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Based on observation and interview, the facility did not provide a common separation wall with closers on all doors. This deficiency could affect 4 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/08/2012 at 8:24 am surveyor observed on the Level 1 floor in the Corridor 1999P & Separation Barrier from POB, that the separation wall was non-compliant because multiple penetrations by sleeves, ducts & pipes not properly fire-sealed though a 2-hour fire barrier. Observed large holes cut into separation wall and patched with non-compliant GWB assemblies. Screws were not double-mudded within drywall assembly. Entire 2-hour separation barrier needs to be reviewed at Level 1 & Level 2. The adjoining POB is of a different construction type to the hospital. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

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Based on observation and interview, the facility did not provide and maintain the required building construction type with a compliant type of construction, support steel covered with rated fire proofing and sealed floor penetrations. This deficiency could affect 21 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 10:47 am surveyor observed that the building's construction type was not compliant because the stair shaft next to Room 1028G showed 1-hour construction when a shaft in Building Type I (332) is required to be 2-hour fire rating. Also observed in Room 1029A, the construction block was penetrated by 8 holes and one 1 inch cable in the smoke compartment 1-SE-1. This observed situation was not compliant with NFPA 101 (2000 edition), Table 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor)and staff M6 (Maintenance Mechanic).

2. On 08/07/2012 at 2:06 pm surveyor observed on the Level 1 floor in the Cafeteria, that fire proofing was missing from the structural steel at 1-story cafeteria roof. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

3. On 08/08/2012 at 2:48 pm surveyor observed on the Level 1 floor in the Fire Alarm Closet 1731A, that fire proofing was missing from the structural steel at Fire Alarm Closet in Smoke Compartment 1-NW-1 was missing fire protection on steel structural members at several locations caused by attached clamps and past construction in the area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

4. On 08/08/2012 at 4:40 pm surveyor observed on the Level 1 floor in the Corridor near Door 1410, that fire proofing was missing from the structural steel at the floor/ ceiling system above where 8 steel clamps attached to the steel structure and not fire protected. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

5. On 08/08/2012 at 6:16 pm surveyor observed on the Level 1 floor in the Mechanical Room 1082B, that fire proofing was missing from the structural steel at steel joists located at the floor/ roof. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

6. On 8/9/2012 at 9:20 am surveyor observed on the Level 1 floor in the Corridor1595 along smoke compartments wall 1-W-1 & 1-SW-1, that the building's construction type was not compliant for the number of floors of a health care occupancy. The facility was built with wood above the ceiling at this location and does not meet the NFPA 101 (2000 edition), Section 3.3.118 Limited Combustible requirements criteria. The construction is Type I (332), non-combustible, 5-Story Building. This observed situation was not compliant with NFPA 101 (2000 edition), Table 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).


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7. On 08/06/2012 at 1:10 pm surveyor observed on the Level-4 floor in the Shaft RET94, that the building's construction type was not compliant because combustible wood used as support. This observed situation was not compliant with NFPA 101 (2000 edition), Table 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

8. On 08/07/2012 at 8:30 am surveyors observed on the Level-5 floor in the Shaft at the end of equipment room 651, that there were penetrations through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included three 8 inch diameter pneumatic tubes penetrating through floor below were not fire stopped. 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), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

9. On 08/07/2012 at 8:35 am surveyors observed on the Level-5 floor in the Equipment room 561 near end of the room, that fire proofing was missing from the structural steel at roof deck in three places. Sizes of the missing fireproof were 1' x 1', 2' x 1' and 2' x 1'. . This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

10. On 08/07/2012 at 3:47 pm surveyors observed on the Sub-Basement level floor in the Equipment room number SB884, that fire proofing was missing from the structural steel at roof decking . This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

11. On 08/08/2012 at 9:00 am surveyors observed on the Sub-Basement level floor in the Storage room number SB967J, that fire proofing was missing from the structural steel at the hanger for pipe attachments and at the uni-strut attachments to the beams. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

12. On 08/08/2012 at 11:10 am surveyor observed on the Lower level floor in the Electrical sub-station, room number B711, that fire proofing was missing from the structural steel at roof deck. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

13. On 08/08/2012 at 1:30 pm surveyors observed on the Lower Level floor in room B503, that fire proofing was missing from the structural steel at the roof on the far left-hand side corner above fluorescent light bulb storage rack . This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

14. On 08/09/2012 at 10:39 am surveyors observed on the Lower Level floor in room B477, (mech. shaft room to biomed) that fire proofing was missing from the structural steel at ceiling (roof) of the room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

15. On 08/09/2012 at 10:55 am surveyors observed on the Lower Level floor in room B991A, that there were penetrations through the floor that were not fire stopped according to a listed testing agency design standard. The deficiency included 5 holes, 4 inches in diameter and 2 holes 2 inches in diameter. 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), 19.1.6 and 8.2.3.2.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

16. On 08/09/2012 at 2:00 pm surveyors observed on the Lower Level floor in the old boiler room, that the building's construction type was not compliant because there are wooded steps leading to the corridor by the wood shop and transfer switch. This observed situation was not compliant with NFPA 101 (2000 edition), Table 19.1.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

17. On 8/07/2012 at 10:45 am surveyor observed that the 2 hour floor deck was penetrated by a plastic utility pipe of approximately 3 inches in diameter that was not protected with a fire stop collar product. Room 3769 was designated a hazardous room and had an open ceiling to the deck above. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).
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Based on observation, interview, and a review of facility flame spread documents, the facility did not provide corridor finishes with corridor finish with the appropriate rating. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDES:
1. On 08/07/2012 at 2:00 PM surveyors observed on the Sub-Basement level floor in the Corridor near generator area, that the facility could not confirm the corridor had an appropriate rating. Corridors were finished with 3'-6" high painted plywood covering. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

2. On 8/06/2012 at 2:50 pm surveyor observed within the stair 62/3 the floor was a carpeting based material. The facility could not confirm the flooring had the appropriate Class A or Class B rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.1 and 19.3.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).


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Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces with a smoke-tight corridor ceiling in a sprinkled smoke zone, rooms open to the corridor with the required safe-guards, no combustible material storage, smoke detection in spaces that are open to the corridor, and smoke detection in spaces that are open to the corridor. This deficiency could affect 25 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/06/2012 at 11:10 am surveyor observed on the Level-4 floor in the Alcoves in the corridor near room number 4032, 4033 and 4035, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. These alcoves in the corridor were furnished with writing kiosks that had turned on computers and monitors. Similar situations occurred in other places in level-4 of the building. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

2. On 08/06/2012 at 11:45 am surveyor observed on the Level-4 floor in the Corridor wall above ceiling near Smoke barrier door number 461NAFD, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 2' x 1' missing drywall membrane portion above ceiling. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

3. On 08/06/2012 at 12:00 PM surveyor observed on the Level-4 floor in the Reception room number 4056, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

4. On 08/06/2012 at 1:50 PM surveyor observed on the Level-4 floor in the Nurse charting room number 4156B, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. Similar situation observed in the Nurse charting room numbers 4154, 4164,4160A, 4170A, 4111, 4114, 4170B, 4731 and 4168B. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

5. On 08/06/2012 at 2:10 PM surveyor observed on the Level-4 floor in the Reception room number 4771, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

6. On 08/06/2012 at 3:00 PM surveyor observed on the Level-4 floor in the corridor alcove next to patient room number 4101, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. Four patient lifts were stored inside the alcove. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

7. On 08/06/2012 at 1:07 PM surveyor observed on the Level-4 floor in the Nutrition room number 4737, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

8. On 08/09/2012 at 11:50 am surveyors observed on the Lower Level floor in room B55, Pathology Consult room, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space was not fully observable from a 24-hour occupied location as an alternative. The space had a stand alone battery-operated local smoke detector, which is not equivalent to the code required "electrically supervised" automatic smoke detection system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

9. On 08/07/2012 at 11:20 am surveyors observed on the Sub-Basement level floor in the Electrical Communication room number SB57B, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included a 2" x 4" hole in the corridor wall inside the room. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

10. On 08/07/2012 at 11:45 am surveyors observed on the Sub-Basement level floor in the Corridor near the Morgue, that the corridor was used to store a large amount of clean linen and was not separated from the corridor by a compliant wall and door. Storage included 2'-4" wide x 5'-6" deep x 4 ' height bins, 14 bins were full of linen and 3 empty bins. Spaces are permitted to be open to the corridor provided they are not used as a hazardous area, per exception 6 to 19.3.6.1. The quantity of materials within the same smoke compartment was deemed hazardous for storage in a corridor. The amount stored exceeded the amount that would fit in a 50 sq. ft. room, which is the threshold for the quantity deemed hazardous under the code in 19.3.2.1(7). This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 (exception 6) . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

11. On 08/09/2012 at 10:52 am surveyors observed on the Lower Level floor in the B57H, that the area was not separated from the exit egress corridor by wall construction and did not satisfy all of the requirements for an exception for spaces that were open to the corridor. The space did not have a smoke detector, nor was it fully observable from a 24 hour occupied location as an alternative. The receptionist area did not have smoke tight corridor window. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

12. On 8/06/2012 at 1:20 pm surveyor observed that spaces were open to the corridor without protection of a smoke detector and were without reliable staff supervision. Nutrition spaces 5737, 5747, and 5167. Charting spaces 5156A, 5156B, 5164, 5168A, 5168B, 5170A, and 5170B. Observation desks outside patient rooms 5730, 5728, 5722, 5720, 5716, 5714, 5713, 5710, 5707, and 5702. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

13. On 8/06/2012 at 2:43 pm surveyor observed that spaces were open to the corridor without protection of a smoke detector and were without reliable staff supervision. Nutrition spaces 3174 and 3749 were open to the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

14. On 8/07/2012 at 11:45 am surveyor observed that spaces were open to the corridor without protection of a smoke detector and were without reliable staff supervision. End of 2 North near rooms 2317, 2318, 2319, and 2320 has a lounge open to the corridor without detector supervision. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

15. On 8/07/2012 at 10:30 am surveyor observed that corridor walls contained glass panels with ¼ " or greater gaps between the meeting edges. These gaps circumvented the smoke tight integrity of the intended corridor wall. The glass panels spanned approximately 20 linear feet between egress corridor 3795 and classroom 3783. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

16. On 08/08/2012 at 4:52 pm surveyor observed on the Level 1 floor in the X-Ray Film Assembly Room 1954, that the corridor separation construction did not resist the passage of smoke because of one or more unsealed holes. The holes included communication window opening in wall was prevented from closure because of a movable door bell left on counter in path of vertical fire/smoke gate that was tied to the fire detection system. Corridors in sprinkled smoke compartments can have either walls or ceiling with construction that resists the passage of smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

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Based on observation and interview, the facility did not provide corridor separation doors with self-latching inactive doors, and positive-latching hardware. This deficiency could affect 5 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/08/2012 at 3:10 pm surveyor observed on the Level 1 floor in the ED Rooms 1827, 1828, 1829, 1833, & 1834 , that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf were not positive latched the entire door assembly would not remain closed when a force of 5 pounds were applied. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

2. On 08/08/2012 at 3:46 pm surveyor observed on the Level 1 floor in the Radiology Interventional Room #9, 1978A, OR #6 and Ante-Rooms #10 & #12, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

3. On 08/08/2012 at 4:48 pm surveyor observed on the Level 1 floor in the Clean Equipment Room 1961A, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

4. On 8/9/2012 at 1:20 pm surveyor observed on the Lower Level floor in the Room B10, that the inactive door leaf on a pair of corridor doors would not positively self-latch when pushed to a closed position because it had manual latching hardware. The active leaf latched into the inactive leaf. If the inactive leaf were not positive latched the entire door assembly would not remain closed when a force of 5 pounds were applied. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff KK (Behavioral Health Mgr.), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

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FINDINGS INCLUDE:
5. On 08/07/2012 at 11:35 am surveyors observed on the Sub-Basement level floor in the Morgue refrigerator room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. After consulting with maintenance person Staff M2 stated that maintenance person had the key to open or lock the door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

6. On 08/08/2012 at 2:15 PM surveyor observed on the Lower level floor in the Pharmacy room number B112, that the door to the corridor was obstructed by storing storage carts. The door would not release with a push or pull. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

7. On 08/08/2012 at 3:02 PM surveyors observed on the Lower Level floor in the Decontaminating room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

8. On 08/08/2012 at 11:40 am surveyors observed on the Lower Level floor in Room B570G, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

9. On 08/08/2012 at 1:10 PM surveyors observed on the Lower Level floor in room B565N, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

10. On 8/06/2012 at 3:20 pm surveyor observed that suite double doors located within a corridor wall were not provided with a reliable means of keeping the door closed. The suite was located in Smoke Zone 3E / S1. The magnetic locks installed on the doors are not reliable in all situations. The magnetic locks can lose power and will default to an open condition. The doors also did not have latching door hardware. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

11. On 8/07/2012 at 9:05 am surveyor observed that double doors 339 had an gap of ¼ " and had no astragal present. Additionally, these doors did not latch into the adjoining frame, floor, or each other to ensure a reliable egress corridor system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).
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Based on observation and interview, the facility did not provide enclosures around multi-floor vertical openings, rated wall construction, compliant vertical opening, ducts in rated walls with fire dampers, sealed wall penetrations,rated doors, rated wall construction, and ducts in rated walls with fire dampers. This deficiency could affect 20 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.


