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Based on observation and interview, it was observed that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 18.1.1.4.1, 18.1.1.4.2. This deficient practice could affect occupants of the facility by permitting fire to spread into the facility from the adjacent non-conforming building, exposing occupants of the facility to fire and the products of combustion.

Findings include:

On 04/23/14 at approximately 11:00 AM during an inspection of separation walls with staff identifier # 1, the following observation was made:

Observed the cross-corridor building separation doors between the hospital and the medical office building not self-close to a positive latch.

This deficiency was confirmed by interview with staff identifier # 1 at the time of observation.

Based on observation and interview, it was determined that the facility failed to provide corridor walls that could provide a barrier to limit the transfer of smoke 18.3.6.1, 18.3.6.2. This deficient practice could affect occupants of the facility by contributing to the spread of smoke into the corridor, exposing occupants to the products of combustion and rendering the corridor system unusable for evacuation of the facility.

Findings include:

On 04/23/14 at approximately 10:10 AM during an inspection of corridor walls with staff identifier # 2, the following observation was made:

Observed the Communication Room 1E102 to have an open penetration thru the corridor wall inside an electrical conduit leaving a hole through the corridor wall.

This deficiency was confirmed by interview with staff identifier # 2 at the time of observation.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 18.3.6.3.6. This deficient practice could affect occupants of the facility by contributing to the spread of fire and smoke into the corridor, exposing occupants to fire and the products of combustion and rendering the corridor unusable for evacuation of the facility.

Findings include:

On 04/23/14 at approximately 11:10 AM during an inspection of corridor doors with staff identifier # 1, the following observation was made:

Observed the Kitchen corridor doors LLE101 to have a gap between the meeting edges of the doors that was larger than 1/8 inch.

This deficiency was confirmed by interview with staff identifier # 1 at the time of observation.

Based on observation and interview, the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could affect occupants of the facility by contributing to delay in exiting in an emergency due to inadequately identified exits.

Findings include:

On 04/23/14 at approximately 1:15 PM during an inspection of exits with staff identifier # 3, the following observation was made:

Observed a corridor exit sign near room # 317 to be non-illuminated. The bulbs did not function.

This deficiency was confirmed by interview with staff identifier # 3 at the time of observation.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could affect occupants by permitting smoke and fire to spread between smoke compartment affecting occupants beyond the area of an original fire, exposing occupants to smoke, fire, and the products of combustion.

Findings include:

1. On 04/23/14 at approximately 1:50 PM during an inspection of smoke barrier walls with staff identifier
# 3, the following observation was made:

Observed a 2" hole through the smoke barrier wall above the ceiling 7' right of the Staff Restroom of the OB Elevator Lobby Area.

This deficiency was confirmed by interview with staff identifier # 3 at the time of observation.

2. On 04/23/14 at approximately 1:40 PM during an inspection of smoke barrier walls with staff identifier
# 2, the following observation was made:

Observed penetration of the smoke barrier wall from a communication cable above the cross-corridor smoke barrier doors 2E100D.1 leaving a hole through the rated assembly.

This deficiency was confirmed by interview with staff identifier # 2 at the time of observation.

Inspections of smoke barrier walls was a random sample inspection and not all inclusive of all penetrations of the smoke barrier walls. The facility is responsible to insure that all penetrations are properly fire stopped and sealed in all areas of the smoke barrier walls throughout the facility.

Based on observation and interview, the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 18.3.7.5, 18.3.7.6, 18.3.7.8. This deficient practice could affect occupants of the facility by contributing to the spread of fire and the products of combustion between smoke compartments, exposing occupants to the products of combustion.

Findings include:

1. On 04/23/14 at approximately 9:40 AM during an inspection of smoke barrier doors with staff identifier # 1, the following observation was made:

Observed the cross-corridor smoke barrier doors LLD188B to have a gap larger than 1/8" between the meeting edges of the smoke barrier doors.

This deficiency was confirmed by interview with staff identifier # 1.

2. On 04/23/14 at approximately 9:50 AM during an inspection of smoke barrier doors with staff identifier # 1, the following observation was made:

Observed the cross-corridor smoke barrier doors LLE100M to have a gap larger than 1/8" between the meeting edges of the smoke barrier doors.

This deficiency was confirmed by interview with staff identifier # 1.

3. On 04/23/14 at approximately 9:45 AM during an inspection of smoke barrier doors with staff identifier # 2, the following observation was made:

Observed the cross-corridor smoke barrier doors 1E184 to have a gap larger than 1/8" between the meeting edges of the smoke barrier doors.

