. The detector was located less than 3' from a supply air grill and the velocity of air flow exceeded the permitted limit for smoke detectors. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 2-2. 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 provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, that included sprinklers free of obstructions near the ceiling. This deficiency occurred in 4 of the 83 smoke compartments, and had the potential to affect 35 of the 1000 staff that were working.

FINDINGS INCLUDE:
1. On 10/4/2010 at 12:30 pm surveyor #14105 observed in the B6/4 smoke compartment on the 4th floor in the 491-Storage Room, that the sprinkler water discharge was prevented from reaching an unprotected area on the opposite side of an obstructing item. The obstruction included stored items on two shelving units that were less than 18" below the sprinkler deflector. 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 dd (Construction Manager).

2. On 10/6/2010 at 10:43 am surveyor #14105 observed in the F8/3 smoke compartment on the 3rd floor in the Room #332A, that the sprinkler water discharge was prevented from reaching an unprotected area on the opposite side of an obstructing item . The obstruction included stored materials on a shelf. 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 dd (Construction Manager).

3. On 10/6/2010 at 10:45 am surveyor #14105 observed in the F8/3 smoke compartment on the 3rd floor in the 332-Storage, that the sprinkler water discharge was prevented from reaching an unprotected area on the opposite side of the obstructing item . The obstruction included materials stored on shelves. 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 dd (Construction Manager).

4. On 10/7/2010 at 10:40 am surveyor #14105 observed in the D6/3 smoke compartment on the 3rd floor in the Room #316, that a sprinkler was located within 4" of a cabinet. Sprinklers cannot be closer to each other than the minimum required separation distance of 60" or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. 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 2:28 pm surveyor #28616 observed in the F6/1 smoke compartment on the 1st floor in the 20-Storage 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 tall stacks of storage racks.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 ee (Construction Coordinator).

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, 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 ceilings sealed above the sprinklers to collect heat, and intact escutcheon rings. This deficiency occurred in 4 of the 83 smoke compartments, and had the potential to affect 32 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 1:30 pm surveyor #28616 observed in the K4/B smoke compartment on the basement floor in the B49(4)-Shell Space, that there were one or more unsealed holes near the ceiling. The hole(s) included 6 holes in the ceiling where tiles were missing. 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 ee (Construction Coordinator).

2. On 10/5/2010 at 10:13 am surveyor #28616 observed in the D6/2 smoke compartment on the 2nd floor in the 223A-Storage Closet, that there were one or more unsealed holes near the ceiling. The hole(s) included a 9" diameter hole in 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 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 10:15 am surveyor #28616 observed in the D6/2 smoke compartment on the 2nd floor in the 221-Office, that there were one or more unsealed holes near the ceiling. The hole(s) included a 3" diameter hole in 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 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 9:32 am surveyor #28616 observed in the B4/6 smoke compartment on the 6th floor in the 699-Conference Room, that there were one or more unsealed holes near the ceiling. The hole(s) included a suspended ceiling tile that was raised out of its grid and created a gap of 1" on two sides. The sprinkler head was too high and its connection to the tile caused the tile to be too high. 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 ee (Construction Coordinator).

5. On 10/7/2010 at 9:21 am surveyor #14105 observed in the E7/3 smoke compartment on the 3rd floor in the Room #383, that the escutcheon ring on the sprinkler was falling off the sprinkler. 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 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 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 egress paths that were free of obstructions. This deficiency occurred in 5 of the 83 smoke compartments, and had the potential to affect 39 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 12:57 pm surveyor #28616 observed in the E1/2 smoke compartment on the 2nd floor in the 200J-Corridor, that items were stored in the exit access pathway, including a 30"x48"x5' high cart. 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), 19.3.6.1 (exception 6), and 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

2. On 10/5/2010 at 2:30 pm surveyor #28616 observed in the B6/6 smoke compartment on the 6th floor in the 600L-Corridor, that items were stored in the exit access pathway, including blood pressure equipment. 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), 19.3.6.1 (exception 6), and 19.7.5.5. 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 9:47 am surveyor #28616 observed in the F6/2 smoke compartment on the 2nd floor in the 285-Clean Supply Room, that items were stored in the exit access pathway, including 30" wide shelves, which left an egress aisle of approximately 24". 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), 19.2.3.3 (exception 1). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ii (Surgery Supervisor).

4. On 10/6/2010 at 10:42 am surveyor #14105 observed in the F8/3 smoke compartment on the 3rd floor in the 300C-Corridor, that items were stored in the exit access pathway, including miscellaneous mobile items. 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), 19.3.6.1 (exception 6), 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).

5. On 10/6/2010 at 11:08 am surveyor #14105 observed in the E7/3 smoke compartment on the 3rd floor in the 300N-Corridor, that items were stored in the exit access pathway, including various mobile items. There was less than 48" clear unobstructed egress width. 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), 19.3.6.1 (exception 6), 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 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 a code compliant environment that had miscellaneous deficiencies, including a generator with a properly located remote stop, a compliant bulk oxygen installation, and medical gas maintenance. 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 10/4/2010 at 11:00 am surveyor #12316, 22219 observed in the Generator smoke compartment on the 1st floor in the "Hanger" Building, that the emergency generator was not provided with a remote stop switch in the required location. A remote switch was installed in the entry portion of the generator room. There was no wall or door that separated the switch location from the generator. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.2 (d)(t). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr. Mechanic), staff aa (Director, Plant Engineering), and staff bb (Electrical Trade Supervisor).