FINDINGS INCLUDE:
1. On 08/07/2012 at 1:22 pm surveyor observed on the Level 1 floor in the Elevator Doors #163 in smoke compartment 1-SE-1, that the vertical shaft wall was not compliant. The doors to the Elevator Lobby would not close and latch. These were 90 minute fire doors. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

2. On 08/08/2012 at 10:46 am surveyor observed on the Level 1 floor in the Exit Passageway 1789, 2-Story Space at West Entrance & Exit Passageway 1790, that the vertical shaft wall was not compliant. Observed multiple penetrations in 2-hour fire-rated walls at both Exit Passageways above ceilings and at the 2-Story West Entrance. A 2-Story space in a hospital is required to be fire-rated to 2-hours and found the Won-Door separating the Level-1 from Level-2 to be only fire-rated to 1-hour. The Won-Door is non-compliant. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

3. On 08/07/2012 at 7:20 pm surveyor observed on the Lower Level floor in the Stair 23, that the door in the vertical shaft wall could not be verified of having the required rating. This was a shaft on two sides of the stair used for exhaust air and intake air, opening to the outside of the building and we were below grade of at least 12 feet making this a shaft. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

4. On 08/07/2012 at 1:35 pm surveyor observed on the Level 1 floor in the Cafeteria Men's Toilet Room, that penetration(s) in a vertical shaft were not sealed according to approved listed testing agency designs. The deficiency included three penetrations of 1" diameter, 1/2" diameter and 3" x 4" opening in the floor assembly above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

5. On 08/07/2012 at 5:25 pm surveyor observed on the Level 1 floor in the Exit Passageway at Door 124 & Chase within Stair 22, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because the top of wall above door 124 and ceiling was not fire sealed properly to meet a UL approved tested assembly for this application. Stair 22 'chase wall' was not built to a 2-hour fire rating. 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 M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

6. On 8/9/2012 at 6:09 am surveyor observed on the Level 1 floor in the Room 1130D, that penetration(s) in a vertical shaft were not sealed according to approved listed testing agency design. The deficiency included several penetrations in floor of vertical chase within Surgery Department. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities)and staff M5 (Maintenance Supervisor ).

7. On 8/9/2012 at 11:30 am surveyor observed on the Level 2 floor in the Room 2007B, that penetration(s) in a vertical shaft were not sealed according to approved listed testing agency designs. The deficiency included multiple holes in the 2-hour fire-rated shaft that was adjacent to Stairs 72. The metal lath and plaster was removed exposing the tile block and electrical flex cable that were penetrating the wall. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

8. On 8/9/2012 at 1:05 pm surveyor observed on the Lower Level floor in the Room 272, that penetration(s) in a vertical shaft were not sealed according to approved listed testing agency designs. The deficiency included a 4" diameter pipe through the floor not sealed per requirements of the floor assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

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FINDINGS INCLUDE:
3. On 08/06/2012 at 4:00 PM surveyor observed on the Level-4 floor in the Visitor lounge 4766A, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because walls separating the atrium from corridor are not rated. 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

10. On 08/07/2012 at 10:10 am surveyors observed on the Level-5 floor in the Equipment room number 561 , that the shaft enclosure wall was not constructed to have a 2-hour fire resistance rating because the dumbwaiter machine room did not have 2 hour rated enclosure. 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 M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

11. On 08/07/2012 at 11:03 am surveyors observed on the Sub-Basement level floor in the Sanitary chase near room number SB54, that the vertical shaft wall was not compliant. Four foldable metal frame fabric chairs were stored inside the chase and the chase room did not have sprinkler protection. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.4, and 8.2.3.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

12. On 08/07/2012 at 11:16 am surveyors observed on the Sub-Basement level floor in the Elevator equipment room number SB57C, that the shaft enclosure wall was not constructed to have a 2-hour fire resistance rating because because shaft wall above ceiling was 1 hour rated. 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 M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

13. On 08/07/2012 at 2:32 PM surveyors observed on the Sub-Basement level floor in the Mechanical room number SB134, that the shaft enclosure wall was not constructed to have a 2-hour fire resistance rating because 3 pipes were embedded in the 2 hour rated wall. Also in the same location shaft room was used for workshop, plant shop and storage, and was not separated by 2-hour fire barrier from shaft room. 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 M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

14. On 08/07/2012 at 2:50 PM surveyors observed on the Sub-Basement level floor in the Dumbwaiter equipment room number SB123, that the shaft enclosure wall was not constructed to have a 2-hour fire resistance rating because a 2 inch diameter hole in the wall. Also in the same location a 12' x 4' portion of ceiling was made with combustible wood. 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 M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

15. On 08/07/2012 at 2:51 PM surveyors observed on the Sub-Basement level floor in the Dumbwaiter equipment room number SB123, that the vertical shaft wall was not compliant. A cabinet and two cardboard boxes were stored inside the Dumbwaiter equipment room. The observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, and 8.2.5.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

16. On 08/08/2012 at 11:05 am surveyors observed on the Lower Level floor at stair 82, that the shaft enclosure wall was not constructed to have a 2-hour fire resistance rating because when looking into the access panel by door 82LL, the wall to the CU/Education storage room did not have dry wall installed and therefore is not a two rated wall. 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 M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

17. On 08/09/2012 at 9:12 am surveyors observed on the Lower Level floor at stairwell 45, that the shaft enclosure wall was not constructed to have a 1-hour fire resistance rating because exterior windows (which are not rated) were 5 feet from exterior ducts. 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 M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

18. On 08/09/2012 at 10:36 am surveyors observed on the Lower Level floor in room B477 (mech. shaft room to biomed) that one or more air ducts penetrated the shaft enclosure and could not be confirmed to have a properly installed fire damper. The duct was missing a fire damper. This observed situation was not compliant with NFPA 90A (1999 edition), 3-3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

19. On 08/09/2012 at 10:37 am surveyors observed on the Lower Level floor in room B477 (mech. shaft room to biomed) that the shaft enclosure wall was not constructed to have a 2-hour fire resistance rating because the wall had holes in it. 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 M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

20. On 08/09/2012 at 10:38 am surveyors observed on the Lower Level floor in the room B477 (mech. shaft room to biomed) that penetrations in a vertical shaft were not sealed according to approved listed testing agency designs. The deficiency included a 6" PVC pipe and a metal 6" pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

21. On 08/09/2012 at 10:50 am surveyors observed on the Lower Level floor in room B992B, that penetration(s) in a vertical shaft were not sealed according to approved listed testing agency designs. The deficiency included 6 pipes and conduits of various sizes. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

22. On 08/09/2012 at 10:56 am surveyors observed on the Lower Level floor in room B991A, that the shaft enclosure wall was not constructed to have a 2-hour fire resistance rating because clay tile and cinder blocks were missing. 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 M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

23. On 08/09/2012 at 2:08 pm surveyors observed on the Lower Level floor in the room B89 Linen Chute, that one or more air ducts penetrated the shaft enclosure and could not be confirmed to have a properly installed fire damper. There were two holes in the block wall. (4"X 8" & 18"X 24") This observed situation was not compliant with NFPA 90A (1999 edition), 3-3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

24. On 8/06/2012 at 1:45 pm surveyor observed on that the Level 5 vertical shaft enclosing wall assembly could not be verified of having the required rating. Non-fire rated tempered glass windows assemblies enclosed a 2 story space for a lower level winter garden. The window assemblies and adjoining walls did not contain the minimum fire rating for an equivalent vertical shaft. The windows occurred in approximately 80% of the enclosing wall space adjoining room 5769 and corridor 5795. The vertical space was not designed as an atrium and did not follow the provisions of 8.2.5.6. The applicable codes in effect for this 2003 addition required a 2 hour fire rating of the wall to match the supporting floor 2 hour fire rating. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1.1, 8.2.5.4, 8.2.3.2 and 4.6.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).
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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 could affect 1 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/08/2012 at 3:00 PM surveyor observed on the Lower level floor in the Print center B901, that the fire barrier door was magnetically held open and did not have an adjacent smoke detector that was interconnected to the fire alarm system. 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

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Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with observable exit signs, "no-exit" signs at that may be confused as exits, and exit signs when the egress path is not readily apparent. This deficiency could affect 4 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 11:58 am surveyor observed on the Level 1 floor in the Exit Passageway from Stair 63, that the path of egress in the corridor/aisle/passage was not readily apparent and an exit sign was not provided near turn in pathway towards the exit discharge after coming out of the Stair 63 and within the Exit Passageway. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4 Exit Access & 7.10.1.7 Visibility. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

2. On 08/07/2012 at 2:19 pm surveyor observed on the Level 1 floor in the Kitchen & Servery Suite, that the path of egress in the corridor/aisle/passage was not readily apparent and an exit sign was not provided near the hot food production area in the Kitchen towards the Servery and the Servery was missing required exit signs leading to the access door when the vertical gates are closed. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4 Exit Access & 7.10.1.7 Visibility. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

3. On 08/07/2012 at 3:20 pm surveyor observed on the Level 1 floor in the Old Kitchen Loading Dock 1042C, Old Compressor Room 1042A & Kitchen Storage Room 1042B , that the path of egress in the corridor/aisle/passage was not readily apparent and an exit sign was not provided near the required Exit and Exit Discharge. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4 Exit Access & 7.10.1.7 Visibility. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

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FINDINGS INCLUDE:
4. On 08/06/2012 at 10:45 am surveyor observed on the Level-4 floor in the door to room number 4036B, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. The 2' x 3' clear glass in the Lounge room door permit viewing of the exterior from the Corridor and appears to be an exit. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).


5. On 08/07/2012 at 12:05 PM surveyors observed on the Sub-Basement level floor in the Stair number 52, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

6. On 08/07/2012 at 2:30 PM surveyors observed on the Sub-Basement level floor in the Mechanical room number SB134, that an exit sign was obstructed from view. Utility pipes were installed at about 8 feet above the floor in front of exit sign. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

7. On 08/07/2012 at 3:00 PM surveyors observed on the Sub-Basement level floor in the Stair number 12, that the path of travel was likely to be mistaken as an exit and a "NO Exit" sign was not provided. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

8. On 08/09/2012 at 11:49 am surveyors observed on the Lower Level floor in room LL-SE-1, (auditorium area) that the path of egress to the corridor was not readily apparent and an exit sign was not provided. This observed situation was not compliant with NFPA 101 (2000 edition), 7.10.1.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with rated wall construction, and taped joints on rated walls . This deficiency could affect 21 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/08/2012 at 3:58 pm surveyor observed on the Level 1 floor in the Smoke Barrier wall between Smoke Compartments 1-SW-1 & 1-SW-2 outside Female & Male Drs. & Staff Locker Rooms, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because large portions of the upper smoke barrier wall above the ceiling were missing due to large ducts blocking wall construction. This is compromising parts of Radiology, Ultrasound, 1/2 of Surgery, Tissue Storage, Central Soiled Utility, Sterile Storage, Orange Elevator Core, Surgery Waiting and Interventional Radiology #9 areas. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

2. On 08/07/2012 at 7:02 pm surveyor observed on the Level 1 floor in the Smoke Barrier at Door 1212 between Smoke Compartments 1-N-1 & 1-C-1, that the smoke barrier wall was not constructed to a 30-minute fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all listed testing agency designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

3. On 08/08/2012 at 9:26 am surveyor observed on the Level 1 floor in the Hallway 1926 & Room 1097A, that the smoke barrier wall was not constructed to a 30-minute fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all listed testing agency designs for rated walls. Drywall 'patches' were not all anchored to metal studs as required by the testing agency and able to with-stand the hose spray after the fire test. The top-of wall at Room 1097A was not completed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

4. On 08/08/2012 at 2:56 pm surveyor observed on the Level 1 floor in the Smoke barrier walls at corridors of Emergency & Urgent Care Department, that the smoke barrier wall was not constructed to a 30-minute fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all listed testing agency designs for rated walls. Also, opening were found at top-of-wall at several locations along entire smoke barrier between smoke compartments 1-NW-2 & 1-NW-3. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

5. On 08/08/2012 at 5:29 pm surveyor observed on the Level 1 floor in the Smoke Barrier at Room 1676, that the smoke barrier wall was not constructed to a 30-minute fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all listed testing agency designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

6. On 8/9/2012 at 8:02 am surveyor observed on the Level1 floor in the Smoke Barrier wall between smoke compartments 1-C-4 and 1-SW-2, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because it was observed that the top-of-wall was not sealed to the required fire-rating along many stretches of the wall above the ceilings in Surgery. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

7. On 8/9/2012 at 9:53 am surveyor observed on the Level 1 floor in the Corridor 1130A above smoke barrier door(s) 134, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because wall was missing to underside of floor deck above ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

8. On 8/9/2012 at 10:10 am surveyor observed on the Level 1 floor in the Corridor 1999E & PACU 1994 at smoke barrier wall between smoke compartments 1-C-4 & 1-C-3, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because wall was missing above ceiling to underside of floor assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

9. On 8/9/2012 at 11:53 am surveyor observed on the Level 2 floor in the Corridors 2014 & 2008 above smoke barrier corridor door 263, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because it was observed to have a hole above the duct in the smoke barrier. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

10. On 8/9/2012 at 12:55 pm surveyor observed on the Lower Level floor in the Corridor B29A at smoke barrier wall between smoke compartments LL-SE-1 & LL-E-1, that the smoke barrier wall was not constructed to a 30 minute fire resistance rating because of a hole next to a metal pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