This deficiency was confirmed by interview with staff identifier # 2.

4. On 04/23/14 at approximately 10:35 AM during an inspection of smoke barrier doors with staff identifier # 2, the following observations were made:

Observed the cross-corridor smoke barrier doors 1E175 to have a gap larger than 1/8" between the meeting edges of the smoke barrier doors.

This deficiency was confirmed by interview with staff identifier # 2.

5. On 04/23/14 at approximately 11:05 AM during an inspection of smoke barrier doors with staff identifier # 2, the following observation was made:

Observed the tower B cross-corridor smoke barrier doors 1H200C to have a gap larger than 1/8" between the meeting edges of the smoke barrier doors.

This deficiency was confirmed by interview with staff identifier # 2.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could affect occupants of the facility by contributing to the spread of fire between a protected area and unprotected area, exposing occupants to fire and the products of combustion.

Findings include:

1. On 04/23/13 between approximately 9:50 AM - 11:20 AM during an inspection of hazard rooms with staff identifier # 1, the following observations were made:

Observed the corridor doors LLE164 to the Clean Linen Storage Room fail to self-close to a positive latch.

Observed two four inch conduits penetrating the corridor wall of room LLD185 to be open through the wall on both sides.

Observed the trash door LLE1000 not self-close to a positive latch.

These deficiencies were confirmed by interview with staff identifier # 1 at the time of observations.

2. On 04/23/13 between approximately 10:20 AM - 11:00 AM during an inspection of hazard rooms with staff identifier # 2, the following observations were made:

Observed the doors to Clinical Engineering 1F118 not self-close to a positive latch.

Observed the Transportation Room 1H289 being used as a Storage Room. The room does not meet storage room requirements.

These deficiencies were confirmed by interview with staff identifier # 2 at the time of observations.

Based on observation and interview, the facility failed to provide the required two-hour fire resistance rating for the exit component in accordance with the LSC sections 8.2.5.4, 18.3.11. This deficient practice could affect occupants of the facility by exposing occupants to fire or the products of combustion.

Findings include:

1. On 04/23/14 at approximately 1:00 PM during an inspection of exits with staff identifier # 2,
the following observation was made:

Observed the stairwell # 2 door 2J200F not self-close to a positive latch.

This deficiency was confirmed by interview with staff identifier # 2 at the time of observation.

2. On 04/23/14 at approximately 1:00 PM during an inspection of exits with staff identifier # 3,
the following observation was made:

Observed a 1" conduit through the stairwell wall near stair door #4 open on both ends of the conduit leaving a hole through the rated wall.

This deficiency was confirmed by interview with staff identifier # 3 at the time of observation.

Based on observation and interview, the facility failed to provide an approved fire alarm system in accordance with the LSC sections 18.3.4, 9.6. This deficient practice could affect occupants of the facility by contributing to a delay in notification of occupants and emergency services in the event of a fire.

Findings include:

On 04/23/14 at approximately 10:25 PM during an inspection of the fire alarm system with staff identifier
# 2, the following observation was made:

Observed smoke detector with-in three feet of an air diffuser near the nursing station of SPR Department.

This deficiency was confirmed by interview with staff identifier # 2 at the time of observation.

Based on observation and interview, the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10. This deficient practice could affect occupants of the facility by contributing to a delay or inability to exit as a result of the means of egress not being maintained for full instant use, increasing occupants exposure to a hazardous condition.

Findings include:

On 04/23/14 at approximately 9:50 AM during an inspection of exits with staff identifier # 1, the following observations were made:

Observed the corridor on the lower level at the entrance to Receiving being used as a storage area for the following items: coats on wall hooks, cart with salt, shop vac, rain coat.
Observed the "morgue corridor" being used as a storage area. The following items: six pallets, six carts, two tables, nine lifts, hazards waste containers and similar items were stored in the exit corridor during the entire inspection.
These deficiencies were confirmed by interview with staff identifier # 1 at the time of observation.

Based on observation and interview, the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could affect occupants of the facility by contributing to the development and spread of fire, exposing occupants to fire and the products of combustion.

Findings include:

On 04/23/14 at approximately 10:10 AM during an inspection of Oxygen Storage with staff identifier # 1, the following observation was made

Observed an oxygen cylinder in the lower level Oxygen Storage Room laying on its side on top of a rack of oxygen cylinders.

This deficiency was confirmed by interview with staff identifier # 1 at the time of observation.