2. On 10/6/2010 at 11:00 am surveyor #12316 observed in the exterior Oxygen Bulk Tank area, that access to the emergency oxygen inlet valve box was obstructed by 2 bundles of high-voltage cabling from a temporary electrical generator, 1 roll of orange innerduct tubing, and 3 orange colored tubings. Also, the pavement under the oxygen delivery truck parking space was made of petroleum-based asphalt. This observed situation was not compliant with NFPA 50. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

3. 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 performance on the medical vacuum system serving the American Family Children's Hospital. There was no evidence of preventive maintenance being performed on the vacuum inlets during the 3 years that the facility was in operation. 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).

K-130-EGRESS
NFPA 101 Life Safety Code Standard
All means of egress shall be arranged so exits are readily accessible at all times and be in accordance with 7.3, 7.4, 7.5, 7.6, and 7.7.

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide egress paths at all times, including door hardware that operated with a single release motion. This deficiency had the potential to affect all of the 3 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/5/2010 at 1:00 pm surveyor #12187 observed on the 1st floor in the west exterior doors, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead-bolt lock(s) plus a lever handle latch. The north door had both a slide bolt and dead bolt. The south door had a flip-bolt. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

K-130-HAZARDOUS
NFPA 101 Life Safety Code Standard
Hazardous areas are protected by one hour rated construction (with 3/4 hour fire-rated doors), or an approved automatic fire extinguishing system in accordance with 39.3.2 or 8.4.1. When an approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing. 39.3.2

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not enclose hazardous rooms, including sealed wall penetrations. This deficiency had the potential to affect all of the 3 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/5/2010 at 1:20 pm surveyor #12187 observed on the 1st floor in the 108-Mechanical Room, that penetration(s) were not sealed according to approved UL designs. The deficiency included four conduits that penetrated the rated wall. The wall was not constructed to a 1-hour fire resistance rating because the screws were not covered with drywall joint compound and the joints were not fully taped. The room contained a gas-fired duct heater and was not sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

K-130-EGRESS
NFPA 101 Life Safety Code Standard
All means of egress shall be arranged so exits are readily accessible at all times and be in accordance with 7.3, 7.4, 7.5, 7.6, and 7.7.

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide egress paths at all times, including doors that were lockable in the egress path, level walking surface at doorways, hinged doors in the egress path, and an exit discharge path that is safe . This deficiency would affect 4 of the 4 smoke compartments, and had the potential to affect all of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 11:40 am surveyor #12187 observed on the basement floor in the L100N-Corridor, that the door could be locked from the egress side. The path to the exit was not readily apparent and exit signs are needed to identify the path. This observed situation was not compliant with NFPA 101 (2000 edition), 39.2.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff(Construction Coordinator), and staff hh (Building Manager).

2. On 10/4/2010 at 2:45 pm surveyor #12187 observed on the 1st floor in the 100B-South Stair discharge, that the stoop on the outside of the door was 9" below the level of the stair threshold. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

3. On 10/4/2010 at 3:29 pm surveyor #12187 observed on the 2nd floor in the 246-Former Darkroom, that the door was installed in the path of egress access and was not side-hinged. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

4. On 10/4/2010 at 3:45 pm surveyor #12187 observed on the 2nd floor in the north exit discharge, that the exit discharge path did not provide a safe travel route to the public way. The discharge sidewalk was within 10' of windows of the exterior walls and traveled past a trash dumpster. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

K-130-ELECTRICAL
NFPA 101 Life Safety Code Standard
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. 9.1.2

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide and maintain an electrical installation that was compliant with NFPA 70 (National Electrical Code), including an emergency generator with the appropriate alarm. This deficiency would affect all of the 4 smoke compartments, and had the potential to affect all of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/5/2010 at 10:50 am surveyor #12187 observed on the basement floor in the L32-Main Electrical Room, that a derangement alarm for the emergency generator was not provided in a location that could be heard when the building was occupied. An alarm was installed in the Electrical Room but persons were not continuously in the room and the alarm could not be heard at the nearest occupied staff location. This observed situation was not compliant with NFPA 101 (2000 edition), 39.2.9.1; 7.9.2.3; and NFPA 110, 3-5.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

K-130-HAZARDOUS ROOMS
NFPA 101 Life Safety Code Standard
Hazardous areas are protected by one hour rated construction (with 3/4 hour fire-rated doors), or an approved automatic fire extinguishing system in accordance with 39.3.2 or 8.4.1. When an approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing. 39.3.2

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not enclose hazardous rooms, including sealed wall penetrations, rated walls in high hazardous rooms, and closers on all doors. This deficiency would affect 1 of the 4 smoke compartments, and had the potential to affect 12 of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 10:55 am surveyor #12187 observed on the basement floor in the L50A-Elevator Equipment, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had 1 layer of gypsum wallboard on the walls. The room was considered high 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), 39.3.2 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

2. On 10/4/2010 at 11:15 am surveyor #12187 observed on the basement floor in the L47-Pharmacy Storage, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had a portion of gypsum drywall that was not extended to the deck to provide a rated enclosure. The room contained rolls of plastic bubble wrap, 6'x3' cart of plastic and paper supplies, a dozen 18'x18"x18" insulated shipping containers. The room was considered hazardous because it exceeded 100 sq ft and the quantity of combustibles in the space was evaluated to rate as a "high" hazard level, which required both sprinkling and 1-hour enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

