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Based on observation and interview, the facility did not provide a common separation wall that had rated wall construction, and rated doors. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 10 of the 29 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
1. On 4/19/2010 at 4:59 pm surveyor #18107 observed on the 2nd floor in the 236B-Public Elevator & Waiting Lobby, located in the Central smoke compartment, that the separation wall was not constructed to a 2-hour fire rating because of a mutual agreement between Select Specialty Hospital and Aurora West Allis Hospital. At the time of final occupancy inspection on 12/18/2009 Staff P (Corporate facilities Director) told surveyor #18107 that a 2-hour separation wall was not intended to be built, knowing that this would extend a compliance survey on either facility into the adjoining facility. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).

2. On 4/19/2010 at 5:00 pm surveyor #18107 observed on the 2nd floor in the 236B-Public Elevator & Waiting Lobby, located in the Central smoke compartment, that the door in the 2-hour rated separation wall could not be verified of having at least a 90 minute rating. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.1.4 and 8.2.3.2.3. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).
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Based on observation and interview, the facility did not provide and maintain the required building construction type that had a compliant type of construction. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 10 of the 29 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
On 4/21/2010 at 12:58 pm surveyor #18107 observed on the 2nd floor in the Enclosed Stairwell connected to Exterior Catwalk, located in the East smoke compartment, that the building's construction type was not compliant with the minimum construction requirements for the occupancy it contained. The steel members, including columns and beams, were exposed with no fire protective membrane around the steel that was holding up the stairwell building enclosure. This observed situation was not compliant with NFPA 101 (2000 edition), Table 18.1.6.2, and NFPA 220 (1999 edition), Table 3-1. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff R (Aurora West Allis Mem. Hosp-Fac. Mgr.).
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Based on observation, interview, and a review of facility flame spread documents, the facility did not provide rooms with rated wall finishes. This deficiency occurred in 1 of the 3 smoke compartments, and would affect 0 of the 20 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
On 4/19/2010 at 12:25 pm surveyor #18107 observed on the 4th floor in the Data/Electrical Closet, located in the 4-Central smoke compartment, that the facility could not provide documentation to confirm the wall had an appropriate rating. The room wall was finished with full height wood paneling on three sides. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.3.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select Spec. Hosp.-Corp. fac. dir.), Staff Q (Aurora St. Luke's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. Dept.).
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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 that had no combustible material storage. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 10 of the 29 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
On 4/19/2010 at 4:42 pm surveyor #18107 observed on the 2nd floor in the 235-Southeast Corridor, located in the South smoke compartment, that the corridor space was used for storage, and was not separated by a wall from the corridor. Storage included 3 wired carts holding linens, miscellaneous boxes of materials and plastic bagged cloth items on several racks within 2' x 4' sized carts. The 3 carts were covered but the zippered corner seams were not closed at the corners. This quantity of materials was deemed hazardous for storage in a corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.1 and 18.7.5.5. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).
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Based on observation and interview, the facility did not provide and maintain doors to protect the corridor from non-corridor spaces with doors with positive latching. This deficiency occurred in 1 of the 3 smoke compartments, and would affect 0 of the 20 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
On 4/19/2010 at 10:20 am surveyor #18107 observed on the 4th floor in the 4013-Nourishment Room, located in the 4-Central smoke compartment, that the corridor door would not remain fully closed if a force of 5 lbs were applied to the latch edge of the door. Positive latching was not possible because the door closer would not close the door sufficiently to latch. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select Spec. Hosp.-Corp. fac. dir.), Staff Q (Aurora St. Luke's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. dept.).
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Based on observation and interview, the facility did not provide and maintain the rated wall assemblies to enclose vertical openings with sealed wall penetrations. This deficiency occurred in 3 of the 3 smoke compartments, and would affect all of the 20 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
On 4/19/2010 at 12:20 pm surveyor #18107 observed on the 4th floor in the 4100-Corridor, located in the 4-Central smoke compartment, that penetration(s) were not sealed according to approved UL designs. The deficiency included fire damper support angle was not bearing against the shaft wall because the wall opening was too large. The annular gap was at least 2-1/2 inches larger than the duct on one side and permitted a visible gap of 1 inch through the wall below the angle. The surveyor could not observe North and West shafts because patient rooms adjacent to the shafts were occupied. The surveyor had a reasonable concern that similar deficiencies existed because the ductwork was installed at the same time and experience has shown that similar work practices are followed in multiple locations. This observed situation was not compliant with NFPA 101 (2000 edition), 8.2.5.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select Spec. Hosp.-Corp. fac. dir.), Staff Q (Aurora St. Luke's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. dept.).
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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 that had smoke-tight seals at meeting edges, and pairs of opposite-swinging cross-corridor doors. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 10 of the 29 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
1. On 4/19/2010 at 5:02 pm surveyor #18107 observed on the 2nd floor in the 236-Corridor where it meets 281-Corridor, located in the Central smoke compartment, that the pair of smoke barrier doors did not resist the passage of smoke because they did not have an effective astragal at their meeting edge. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.6 and 8.3.4. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).