Based on observation and interview, it was observed that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 18.1.1.4.1, 18.1.1.4.2. This deficient practice could affect occupants of the facility by permitting fire to spread into the facility from the adjacent non-conforming building, exposing occupants of the facility to fire and the products of combustion.

Findings include:

On 04/23/14 at approximately 11:00 AM during an inspection of separation walls with staff identifier # 1, the following observation was made:

Observed the cross-corridor building separation doors between the hospital and the medical office building not self-close to a positive latch.

This deficiency was confirmed by interview with staff identifier # 1 at the time of observation.

Based on observation and interview, it was determined that the facility failed to provide corridor walls that could provide a barrier to limit the transfer of smoke 18.3.6.1, 18.3.6.2. This deficient practice could affect occupants of the facility by contributing to the spread of smoke into the corridor, exposing occupants to the products of combustion and rendering the corridor system unusable for evacuation of the facility.

Findings include:

On 04/23/14 at approximately 10:10 AM during an inspection of corridor walls with staff identifier # 2, the following observation was made:

Observed the Communication Room 1E102 to have an open penetration thru the corridor wall inside an electrical conduit leaving a hole through the corridor wall.

This deficiency was confirmed by interview with staff identifier # 2 at the time of observation.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 18.3.6.3.6. This deficient practice could affect occupants of the facility by contributing to the spread of fire and smoke into the corridor, exposing occupants to fire and the products of combustion and rendering the corridor unusable for evacuation of the facility.

Findings include:

On 04/23/14 at approximately 11:10 AM during an inspection of corridor doors with staff identifier # 1, the following observation was made:

Observed the Kitchen corridor doors LLE101 to have a gap between the meeting edges of the doors that was larger than 1/8 inch.

This deficiency was confirmed by interview with staff identifier # 1 at the time of observation.

Based on observation and interview, the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could affect occupants of the facility by contributing to delay in exiting in an emergency due to inadequately identified exits.

Findings include:

On 04/23/14 at approximately 1:15 PM during an inspection of exits with staff identifier # 3, the following observation was made:

Observed a corridor exit sign near room # 317 to be non-illuminated. The bulbs did not function.

This deficiency was confirmed by interview with staff identifier # 3 at the time of observation.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could affect occupants by permitting smoke and fire to spread between smoke compartment affecting occupants beyond the area of an original fire, exposing occupants to smoke, fire, and the products of combustion.

Findings include:

1. On 04/23/14 at approximately 1:50 PM during an inspection of smoke barrier walls with staff identifier
# 3, the following observation was made:

Observed a 2" hole through the smoke barrier wall above the ceiling 7' right of the Staff Restroom of the OB Elevator Lobby Area.

This deficiency was confirmed by interview with staff identifier # 3 at the time of observation.

2. On 04/23/14 at approximately 1:40 PM during an inspection of smoke barrier walls with staff identifier
# 2, the following observation was made:

Observed penetration of the smoke barrier wall from a communication cable above the cross-corridor smoke barrier doors 2E100D.1 leaving a hole through the rated assembly.

This deficiency was confirmed by interview with staff identifier # 2 at the time of observation.

Inspections of smoke barrier walls was a random sample inspection and not all inclusive of all penetrations of the smoke barrier walls. The facility is responsible to insure that all penetrations are properly fire stopped and sealed in all areas of the smoke barrier walls throughout the facility.

Based on observation and interview, the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 18.3.7.5, 18.3.7.6, 18.3.7.8. This deficient practice could affect occupants of the facility by contributing to the spread of fire and the products of combustion between smoke compartments, exposing occupants to the products of combustion.

Findings include:

1. On 04/23/14 at approximately 9:40 AM during an inspection of smoke barrier doors with staff identifier # 1, the following observation was made:

Observed the cross-corridor smoke barrier doors LLD188B to have a gap larger than 1/8" between the meeting edges of the smoke barrier doors.

This deficiency was confirmed by interview with staff identifier # 1.

2. On 04/23/14 at approximately 9:50 AM during an inspection of smoke barrier doors with staff identifier # 1, the following observation was made:

Observed the cross-corridor smoke barrier doors LLE100M to have a gap larger than 1/8" between the meeting edges of the smoke barrier doors.

This deficiency was confirmed by interview with staff identifier # 1.

3. On 04/23/14 at approximately 9:45 AM during an inspection of smoke barrier doors with staff identifier # 2, the following observation was made:

Observed the cross-corridor smoke barrier doors 1E184 to have a gap larger than 1/8" between the meeting edges of the smoke barrier doors.