3. On 10/4/2010 at 1:17 pm surveyor #12187 observed on the basement floor in the L39- Ophthalmology Medical Records Room, that the door would not self-close because there was no closer on the door. The door was not rated. The wall was not constructed to the full height of the wall. The room was considered hazardous because it exceeded 100 sq ft and the quantity of combustibles in the space was evaluated to rate as a "high" hazard level, which required both sprinkling and 1-hour enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

K-130-MEDICAL GASES
NFPA 101 Life Safety Code Standard
Medical gas storage and storage materials shall be separated in accordance with NFPA 99. NFPA 99

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, including separation of oxygen from combustibles. This deficiency would affect 1 of the 4 smoke compartments, and had the potential to affect 17 of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/4/2010 at 3:35 pm surveyor #12187 observed on the 2nd floor in the Gas Supply Room, that combustible materials were stored too close to the storage site of cylinders of oxygen. Boxes of combustible supplies were stored closer than 5' from 2 nitrous oxide and 5 oxygen E-size cylinders. 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 ff (Construction Coordinator), and staff hh (Building Manager).

K-130-SHAFTS
NFPA 101 Life Safety Code Standard
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. 8.2.5.6, 39.3.1

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings, including ducts in rated walls with fire dampers, an adjacent smoke detector, and rated wall construction. This deficiency would affect all of the 4 smoke compartments, and had the potential to affect all of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/5/2010 at 9:00 am surveyor #12187 observed on the basement floor in the L62-IT Closet, that ventilation duct(s) penetrated the shaft wall and could not be confirmed to have a properly installed fire damper. The duct was a 12" round exhaust air duct. This observed situation was not compliant with NFPA 101 (1999 edition), 3-3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

2. On 10/4/2010 at 11:50 am surveyor #12187 observed on the basement floor in the bottom of duct shaft space, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because concrete was missing and only a layer of gypsum board appeared to cover the floor. A duct that penetrated the floor of the shaft had flanges on its nearest joint that did not form a break-away connection. 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 ff (Construction Coordinator), and staff hh (Building Manager).

3. On 10/4/2010 at 12:00 pm surveyor #12187 observed on the basement floor in the L32-North Stairwell, that the fire barrier door was magnetically held open and did not have a smoke detector within 5' of the door. This situation was also observed in the North Stairwell at the 1st floor. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

4. On 10/4/2010 at 2:19 pm surveyor #12187 observed on the 1st floor in the 100B-Corridor and all around the duct shaft, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because drywall from missing in various locations and joints/screws were not taped and covered with drywall joint compound. Ducts did not have an access panel and it could not be confirmed that fire dampers were installed at the wall-line. This situation was typical of all sides of the shaft on the 1st, 2nd and 3rd floors. 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 ff (Construction Coordinator), and staff hh (Building Manager).

5. On 10/4/2010 at 10:43 am surveyor #12187 observed on the basement floor in the L43-Housekeeping Room, (which shares a wall with the east stairwell) that penetration(s) were not sealed according to approved UL designs. The deficiency included 1-1/2" and 3" sprinkler pipes. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

K-130-SPRINKLER SYSTEM
NFPA 101 Life Safety Code Standard
Where required by the code, spaces shall be protected by an approved, supervised automatic sprinkler system in accordance with section 9.7 Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. NFPA 13

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, that included unobstructed water distribution, sprinklers free of lint, and all rooms sprinkled when full sprinkling is required due to the use of a construction exception. This deficiency would affect all of the 4 smoke compartments, and had the potential to affect all of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/5/2010 at 10:25 am surveyor #12187 observed on the 3rd floor in the 313 and 314-Exam Rooms, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. 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 ff (Construction Coordinator).

2. On 10/4/2010 at 10:30 am surveyor #12187 observed on the 1st floor in the exterior entrance canopy, that the area was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The canopy was constructed of combustible canvas and was required to be sprinkled under NFPA 13 (1999 edition), 5-13.8.1. The facility claimed to be fully sprinkled and took advantage of the code exception for reduced spacing of oxygen storage when the building was sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

3. On 10/4/2010 at 11:30 am surveyor #12187 observed on the basement floor in the L58-Old Dark Room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 6" below the adjacent sprinkler deflector. 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 ff (Construction Coordinator), and staff hh (Building Manager).

4. On 10/4/2010 at 1:17 pm surveyor #12187 observed on the basement floor in the L39- Ophthalmology Medical Records Room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of a shelving unit. Hi-density shelving units were 7' high and the top was located 14" below the sprinkler deflector. 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 ff (Construction Coordinator), and staff hh (Building Manager).

5. On 10/4/2010 at 1:32 pm surveyor #12187 observed on the basement floor in the L19-Eye Clinic Closet, 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 stored items on a shelf that were 13" below the sprinkler. The sprinkler was directly above the shelf. 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 ff (Construction Coordinator), and staff hh (Building Manager).

6. On 10/4/2010 at 1:40 pm surveyor #12187 observed on the basement floor in the L14-Eye Clinic Office, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included wing walls at an alcove space created a shadow. 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 ff (Construction Coordinator), and staff hh (Building Manager).

7. On 10/4/2010 at 1:48 pm surveyor #12187 observed on the 1st floor in the 138-Peds Nurse Station, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. 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 ff (Construction Coordinator), and staff hh (Building Manager).