11. On 8/9/2012 at 8:13 am surveyor observed on the Level 1 floor in the Smoke Barrier wall above door 116 between smoke compartments 1-WSW-2 and 1-W-2, that the smoke barrier wall was not constructed to a 30-minute fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all listed testing agency designs for rated walls. Sixteen (16) screws were observed not mudded above ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

12. On 8/9/2012 at 9:02 am surveyor observed on the Level 1 floor in the Smoke Barrier wall above ceiling at Room 1645 between smoke compartments 1-W-2 & 1-WSW-2, that the smoke barrier wall was not constructed to a 30-minute fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all listed testing agency designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

13. On 8/9/2012 at 9:58 am surveyor observed on the Level 1 floor in the Corridor 1199C at door 1415, that the smoke barrier wall was not constructed to a 30-minute fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all listed testing agency designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

14. On 8/9/2012 at 10:19 am surveyor observed on the Level 1 floor in the Corridors 1999C & 1985G at smoke compartments 1-C-3 & 1-C-4, that the smoke barrier wall was not constructed to a 30-minute fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all listed testing agency designs for rated walls. this included top-of-wall for a length of 48 inches from the corridor edge. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

15. On 8/9/2012 at 1:15 pm surveyor observed on the Lower Level floor in the separating Corridor wall between smoke compartments LL-SE-1 & LL-SE-2, that the smoke barrier wall was not constructed to a 30-minute fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all listed testing agency designs for rated walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

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FINDINGS INCLUDE:
16. On 08/07/2012 at 11:55 am surveyors observed on the Sub-Basement level floor in the Smoke barrier wall above smoke barrier door number SB99B, that penetration was not sealed according to approved listed testing agency designs. The deficiency included a 1 inch diameter unsealed pipe penetration. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager, staff M4 (Maintenance Mechanic, staff M9(Steamfitter/ Mechanic, and staff M10 (Principal, Pearson Engineering, LLC).
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Based on observation and interview, the facility did not provide and maintain smoke barrier door assemblies that meet code requirements for separation of smoke compartments with smoke-tight seals at meeting edges and doors lacking vision panels. This deficiency could affect 12 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 6:12 pm surveyor observed on the Level 1 floor in the Smoke Barrier Doors 126, that the smoke barrier door was not compliant. The vision panels were blocked by paper material that did not meet the combustibility requirements for these fire rated doors and did not meet the required visibility to see through the doors for person(s) coming at you or standing on the other side in a fire emergency. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 and 8.3.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

2. On 8/9/2012 at 8:05 am surveyor observed on the Level 1 floor in the Smoke Barrier Door 1413 between smoke compartments 1-C-4 and 1-SW-2, that the smoke barrier door(s) would not self-close because the meeting edges of the doors would not allow the doors to close completely to stop smoke. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.6 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

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FINDINGS INCLUDE:
3. On 08/06/2012 at 2:30 PM surveyor observed on the Level-4 floor in the Smoke barrier door number 431 and 432, that the pair of cross-corridor 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2(Manager)and staff M4(Maintenance Mechanic).

4. On 8/06/2012 at 1:50 pm surveyor observed that smoke barrier doors did not contain a door closer to ensure a reliable separation from smoke compartment to neighboring smoke compartment. Doors 5762, 5777, and 5151 did not contain a door closer, yet were located within a facility designated smoke barrier wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

5. On 8/08/2012 at 3:50 pm surveyor observed that smoke barrier doors 224 did not have vision panels. Waukesha Memorial Hospital life safety plans, Level 2, indicate this section of the facility was constructed in 1979. Smoke barrier doors have been required to have vision panels for structures completed on or after October of 1971. This observed situation was not compliant with NFPA 101 (2000 edition), sections 19.3.7.5, 8.3, and 4.6.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

6. On 8/08/2012 at 1:50 pm surveyor observed the meeting edge of a pair of fire rated smoke barrier doors (labeled 231) were covered with a plastic gasket. These gaskets provide draft control to listings UL10C and UL10B per the facility obtained product document from National Guard Products (NGP) dated 5/2011. These gaskets provide draft control yet do not provide the fire rated hardware requirements as an " astragal " under NFPA 80. The plastic gaskets are not tested as an "astragal" by Underwriters Laboratory (UL) and will not maintain the fire rating of the smoke barrier doors and hence these gaskets will prematurely fail due to their low melting point. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M4 (Maintenance Mechanic).

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Based on observation and interview, the facility did not enclose hazardous rooms with doors with positive-latching hardware, a smoke-tight room enclosure (in a sprinkled smoke zone), closer on all doors, fire rated astragals, rated walls in a non-sprinkled hazardous room, taped joints on rated walls, and sealed wall penetrations. This deficiency could affect 27 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 2:11 pm surveyor observed on the Level 1 floor in the Servery Storage Room, that the door would not self-close because it was missing a door closer on the storage room door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

2. On 08/08/2012 at 5:40 pm surveyor observed on the Level 1 floor in the Clean Holding Room 1682, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included several holes of differing sizes caused by penetrations of pipes, cables and ducts. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

3. On 08/08/2012 at 6:08 pm surveyor observed on the Level 1 floor in the Storage Room 1069B, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included 3 sleeves not fire caulked. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

4. On 08/08/2012 at 6:22 pm surveyor observed on the Level 1 floor in the Bagged Waste/ Garbage Room 1069E, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included multiple penetrations by pipes not properly fire-sealed though a 1-hour fire barrier. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

5. On 08/08/2012 at 10:54 am surveyor observed on the Level 1 floor in the Corridor 1789 & Storage Room 1921B, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

6. On 08/07/2012 at 5:10 pm surveyor observed on the Level 1 floor in the Sleep Lab Stock Room 1366A & Pain Management Soiled Utility Room 1425F, that the enclosing wall was not constructed to a 1-hour fire resistance rating because not all of the drywall joints were taped and screws covered with drywall compound as required for all listed testing agency designs for rated walls. The openings around the ducts above the ceiling were not fire caulked for 1-hour fire-rated wall assemblies and screws were not double mudded and seams not taped at several locations. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

7. On 8/9/2012 at 6:45 am surveyor observed on the Level 1 floor in the Great Equipment Storage Room Door 135, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

8. On 8/9/2012 at 6:43 am surveyor observed on the Level 1 floor in the Great Equipment Storage Room 1660, that penetration(s) were not sealed according to approved listed testing agency designs. The deficiency included multiple penetrations in walls and screws were not all mudded. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

9. On 8/9/2012 at 1:01 pm surveyor observed on the Lower Level floor in the Room 272, that penetration(s) were not sealed according to approved listed testing agency designs. The deficiency included a 4" diameter pipe through the wall. The room had an amount of combustibles considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

10. On 8/9/2012 at 1:24 pm surveyor observed on the Lower Level floor in the Room B13, that penetration(s) were not sealed according to approved listed testing agency designs. The deficiency included two 1 inch penetrations above the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

11. On 8/9/2012 at 9:35 am surveyor observed on the Level 1 floor in the Women's Surgery Drs. & Staff Locker Room 1129, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall around the locker room was not built to the required 1-hour construction, including 45-minute fire-rated doors with closers. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

12. On 8/9/2012 at 11:39 am surveyor observed on the Level 2 floor in the Room 2006A & Volunteer Room 2003A at smoke compartment 2-SE-1, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall at storage room 2006A, top-of-wall was not sealed and at room 2003A, had a significant amount of combustibles. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

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FINDINGS INCLUDE:
13. On 08/06/2012 at 11:05 am surveyor observed on the Level-4 floor in the Soiled linen pass thru cabinet door from patient rooms in the corridor side, that the door would not positively self-latch when released. When pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. Additionally these soiled linen spaces did not have sprinkler protection or 1 hour rated enclosure. Also doors to these soiled linen spaces were not equipped with automatic or self closing device. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

14. On 08/06/2012 at 2:00 PM surveyor observed on the Level-4 floor in the Electric Equipment room number 4155, that the door would not self-close because door was not equipped with a automatic or self closing device. The room was considered hazardous because it exceeded 50 sq ft and contained hazardous electrical equipments. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

15. On 08/06/2012 at 2:17 PM surveyor observed on the Level-4 floor in the Electrical equipment room number 4141, that the door would not self-close because the door was not equipped with an automatic or self closing device. The room was considered hazardous because it exceeded 50 sq ft and contained hazardous electrical equipments. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

16. On 08/06/2012 at 3:15 PM surveyor observed on the Level-4 floor in the Electrical closet number 4744, that the door would not self-close because the door was not equipped with an automatic or self closing device. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

17. On 08/06/2012 at 3:30 PM surveyor observed and reviewed records on the Level-4 floor in the Electrical room number 4735, that the door would not self-close because the door was not equipped with an automatic or self closing device. The room was considered hazardous because it exceeded 50 sq ft and contained hazardous electrical equipments. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

18. On 08/08/2012 at 9:55 am surveyor observed and reviewed records on the Sub-Basement level floor in the Boiler room SB146D, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The wall The deficiency included four (4) holes in the rated wall where sign above oxygen tanks was removed. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

19. On 08/08/2012 at 2:40 PM surveyor observed on the Lower level floor in the IT room number B90, that the door would not self-close because the door was not equipped with an automatic or self closing device. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

20. On 08/08/2012 at 3:15 PM surveyor observed on the Lower level floor in the Center for Thoracic care room number B905, that the door would not self-close because the door was not equipped with an automatic or self closing device. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

21. On 08/08/2012 at 3:55 PM surveyor observed on the Lower level floor in the Storage room number B702A, that the door would not self-close because the doors was not equipped with an automatic or self closing device. The double doors also did have astragal and door coordinator. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1 and 8.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

22. On 08/08/2012 at 2:55 PM surveyors observed and reviewed records on the Lower Level floor in the material Management room that the enclosing wall was not constructed to a 1-hour fire resistance rating. The window opening in the wall is protected by a fire shutter. The shutter does not rest on a 1 hour rated wall when closed. In addition, there is not a smoke detector in the corridor to operate the shutter. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

23. On 08/09/2012 at 9:48 am surveyors observed and reviewed records on the Lower Level floor in room B955, Maintenance room, that the enclosing wall was not constructed to a 1-hour fire resistance rating. The room had drywall missing on one face of the wall near the exit door. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

24. On 08/09/2012 at 2:30 PM surveyors observed and reviewed records on the Lower Level floor in the old boiler room, that penetrations were not sealed according to approved listed testing agency designs. The deficiency included four (4) pipes that were not sealed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

25. On 08/07/2012 at 3:45 pm surveyors observed on the Sub-Basement level floor in the Plumbing storage room number SB673, that the hazardous room enclosure was sprinkled, but did not resist the passage of smoke because of one or more unsealed holes. The holes included a 2 inch continuous gap at the top of the wall joint between the wall and the floor. The room was considered hazardous because it exceeded 50 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

26. On 8/06/2012 at 11:30 am surveyor observed the meeting edge of a pair of 90 minute fire rated doors were covered with a gasket. Doors 701 provided a fire separation to the 7th level heliport. These gaskets provide draft control to listings UL10C and UL10B per the facility obtained product document from National Guard Products (NGP) dated 5/2011. These gaskets provide draft control yet do not provide the fire rated hardware requirements as an " astragal " under NFPA 80. The plastic gaskets are not tested as an "astragal" by Underwriters Laboratory (UL) and will not maintain the 90 minute fire rating of these fire doors and hence these gaskets will prematurely fail due to their low melting point. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

27. On 8/06/2012 at 11:35 am surveyor observed a 90 minute fire rated door assembly were the doors do not latch. Doors 701 provided a fire separation to the 7th level heliport and were on an automatic door closer, yet failed to engage a required latch into the frame, neighboring floor, or other door leaf. Fire rated doors are required to latch per NFPA 80. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

28. On 8/06/2012 at 2:45 pm surveyor observed a newly formed hazardous room without the proper enclosure or door assembly. Vacated patient room 3129 was being used to store new furniture and cardboard packing materials. The room enclosure and door assembly were not consistent with a hazardous room configuration. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.7.5 and 8.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).
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Based on observation and interview, the facility did not provide and maintain at least 2 approved and remote exits on each floor and at exit access corridors with two exits from a floor. This deficiency could affect 1 of the 80 compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/07/2012 at 10:00 am surveyors observed on the Level-5 floor in Equipment room number 561, that the floor had a single exit. The story did not meet the exception for mechanical stories [NFPA 101 (2000 edition), 7.12.2] that permit a single exit since the space was also used for storage. The common path of egress travel was about 140 feet, travelled through intervening rooms and was not easily identifiable. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Enginering, LLC).

