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Based on observation and staff interview the facility failed to provide a structural framing system with adequate fireproofing material in accordance to NFPA 101 Section 19.1.6.2 and Table 19.1.6.2. This deficient practice could affect the patients in one of twelve smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On July 14th, 2015 at 11:24 am, it was observed that the fireproofing, providing the proper hourly rating for the structural frame, had fallen off the steel in several locations. Three bare spots were found on the east-west steel beam (nearest the north wall) at four and six feet from the east wall of the Chiller room #0-12.

2. On July 14th, 2015 at 11:27 am, it was observed that the fireproofing providing the proper hourly rating for the structural frame had fallen off the steel in numerous locations within the Chiller room #0-12. Also many anchor points for utilities did not have the points of attachment covered with fireproofing.

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

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

Findings include:
1. On July 14th, 2015 at 11:12 am (on the lower level), it was observed that the paired doors into the Corridor from Fold and Press #B15 were not equipped with an astragal at the meeting edge of the doors to resist the passage of smoke.

2. On July 14th, 2015 at 11:17 am (on the lower level), it was observed that the door into the Corridor from Sorting #B12 did not properly latch. The negative pressure within the room was holding the door slightly ajar preventing the door strike from engaging into the frame.

3. On July 14th, 2015 at 2:56 pm (on the second floor), it was observed that the south paired doors from the Med surgery suite into the Corridor #1367 were not provided with an astragal to ensure the smoke tight quality of the corridor.

4. On July 14th, 2015 at 2:56 pm (on the second floor), it was observed that the north paired doors from the Med surgery suite into the Corridor, near #2021, were not provided with an astragal to ensure the smoke tight quality of the corridor.

5. On July 15th, 2015 at 9:07 am, (on the first floor) it was observed that the paired exit access door from the ED suite into the Corridor #1367 was not provided with an astragal to ensure the smoke tight quality of the corridor.

These deficient practices were confirmed by an observation and interview with Staff A (Director of Environmental Services) at the time of discovery.

Based on observation and staff interviews, the facility failed to provide and maintain openings in smoke barriers that resists fire for not less than 20 minutes in accordance to NFPA 101 Section 19.3.7.5. This deficient practice could affect the patients in 2 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On July 14th, 2015 at 10:35am (on the lower level), it was observed that no astragal was installed at the paired doors of the smoke compartment near Construction office #B20.

2. On July 14th, 2015 at 12:45pm (on the first floor), it was observed that no astragal was installed at the paired doors of the smoke compartment near Breakroom #1115.

3. On July 14th, 2015 at 1:15pm (on the first floor), it was observed that no astragal was installed at the paired doors of the smoke compartment near Equipment room #1051.

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

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

Findings include:

1. On July 14th, 2015 at 10:46 am, (lower level) it was observed that the one-hour fire barrier which separated the kitchen from the remainder of the hospital was removed where the barrier crossed the cart washing area. The remainder of the one-hour fire barrier does not protect any area since a complete enclosure is missing.

2. On July 14th, 2015 at 10:50 am, (lower level) it was observed that the one-hour fire barrier which separated the corridor from the kitchen to the north exit was not compliant to code minimum standards. The door at the east end of this corridor was not a rated door, was mounted in a wood framed opening without stops, and had no door closer on the door.

3. On July 14th, 2015 at 2:37 pm, (First floor) it was observed that the 3'-0" door into CT, located within a two-hour smoke barrier, was not labeled to 90 minutes and had no door closer on the door.

4. On July 14th, 2015 at 2:37 pm, (First floor) it was observed that Equipment Room #1132 had changed functions and was now a storage room. The entire enclosure around this room (greater than 100 square feet in area) was not built to a one-hour fire barrier, including the door.

5. On July 15th, 2015 at 9:34 am, (Second floor) it was observed that a 3/4" round electrical conduit in the east and north walls was not fire caulked to a one-hour fire barrier within the Soiled Utility Room #2028.

These deficient practice were confirmed by an observation and interview with Staff A (Director of Environmental Services) at the time of discovery.

Based on observation and staff interviews the facility failed to provide access to an exit at all times as required by Section 19.2.1 and subsection 19.2.2.2.5. This deficient practice could affect the patients in two of the twelve smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On July 15th, 2015 at 9:35 am (on the second level), it was observed that a delayed locking device was installed at two locations in one means of egress, from the patient floor of the hospital toward the northeast exit enclosure. The hospital has an active waiver for this condition.

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

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

Findings include:
1. On July 14, 2015 at 12:23 pm, (lower level) it was observed that the two pairs of sprinkler heads were located closer than 6'-0" to each other within the Purchasing Receiving Office #B8.