8. On 10/4/2010 at 3:32 pm surveyor #12187 observed on the 2nd floor in the 279-Closet, that the area was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. No sprinkler was installed in the room. The facility claimed to be fully sprinkled and took advantage of the code exception for reduced spacing of oxygen storage when the building was sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

9. On 10/5/2010 at 9:17 am surveyor #12187 observed on the basement floor in the east side of the building above rooms L53 and L67 that the area above the ceiling was not sprinkler protected. This concealed space contained wood support structures and the top of wood walls. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. No sprinkler was installed in the concealed space. The facility claimed to be fully sprinkled and took advantage of the code exception for reduced spacing of oxygen storage when the building was sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

K-130-VENTILATION SYSTEM
NFPA 101 Life Safety Code Standard
Heating, ventilating, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 39.5.2, 9.2, NFPA 90A.

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A, including air handling units that comply with the code. This deficiency would affect all of the 4 smoke compartments, and had the potential to affect 45 of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/5/2010 at 9:00 am surveyor #12187 observed on the basement floor in the entire area, that the space was not provides with compliant ventilation. It was observed that a pipe made of combustible polyvinyl chloride material was within the return air plenum space above the ceiling. Exposed wood was also in the plenum space. This situation was typical of all areas on the floor space. This observed situation was not compliant with NFPA 101 (2000 edition), 39.5.2, section 9.2, and NFPA 90A (1999 edition). . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

2. On 10/5/2010 at 10:34 am surveyor #12187 observed on the roof that the air handling was not provided with compliant equipment. It was observed that air handling units #1 and #2 each provided 23,000 cubic feet of air and was not equipped with duct smoke detectors on the return ducts at any branch connections to the riser on any floor and at the supply air ducts. The air handlers were not equipped with isolation dampers on the supply and return duct. This observed situation was not compliant with NFPA 101 (2000 edition), 39.5.2, section 9.2, and NFPA 90A (1999 edition). . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

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 and maintain an electrical installation that was compliant with NFPA 70, National Electrical Code, including closed electrical raceways. This deficiency occurred in 4 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 1:55 pm surveyor #14105 observed in the B7/4 smoke compartment on the 4th floor in the 461-Room, that a junction 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 dd (Construction Manager).

2. On 10/4/2010 at 11:15 am surveyor #14105 observed in the B4/5 smoke compartment on the 4th floor in the Core Space, that a junction 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 dd (Construction Manager).

3. On 10/5/2010 at 1:25 pm surveyor #14105 observed in the B4/5 smoke compartment on the 5th floor in the B4/5 (at D4/5), that a open junction 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 dd (Construction Manager).

4. On 10/5/2010 at 11:03 am surveyor #14105 observed in the F4/4 smoke compartment on the 4th floor in the Core, that a 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 dd (Construction Manager).

5. On 10/5/2010 at 11:08 am surveyor #14105 observed in the F4/4 smoke compartment on the 4th floor in the Core (at G4/4), that a knock-out in an 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 dd (Construction Manager).

6. On 10/5/2010 at 8:54 am surveyor #14105 observed in the E5/4 smoke compartment on the 4th floor in the 446-Office, that a 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 dd (Construction Manager).

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).

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 and maintain wall construction to protect the corridor from non-corridor spaces, including compliance with requirements for spaces that were open to the corridors. This deficiency would affect 1 of the 14 smoke compartments, and had the potential to affect 8 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 8:42 am surveyor #22219 observed in the 3-North smoke compartment on the 3rd floor in the 3203-OR Control Station, that the area had a sliding window that did not positively latch, and would not resist the passage of smoke so the room 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 are open to the corridor. The space did not have a smoke detector and was not fully observable from a 24 hour occupied location. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff aa (Director, Plant Engineering).

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 enclosures around multi-floor vertical openings, including closers on all doors, and doors with positive-latching hardware. This deficiency would affect 3 of the 14 smoke compartments, and had the potential to affect 31 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 3:15 pm surveyor #22219 observed in the 2-South smoke compartment on the 2nd floor in the 2650-Lab Passage, that the door was in a vertical opening and would not self-close because the closure spring was not attached to the access fire door into a mechanical shaft. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.1.1, and 8.2.5.4, and 8.2.3.2. The 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 11:15 am surveyor #22219 observed in the Bsmt-West smoke compartment on the Basement floor in the B230-Main Electrical Room, that the door in the vertical opening and would not positively self-latch because the inactive door had a manual latch bolt that would not engage without manual operation. The room was open to the bottom of a 3-story electrical riser shaft and was required to be enclosed the same rating as a shaft. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.1.1, and 8.2.5.4, and 8.2.3.2. The 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 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 provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments that had smoke-tight seals at meeting edges. This deficiency occurred in 2 of the 83 smoke compartments, and had the potential to affect 32 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 10:10 am surveyor #14105 observed in the F8/3 smoke compartment on the 3rd floor in the Space #FA001497, that the cross-corridor double smoke 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), 19.3.7.6 and 8.3.4. 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 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 properly enclose hazardous rooms, including rated doors. 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 9:07 am surveyor #22219 observed in the 3-North smoke compartment on the 3rd floor in the 3312-Anesthesia Work Room, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The room was 24' x 20' in size and contained 2 large supply carts full of combustible materials and 40 linear feet of floor to ceiling shelving with combustible materials. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff aa (Director, Plant Engineering).

