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Based on observation and interview, the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect 2 occupants of the facility.

Findings include:

On 10/12/16 at approximately 2:48 PM, the following observation was made:

While performing a visual inspection of the interior finish materials in the Gift Shop storage room with employees MEVSM, SOC and MSII, it was observed that there was a 4 inch hole in the ceiling tile.

This finding was confirmed by observation and discussion by employee MEVSM.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 5 occupants of the facility.

Findings include:

On 10/12/16 at approximately 2:05 PM, the following observation was made:

While performing a visual inspection of the exit corridor smoke/fire barrier walls above the ceiling across from room 1211 with employees MEVSM, SOC and MSII, it was observed that there was a 4 inch, white pipe penetrating the one hour fire rated wall that was not sealed.

This finding was confirmed by observation and discussion by employee MEVSM.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/12/16 between approximately 11:57 AM, and 3:00 PM the following observations were made:

1. While performing a visual inspection above the ceiling of the corridor wall to the elevator equipment room in the basement with employees MEVSM, SOC and MSII, it was observed that there was a 2 inch black pipe and a 1/2 inch gray electrical conduit penetrating the wall that was not sealed with any form of fire rated material.

This finding was confirmed by employees MEVSM and MSII by observation and interview at the time of discovery.

2. While performing a visual inspection above the ceiling of the walls inside the soiled utility room 1320 on the first floor with employees MEVSM, SOC, and MSII, it was observed that there was a 12 inch by 12 inch hole in the drywall.

This finding was confirmed by employees MEVSM and MSII by observation and interview at the time of discovery.

3. While performing a visual inspection above the ceiling of the walls inside the soiled utility room 1618 in the Operating Room with employees MEVSM, SOC, and MSII, it was observed that at the top of the one hour rated wall where it butted against the second floor, it had been sealed with an unknown type of green calk. Employees MEVSM, MSII could not provide information as to the type of calk and if it had any form of fire rating.

This finding was confirmed by employees MEVSM and MSII by observation and interview at the time of discovery.

4. While performing a visual inspection above the ceiling of the walls inside the soiled utility room 1618 in the Operating Room with employees MEVSM, SOC, and MSII, it was observed that there was a 4 inch white pipe that penetrated the 1 hour rated wall that was not sealed.

This finding was confirmed by employees MEVSM and MSII by observation and interview at the time of discovery.

5. While performing a visual inspection of the door in the Soiled Utility room in the Emergency Department with employees MEVSM, SOC, and MSII, it was observed that the gray, flexible electrical cable from the doors self closer penetrated the door and was not sealed.

This finding was confirmed by employees MEVSM and MSII by observation and interview at the time of discovery.

Based on observation and interview, the facility failed to provide lighting in accordance with the LSC section 19.2.8. This deficient practice could potentially affect 20 occupants of the facility.

Findings include:

On 10/12/16 at approximately 3:11 PM, the following observation was made:

While performing a visual inspection of the emergency lighting units with employees MEVSM, SOC, and MSII, outside of the marked exit from the basement by the ambulance entrance, it was observed that there was a single lighting unit connected to the emergency power system outside the door with no secondary lights in the event of a failure of the single unit.

This finding was confirmed by employees MEVSM, SOC, and MSII by observation and interview at the time of discovery.

Based on observation and interview, the facility failed to provide a sprinkler system in accordance with the LSC section 9.7.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/112/16 between approximately 11:30 AM and 2:42 PM the following observations were made:

1. While performing a visual inspection of the fire sprinkler system with employees MEVSM, SOC, and MSII above the ceiling by room 2404, it was observed that there was a black cable, ceiling grid wire, and a white cable tied to the sprinkler pipes and supporting brackets.

This finding was confirmed by employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

2. While performing a visual inspection of the fire sprinkler system with employees MEVSM, SOC, and MSII above the ceiling by room 0117, it was observed that there was a white cable tied to the sprinkler supporting system

This finding was confirmed by employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

3. While performing a visual inspection of the fire sprinkler system with employees MEVSM, SOC, and MSII in room 0301, it was observed that there were 4 sprinkler heads that were excessively corroded.