2. On 4/19/2010 at 5:04 pm surveyor #18107 observed on the 2nd floor in the 236-Corridor where it meets 281-Corridor, located in the Central smoke compartment, that the cross-corridor smoke barrier door were not opposite swinging. When this hospital was relocated from the 4th Floor, everything in the new location was required to meet new health care occupancy requirements. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.7.5 . This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).
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Based on observation and interview, the facility did not enclose hazardous rooms with rated doors. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 10 of the 29 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
On 4/19/2010 at 5:08 pm surveyor #18107 observed on the 2nd floor in the 281-Corridor in front of Elevators on Fertility Clinic side, located in the East smoke compartment, that the door in the hazard enclosure wall could not be verified of having at least a 45 minute rating. The reason this is considered storage is because both Select Specialty and Aurora West Allis Hospitals use this Corridor and Service Elevator Lobby as cart storage. Carts are left there greater than 60 minutes as observed between 4:40 PM till 5:45 PM by This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.2.1 . This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).
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Based on observation and interview, the facility did not ensure that all means of egress were readily available at all times with door hardware that operated with a single release. This deficiency occurred in 1 of the 3 smoke compartments, and would affect 1 of the 20 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
1. On 4/19/2010 at 10:35 am surveyor #18107 observed on the 4th floor in the 4106-Materials Management Office, located in the 4-West smoke compartment, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a deadbolt and latch that requires two motions to open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp. fac. dir.), Staff Q (Aurora St. Luke's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. dept.).

2. On 4/19/2010 at 11:00 am surveyor #18107 observed on the 4th floor in the 4111-Pharmacy, located in the 1025 smoke compartment, that the door release hardware required more than a single motion to release the door for exiting. The hardware included a deadbolt and latch that requires two motions to open. This observed situation was not compliant with NFPA 101 (2000 edition), 7.2.1.5.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp. fac. dir.), Staff Q (Aurora St. Lukes's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. dept.).
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Based on observation and interview, the facility did not provide and maintain horizontal exits to meet code requirements with compliant construction. This deficiency occurred in 1 of the 3 smoke compartments, and would affect 0 of the 20 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
On 4/19/2010 at 10:25 am surveyor #18107 observed on the 4th floor in the 4100C-Separation , located in the 4-Central smoke compartment, that the horizontal exit had a set of doors that had meeting edges that were greater than 1/8 inch apart. This observed situation was not compliant with NFPA 101 (2000 edition), 19.2.2.5 and 7.2.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (SelectSpec.Hosp.-Corp.Fac.Dir.), Staff Q (Aurora St.Luke's Med.Ctr-Mgr.PO), Staff S (Aurora St. Luke's Med.Ctr.-Supervisor Maint.Dept.).
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Based on observation and interview, the facility did not provide and maintain multiple fixtures or lamps in the interior and exterior means of egress so the path would still be illuminated if any single fixture or bulb failed that had egress paths with redundant lighting. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 10 of the 29 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
On 4/21/2010 at 12:49 pm surveyor #18107 observed on the 2nd floor in the 293-Exit Stairwell leading to 0000-Exterior Catwalk, located in the East smoke compartment, that the path of egress was illuminated by a single fixture with a single lamp, and did not have the ability to provide 0.2 foot-candles of lighting on the exit path if a single lamp was not operational. The exterior wall mounted light fixture had only one lamp. The next adjacent fixtures was at least 70 feet away. This observed situation was not compliant with NFPA 101 (2000 edition), 7.8.1.4. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff R (Aurora West Allis Mem. Hosp-Fac. Mgr.).
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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 with intact escutcheon rings, sprinklers with a tight enclosure to collect heat and sprinklers with a tight enclosure to collect heat. This deficiency occurred in 2 of the 3 smoke compartments, and would affect all of the 20 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
1. On 4/19/2010 at 10:00 am surveyor #18107 observed on the 4th floor in the 4114-Inpatient Toilet Room, located in the 1018 smoke compartment, that the escutcheon ring on the sprinkler was not tight to ceiling. This gap would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1 . The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp. fac. dir.), Staff Q (Aurora St. Lukes's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. dept.).