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Based on observation and interview, the facility did not provide enclosures around exit stairs with closer on all doors, exit stairwells without openings to unoccupied rooms, and stairwell requirements. This deficiency could affect 8 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/06/2012 at 11:40 am surveyor observed on the Level-4 floor in the Stair 61, that an opening in an exit enclosure was from an unoccupied space. Unoccupied Mechanical Penthouse had access through the Stair Enclosure number 61. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

2. On 08/06/2012 at 1:45 PM surveyor observed on the Level-4 floor in the Stair number 33, that the door would not self-close because the medical gas access panel door inside the stair enclosure was not equipped with self or automatic closing device. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

3. On 08/07/2012 at 3:10 PM surveyors observed on the Sub-Basement level floor in the exit passageway for Stair number 13, that an opening in an exit enclosure was from an unoccupied space. Unoccupied Mechanical equipment room and elevator equipment opened in the exit passageway for Stair number 13. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

4. On 08/08/2012 at 8:30 am surveyors observed on the Sub-Basement level floor in the Exit passage of Stair number 13, that the stairwell was not compliant. Two 5 inch diameter electrical pipes running right below ceiling inside the exit passage that do not serve the stair exiting function and have the potential to interfere with its use as an exit. These observed situations were not compliant with NFPA 101 (2000 edition), 8.2.3.2.4.2, 7.1.3.2.1, 7.1, and 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

5. On 08/08/2012 at 10:20 am surveyors observed on the Sub-Basement level floor in the Mezzanine B154, that an opening in an exit enclosure was from an unoccupied space. The deficiency included unoccupied Mezzanine B154 open to the Stair number 46 enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

6. On 08/08/2012 at 11:10 am surveyors observed on the Lower Level floor doors for stair 82 in Education wing, 82LL, that the stairwell doors were not compliant. The stairwell doors were magnetically held open and did not have a local smoke detector tied to the fire alarm system This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

7. On 08/06/2012 at 11:50 am surveyor observed on the Level-4 floor in the Stair number 63, that the stairwell was not compliant. The Radio frequency signal receiver device installed inside the stair enclosure do not serve the stair exiting function and have the potential to interfere with its use as an exit. These observed situations were not compliant with NFPA 101 (2000 edition), 8.2.3.2.4.2, 7.1.3.2.1, 7.1, and 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

8. On 08/07/2012 at 3:10 PM surveyors observed on the Sub-Basement level floor in the exit passageway for Stair number 13, that the stairwell was not compliant. The Radio frequency signal receiver device installed inside the exit passageway do not serve the stair exiting function and have the potential to interfere with its use as an exit. These observed situations were not compliant with NFPA 101 (2000 edition), 8.2.3.2.4.2, 7.1.3.2.1, 7.1, and 7.1.3.2.1(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

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Based on observation and interview, the facility failed to provide and ensure compliant means of egress systems due to locking mechanisms, none uniform door hardware, and none fire rated gasket materials. This deficient practice could affect 10 of 80 smoke compartments of the facility.

FINDINGS INCLUDE:

1. On 8/06/2012 at 3:05 pm surveyor observed that the 3rd level patient and staff level egress doors were operated by lever handle door devices, yet the exit stair doors were operated by outdated knob devices. Exit stair doors 61/3 and 63/3 were operated by knob latch operating devices which is inconsistent to the main floor were all treatment, support, and auxiliary spaces had been upgraded to lever handle door latch operating devices. These knob devices reduced the ease with which staff and operate and release the latch from the egress side during an emergency. This observed situation was not compliant with NFPA 101 sections 8.2.3.2.1, 7.2.1.5.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

2. On 8/06/2012 at 11:15 am surveyor observed that the 6rd level heliport access doors were operated by lever handle door devices, yet a required exit stair door was operated by an outdated knob device. Exit stair door 31/6 was operated by a knob latch operating device which is inconsistent to the main service level were all spaces have been upgraded to lever handle door latch operating devices. This knob device reduces the ease with which staff can operate and release the latch from the egress side during an emergency. This observed situation was not compliant with NFPA 101 sections 8.2.3.2.1 and 7.2.1.5.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

3. On 8/06/2012 at 11:50 am surveyor observed that the exit stair doors contained locking devices that when activated eliminated re-entry onto the patient floors. Exit stairs 101, 102 and 31 had cylinder locksets that prohibited re-entry onto the patient floors. Facility staff stated the locksets were not used, nor necessary for their current operations. Facility staff were asked to test the locks for the capability to be locked, and the keys used by staff readily locked the door(s) in the inoperable mode. Existing life safety features obvious to the public, if not required, shall be either maintained or removed. This observed situation was not compliant with NFPA 101 section 4.6.12.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

4. On 8/08/2012 at 8:45 am surveyor observed the meeting edge of a pair of 90 minute fire rated exit passage doors were covered with a plastic gasket. Doors 1101, 1102, 1108, 1109 and 11014 were using this gasket material attempting to seal door meetings edges that exceeded 1/8 " in width. These gaskets provide draft control to listings UL10C and UL10B per the facility obtained product document from National Guard Products (NGP) dated 5/2011. These gaskets provide draft control yet do not provide the fire rated hardware requirements as an " astragal " under NFPA 80. The plastic gaskets are not tested as an "astragal" by Underwriters Laboratory (UL) and will not maintain the 90 minute fire rating of the exit passage doors and hence these gaskets will prematurely fail due to their low melting point. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.1 and 7.2.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities).

Based on observation and interview, the facility did not provide sufficient exit width capacity for the number of persons in the facility that included proper width of exits. This deficiency could affect 1 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/08/2012 at 11:32 am surveyors observed on the Lower Level floor in the room B630, (Classrooms 'F'&'G'), that the exit width was 10 inches when the top left row of Classroom 'F' was occupied. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.3.1 and 7.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).
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Based on observation and interview, the facility did not provide and maintain the exit access travel distance to exits as with egress paths within the required travel distance . This deficiency could affect 3 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.


FINDINGS INCLUDE:
On 8/9/2012 at 6:53 am surveyor observed on the Level 1 floor in the Suite Area including; OR 15, OR 12, OR 10, OR 16, OR 14, Clean Equipment 1644 & Great Eq. Rm., that a travel distance from the corner of the inside of Electrical Room 1664 & Room 1666 to the closest corridor door exceeded 100'-0". This exceeded the permitted distance of maximum 150' from inside room to exit and 200'-0" if fully-sprinkled. Currently two dissimilar suites are adjacent to each other using a smoke barrier door as a point of exit egress, but the code states you cannot exit from one suite to another suite in the event of a fire. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.6 and 7.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff E (VP Support Services), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

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Based on observation and interview, the facility did not provide egress paths at all times with doors that were unlockable in the egress path, compliant egress path , paths with sufficient headroom, paths that are maintainable in all weather conditions, doors that opened with under 50 pounds of force, and egress without passing through intervening hazardous rooms. This deficiency could affect 28 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 6:52 pm surveyor observed on the Level 1 floor in the Dumb Waiter Alcove off Corridor 1399 N, that the egress path was not compliant. The Alcove width is less than 32 inches. Section 19.2.3.3 Exception No. 1 (States): Aisles, corridors, and or ramps in adjunct areas not intended for treatment, or use of inpatients shall be not less than 44 inches in clear and unobstructed width. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2, 7.2, 7.5 and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

2. On 08/07/2012 at 7:15 pm surveyor observed on the Lower Level floor in the Exit Passageway between Stair 22 & Stair 23 , that the egress path was not compliant. Observed a housekeeping cart in the Exit Passageway between the Stairs. Cart was un-attended for over 30 minutes. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2, 7.2, 7.5 and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

3. On 08/08/2012 at 10:31 am surveyor observed on the Level 1 floor in the Room 1066A, that the door in the path of egress would not open when a force of greater than 51 lbs. pounds was applied, which exceeded the maximum 50 pounds needed to open an existing exit access door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.4.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

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FINDINGS INCLUDE:
4. On 08/06/2012 at 2:18 PM surveyor observed on the Level-4 floor in the Electrical equipment room number 4141, that the door was locked from the egress side. The locking system included a dead bolt. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

5. On 08/06/2012 at 3:09 PM surveyor observed on the Level-4 floor in Stair number 101, that the door was locked from the stair side. Exit doors in this Stair enclosure number 34 can be locked from stair side at all floors that would prevent re-entry to the building. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.3 and 7.2.1.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

6. On 08/06/2012 at 3:20 PM surveyor observed on the Level-4 floor in the Stair number 102, that the door was locked from the stair side. Exit doors in this Stair enclosure number 34 can be locked from stair side at all floors that would prevent re-entry to the building. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.3 and 7.2.1.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

7. On 08/07/2012 at 12:00 PM surveyors observed on the Sub-Basement level floor in the Corridor SB990, that the egress path was not compliant. A morgue lift was stored in the exit access path that obstructed access to exit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

8. On 08/08/2012 at 9:22 am surveyors observed on the Sub-Basement level floor in the Boiler area receiving room, that the door could be blocked from the egress side. A 10 feet wide manual old roll up door was left installed in the old building in the exit access route. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

9. On 08/08/2012 at 9:30 am surveyors observed on the Sub-Basement level floor in the Pipe shop near boiler room, that the door was obstructed from the egress side. A large wet-dry vacuum machine was stored in front of the door blocking the access to the exit access door. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

10. On 08/08/2012 at 10:10 am surveyors observed on the Sub-Basement level floor in the Boiler room, SB146D, that the door was obstructed from the egress side. Access to the exit access door under the mezzanine stair was obstructed by four stored vacuum machine. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

11. On 08/08/2012 at 2:15 PM surveyor observed on the Sub-Basement level floor in room number SB114, that the headroom was 5'-4". A 1' x 1' air duct ran across at about 5'-4" height from the floor right in front of the exit door for stair number 31. This observed situation was not compliant with NFPA 101 (2000 edition), 7.1.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

12. On 08/08/2012 at 1:19 PM surveyors observed on the Lower Level floor in room B565N, that the egress path was not compliant. The corridor did not have 2 exits. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

13. On 08/08/2012 at 11:44 am surveyors observed on the Lower Level floor in room B75G, Healing Gardens, that the exit discharge path did not have a maintainable surface. The path was composed of stone slabs with dirt in between. The surface is unstable and narrow. This observed situation was not compliant with NFPA 101 (2000 edition), 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

14. On 08/08/2012 at 11:45 am surveyors observed on the Lower Level floor in room B75G, Healing Gardens, that the door was locked from the egress side. The latch on the exit (wrought iron) gate did not work. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

15. On 08/08/2012 at 11:47 am surveyors observed on the Lower Level floor in room B75G, Healing Gardens, that the egress path was not compliant. There are building windows (Doctors Lounge) along the exit path. If a fire was located in doctor's lounge, then there would not be a safe path to public way. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.7, and 7.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

16. On 08/08/2012 at 11:25 am surveyors observed on the Lower Level floor in room B654, that an intervening room in the means of egress was hazardous. The projection room exits into a hazardous storage room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

17. On 08/09/2012 at 11:48 am surveyors observed on the Lower Level floor in room LL-SE-1, that the door was locked from the egress side. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

18. On 08/06/2012 at 2:50 pm surveyor observed that exit access doors 3053A, 3100, 2336, 2337, and 2327 were locked from the egress side. The locking system on each door included a dead bolt. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

19. On 08/09/2012 at 3:50 pm surveyor observed on the Lower Level floor in the outpatient behavior health, that the door was locked from the egress side. When the lock was enabled, outpatients and visitors could not exit through the required exit door to the elevator area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.2.4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), staff M2 (Manager) and KK, Manager of Behavior Health.



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Based on observation and interview, the facility did not provide rooms, or patient sleeping suites, larger than 1,000 square feet with at least 2 remote exit access doors with and at least two exits from large suites. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 2:17 pm surveyor observed on the Level 1 floor in the Kitchen & Servery Suite, that the suite of rooms were greater than 2,500 SF and the only exit egress through the Servery were through two existing vertical gates that are closed at off hours without a egress swinging side door. The other egress out of the Servery was through the Kitchen, which is considered hazardous and not allowed. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5 Arrangement of Means of Egress, 19.2.5.1 thru 19.2.5.8 Suite of Rooms, and 7.5.1.2 & 7.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

2. On 08/07/2012 at 3:00 pm surveyor observed on the Level 1 floor in the Old Kitchen Loading Dock 1042C, Old Compressor Room 1042A & Kitchen Storage Room 1042B , that the suite of rooms were greater than 2,500 SF and there was no code compliant exit egress to an exit. The access around the abandoned Elevator to Stairway 62 was less than 36 inches in clear width for a non-patient access route. The loading dock doors were vertical and did not meet the minimum requirements for egress per section 19.2.5. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5 Arrangement of Means of Egress, 19.2.5.1 thru 19.2.5.8 Suite of Rooms, and 7.5.1.2 & 7.2.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide all spaces that can be exited without the use of a key or locked as permitted by the code, such as delayed egress with and the required signage. This deficiency could affect 7 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/06/2012 at 10:50 am surveyor observed on the Level-4 floor in the Stair number 43 door, that a delayed egress lock (DEL) did not did not have the required signage on the door. A deactivated magnetic delayed egress locking system was installed in the stair exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

2. On 08/06/2012 at 11:41 am surveyor observed on the Level-4 floor in the Smoke barrier door number 461NAFD in the corridor, that a delayed egress lock (DEL) did not did not have the required signage on the door. A deactivated magnetic delayed egress locking system were installed in both the smoke barrier doors. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

3. On 08/06/2012 at 11:43 am surveyor observed on the Level-4 floor in the Stair number 61 door, that a delayed egress lock (DEL) did not did not have the required signage on the door. A deactivated magnetic delayed egress locking system was installed in the stair exit door. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

4. On 8/6/2012 at 11:45 am surveyor observed on the 5th floor level that delayed egress lock (DEL) devices did not have the required signage on doors 5103, doors 5104, and on exit stair 102. These door assemblies had magnetic locks interlocked with the facility ' s fire alarm system timed to release locks at 15 seconds, yet the doors lacked any signage informing occupants on how to release the locks in the event of an emergency. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.6.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).