This finding was confirmed by employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

4. While performing a visual inspection of the fire sprinkler system with employees MEVSM, SOC, and MSII in room 1403, it was observed that there was 1 sprinkler head that had an unacceptable amount of dust build up on it.

This finding was confirmed by employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

Based on observationand interview, the facility failed to provide building services in accordance with the LSC sections 19.5.2.1, 9.2, 19.6.2.2. This deficient practice could potentially affect 18 occupants of the facility.

Findings include:

On 10/12/16 at approximately 11:13 AM, the following observation was made:

While performing a visual inspection of the heating and ventilation system with employees MEVSM, SOC, and MSII above the ceiling by the elevator shaft on the second floor, it was observed that there was intumesent calk material sealing the duct work penetrating the fire rated wall. This duct work had a smoke/fire damper it it.

This finding was confirmed by employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

Based on observation and interview, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 2 occupants of the facility.

Findings include:

On 10/12/16 between approximately 11:36 AM and 12:55 PM, the following observations were made:

1. While performing a visual inspection of the electrical systems with employees MEVSM, SOC and MSII, in room 2014, it was observed that there was an extension cord being used as permanent wiring.

This finding was confirmed with employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

2. While performing a visual inspection of the electrical systems with employees MEVSM, SOC and MSII, in room 0403, it was observed that there was a brown extension cord being used as permanent wiring.

This finding was confirmed with employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

Based on a review of records and interview, the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/12/16 at approximately 9:10 AM, the following finding was made:

While reviewing records with employees MEVSM, SOC and MSII, it was found that the policy entitled BLH-MTN-59 Fire Watch Duties and Responsibilities dated 6-3-16, did not include a provision for constant rounds while on fire watch duty.

This finding was confirmed at the time of discovery by interview with employees MEVSM, SOC and MSII.

Based on observation and interview, the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect 2 occupants of the facility.

Findings include:

On 10/12/16 at approximately 2:48 PM, the following observation was made:

While performing a visual inspection of the interior finish materials in the Gift Shop storage room with employees MEVSM, SOC and MSII, it was observed that there was a 4 inch hole in the ceiling tile.

This finding was confirmed by observation and discussion by employee MEVSM.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 5 occupants of the facility.

Findings include:

On 10/12/16 at approximately 2:05 PM, the following observation was made:

While performing a visual inspection of the exit corridor smoke/fire barrier walls above the ceiling across from room 1211 with employees MEVSM, SOC and MSII, it was observed that there was a 4 inch, white pipe penetrating the one hour fire rated wall that was not sealed.

This finding was confirmed by observation and discussion by employee MEVSM.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/12/16 between approximately 11:57 AM, and 3:00 PM the following observations were made:

1. While performing a visual inspection above the ceiling of the corridor wall to the elevator equipment room in the basement with employees MEVSM, SOC and MSII, it was observed that there was a 2 inch black pipe and a 1/2 inch gray electrical conduit penetrating the wall that was not sealed with any form of fire rated material.

This finding was confirmed by employees MEVSM and MSII by observation and interview at the time of discovery.

2. While performing a visual inspection above the ceiling of the walls inside the soiled utility room 1320 on the first floor with employees MEVSM, SOC, and MSII, it was observed that there was a 12 inch by 12 inch hole in the drywall.

This finding was confirmed by employees MEVSM and MSII by observation and interview at the time of discovery.

3. While performing a visual inspection above the ceiling of the walls inside the soiled utility room 1618 in the Operating Room with employees MEVSM, SOC, and MSII, it was observed that at the top of the one hour rated wall where it butted against the second floor, it had been sealed with an unknown type of green calk. Employees MEVSM, MSII could not provide information as to the type of calk and if it had any form of fire rating.

This finding was confirmed by employees MEVSM and MSII by observation and interview at the time of discovery.