2. On 4/19/2010 at 10:18 am surveyor #18107 observed on the 4th floor in the 4013-Nourishment Room, located in the 4-Central smoke compartment, that there was one or more unsealed holes near the ceiling. The hole(s) included multiple gaps of approximately 1 inch by 1 inch in the ceiling tiles. This would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp. fac. dir.), Staff Q (Aurora St. Luke's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. dept.).

3. On 4/19/2010 at 10:42 am surveyor #18107 observed on the 4th floor in the 4108B-Storage Closet, located in the 4-West smoke compartment, that there was one or more unsealed holes near the ceiling. The hole(s) included a 12 inch by 24 inch hole in the ceiling. This would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler UL certification test. This observed situation was not compliant with NFPA 25 (1998 edition), 1-11.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp. fac. dir.), Staff Q (Aurora St. Luke's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. dept.).
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Based on observation and interview, the facility did not provide a sprinkler system that complies that had NFPA 13 (1999 edition) requirements that had the exceptions for not sprinkling a space. all rooms sprinkled when the code required sprinkling. This deficiency occurred in 1 of the 4 smoke compartments, and would affect 10 of the 29 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
On 4/21/2010 at 12:55 pm surveyor #18107 observed on the 2nd floor in the Enclosed Stairwell connected to Exterior Catwalk, located in the East smoke compartment, that the room was not sprinkled. All areas of new healthcare must be protected with sprinklers. This observed situation was not compliant with NFPA 101 (2000 edition), 18.2.2.2.4 and 7.2.1.6.1. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff R (Aurora West Allis Mem. Hosp-Fac. Mgr.).
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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. intact escutcheon trim rings, and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in 3 of the 4 smoke compartments, and would affect all of the 29 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
1. On 4/19/2010 at 4:52 pm surveyor #18107 observed on the 2nd floor in the 257-Medical Records, located in the Central smoke compartment, that the escutcheon ring on the sprinkler was not tight to the ceiling tile. 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 . This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).

2. On 4/19/2010 at 5:16 pm surveyor #18107 observed on the 2nd floor in the 276-Staff Lounge, located in the North smoke compartment, that there was one or more unsealed holes near the ceiling. The hole(s) included several ceiling tiles with their corners damaged and creating 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 . This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).

3. On 4/21/2010 at 1:02 pm surveyor #18107 observed on the 2nd floor in the 2305-Electrical Closet, located in the East smoke compartment, that there was one or more unsealed holes near the ceiling. The hole(s) included several ceiling tiles with their corners removed to allow pipes to penetrate the ceiling, that created an opening greater than 4 square inches. 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 . This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff R (Aurora West Allis Mem. Hosp-Fac. Mgr.).