This deficiency was confirmed by interview with staff identifier # 2.

4. On 04/23/14 at approximately 10:35 AM during an inspection of smoke barrier doors with staff identifier # 2, the following observations were made:

Observed the cross-corridor smoke barrier doors 1E175 to have a gap larger than 1/8" between the meeting edges of the smoke barrier doors.

This deficiency was confirmed by interview with staff identifier # 2.

5. On 04/23/14 at approximately 11:05 AM during an inspection of smoke barrier doors with staff identifier # 2, the following observation was made:

Observed the tower B cross-corridor smoke barrier doors 1H200C to have a gap larger than 1/8" between the meeting edges of the smoke barrier doors.

This deficiency was confirmed by interview with staff identifier # 2.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could affect occupants of the facility by contributing to the spread of fire between a protected area and unprotected area, exposing occupants to fire and the products of combustion.

Findings include:

1. On 04/23/13 between approximately 9:50 AM - 11:20 AM during an inspection of hazard rooms with staff identifier # 1, the following observations were made:

Observed the corridor doors LLE164 to the Clean Linen Storage Room fail to self-close to a positive latch.

Observed two four inch conduits penetrating the corridor wall of room LLD185 to be open through the wall on both sides.

Observed the trash door LLE1000 not self-close to a positive latch.

These deficiencies were confirmed by interview with staff identifier # 1 at the time of observations.

2. On 04/23/13 between approximately 10:20 AM - 11:00 AM during an inspection of hazard rooms with staff identifier # 2, the following observations were made:

Observed the doors to Clinical Engineering 1F118 not self-close to a positive latch.

Observed the Transportation Room 1H289 being used as a Storage Room. The room does not meet storage room requirements.

These deficiencies were confirmed by interview with staff identifier # 2 at the time of observations.

Based on observation and interview, the facility failed to provide the required two-hour fire resistance rating for the exit component in accordance with the LSC sections 8.2.5.4, 18.3.11. This deficient practice could affect occupants of the facility by exposing occupants to fire or the products of combustion.

Findings include:

1. On 04/23/14 at approximately 1:00 PM during an inspection of exits with staff identifier # 2,
the following observation was made:

Observed the stairwell # 2 door 2J200F not self-close to a positive latch.

This deficiency was confirmed by interview with staff identifier # 2 at the time of observation.

2. On 04/23/14 at approximately 1:00 PM during an inspection of exits with staff identifier # 3,
the following observation was made:

Observed a 1" conduit through the stairwell wall near stair door #4 open on both ends of the conduit leaving a hole through the rated wall.

This deficiency was confirmed by interview with staff identifier # 3 at the time of observation.

Based on observation and interview, the facility failed to provide an approved fire alarm system in accordance with the LSC sections 18.3.4, 9.6. This deficient practice could affect occupants of the facility by contributing to a delay in notification of occupants and emergency services in the event of a fire.

Findings include:

On 04/23/14 at approximately 10:25 PM during an inspection of the fire alarm system with staff identifier
# 2, the following observation was made:

Observed smoke detector with-in three feet of an air diffuser near the nursing station of SPR Department.

This deficiency was confirmed by interview with staff identifier # 2 at the time of observation.

Based on observation and interview, the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10. This deficient practice could affect occupants of the facility by contributing to a delay or inability to exit as a result of the means of egress not being maintained for full instant use, increasing occupants exposure to a hazardous condition.

Findings include:

On 04/23/14 at approximately 9:50 AM during an inspection of exits with staff identifier # 1, the following observations were made:

Observed the corridor on the lower level at the entrance to Receiving being used as a storage area for the following items: coats on wall hooks, cart with salt, shop vac, rain coat.
Observed the "morgue corridor" being used as a storage area. The following items: six pallets, six carts, two tables, nine lifts, hazards waste containers and similar items were stored in the exit corridor during the entire inspection.
These deficiencies were confirmed by interview with staff identifier # 1 at the time of observation.

Based on observation and interview, the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could affect occupants of the facility by contributing to the development and spread of fire, exposing occupants to fire and the products of combustion.

Findings include:

On 04/23/14 at approximately 10:10 AM during an inspection of Oxygen Storage with staff identifier # 1, the following observation was made

Observed an oxygen cylinder in the lower level Oxygen Storage Room laying on its side on top of a rack of oxygen cylinders.

This deficiency was confirmed by interview with staff identifier # 1 at the time of observation.