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Based on observation and interview, the facility did not provide and maintain emergency illumination of the interior and exterior means of egress for at least 90 minutes after a power failure. This deficiency occurred in 4 of the 8 smoke compartments of the POB, and had the potential to affect 60 of the 100 staff that were working.

FINDINGS INCLUDE:
1. On 8/6/12 at 11:03 am surveyor #28616 observed in the 2-SC-2 smoke compartment on the 2nd floor in the waiting room, that the path of egress to the public way was not illuminated to at least 1 foot-candle. The battery powered emergency egress light fixture did not function when the test button was depressed. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Property Manager).

2. On 8/6/12 at 11:08 am surveyor #28616 observed in the 2-SC-2 smoke compartment on the 2nd floor in the gym, that the path of egress to the public way was not illuminated to at least 1 foot-candle. The battery powered emergency egress light fixture did not function when the test button was depressed. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Property Manager).

3. On 8/6/12 at 11:14 am surveyor #28616 observed in the 2-SC-2 smoke compartment on the 2nd floor in the dialysis room, that the path of egress to the public way was not illuminated to at least 1 foot-candle. The battery powered emergency egress light fixture did not function when the test button was depressed. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Property Manager).

4. On 8/6/12 at 11:57 am surveyor #28616 observed in the 3-SC smoke compartment on the 3rd floor in the suite corridor, that the path of egress to the public way was not illuminated to at least 1 foot-candle. The battery powered emergency egress light fixture did not function when the test button was depressed. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Property Manager).

5. On 8/6/12 at 11:59 am surveyor #28616 observed in the 4-SC smoke compartment on the 4th floor in the corridor, that the path of egress to the public way was not illuminated to at least 1 foot-candle. The battery powered emergency egress light fixture did not function when the test button was depressed. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Property Manager).

6. On 8/6/12 at 12:02 pm surveyor #28616 observed in the 4-SC smoke compartment on the 4th floor in the corridor, that the path of egress to the public way was not illuminated to at least 1 foot-candle. The battery powered emergency egress light fixture did not function when the test button was depressed. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Property Manager).

7. On 8/6/12 at 12:31 pm surveyor #28616 observed in the 5-SC smoke compartment on the 5th floor in the corridor, that the path of egress to the public way was not illuminated to at least 1 foot-candle. The battery powered emergency egress light fixture did not function when the test button was depressed. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Property Manager).

Based on observation and interview, the facility did not provide and maintain emergency illumination of exit and directional signs with and exit signs that were continuously illuminated. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 1:00 pm surveyors observed on the Sub-Basement level floor in stair number 51, that the exit sign was not continuously illuminated and was not served by the emergency lighting system. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.8 and 7.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

2. On 08/08/2012 at 11:46 am surveyor observed on the Lower Level floor in room B75G, Healing Gardens, that the exit sign was not continuously illuminated and was not served by the emergency lighting system. There was not an exit sign that was lit. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.8 and 7.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).
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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72. The Life Safety Code, section 9.6.1.4, requires approval of the authority having jurisdiction (AHJ) in an existing healthcare facility that is not installed in compliance with NFPA 72. The facility did not provide a fire alarm system with smoke detectors at required locations and the facility did not provide a fire alarm system with alarm power accessible by authorized persons only. This deficiency could affect 80 of the 80 smoke compartments in the hospital building and all levels of the attached POB, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/08/2012 at 10:20 am surveyor observed on the Level 1 floor in the Room off Corridor 1999R, that the smoke detector was not located in accordance with NFPA 72 requirements. The Room was open to the Corridor and no smoke detector was provided within the adjoining open room. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 2-2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

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FINDINGS INCLUDE:
2. On 08/08/2012 at 10:30 am surveyors observed on the Sub-Basement level floor in the Power plant room SB146, that the fire alarm power source was not locked and was accessible to more than the authorized personnel. The access key for the fire alarm panel kept hanging from a pipe next to the fire alarm panel. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.4 and NFPA 72 (1999 edition), 1-5.2.5.2. . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Enginering, LLC), and staff M11 (Safety Officer).

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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 with required testing. This deficiency occurred in 1 of the 1 smoke compartments, and had the potential to affect all of the patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 8/7/12 at 8:00 am surveyor #28616 observed that during a review of facility documents reports were not available to verify that code-required tests of the fire alarm system were conducted. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.7 and NFPA 72 (1999 edition), Chapter 7-5.2.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Property Manager).

Based on a review of maintenance documents, the facility did not inspect and test smoke detectors in accordance with manufacturer's specifications. complete smoke detector sensitivity test records. This deficiency could affect 80 of the 80 smoke compartments in the building and all levels of the attached POB, as well as an undetermined number of staff and visitors.


FINDINGS INCLUDE:
On 08/06/2012 at 1:00 pm surveyor observed that during a review of facility documents the records of smoke detector sensitivity tests did not contain all the required information in the WMH Annual Fire Alarm Report dated February 2, 2012, completed in-house by staff M14 (Electrician) did not have the following elements within the F.A. Report; (1) List each device with location, (2) show acceptable range, (3) show current reading with date, (4) Pass/ Fail Evaluation and (5) when corrected, per 1999 edition NFPA 72, section 7-5.2.2. This observed situation was not compliant with NFPA 101 (2000 edition), 9.6.1.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor).

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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition requirements, with non-sprinkled rooms that met permitted exceptions , sprinklers that were too far from the ceiling, sprinklers free of obstructions near the ceiling, with sprinklers at required exterior locations, matching response sensitivity, water flow free of wall obstructions, unobstructed water distribution and all rooms sprinkled when the code required full sprinkling. This deficiency could affect 30 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 5:30 pm surveyor observed on the Level 1 floor in the Far North Stair 24, that the sprinkler was placed farther than 22" below the ceiling. The sprinkler head was coming out of the side wall in the Stairwell and should have been extended to the ceiling within the Stairwell. The same applies to a dry or wet system per NFPA 13. This situation would delay release of water and does not satisfy designed listing requirements. This observed situation was not compliant with NFPA 13 (1999 edition), 5-5.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

2. On 08/07/2012 at 6:35 pm surveyor observed on the Level 1 floor in the 1422C File Film Storage, that the sprinkler was placed farther than 22" below the ceiling. This situation would delay release of water and does not satisfy designed listing requirements. This observed situation was not compliant with NFPA 13 (1999 edition), 5-5.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

3. On 08/07/2012 at 1:55 pm surveyor observed on the Level 1 floor in the Cafeteria and Servery Areas. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The upper area within the skylight, in the Cafeteria, was missing a sprinkler head and a sprinkler was missing at the Salad Bar and Fryer Area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5, 19.3.5.1, 19.1.6 & 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

4. On 08/07/2012 at 5:16 pm surveyor observed on the Level 1 floor in the Sleep Lab/ EEG Procedure & Reading Rooms 1361, 1363 & 1365. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. These rooms had large & deep built-in cabinets that would hold a considerable amount of combustibles like pillows, linens, sheets, towels, and other combustible products used in changing out the rooms after each patient use. The Wood Cabinets also appeared to penetrate the acoustical ceiling at times, which is also not allowed for a limited combustible facility per 2000 NFPA 101, Section 3.3.118. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5, 19.3.5.1, 19.1.6 & 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

5. On 08/07/2012 at 6:39 pm surveyor observed on the Level 1 floor in the Stress Lab Room 1396C. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The sprinkler head was greater than 12'-5" to the back of the Linen Cabinet within the room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5, 19.3.5.1, 19.1.6 & 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

6. On 08/08/2012 at 9:13 am surveyor observed on the Level 1 floor in the Office Room 1921A. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. Sprinkler coverage missing at one of the cubicles due to blockage by modular cubicle partition is so close to the ceiling. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5, 19.3.5.1, 19.1.6 & 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

7. On 08/08/2012 at 3:02 pm surveyor observed on the Level 1 floor in the ED Arena 1 at Room 1857. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The Emergency Department 'skylight' was greater than 64 square feet in area and higher than 8 vertical feet above the existing ceiling, requiring this space to have a sprinkler at the highest point per NFPA 13 Chapter 5. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5, 19.3.5.1, 19.1.6 & 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

8. On 08/08/2012 at 5:43 pm surveyor observed on the Level 1 floor in the Central Nurses Station of ICU. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. the 'skylight' near the center of the ICU Nurses Station was missing a sprinkler near the top of the skylight. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5, 19.3.5.1, 19.1.6 & 9.7. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

9. On 08/07/2012 at 6:25 pm surveyor observed on the Level 1 floor in the Pain Management Room 1442B, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included Modular Wall Panels closer than 18 inches to the ceiling and blocked the spray pattern to the adjoining cubicle from the sprinkler head. 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 M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

10. On 8/9/2012 at 12:42 pm surveyor observed on the Lower Level floor in the Paint Room B01, that the facility took advantage of a construction exception in the code, which required this space to be sprinkled. The paint exhaust hood was missing a sprinkler head. 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 KK (Behavioral Health Mgr.), staff M2 (Manager of Facilities) and staff M5 (Maintenance Supervisor ).

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FINDINGS INCLUDE:
11. On 08/07/2012 at 11:33 am surveyors observed on the Sub-Basement level floor in the Freezer inside the Food Service storage room number SB56, 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 food storage card board boxes. 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 M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

12. On 08/07/2012 at 1:35 PM surveyors observed on the Sub-Basement level floor in the Generator control room number SB952, that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided. A six inch diameter pipe embedded in the 2-hour rated wall. Also the room was used for 30 KVA battery charger. This observed situation was not compliant with NFPA 13 (1999 edition) Section 5-13.11. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

13. On 08/08/2012 at 9:25 am surveyors observed on the Sub-Basement level floor in the Boiler area receiving room, that the sprinkler was placed farther than 22" below the ceiling. 3 sprinkler heads were installed at distance 24 inches from the ceiling and 1 was installed at 30 inches from the ceiling. This situation would delay release of water and does not satisfy listing requirements. This observed situation was not compliant with NFPA 13 (1999 edition), 5-5.4.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

14. On 08/08/2012 at 12:00 PM surveyor observed on the Lower level floor in the Electrical sub-station room number B708, that the room was not sprinkler protected, although the entire facility was required to be sprinkled to meet a construction exception. The facility did not meet all the requirements of the code to avoid sprinkling the space. The room was enclosed with 2-hour rated construction, but the following was not provided. The room was also used for parking structure lighting inverter UPS. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

15. On 08/08/2012 at 1:45 PM surveyor observed on the Lower level floor in the Information services room number B704A, 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 top of the storage cabinet was 4 inches below the sprinkler deflector. 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

16. On 08/08/2012 at 1:50 PM surveyor observed on the Lower level floor in the PHC library room number B520, 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 top of all book cases were one foot below the sprinkler deflectors. 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

17. On 08/08/2012 at 2:12 PM surveyor observed on the Lower level floor in the Pharmacy room number B112, 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 storage boxes within 1 foot of sprinkler deflector. 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

18. On 08/08/2012 at 3:25 PM surveyors observed on the Lower Level floor in the employee's lounge (electric room inside the women's locker room), that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because the smoke dampers are not installed in the smoke barrier walls. The room was not enclosed in 2 hour walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

19. On 08/08/2012 at 3:27 PM surveyors observed on the Lower Level floor in the employee's lounge (locker room), that items were placed near the ceiling within 18" below the sprinkler deflector that obstructed the discharge of sprinkler water from reaching the other side of the obstruction. The obstruction included the lockers This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

20. On 08/08/2012 at 12:17 PM surveyors observed on the Lower Level floor in room B513, 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 file cabinets located 15" below the sprinklers. In addition, the area is a high hazardous area, requiring a water density of 130 square foot per sprinkler. 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 M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

21. On 08/08/2012 at 12:13 PM surveyors observed on the Lower Level floor in the medical staff library receptionist office's closet, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because the smoke dampers are not installed in the smoke barrier walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

22. On 08/08/2012 at 12:05 PM surveyors observed on the Lower Level floor in the medical staff library 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 shelving that was 10" below the sprinkler head. 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 M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

23. On 08/08/2012 at 11:40 am surveyors observed on the Lower Level floor in Room B570G in coat room , that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because the smoke dampers are not installed in the smoke barrier walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

24. On 08/08/2012 at 11:36 am surveyors observed on the Lower Level floor in room B617,the shower of the men's locker room, that there was no sprinkler or approved alternative suppression measures. The building was required to be fully sprinkled because the smoke dampers are not installed in the smoke barrier walls. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.1 (exception). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

25. On 08/08/2012 at 12:09 PM surveyors observed on the Lower Level floor in the corridor outside of Medical Staff Offices, that sprinkler protection was not provided at the 2 vending machine area. This observed situation was not compliant with NFPA 13 (1999 edition), 5-13.8.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

26. On 08/08/2012 at 1:14 PM surveyors observed on the Lower Level floor in room B565, 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 partitions that were 14 inches below the sprinkler heads. 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 M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

27. On 08/09/2012 at 9:21 am surveyors observed on the Lower Level floor in room B964A (Pharmacy cooler), 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 ceiling lights 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 M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

28. On 08/09/2012 at 9:47 am surveyors observed on the Lower Level floor in room B955, Maintenance 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 ducts and pipes blocked the sprinklers. 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 M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

29. On 08/09/2012 at 12:05 PM surveyors observed on the Lower Level floor in room B83D, Bulk Storage, 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 movable partitions. 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 M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