4. On 4/21/2010 at 1:08 pm surveyor #18107 observed on the 2nd floor in the 2351-Sterilization Room, located in the East smoke compartment, that there was one or more unsealed holes near the ceiling. The hole(s) included several ceiling tiles with their corners damaged and creating 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 . This deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff R (Aurora West Allis Mem. Hosp-Fac. Mgr.).
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Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with deficiencies found during tests are corrected. This deficiency occurred in 3 of the 3 smoke compartments, and would affect all of the 20 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
1. On 4/20/2010 at 11:05 am surveyor #18107 observed during a review of documents that deficiencies found in an inspection were not corrected. The Medical Gas Solutions annual inspection, dated 4/13/2010, reported in the pulmonary lab that a replacement gauge was required on the left bank. Documentation was not available to show this condition was corrected. Select Specialty Hospital patients received treatment and diagnostics in Aurora St. Luke's Medical Center so deficiencies located in that facility must be corrected. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chap 4-3.4.1.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp. fac. dir.), Staff Q (Aurora St. Luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. dept.).

2. On 4/20/2010 at 11:05 am surveyor #18107 observed during a review of documents that deficiencies found in an inspection were not corrected. The Medical Gas Solutions annual inspection, dated 4/13/2010, reported that the left final line regulator on the nitrous oxide manifold was defective. Documentation was not available to show the situation was corrected. Select Specialty Hospital patients received treatment and diagnostics in Aurora St. Luke's Medical Center so deficiencies located in that facility must be corrected. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chap 4-3.4.1.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp. fac. dir.), Staff Q (Aurora St. Luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. dept.).

3. On 4/20/2010 at 11:05 am surveyor #18107 observed during a review of documents that deficiencies found in an inspection were not corrected. The Medical Gas Solutions annual inspection, dated 4/13/2010, reported in the 1st floor Immunotherapy area that two cracked solenoids needed repair. Documentation was not available to show this situation was corrected. Select Specialty Hospital patients received treatment and diagnostics in Aurora St. Luke's Medical Center so deficiencies located in that facility must be corrected. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), Chap 4-3.4.1.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp. fac. dir.), Staff Q (Aurora St. Luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. ctr.-Supervisor Maint. dept.).
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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 that had working clearances at electrical panels, electrical panels with complete directories, and ground fault protection. This deficiency occurred in 3 of the 4 smoke compartments, and would affect all of the 29 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29.

FINDINGS INCLUDE:
1. On 4/19/2010 at 4:46 pm surveyor #18107 observed on the 2nd floor in the 244-Material Mgmt. Rm., located in the South smoke compartment, that clearance in front of electrical equipment was less than 3'-0". A cart with boxes stacked high on it, blocked the electrical panel. This observed situation was not compliant with NFPA 70 (1999 edition), 110-26. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).

2. On 4/19/2010 at 5:19 pm surveyor #18107 observed on the 2nd floor in the 271-Pharmacy, located in the North smoke compartment, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #H2L08 was observed to be missing information on electrical breakers #30, #15 & #17. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).

3. On 4/19/2010 at 5:21 pm surveyor #18107 observed on the 2nd floor in the 271-Pharmacy, located in the North smoke compartment, that electrical panel breaker(s) were not labeled to identify the loads they fed. Panel #H2L07 was observed to be missing information on electrical breaker #8 and could not find electrical reference to Room #2004, Rec Room. This observed situation was not compliant with NFPA 70 (1999 edition), Section 110-22. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).

4. On 4/21/2010 at 1:10 pm surveyor #18107 observed on the 2nd floor in the 2351-Sterilization Room, located in the East smoke compartment, that an outlet within 4' of a sink was not provided with ground fault circuit interruption. An outlet was approximately 2 feet from the counter sink. This observed situation was not compliant with NFPA 70 (1999 edition), 210-8. This deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff R (Aurora West Allis Mem. Hosp-Fac. Mgr.).
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