4. While performing a visual inspection above the ceiling of the walls inside the soiled utility room 1618 in the Operating Room with employees MEVSM, SOC, and MSII, it was observed that there was a 4 inch white pipe that penetrated the 1 hour rated wall that was not sealed.

This finding was confirmed by employees MEVSM and MSII by observation and interview at the time of discovery.

5. While performing a visual inspection of the door in the Soiled Utility room in the Emergency Department with employees MEVSM, SOC, and MSII, it was observed that the gray, flexible electrical cable from the doors self closer penetrated the door and was not sealed.

This finding was confirmed by employees MEVSM and MSII by observation and interview at the time of discovery.

Based on observation and interview, the facility failed to provide lighting in accordance with the LSC section 19.2.8. This deficient practice could potentially affect 20 occupants of the facility.

Findings include:

On 10/12/16 at approximately 3:11 PM, the following observation was made:

While performing a visual inspection of the emergency lighting units with employees MEVSM, SOC, and MSII, outside of the marked exit from the basement by the ambulance entrance, it was observed that there was a single lighting unit connected to the emergency power system outside the door with no secondary lights in the event of a failure of the single unit.

This finding was confirmed by employees MEVSM, SOC, and MSII by observation and interview at the time of discovery.

Based on observation and interview, the facility failed to provide a sprinkler system in accordance with the LSC section 9.7.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/112/16 between approximately 11:30 AM and 2:42 PM the following observations were made:

1. While performing a visual inspection of the fire sprinkler system with employees MEVSM, SOC, and MSII above the ceiling by room 2404, it was observed that there was a black cable, ceiling grid wire, and a white cable tied to the sprinkler pipes and supporting brackets.

This finding was confirmed by employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

2. While performing a visual inspection of the fire sprinkler system with employees MEVSM, SOC, and MSII above the ceiling by room 0117, it was observed that there was a white cable tied to the sprinkler supporting system

This finding was confirmed by employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

3. While performing a visual inspection of the fire sprinkler system with employees MEVSM, SOC, and MSII in room 0301, it was observed that there were 4 sprinkler heads that were excessively corroded.

This finding was confirmed by employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

4. While performing a visual inspection of the fire sprinkler system with employees MEVSM, SOC, and MSII in room 1403, it was observed that there was 1 sprinkler head that had an unacceptable amount of dust build up on it.

This finding was confirmed by employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

Based on observationand interview, the facility failed to provide building services in accordance with the LSC sections 19.5.2.1, 9.2, 19.6.2.2. This deficient practice could potentially affect 18 occupants of the facility.

Findings include:

On 10/12/16 at approximately 11:13 AM, the following observation was made:

While performing a visual inspection of the heating and ventilation system with employees MEVSM, SOC, and MSII above the ceiling by the elevator shaft on the second floor, it was observed that there was intumesent calk material sealing the duct work penetrating the fire rated wall. This duct work had a smoke/fire damper it it.

This finding was confirmed by employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

Based on observation and interview, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 2 occupants of the facility.

Findings include:

On 10/12/16 between approximately 11:36 AM and 12:55 PM, the following observations were made:

1. While performing a visual inspection of the electrical systems with employees MEVSM, SOC and MSII, in room 2014, it was observed that there was an extension cord being used as permanent wiring.

This finding was confirmed with employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

2. While performing a visual inspection of the electrical systems with employees MEVSM, SOC and MSII, in room 0403, it was observed that there was a brown extension cord being used as permanent wiring.

This finding was confirmed with employees MEVSM, SOC and MSII by interview and observation at the time of discovery.

Based on a review of records and interview, the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/12/16 at approximately 9:10 AM, the following finding was made:

While reviewing records with employees MEVSM, SOC and MSII, it was found that the policy entitled BLH-MTN-59 Fire Watch Duties and Responsibilities dated 6-3-16, did not include a provision for constant rounds while on fire watch duty.

This finding was confirmed at the time of discovery by interview with employees MEVSM, SOC and MSII.