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 and maintain emergency illumination of exit and directional signs, including provision of exit signs when the egress path was not readily apparent. 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 11:30 am surveyor #12316 observed in the 6-North smoke compartment on the 6th floor in the 6001-Shell Space, that the path of egress was not readily apparent due to lack of an exit sign near the door in the temporary wall between the 6001-Shell Space and the exit stair #3. 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 cc (Building Trade Supervisor).

2. On 10/5/2010 at 10:50 am surveyor #12316 observed in the 4-North smoke compartment on the 4th floor in the 4013-Corridor, that the path of egress in the corridor was not readily apparent and an exit sign was not provided near the south side of the cross-corridor doors near patient room #4133. 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 cc (Building Trade Supervisor).

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 and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The facility did not provide a fire alarm system that had smoke detectors at required locations. This deficiency occurred in 2 of the 83 smoke compartments, and had the potential to affect 18 of the 1000 staff that were working.

FINDINGS INCLUDE:
1. 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 smoke detector was not located in accordance with NFPA 72 requirements. The detector was located less than 3' from a supply air grill and the velocity of air flow exceeded the permitted limit for smoke detectors. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 2-2. 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 9:53 am surveyor #14105 observed in the G5/3 smoke compartment on the 3rd floor in the G5 Core, that the smoke detector was not located in accordance with NFPA 72 requirements. The detector was located less than 3' from a supply air grill and the velocity of air flow exceeded the permitted limit for smoke detectors. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 2-2. 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 provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, that included sprinklers free of obstructions near the ceiling. This deficiency occurred in 4 of the 83 smoke compartments, and had the potential to affect 35 of the 1000 staff that were working.

FINDINGS INCLUDE:
1. On 10/4/2010 at 12:30 pm surveyor #14105 observed in the B6/4 smoke compartment on the 4th floor in the 491-Storage Room, that the sprinkler water discharge was prevented from reaching an unprotected area on the opposite side of an obstructing item. The obstruction included stored items on two shelving units that were less than 18" below the sprinkler deflector. 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 dd (Construction Manager).

2. On 10/6/2010 at 10:43 am surveyor #14105 observed in the F8/3 smoke compartment on the 3rd floor in the Room #332A, that the sprinkler water discharge was prevented from reaching an unprotected area on the opposite side of an obstructing item . The obstruction included stored materials on a shelf. 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 dd (Construction Manager).

3. On 10/6/2010 at 10:45 am surveyor #14105 observed in the F8/3 smoke compartment on the 3rd floor in the 332-Storage, that the sprinkler water discharge was prevented from reaching an unprotected area on the opposite side of the obstructing item . The obstruction included materials stored on shelves. 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 dd (Construction Manager).

4. On 10/7/2010 at 10:40 am surveyor #14105 observed in the D6/3 smoke compartment on the 3rd floor in the Room #316, that a sprinkler was located within 4" of a cabinet. Sprinklers cannot be closer to each other than the minimum required separation distance of 60" or closer to a wall than 4". This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.3. 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 2:28 pm surveyor #28616 observed in the F6/1 smoke compartment on the 1st floor in the 20-Storage 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 tall stacks of storage racks.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 ee (Construction Coordinator).

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, 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 ceilings sealed above the sprinklers to collect heat, and intact escutcheon rings. This deficiency occurred in 4 of the 83 smoke compartments, and had the potential to affect 32 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 1:30 pm surveyor #28616 observed in the K4/B smoke compartment on the basement floor in the B49(4)-Shell Space, that there were one or more unsealed holes near the ceiling. The hole(s) included 6 holes in the ceiling where tiles were missing. 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 ee (Construction Coordinator).

2. On 10/5/2010 at 10:13 am surveyor #28616 observed in the D6/2 smoke compartment on the 2nd floor in the 223A-Storage Closet, that there were one or more unsealed holes near the ceiling. The hole(s) included a 9" diameter hole in 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 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 10:15 am surveyor #28616 observed in the D6/2 smoke compartment on the 2nd floor in the 221-Office, that there were one or more unsealed holes near the ceiling. The hole(s) included a 3" diameter hole in 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 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 9:32 am surveyor #28616 observed in the B4/6 smoke compartment on the 6th floor in the 699-Conference Room, that there were one or more unsealed holes near the ceiling. The hole(s) included a suspended ceiling tile that was raised out of its grid and created a gap of 1" on two sides. The sprinkler head was too high and its connection to the tile caused the tile to be too high. 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 ee (Construction Coordinator).

5. On 10/7/2010 at 9:21 am surveyor #14105 observed in the E7/3 smoke compartment on the 3rd floor in the Room #383, that the escutcheon ring on the sprinkler was falling off the sprinkler. 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 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 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 egress paths that were free of obstructions. This deficiency occurred in 5 of the 83 smoke compartments, and had the potential to affect 39 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 12:57 pm surveyor #28616 observed in the E1/2 smoke compartment on the 2nd floor in the 200J-Corridor, that items were stored in the exit access pathway, including a 30"x48"x5' high cart. 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), 19.3.6.1 (exception 6), and 19.7.5.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ee (Construction Coordinator).