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

Based on observation and staff interview the facility failed to provide a structural framing system with adequate fireproofing material in accordance to NFPA 101 Section 19.1.6.2 and Table 19.1.6.2. This deficient practice could affect the patients in one of twelve smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On July 14th, 2015 at 11:24 am, it was observed that the fireproofing, providing the proper hourly rating for the structural frame, had fallen off the steel in several locations. Three bare spots were found on the east-west steel beam (nearest the north wall) at four and six feet from the east wall of the Chiller room #0-12.

2. On July 14th, 2015 at 11:27 am, it was observed that the fireproofing providing the proper hourly rating for the structural frame had fallen off the steel in numerous locations within the Chiller room #0-12. Also many anchor points for utilities did not have the points of attachment covered with fireproofing.

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

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

Findings include:
1. On July 14th, 2015 at 11:12 am (on the lower level), it was observed that the paired doors into the Corridor from Fold and Press #B15 were not equipped with an astragal at the meeting edge of the doors to resist the passage of smoke.

2. On July 14th, 2015 at 11:17 am (on the lower level), it was observed that the door into the Corridor from Sorting #B12 did not properly latch. The negative pressure within the room was holding the door slightly ajar preventing the door strike from engaging into the frame.

3. On July 14th, 2015 at 2:56 pm (on the second floor), it was observed that the south paired doors from the Med surgery suite into the Corridor #1367 were not provided with an astragal to ensure the smoke tight quality of the corridor.

4. On July 14th, 2015 at 2:56 pm (on the second floor), it was observed that the north paired doors from the Med surgery suite into the Corridor, near #2021, were not provided with an astragal to ensure the smoke tight quality of the corridor.

5. On July 15th, 2015 at 9:07 am, (on the first floor) it was observed that the paired exit access door from the ED suite into the Corridor #1367 was not provided with an astragal to ensure the smoke tight quality of the corridor.

These deficient practices were confirmed by an observation and interview with Staff A (Director of Environmental Services) at the time of discovery.

Based on observation and staff interviews, the facility failed to provide and maintain openings in smoke barriers that resists fire for not less than 20 minutes in accordance to NFPA 101 Section 19.3.7.5. This deficient practice could affect the patients in 2 of 4 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On July 14th, 2015 at 10:35am (on the lower level), it was observed that no astragal was installed at the paired doors of the smoke compartment near Construction office #B20.

2. On July 14th, 2015 at 12:45pm (on the first floor), it was observed that no astragal was installed at the paired doors of the smoke compartment near Breakroom #1115.

3. On July 14th, 2015 at 1:15pm (on the first floor), it was observed that no astragal was installed at the paired doors of the smoke compartment near Equipment room #1051.

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

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

Findings include:

1. On July 14th, 2015 at 10:46 am, (lower level) it was observed that the one-hour fire barrier which separated the kitchen from the remainder of the hospital was removed where the barrier crossed the cart washing area. The remainder of the one-hour fire barrier does not protect any area since a complete enclosure is missing.

2. On July 14th, 2015 at 10:50 am, (lower level) it was observed that the one-hour fire barrier which separated the corridor from the kitchen to the north exit was not compliant to code minimum standards. The door at the east end of this corridor was not a rated door, was mounted in a wood framed opening without stops, and had no door closer on the door.

3. On July 14th, 2015 at 2:37 pm, (First floor) it was observed that the 3'-0" door into CT, located within a two-hour smoke barrier, was not labeled to 90 minutes and had no door closer on the door.

4. On July 14th, 2015 at 2:37 pm, (First floor) it was observed that Equipment Room #1132 had changed functions and was now a storage room. The entire enclosure around this room (greater than 100 square feet in area) was not built to a one-hour fire barrier, including the door.

5. On July 15th, 2015 at 9:34 am, (Second floor) it was observed that a 3/4" round electrical conduit in the east and north walls was not fire caulked to a one-hour fire barrier within the Soiled Utility Room #2028.

These deficient practice were confirmed by an observation and interview with Staff A (Director of Environmental Services) at the time of discovery.

Based on observation and staff interviews the facility failed to provide access to an exit at all times as required by Section 19.2.1 and subsection 19.2.2.2.5. This deficient practice could affect the patients in two of the twelve smoke compartments of the facility, as well as an undetermined number of staff and visitors.

Findings include:
1. On July 15th, 2015 at 9:35 am (on the second level), it was observed that a delayed locking device was installed at two locations in one means of egress, from the patient floor of the hospital toward the northeast exit enclosure. The hospital has an active waiver for this condition.

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

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

Findings include:
1. On July 14, 2015 at 12:23 pm, (lower level) it was observed that the two pairs of sprinkler heads were located closer than 6'-0" to each other within the Purchasing Receiving Office #B8.

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