30. On 08/06/2012 at 10:55 am surveyor observed on the Level-4 floor in the Alcove near room number 4035, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The exceptions that required the space to be sprinkled are reduced rating of the corridor walls and rooms open to the corridor in the building. 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

31. On 08/06/2012 at 11:20 am surveyor observed on the Level-4 floor in the alcove in Medical Supply room number 4043B, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The exceptions that required the space to be sprinkled are reduced rating of the corridor walls and rooms open to the corridor in the building. 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

32. On 08/07/2012 at 11:25 am surveyors observed on the Sub-Basement level floor in the Concealed space access through the Electrical communication room number SB57B, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The exceptions that required the space to be sprinkled are reduced rating of the corridor walls and rooms open to the corridor in the building. 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 M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

33. On 08/07/2012 at 11:50 am surveyors observed on the Sub-Basement level floor in the Corridor SB990, that the space was equipped with both quick response and standard response sprinklers. The sprinkler heads included both blue and red color tubes. This observed situation was not compliant with NFPA 13 (1999 edition), 5-3.1.5.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

34. On 08/07/2012 at 1:10 PM surveyors observed on the Sub-Basement level floor in the Stair number 51, that the sprinkler installation was not compliant. Sprinkler deflector at the bottom of the stair was not aligned parallel to the incline of the stair. The observed situation was not compliant with NFPA 13 (1999 edition) Section 5-5.4.2. 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 M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

35. On 08/07/2012 at 2:25 PM surveyors observed on the Sub-Basement level floor in the Chiller room SB138, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The exceptions that required the space to be sprinkled are reduced rating of the corridor walls and rooms open to the corridor in the building. 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 M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

36. On 08/08/2012 at 10:00 am surveyors observed on the Sub-Basement level floor in Stair number 34, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included Sprinkler deflector at the bottom of the stair was not aligned parallel to the incline of the stair. The observed situation was not compliant with NFPA 13 (1999 edition) Section 5-5.4.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

37. On 08/08/2012 at 1:55 PM surveyor observed on the Lower level floor in the Conference room number B510, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side obstructing item . The obstruction included a continuous projection 1 foot below vertically and 1 foot away horizontally from 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

38. On 08/08/2012 at 2:10 PM surveyor observed on the Lower level floor in the Pharmacy room number B704J, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The exceptions that required the space to be sprinkler are reduced rating of the corridor walls and rooms open to the corridor in the building. 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

39. On 08/08/2012 at 2:45 PM surveyor observed on the Lower level floor in the Closet of IT room number B90, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The exceptions that required the space to be sprinkler are reduced rating of the corridor walls and rooms open to the corridor in the building. 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

40. On 08/08/2012 at 3:50 PM surveyor observed on the Lower level floor in the Electrical closet 946B, that the room was not sprinkler protected. The facility took advantage of a construction exception in the code, which required this space to be sprinkled. The exceptions that required the space to be sprinkler are reduced rating of the corridor walls and rooms open to the corridor in the building. 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

41. On 08/08/2012 at 3:23 PM surveyors observed on the Lower Level floor in the employee's lounge women's locker room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side obstructing item . The obstruction included the toilet stall panel 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 M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

42. On 08/08/2012 at 1:40 PM surveyors observed on the Lower Level floor in room B124, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side obstructing item . The obstruction included a column. 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 M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

43. On 08/08/2012 at 1:24 PM surveyors observed on the Lower Level floor in room B559, infection control Coordinator office, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side obstructing item . The obstruction included a light fixture. 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 M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

44. On 08/08/2012 at 11:35 am surveyors observed on the Lower Level floor in room B617, men's locker room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side obstructing item . The obstruction included the toilet partition. 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 M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

45. On 08/08/2012 at 11:15 am surveyors observed on the Lower Level floor in the Audio Projector room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side obstructing item . The obstruction included a bundle of wires. 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 M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

46. On 08/09/2012 at 9:26 am surveyors observed on the Lower Level floor in room B995B, that the sprinkler installation was not compliant. Sprinklers were missing below ducts that were 4 feet wide. 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 M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

47. On 08/09/2012 at 11:46 am surveyors observed on the Lower Level floor in the lab break room, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side obstructing item . 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 M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Man

Based on observation and interview, the facility did not provide supervision of the control valves on the sprinkler system. The valves were not all supervised. This deficiency could affect 1 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/08/2012 at 9:40 am surveyors observed on the Sub-Basement Level floor in the Fire Pump Room, number SB146H, that the sprinkler control valve was not supervised by the fire alarm system. Paper documentation is required for verification from the Annual Inspection. The deficiency included the over-flow valve at the jockey pump that was not supervised by fire alarm system. This observed situation was not compliant with NFPA 101 (2000 edition), 9.7.2.1 and NFPA 72. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).
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Based on observation, interview, and review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have a complete annual inspection, sprinklers free of lint, sprinklers free of corrosion, sprinkler blockage, intact escutcheon rings, and ceilings sealed above the sprinklers to collect heat. Many areas had the old metal ceilings with holes in them. This deficiency could affect 80 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 9:00 am surveyor observed that during a review of facility documents the 'Annual Sprinkler Inspection' was missing the required Churn for 30 minutes and missing documentation to validate the pump and coupling lube were performed. These were missing in the Annual Report from Total Mechanical Company as part of the Chubb Group of Insurance Companies, Dated May 2, 2012. Referenced code sections are: NFPA 25 (1998), Sections 5-3.3.1 and 5-3.3.2. This observed situation was not compliant with NFPA 25 (998 edition), 2-2. and Table 2-1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor).

2. On 08/07/2012 at 2:09 pm surveyor observed on the Level 1 floor in the Rooms; Cafeteria and Servery, that the blockage would reduce the effectiveness of the spray pattern to control the spread of the fire. The soda dispenser equipment in the Servery only allowed a few inches to the sprinkler above it and the Cafeteria 'fake' skylights were within a few inches of several sprinkler heads. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1 .2 and Table 2-1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

3. On 08/08/2012 at 7:14 pm surveyor observed on the Level 1 floor in the Radiology Room (#6), 1981, that the blockage would reduce the effectiveness of the spray pattern to control the spread of the fire. The overhead gantry of the x-ray equipment can block the sprinkler spray if ceiling mounted movable equipment is 'parked' incorrectly, when not in use. Typically we see side-mounted heads in X-Ray Rooms. This observed situation was not compliant with NFPA 25 (1998 edition), 2-2.1 .2 and Table 2-1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

4. On 08/07/2012 at 1:30 pm surveyor observed on the Level 1 floor in the Cafeteria Women's Toilet Room, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

5. On 08/07/2012 at 6:07 pm surveyor observed on the Level 1 floor in the Room 1424, that the escutcheon ring on the sprinkler was missing. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

6. On 08/08/2012 at 11:45 am surveyor observed on the Level 1 floor in the Waiting Room 1741 at Lab Testing Center, Rooms 1740c+1740B+1706, Emergency Department at smoke compartments 1-NW-2 + 1-NW-3 & Room 1552, that the escutcheon ring on the sprinkler was not tight to ceiling at many locations through-out this portion of the facility. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

7. On 08/08/2012 at 5:50 pm surveyor observed on the Level 1 floor in the Clean Holding Room 1671, that the escutcheon ring on the sprinkler was not tight to ceiling at many locations through-out this portion of the facility. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

8. On 08/07/2012 at 11:27 am surveyor observed on the Level 1 floor in the Rooms 1028F & 1024B, that there was one or more unsealed holes near the ceiling. The hole(s) included an opening around an exhaust vent in Room 1028f and 1/2 inch pipe hole in Room 1024B. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

9. On 08/07/2012 at 1:47 pm surveyor observed on the Level 1 floor in the Rooms; Corridor outside JC 1030C & Cafeteria, that there was one or more unsealed holes near the ceiling. The hole(s) included 1" diameter in corridor, 2 locations of 7-3/4" x 12-1/2" opening in Cafeteria These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

10. On 08/07/2012 at 3:35 pm surveyor observed on the Level 1 floor in the Kitchen Housekeeping Closet 1058, that there was one or more unsealed holes near the ceiling. The hole(s) included three ceiling tiles missing or out within the closet. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

11. On 08/07/2012 at 5:45 pm surveyor #18107 observed on the Level 1 floor in the Smoke Compartments 1-N-1, 1-N-2, 1-C-1, 1-C-2, 1-C-3, 1-S-1, 1-SW-1 & 1-W-1, that there was one or more unsealed holes near the ceiling. The hole(s) included many small holes from the metal pan ceiling throughout the facility and specifically in these smoke compartments in corridors and rooms. These holes would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and M2 (Facilities Manager).


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FINDINGS INCLUDE:
12. On 08/06/2012 at 1:20 PM surveyor observed on the Level-4 floor in the House Keeping room number 4064A, that there was one or more unsealed holes near the ceiling. The holes included two 1 inch diameter holes. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

13. On 08/06/2012 at 1:30 PM surveyor observed on the Level-4 floor in the Linen Chute near Stair Number 43, 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 M2 (Manager) and staff M4 (Maintenance Mechanic).

14. On 08/06/2012 at 2:15 PM surveyor observed on the Level-4 floor in the Charge Nurses room number 4774A, that there was one or more unsealed holes near the ceiling. The hole included a 2' x 2' missing ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

15. On 08/06/2012 at 3:05 PM surveyor observed on the Level-4 floor in the House Keeping room number 4736, that there was one or more unsealed holes near the ceiling. The hole included a missing ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

16. On 08/07/2012 at 8:37 am surveyors observed on the Level-5 floor in the Equipment room number 561, that there was one or more unsealed holes near the ceiling. The holes included a 3 inch diameter hole in the ceiling and a 2 inch diameter unsealed pipe penetration in the ceiling over AHU-2101 control panel. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

17. On 08/07/2012 at 11:31 am surveyors observed on the Sub-Basement level floor in the Freezer inside the Food Service storage room number SB56, 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 M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

18. On 08/08/2012 at 8:45 am surveyors observed on the Sub-Basement level floor in the Corridor near equipment room number SB95, that the sprinkler showed signs of corrosion. The deficiency included 3 rusted and broken escutcheon rings. This observed situation was not compliant with NFPA 25 (998 edition), 2-2.1.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

19. On 08/08/2012 at 9:35 am surveyors observed on the Sub-Basement level floor in the Fire pump room number SB146H, that the sprinkler system maintenance was not compliant. Two large storage cabinets were stored inside the fire pump room. This observed situation was not compliant with NFPA 20 (1999 edition), 2-7.1.1 This observed situation was not compliant with NFPA 25 (1998 edition), 2-2. and Table 2-1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

20. On 08/08/2012 at 11:00 am surveyor observed on the Lower level floor in the Corridor near Stair number 43, that the escutcheon ring on the sprinkler was loose that created 1 1/2 " x 1 " gap. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

21. On 08/08/2012 at 2:30 PM surveyor observed on the Lower level floor in the Corridor near electrical room number B93, that the escutcheon ring on the sprinkler was loose that created gap. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

22. On 08/08/2012 at 2:42 PM surveyor observed on the Lower level floor in IT room number B90, that there was one or more unsealed holes near the ceiling. The hole included a 1' x 6" missing ceiling tile. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

23. On 08/06/2012 at 2:10 pm surveyor observed that the linen chute sprinkler head was covered with a significant build-up of material, dirt and lint. This observed situation was not compliant with NFPA 101 (2000 edition), sections 19.3.5 and 9.7 and NFPA 25 - 1998 edition, Sections 2.2.1.1, 2-4.1.4 and 2-4.1.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).
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Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes with fully visible extinguishers. This deficiency could affect 4 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/08/2012 at 9:10 am surveyors observed on the Sub-Basement level floor in the Storage room number SB967J, that a fire extinguisher was obstructed from view and access by storing hampers around the fire extinguisher. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 edition), 1-6.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

2. On 08/09/2012 at 6:30 am surveyor 18107 observed on the Level 1 floor in the Surgery Department and Day Surgery Department that fire extinguishers were not reviewed monthly. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.6, 9.7.4.1 and NFPA 10 (1998 edition), 1-6.6. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities), staff M2 (Manager of Facilities)and staff M6 (Maintenance Mechanic).