2. On 10/5/2010 at 2:30 pm surveyor #28616 observed in the B6/6 smoke compartment on the 6th floor in the 600L-Corridor, that items were stored in the exit access pathway, including blood pressure equipment. 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), 19.3.6.1 (exception 6), and 19.7.5.5. 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 9:47 am surveyor #28616 observed in the F6/2 smoke compartment on the 2nd floor in the 285-Clean Supply Room, that items were stored in the exit access pathway, including 30" wide shelves, which left an egress aisle of approximately 24". 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), 19.2.3.3 (exception 1). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff ii (Surgery Supervisor).

4. On 10/6/2010 at 10:42 am surveyor #14105 observed in the F8/3 smoke compartment on the 3rd floor in the 300C-Corridor, that items were stored in the exit access pathway, including miscellaneous mobile items. 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), 19.3.6.1 (exception 6), 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).

5. On 10/6/2010 at 11:08 am surveyor #14105 observed in the E7/3 smoke compartment on the 3rd floor in the 300N-Corridor, that items were stored in the exit access pathway, including various mobile items. There was less than 48" clear unobstructed egress width. 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), 19.3.6.1 (exception 6), 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 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 a code compliant environment that had miscellaneous deficiencies, including a generator with a properly located remote stop, a compliant bulk oxygen installation, and medical gas maintenance. 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 10/4/2010 at 11:00 am surveyor #12316, 22219 observed in the Generator smoke compartment on the 1st floor in the "Hanger" Building, that the emergency generator was not provided with a remote stop switch in the required location. A remote switch was installed in the entry portion of the generator room. There was no wall or door that separated the switch location from the generator. This observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.2 (d)(t). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff gg (Sr. Mechanic), staff aa (Director, Plant Engineering), and staff bb (Electrical Trade Supervisor).

2. On 10/6/2010 at 11:00 am surveyor #12316 observed in the exterior Oxygen Bulk Tank area, that access to the emergency oxygen inlet valve box was obstructed by 2 bundles of high-voltage cabling from a temporary electrical generator, 1 roll of orange innerduct tubing, and 3 orange colored tubings. Also, the pavement under the oxygen delivery truck parking space was made of petroleum-based asphalt. This observed situation was not compliant with NFPA 50. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff cc (Building Trade Supervisor).

3. 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 performance on the medical vacuum system serving the American Family Children's Hospital. There was no evidence of preventive maintenance being performed on the vacuum inlets during the 3 years that the facility was in operation. 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).

K-130-EGRESS
NFPA 101 Life Safety Code Standard
All means of egress shall be arranged so exits are readily accessible at all times and be in accordance with 7.3, 7.4, 7.5, 7.6, and 7.7.

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide egress paths at all times, including door hardware that operated with a single release motion. This deficiency had the potential to affect all of the 3 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/5/2010 at 1:00 pm surveyor #12187 observed on the 1st floor in the west exterior doors, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a dead-bolt lock(s) plus a lever handle latch. The north door had both a slide bolt and dead bolt. The south door had a flip-bolt. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

K-130-HAZARDOUS
NFPA 101 Life Safety Code Standard
Hazardous areas are protected by one hour rated construction (with 3/4 hour fire-rated doors), or an approved automatic fire extinguishing system in accordance with 39.3.2 or 8.4.1. When an approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing. 39.3.2

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not enclose hazardous rooms, including sealed wall penetrations. This deficiency had the potential to affect all of the 3 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/5/2010 at 1:20 pm surveyor #12187 observed on the 1st floor in the 108-Mechanical Room, that penetration(s) were not sealed according to approved UL designs. The deficiency included four conduits that penetrated the rated wall. The wall was not constructed to a 1-hour fire resistance rating because the screws were not covered with drywall joint compound and the joints were not fully taped. The room contained a gas-fired duct heater and was not sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

K-130-EGRESS
NFPA 101 Life Safety Code Standard
All means of egress shall be arranged so exits are readily accessible at all times and be in accordance with 7.3, 7.4, 7.5, 7.6, and 7.7.

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide egress paths at all times, including doors that were lockable in the egress path, level walking surface at doorways, hinged doors in the egress path, and an exit discharge path that is safe . This deficiency would affect 4 of the 4 smoke compartments, and had the potential to affect all of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 11:40 am surveyor #12187 observed on the basement floor in the L100N-Corridor, that the door could be locked from the egress side. The path to the exit was not readily apparent and exit signs are needed to identify the path. This observed situation was not compliant with NFPA 101 (2000 edition), 39.2.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff(Construction Coordinator), and staff hh (Building Manager).

2. On 10/4/2010 at 2:45 pm surveyor #12187 observed on the 1st floor in the 100B-South Stair discharge, that the stoop on the outside of the door was 9" below the level of the stair threshold. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

3. On 10/4/2010 at 3:29 pm surveyor #12187 observed on the 2nd floor in the 246-Former Darkroom, that the door was installed in the path of egress access and was not side-hinged. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

4. On 10/4/2010 at 3:45 pm surveyor #12187 observed on the 2nd floor in the north exit discharge, that the exit discharge path did not provide a safe travel route to the public way. The discharge sidewalk was within 10' of windows of the exterior walls and traveled past a trash dumpster. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

K-130-ELECTRICAL
NFPA 101 Life Safety Code Standard
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. 9.1.2