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Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with missing smoke damper, missing fire damper, plenum mechanical rooms free of storage, neutral airflow between the corridor and rooms, and flange & sleeve around fire damper. This deficiency could affect 14 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 3:10 pm surveyor observed on the Level 1 floor in the Old Kitchen Loading Dock 1042C, Old Compressor Room 1042A & Kitchen Storage Room 1042B , that a fire damper was not installed in an air transfer duct that penetrated the rated wall or floor assembly. Observed a duct that penetrated a floor at the loading dock floor and was not fire dampered. The relief exhaust emptied directly onto the exit discharge to a public way. There should have been a 10 feet setback per HVAC Code. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

2. On 08/07/2012 at 3:15 pm surveyor observed on the Level 1 floor in the Old Kitchen Loading Dock 1042C, Old Compressor Room 1042A & Kitchen Storage Room 1042B , that a fire damper was not installed in an air transfer duct that penetrated the rated wall or floor assembly. Observed a air handling unit installed between the kitchen ceiling and old compressor room and the fire-rated access door was missing. Life Safety Plans showed this Fire Barrier wall assembly to be a 2-hour fire-rated wall assembly. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

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FINDINGS INCLUDE:
3. On 08/07/2012 at 8:31 am surveyors observed on the Level-5 floor in the Shaft at the end of equipment room 651, that a fire damper was not installed in an air transfer duct that penetrated the rated wall. Two large air ducts penetrating floor below did not have fire damper. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

4. On 08/07/2012 at 11:15 am surveyors observed on the Sub-Basement level floor in the Elevator equipment room number SB57C, that a fire damper was not installed in an air transfer duct that penetrated the rated wall. Two 8 inch diameter air ducts did not have fire damper. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

5. On 08/07/2012 at 2:34 PM surveyors observed on the Sub-Basement level floor in the Mechanical room number SB134, that a smoke damper was not installed in an air handling machine that has capacity more than 15000 cfm. Air handling Machine number 383-A2 did have a smoke isolation damper. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 2-3.9.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

6. On 08/07/2012 at 2:40 PM surveyors observed on the Sub-Basement level floor in the Mechanical room number SB134, that a fire damper was not installed in an air transfer duct that penetrated the rated wall. Fire damper was missing in 2-hour rated wall. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A (1999 edition), 3-3.1.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

7. On 08/07/2012 at 3:15 PM surveyors observed on the Sub-Basement level floor in the Equipment room 184, that fire damper was installed in the wall without any flange and sleeve and the annular space was filled with intumesce material. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A, (1999 edition) 3-4.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

8. On 08/07/2012 at 3:20 PM surveyors observed on the Sub-Basement level floor in the Electrical room number SB553, that fire damper was installed in the wall without any flange and sleeve and the annular space was filled with intumesce material. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A, (1999 edition) 3-4.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

9. On 08/08/2012 at 10:45 am surveyors observed on the Sub-Basement level floor in the Chiller room next to boiler room., that fire damper was installed in the wall without any flange and sleeve and the annular space was filled with intumesce material. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A, (1999 edition) 3-4.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

10. On 08/08/2012 at 2:00 PM surveyor observed on the Lower level floor in the 4 four fire dampers in the Mechanical equipment room number B506, that fire damper was installed in the wall without any flange and sleeve and the annular space was filled with intumesce material. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A, (1999 edition) 3-4.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

11. On 08/09/2012 at 1:41 PM surveyors observed on the Lower Level floor in the room B38, that fire damper was installed in the wall without any flange and sleeve and the annular space was filled with intumesce material. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 and NFPA 90A, (1999 edition) 3-4.6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

12. On 08/07/2012 at 2:35 PM surveyors observed on the Sub-Basement level floor in the Mechanical room number SB134, that the mechanical room was used as a plenum for air returning to the air handling unit and was used to store plant shop equipment's. Access door to Air handling machine 383-A3SF was kept open. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1 , 9.2 and NFPA 90A, 2-3.10.5.2. . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

13. On 08/08/2012 at 11:37 am surveyors observed on the Lower Level floor in the room B611, physicians relations analyst office,, that airflow between the corridor and this room was not neutral. There was a supply grill, but no return grill. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. . The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

14. On 08/08/2012 at 1:12 PM surveyors observed on the Lower Level floor in the room B565N, medical records, that airflow between the corridor and this room was not neutral. The air was positive to the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

15. On 08/09/2012 at 11:19 am surveyors observed on the Lower Level floor in the room B74C, Lab storage, that airflow between the corridor and this room was not neutral. The room has exhaust only and was negative to the corridor. Nothing stored in the room required the room to be negative. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

16. On 08/09/2012 at 12:00 PM surveyors observed on the Lower Level floor in Room B77, Electrical room, that airflow between the corridor and this room was not neutral. The air was being exhausted from the room. It has no supply air. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

17. On 08/09/2012 at 2:10 PM surveyors observed on the Lower Level floor in the old boiler room, that airflow between the corridor and this room was not neutral. There is exhaust air, but not a source of supply air. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.2.1, section 9.2, and NFPA 90A (1999 edition), 2-3.11.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).
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Based on observation and interview, the facility did not provide a kitchen extinguishing system as required by NFPA 96. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/09/2012 at 2:15 PM surveyors observed on the Lower Level floor in the old boiler room, that the kitchen hood suppression system was not compliant. The wrapped grease duct was not sealed per manufactures instructions where the duct passes through the floor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6, 9.2.3 and NFPA 96. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

2. On 08/07/2012 at 2 PM Surveyor 18107 could not verify the kitchen exhaust ducts were properly wrapped from kitchen hood to exterior of building in fire-rated insulation and meeting all the requirements of NFPA 96 as well as proper slope of horizontal duct above ceiling (pictures required since opening ceiling was not possible during survey and kitchen in 'active' operation). This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.6, 9.2.3 and NFPA 96. The condition was confirmed at the time of follow-up 'record documentation interview' with staff M5 (maintenance Supervisor).
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Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as flammability or sprinkler obstruction with and cubical curtains that permit the designed distribution of sprinkler water. This deficiency could affect 4 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.


FINDINGS INCLUDE:
1. On 08/07/2012 at 5:17 pm surveyor observed on the Level 1 floor in the Room 1365A, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the walk-in shower area. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

2. On 08/08/2012 at 2:32 pm surveyor observed on the Level 1 floor in the Room 1714, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to Emergency Department showers. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

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FINDINGS INCLUDE:
3. On 08/08/2012 at 1:15 PM surveyor observed on the Lower level floor in the Men's locker room number B707, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

4. On 08/08/2012 at 1:20 PM surveyor observed on the Lower level floor in the Women's locker room, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

5. On 08/08/2012 at 3:58 PM surveyor observed on the Lower level floor in the Room number B701Q, that a cubical curtain was installed that did not have a mesh top with 1/2" openings and would restrict the proper flow of sprinkler water to the shower. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.5.5 and NFPA 13 (1999 edition) 5-6.5.2.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes with properly sized storage containers for soiled/trash, and properly sized storage containers for soiled/trash. This deficiency could affect 7 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.


FINDINGS INCLUDE:
1. On 08/08/2012 at 3:36 pm surveyor observed on the Level 1 floor in the Room 1557B, that mobile collection receptacles exceeded the 32 gallon maximum size per 64 square feet of floor space when located inside of a hazardous area. Observed four 32 gal. containers within a 120 square foot room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).
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FINDINGS INCLUDE:
2. On 08/07/2012 at 1:20 PM surveyors observed on the Sub-Basement level floor in the Exit passageway for Stair number 52, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. The deficiency included two large trash receptacles, each one them more than 50 gallon capacity were stored together inside exit passageway. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

3. On 08/07/2012 at 1:15 PM surveyors observed on the Sub-Basement level floor in the Corridor near Smoke barrier door number SB99B, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. The deficiency included three 32 gallon trash cans, ladder, broom, shovel, metal cart stored in the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

4. On 08/08/2012 at 11:35 am surveyor observed on the Lower level floor in the Hold area inside the endoscopy suite, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. Three 14 gallon trash receptacles were stored in close proximity. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

5. On 08/08/2012 at 12:20 PM surveyors observed on the Lower Level floor in room B136, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. A gray soiled bin, 5 feet by 4 foot by 2.5 feet, was located in an alcove blocking the entrance to the linen chute room. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

6. On 08/08/2012 at 11:20 am surveyors observed on the Lower Level floor in the room B669, Auditorium, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. Two 32 gallon trash containers are within 2 feet of each other. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

7. On 08/09/2012 at 11:45 am surveyors observed on the Lower Level floor in the lab break room, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. There are three 25 gallon trash containers next to each other. This observed situation was not compliant with NFPA 101 (2000 edition), 19.7.5.5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).
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Based on observation and interview, the facility did not provide the safe storage and use of medical gases, and proper labeling of cyclinders as required by NFPA 99. This deficiency could affect 3 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/08/2012 at 8:00 am surveyor observed that medical gas piping was not installed according to the requirements of the code and the Annual Report did not show elements within the Annual Report corrected since January and June 2011. The Report was completed by Gary Canter, Tim Connell & Steve Knezic of Med Gas Solutions, Franklin, WI 53132. Items identified in the Annual Report included Zone Valves at OR 11 and NICU. The piping installation was missing directional arrows at most zone valves and some piping above the ceiling at many areas on Level 1 Surgery and Treatment areas. Another Annual Report was produced by Clark Zeit-Inspector, for Medical Technologies Associates, December 19-23, 2011. This report identified the following rooms having leaks with no confirmation the leaks were fixed. The rooms included: 5712, 5720, 5721, 5722, 5727, 4723, 4725, 4727, 4728, 4730, 4731, 4034 & 4035. Zone Valve Box for NICU 3181 & 3184 was in the same room as the outlets, which is not allowed per the 1999 (edition) NFPA 99, section 4-3.1.2.3(b)(d) shutoff valve. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and 1999 (edition) NFPA 99, section 4-3.1.2.3(b)(d) shutoff valve. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

2. On 08/07/2012 at 5:47 pm surveyor observed on the Level 1 floor in the Room 1380, that cylinders of medical gas in storage were not secured to keep them from falling by type or by full, partially full or empty. The following 'H' cylinders were grouped together (1-Helium +1-Nitrogen+1-combination tank of Helium/Oxygen/Nitrogen. They were anchored to a 'wood board' that is not allowed per NFPA 99. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chapter 5. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).
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FINDINGS INCLUDE:
3. On 08/08/2012 at 9:45 am surveyors observed on the Sub-Basement level floor in the Medical gas room number SB146J, that cylinders were not labeled or mislabeled. 12 " G" size empty oxygen cylinder was labeled as full. This observed situation was not compliant with NFPA 99 (1999 edition), 4-3.5.2.2(a) & 4-5.2.2(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

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Based on observation and interview, the facility did not provide and maintain combustibles at least 50 feet away from a 1000 gallon or greater liquid oxygen tank, 25 feet away from 1000 gallon tank or less liquid oxygen, proper labeling of the med gas pipes. This deficiency could affect 6 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.
Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with and . This deficiency could affect 5 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/8/2012 at 1:07 PM surveyors observed the bulk oxygen tank near the old Kitchen Loading Dock, that combustibles like 'grease canisters' were being stored within 50 feet of the Oxygen Tank, greater than 1000 gallons. Items besides grease canisters include trees, shrubs and plastic fencing. Surveyor 18107 observed many contractor vehicles are often parked within 10'-0" of the Oxygen Farm. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.4 and NFPA 99 section 4-3.1.1.2(a) 10 b. The condition was confirmed at the time of discovery by concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

2. On 8/07/2012 at 8:45 am surveyor observed in the Neonatal Intensive Care Unit (NICU), that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the medical gas shut-off valves located in the same room as the supply outlets. Zone valve box ZVB-3-3-7 was located in the same room serving patient spaces 3181 and 3184. These observed situations are not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chap 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

3. On 8/07/2012 at 9:30 am surveyor observed that medical gas zone valve boxes were abandoned yet still obvious and accessible via public egress corridors. Zone valve boxes ZVB-3-3-5 and ZVB-5-2-1 were labeled by the facility as " Not in Service" . Existing life safety features obvious to the public, if not required, shall be either maintained or removed. This observed situation was not compliant with NFPA 101 section 4.6.12.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).
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18107

FINDINGS INCLUDE:
4. On 08/07/2012 at 6:48 pm surveyor observed on the Level 1 floor in the Corridor 1399 N, that the Medical Gas 'shut-off' piping did not show gas flow direction. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chapter 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

5. On 08/08/2012 at 9:07 am surveyor observed on the Level 1 floor in the Neuroscience Hallway 1927, that medical gas piping not identified with proper direction of gas flow at Rooms 1910-1913, 1915-1917, 1919 & 1920. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chapter 4. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide interior walls and partitions made of noncombustible or limited-combustible materials with and non-combustible wall materials. This deficiency could affect 4 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 11:23 am surveyor observed that a wall or ceiling was made with combustible materials, which is not permitted in 'non-combustible' types of building construction. The wall or ceiling was constructed with wood members above the ceiling that was not protected by the sprinkler system and the wood could not meet NFPA 259 requirements per 2000 NFPA 101, section 3.3.118 Limited Combustibility. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

2. On 08/08/2012 at 9:29 am surveyor observed on the Level 1 floor in the Hallway 1926, that a wall or ceiling was made with combustible materials, which is not permitted in 'non-combustible' types of building construction. The wall or ceiling was constructed with wood members above the ceiling that was not protected by the sprinkler system and the wood could not meet NFPA 259 requirements per 2000 NFPA 101, section 3.3.118 Limited Combustibility. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).
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Based on observation and interview, the facility did not provide a code compliant environment with miscellaneous deficiencies, did not meet limited combustibility requirements, did not provide a code compliant environment with two exit access from a room or suite of rooms, and did not provide suite travel distance under the required limits. This deficiency could affect 9 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 2:45 pm surveyor observed on the Level 1 floor in the Dishwashing Room 1036, Kitchen 1040 & Servery 1041, that the air was not balanced and documentation was not provided to show the entire Kitchen, Serving and Cafeteria were balanced to the adjoining East-West Corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 and installed per NFPA 90A & B (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

2. On 08/08/2012 at 12:00 pm surveyor observed on the Level 1 floor in the Lab Testing Center, that the Lab Testing Center (LTC) is open to the 2-Story space and all areas are not easily visible from all areas within a 2-Story space. The 2-Story Space does not meet Atrium requirements since there is no 'smoke evacuation system' present. The LTC does not meet normal corridor access requirements since at least one area is exposed to the 2-Story Space (shaft), not allowed to be a Exit unless it meets Atrium requirements. The Lab Testing Center should be separated from the 2-Story Space by 2-hour fire-rated construction. Currently perimeter glass panels with 1/4 inch vertical openings are exposing the LTC to the 2-Story Space. This situation was shared with the entire Executive Hospital Administration and staff M1 (Director of Facilities). This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 and installed per NFPA 90A & B (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