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide and maintain an electrical installation that was compliant with NFPA 70 (National Electrical Code), including an emergency generator with the appropriate alarm. This deficiency would affect all of the 4 smoke compartments, and had the potential to affect all of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/5/2010 at 10:50 am surveyor #12187 observed on the basement floor in the L32-Main Electrical Room, that a derangement alarm for the emergency generator was not provided in a location that could be heard when the building was occupied. An alarm was installed in the Electrical Room but persons were not continuously in the room and the alarm could not be heard at the nearest occupied staff location. This observed situation was not compliant with NFPA 101 (2000 edition), 39.2.9.1; 7.9.2.3; and NFPA 110, 3-5.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

K-130-HAZARDOUS ROOMS
NFPA 101 Life Safety Code Standard
Hazardous areas are protected by one hour rated construction (with 3/4 hour fire-rated doors), or an approved automatic fire extinguishing system in accordance with 39.3.2 or 8.4.1. When an approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing. 39.3.2

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not enclose hazardous rooms, including sealed wall penetrations, rated walls in high hazardous rooms, and closers on all doors. This deficiency would affect 1 of the 4 smoke compartments, and had the potential to affect 12 of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/4/2010 at 10:55 am surveyor #12187 observed on the basement floor in the L50A-Elevator Equipment, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had 1 layer of gypsum wallboard on the walls. The room was considered high 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), 39.3.2 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

2. On 10/4/2010 at 11:15 am surveyor #12187 observed on the basement floor in the L47-Pharmacy Storage, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall had a portion of gypsum drywall that was not extended to the deck to provide a rated enclosure. The room contained rolls of plastic bubble wrap, 6'x3' cart of plastic and paper supplies, a dozen 18'x18"x18" insulated shipping containers. The room was considered hazardous because it exceeded 100 sq ft and the quantity of combustibles in the space was evaluated to rate as a "high" hazard level, which required both sprinkling and 1-hour enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

3. On 10/4/2010 at 1:17 pm surveyor #12187 observed on the basement floor in the L39- Ophthalmology Medical Records Room, that the door would not self-close because there was no closer on the door. The door was not rated. The wall was not constructed to the full height of the wall. The room was considered hazardous because it exceeded 100 sq ft and the quantity of combustibles in the space was evaluated to rate as a "high" hazard level, which required both sprinkling and 1-hour enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

K-130-MEDICAL GASES
NFPA 101 Life Safety Code Standard
Medical gas storage and storage materials shall be separated in accordance with NFPA 99. NFPA 99

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide the safe storage and use of medical gases, including separation of oxygen from combustibles. This deficiency would affect 1 of the 4 smoke compartments, and had the potential to affect 17 of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
On 10/4/2010 at 3:35 pm surveyor #12187 observed on the 2nd floor in the Gas Supply Room, that combustible materials were stored too close to the storage site of cylinders of oxygen. Boxes of combustible supplies were stored closer than 5' from 2 nitrous oxide and 5 oxygen E-size cylinders. 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 ff (Construction Coordinator), and staff hh (Building Manager).

K-130-SHAFTS
NFPA 101 Life Safety Code Standard
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. 8.2.5.6, 39.3.1

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings, including ducts in rated walls with fire dampers, an adjacent smoke detector, and rated wall construction. This deficiency would affect all of the 4 smoke compartments, and had the potential to affect all of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/5/2010 at 9:00 am surveyor #12187 observed on the basement floor in the L62-IT Closet, that ventilation duct(s) penetrated the shaft wall and could not be confirmed to have a properly installed fire damper. The duct was a 12" round exhaust air duct. This observed situation was not compliant with NFPA 101 (1999 edition), 3-3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

2. On 10/4/2010 at 11:50 am surveyor #12187 observed on the basement floor in the bottom of duct shaft space, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because concrete was missing and only a layer of gypsum board appeared to cover the floor. A duct that penetrated the floor of the shaft had flanges on its nearest joint that did not form a break-away connection. 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 ff (Construction Coordinator), and staff hh (Building Manager).

3. On 10/4/2010 at 12:00 pm surveyor #12187 observed on the basement floor in the L32-North Stairwell, that the fire barrier door was magnetically held open and did not have a smoke detector within 5' of the door. This situation was also observed in the North Stairwell at the 1st floor. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

4. On 10/4/2010 at 2:19 pm surveyor #12187 observed on the 1st floor in the 100B-Corridor and all around the duct shaft, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because drywall from missing in various locations and joints/screws were not taped and covered with drywall joint compound. Ducts did not have an access panel and it could not be confirmed that fire dampers were installed at the wall-line. This situation was typical of all sides of the shaft on the 1st, 2nd and 3rd floors. 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 ff (Construction Coordinator), and staff hh (Building Manager).

5. On 10/4/2010 at 10:43 am surveyor #12187 observed on the basement floor in the L43-Housekeeping Room, (which shares a wall with the east stairwell) that penetration(s) were not sealed according to approved UL designs. The deficiency included 1-1/2" and 3" sprinkler pipes. This observed situation was not compliant with NFPA 101 (2000 edition), 39.3.2 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

K-130-SPRINKLER SYSTEM
NFPA 101 Life Safety Code Standard
Where required by the code, spaces shall be protected by an approved, supervised automatic sprinkler system in accordance with section 9.7 Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. NFPA 13

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, that included unobstructed water distribution, sprinklers free of lint, and all rooms sprinkled when full sprinkling is required due to the use of a construction exception. This deficiency would affect all of the 4 smoke compartments, and had the potential to affect all of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/5/2010 at 10:25 am surveyor #12187 observed on the 3rd floor in the 313 and 314-Exam Rooms, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. 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 ff (Construction Coordinator).

2. On 10/4/2010 at 10:30 am surveyor #12187 observed on the 1st floor in the exterior entrance canopy, that the area was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The canopy was constructed of combustible canvas and was required to be sprinkled under NFPA 13 (1999 edition), 5-13.8.1. The facility claimed to be fully sprinkled and took advantage of the code exception for reduced spacing of oxygen storage when the building was sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

3. On 10/4/2010 at 11:30 am surveyor #12187 observed on the basement floor in the L58-Old Dark Room, that the discharge of sprinkler water was obstructed from reaching an unprotected area on the other side of a surface mounted light fixture. The light fixture was located 6" below the adjacent sprinkler deflector. 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 ff (Construction Coordinator), and staff hh (Building Manager).

4. On 10/4/2010 at 1:17 pm surveyor #12187 observed on the basement floor in the L39- Ophthalmology Medical Records Room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of a shelving unit. Hi-density shelving units were 7' high and the top was located 14" below the sprinkler deflector. 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 ff (Construction Coordinator), and staff hh (Building Manager).

5. On 10/4/2010 at 1:32 pm surveyor #12187 observed on the basement floor in the L19-Eye Clinic Closet, 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 stored items on a shelf that were 13" below the sprinkler. The sprinkler was directly above the shelf. 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 ff (Construction Coordinator), and staff hh (Building Manager).

6. On 10/4/2010 at 1:40 pm surveyor #12187 observed on the basement floor in the L14-Eye Clinic Office, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included wing walls at an alcove space created a shadow. 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 ff (Construction Coordinator), and staff hh (Building Manager).

7. On 10/4/2010 at 1:48 pm surveyor #12187 observed on the 1st floor in the 138-Peds Nurse Station, that a sprinkler was not kept free of lint or other foreign material and maintained to keep the system fully operable as designed. 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 ff (Construction Coordinator), and staff hh (Building Manager).

8. On 10/4/2010 at 3:32 pm surveyor #12187 observed on the 2nd floor in the 279-Closet, that the area was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. No sprinkler was installed in the room. The facility claimed to be fully sprinkled and took advantage of the code exception for reduced spacing of oxygen storage when the building was sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

9. On 10/5/2010 at 9:17 am surveyor #12187 observed on the basement floor in the east side of the building above rooms L53 and L67 that the area above the ceiling was not sprinkler protected. This concealed space contained wood support structures and the top of wood walls. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. No sprinkler was installed in the concealed space. The facility claimed to be fully sprinkled and took advantage of the code exception for reduced spacing of oxygen storage when the building was sprinkled. This observed situation was not compliant with NFPA 101 (2000 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

K-130-VENTILATION SYSTEM
NFPA 101 Life Safety Code Standard
Heating, ventilating, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 39.5.2, 9.2, NFPA 90A.

This standard is not met, as evidenced by:
Surveyor: 12187

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A, including air handling units that comply with the code. This deficiency would affect all of the 4 smoke compartments, and had the potential to affect 45 of the 45 facility-estimated number of outpatients that the building could serve at a peak time, as well as an undeterminal number of staff and visitors.

FINDINGS INCLUDE:
1. On 10/5/2010 at 9:00 am surveyor #12187 observed on the basement floor in the entire area, that the space was not provides with compliant ventilation. It was observed that a pipe made of combustible polyvinyl chloride material was within the return air plenum space above the ceiling. Exposed wood was also in the plenum space. This situation was typical of all areas on the floor space. This observed situation was not compliant with NFPA 101 (2000 edition), 39.5.2, section 9.2, and NFPA 90A (1999 edition). . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator).

2. On 10/5/2010 at 10:34 am surveyor #12187 observed on the roof that the air handling was not provided with compliant equipment. It was observed that air handling units #1 and #2 each provided 23,000 cubic feet of air and was not equipped with duct smoke detectors on the return ducts at any branch connections to the riser on any floor and at the supply air ducts. The air handlers were not equipped with isolation dampers on the supply and return duct. This observed situation was not compliant with NFPA 101 (2000 edition), 39.5.2, section 9.2, and NFPA 90A (1999 edition). . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff ff (Construction Coordinator), and staff hh (Building Manager).

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 and maintain an electrical installation that was compliant with NFPA 70, National Electrical Code, including closed electrical raceways. This deficiency occurred in 4 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 1:55 pm surveyor #14105 observed in the B7/4 smoke compartment on the 4th floor in the 461-Room, that a junction 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 dd (Construction Manager).

2. On 10/4/2010 at 11:15 am surveyor #14105 observed in the B4/5 smoke compartment on the 4th floor in the Core Space, that a junction 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 dd (Construction Manager).

3. On 10/5/2010 at 1:25 pm surveyor #14105 observed in the B4/5 smoke compartment on the 5th floor in the B4/5 (at D4/5), that a open junction 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 dd (Construction Manager).

4. On 10/5/2010 at 11:03 am surveyor #14105 observed in the F4/4 smoke compartment on the 4th floor in the Core, that a 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 dd (Construction Manager).

5. On 10/5/2010 at 11:08 am surveyor #14105 observed in the F4/4 smoke compartment on the 4th floor in the Core (at G4/4), that a knock-out in an 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 dd (Construction Manager).

6. On 10/5/2010 at 8:54 am surveyor #14105 observed in the E5/4 smoke compartment on the 4th floor in the 446-Office, that a 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 dd (Construction Manager).