3. On 08/08/2012 at 2:18 pm surveyor observed on the Level 1 floor in the Exit Passageway 1793 from Stairs 101 + Stairs 31 & Stairs 33, that the heating ventilation and air conditioning for this space is required to be independent from other areas of the hospital per references in the State Licensing Code (DHS-124) and State (Safety & Professional Services) Commercial Building Code. The air is not balance between adjoining Smoke Compartments, Exit Passageway and the 2-Story Space based on air rushing past us at the fire-rated doors separating these spaces and not having seen the most recent HVAC Balance Report for these areas. The 2 hot water heating cabinets near the exit discharge of the Exit Passageway project out into the corridor greater than 4 inches creating the potential of injury and not meeting the ADA Accessibility and NFPA 101 Life Safety Code minimum requirements. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 and installed per NFPA 90A & B (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

4. On 08/08/2012 at 2:53 pm surveyor observed on the Level 1 floor in the Radiology West Waiting Room 1801, that the air within the Radiology Waiting Room was stagnant to the feel. Per 2010 Guidelines for Design and Construction of Health Care Facilities by FGI, Radiology Waiting Rooms are required to have 10 air changes per hour per Table 7-1. Documentation was not provided to this Surveyor, prior to exiting the facility, that this requirement was met. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 and installed per NFPA 90A & B (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

5. On 08/08/2012 at 4:35 pm surveyor observed on the Level 1 floor in the Biohazard Waste Room 1985H, that the Biohazard Waste Room 1985H was not properly balanced per NFPA 99, Section 5-4.3.4 and a Annual Inspection and Testing record was not kept on this Exhaust System because noxious odors were present while standing in the room. Patients could be present outside the room effecting patients in the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 and installed per NFPA 90A & B (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

6. On 08/07/2012 at 1:53 pm surveyor observed on the Level 1 floor in the Cafeteria, that Any alteration or renovation shall meet, as nearly as practicable, the requirements for new construction. If the alteration, renovation, or modernization adversely impacts required life safety features, additional upgrading shall be required. Wood above non-sprinkled ceiling areas must be removed or encapsulated with approved fire protective materials. THE 2000 NFPA 101 requires hospitals and health care facilities to be built to the minimum 'definition' of Section 3.3.118 for Limited Combustibility. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.7 and Section 3.3.118. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

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29942

FINDINGS INCLUDE:
7. On 08/08/2012 at 11:30 am surveyor observed on the Lower Level floor in the Endoscopy Suite, that the travel distance of 100 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

8. On 08/08/2012 at 3:30 PM surveyor observed on the Lower Level floor in the Room number B910, that the Suite of rooms did not have two legal exit access because one of the exit access doors did not have exit direction and sign. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

9. On 08/08/2012 at 11:38 am surveyors observed on the Lower Level floor in the room B626B, that the travel distance of 69 feet through (2) intervening rooms exceeded the maximum of 50 feet in a non-sleeping suite. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.5.8. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

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Based on observation and interview, the facility did not provide a code compliant environment with compliant fume hoods. This deficiency could affect 2 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/07/2012 at 6:58 pm surveyor observed on the Level 1 floor in the Linen Chute Room 1314, that the Linen Chute Room 1314 was not properly balanced per NFPA 99, Section 5-4.3.4 and a Annual Inspection and Testing Record was not kept on this Exhaust Hood. This observed situation was not compliant with NFPA 101 (2000 edition), Sections 19.3.2.1, 19.3.2.2, and NFPA 99 (1999 edition), Sections 5-4.2.2, 5-4.3.1, 5-4.3.4, 5-4.3.5 and 5-6.2. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).
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Based on interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes with derangement signals at a continuously monitored location., and low fuel main tank indicator. This deficiency could affect 1 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/07/2012 at 2:10 PM surveyors observed on the Sub-Basement Level floor in the Plant room SB146E, that audible and visual derangement signals were not located in continuously monitored location. Generator enunciator panels were located in the computer room that was not supervised 24 hours. Enunciator panel had paging system that was not power by battery. The observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.2(d) & NFPA 99 (1999 edition), 3-4.1.1.15(b). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

2. On 08/07/2012 at 2:11 PM surveyors observed on the Sub-Basement Level floor in the Plant room SB146E, that generator enunciator panel did not have a low fuel main tank indicator power by a battery. This observed situation was not compliant with NFPA 110 (1999 edition), Table 3-5.5.2(d). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).
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Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with removal of abandoned wiring, National Electrical Code with closed electrical raceways, working clearances at electrical panels, two exits from high voltage rooms, closed electrical raceways, proper use of flexible cords, electrical panels with complete directories and fixed wiring rather than extension cords. This deficient practice affected all patients, staff, and visitors in 20 of 80 smoke compartments of the facility, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 8/07/2012 at 8:35 am surveyor observed outside door 332, above the lay-in ceiling, abandoned wiring. New wiring for the facility was installed and the existing wiring was disconnected and left inside the ceiling plenum. This observed situation was not compliant with NFPA 101 (2000 edition), 4.6.1.2 and NFPA 70: Articles 800, 760, 770 and 725. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

2. On 8/07/2012 at 9:00 am surveyor observed in room 3118 that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a coffee pot. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M8 (Plant Mechanic).

3. On 08/06/2012 at 11:35 am surveyor observed on the Level-4 floor in the Electrical Closet near stair 61, that electrical panel breakers were not labeled to identify the loads they fed. Panel #E-4-N-2 directory did not have any identification for circuit breakers 6,8,10,12,14,16,18,20,22,24,21,25,27 and 29. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

4. On 08/06/2012 at 1:15 PM surveyor observed on the Level-4 floor in the Electrical closet 4057A, that electrical panel breakers were not labeled to identify the loads they fed. Panel #C-4-EC-1 directory did not have identification for circuit breaker number 13, 36,27, 28, 29, 30 and 35. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

5. On 08/06/2012 at 2:50 PM surveyor observed on the Level-4 floor in the Soiled utility room number 4118B, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to non-computer equipment and had ten outlets. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

6. On 08/07/2012 at 1:30 PM surveyors observed on the Sub-Basement level floor in the Generator control room number SB952, that electrical panel breakers were not labeled to identify the loads they fed. Panel #C-SB-EL-4 did not have directory for circuit breakers. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

7. On 08/07/2012 at 3:30 PM surveyors observed on the Sub-Basement level floor in the Electrical room number SB553, that a 4" x 4" 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M9 (Steamfitter/ Mechanic), and staff M10 (Principal, Pearson Engineering, LLC).

8. On 08/08/2012 at 9:15 am surveyors observed on the Sub-Basement level floor in the Training room number SB967L, that electrical panel breakers were not labeled to identify the loads they fed. Panel #C-SB-P-3 did not have identification for circuit breaker number 3 & 4. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

9. On 08/08/2012 at 9:20 am surveyors observed on the Sub-Basement level floor in the Boiler area receiving room, that access to electrical panel was less than 3'-0" clearance. Access to panel #SW-SB-N-3 was obstructed with storage. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager), staff M4 (Maintenance Mechanic), staff M10 (Principal, Pearson Engineering, LLC), and staff M11 (Safety Officer).

10. On 08/08/2012 at 1:30 PM surveyor observed on the Lower level floor in the Electrical Communication room number B743F, that electrical panel breakers were not labeled to identify the loads they fed. Inside the electrical panel circuit breaker number 28 did not have label which circuit it was feeding. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

11. On 08/08/2012 at 3:05 PM surveyor observed on the Lower Level floor in the CSD Decontaminating room, that access to electrical panel was less than 3'-0" clearance. The two electrical plans near the washer, was blocked by 2 metal carts. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

12. On 08/08/2012 at 11:27 am surveyor observed on the Lower Level floor in the room B630 (classroom H), that a flexible cord was used in a manner that is not permitted by the code. The cord ran from the storage closet into the room. This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M10 (Principal, Pearson Engineering, LLC) and staff M11 (Safety Officer).

13. On 08/09/2012 at 9:00 am surveyor observed on the Lower Level floor in the near stairwell 45, that electrical panel breakers were not labeled to identify the loads they fed. Panel #C-LL-EC-7 did not have the breakers labeled. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

14. On 08/09/2012 at 10:48 am surveyor observed on the Lower Level floor in the room B992B, that electrical panel breakers were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

15. On 08/09/2012 at 11:26 am surveyor observed on the Lower Level floor in the room core lab, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to the lab bench This observed situation was not compliant with NFPA 70 (1999 edition), 400-8(1) and 517-18. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).

16. On 08/09/2012 at 12:01 PM surveyor observed on the Lower Level floor in the Room B77, Electrical room, that electrical panel breakers were not labeled to identify the loads they fed. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director), staff M11 (Safety Officer), staff M10 (Principal, Pearson Engineering, LLC), and staff M2 (Manager).
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18107

FINDINGS INCLUDE:
17. On 08/07/2012 at 10:58 am surveyor observed that the electrical code was not followed. At Electrical Closet Door #1-72, observed Breaker 22 of Panel SE-1-N-1 was in an 'ON' position and not identified. This also happened at Panel E-1-EC-1 with Breakers 18 & 19 in Room 1033. This observed situation was not compliant with NFPA 70 (1999 edition). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

18. On 08/08/2012 at 5:27 pm surveyor observed on the Level 1 floor in the Electrical Room 1630, that two means of access was not provided at each end of the working space, which had electrical panels that were rated at 600 volts amperes or more, and was not over 6' wide in width of distance from the electrical panels. Six feet was not attained in front of the electrical panels. This room was not designed to a 1-hour fire-rating for this high of voltage. This observed situation was not compliant with NFPA 70 (1999 edition), 110-33(a)(1). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

19. On 08/07/2012 at 6:30 pm surveyor observed on the Level 1 floor in the Storage Room 1446E, that 4" x 4" electrical box open above the acoustical ceiling. electrical box(s) 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

20. On 08/08/2012 at 4:41 pm surveyor observed on the Level 1 floor in the Corridor near Door 1410 above the ceiling & Clean Holding Room 1671 above the ceiling, that 4"x 4" electrical box(s) 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 condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).

21. On 08/07/2012 at 2:48 pm surveyor observed on the Level 1 floor in the Kitchen Hallway 1036, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #E-1-N-5, including breakers #40, #42, #6 & #8 were incorrectly labeled. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

22. On 08/07/2012 at 5:35 pm surveyor observed on the Level 1 floor in the Electrical Room 1374 in Stairwell 21 & Electrical Room in Stairwell 22, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #N-1-N-1, breakers 40 & 42 were in the 'ON' position and not identified to the loads they served. Same for Panel #N-1-N-2, breakers 20 + 24 +36. Also Panel #N-1-EC-1, breakers 11 & 30. This appears to be a 'common theme' throughout the hospital. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor), staff M6 (Maintenance Mechanic) and staff M2 (Manager of Facilities).

23. On 08/08/2012 at 10:15 am surveyor observed on the Level 1 floor in the Corridor 1999J outside Room 1966D & Corridor 1097, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #C-1-EC-2 all breakers were incorrectly identified and at Corridor 1097 Panel #S-1-N-1 breakers 6, 10, 12, 14, & 16 were incomplete. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

24. On 08/08/2012 at 5:21 pm surveyor observed on the Level 1 floor in the Electrical Room 1630, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #WS-1-N-4, breakers 13, 17, 14 & 16 were miss-labeled. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M1 (Director of Facilities) and staff M6 (Maintenance Mechanic).___________________________________

Based on observation and interview, the facility did not provide existing elevators with proper 'firefighter controls' with elevators that were accessible with fire fighters service. This deficiency could affect 6 of the 80 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 08/08/2012 at 3:50 pm surveyor observed on the Level 1 floor in the Exit Passageway & Elevator Lobby 1793, that the elevator traveled greater than 25 ft above/below the level of building entry and did not have firefighter service capability, unfortunately it opened into a space less than 2 feet in depth because the fire and smoke system would close the Won-Door in front of these Elevators. The Elevators 'fire recall' should be located to another floor level or relocate the Exit Passageway around the Elevator Lobby. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.3, 9.4.3.2, and ANSI A17.3. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M5 (Maintenance Supervisor) and staff M6 (Maintenance Mechanic).

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Based on observation and interview, the facility did not provide dumbwaiter car devices with required rated hoist-way door, and required dumbwaiter controls. This deficiency could affect 2 of the 80 compartments in the facility, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 08/06/2012 at 1:00 PM surveyor observed on the Level-4 floor in the Dumbwaiter opening door in the corridor near room number 4052, that the dumbwaiter hoist way door that opened directly into the corridor did not have a label that would verify the door is rated. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.3, 9.4.2.2, and ANSI A17.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).

2. On 08/08/2012 at 3:45 PM surveyor observed on the Lower Level floor in the Dumbwaiter door in the corridor 904C, that the controls in the dumbwaiter did not include provision to lock the hoist way door so it would remain closed except for the floor where the car is located. This observed situation was not compliant with NFPA 101 (2000 edition), 19.5.3, 9.4.2.2, and ANSI A17.1. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff M2 (Manager) and staff M4 (Maintenance Mechanic).
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