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Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with LSC Section 19.3.6.3 in the lower level leading to the tunnel. This deficient practice could potentially affect an isolated number of occupants, staff and visitors.

Findings Include:

On 10/26/16 at approximately 11:27 AM during facility tour with the Maintenance Director, observation of the door in the lower level leading to the tunnel revealed it failed to properly close and latch when tested. When queried, the Maintenance Director indicated that he was unaware of this situation and would have it repaired.

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 the mechanical room in the X-Ray corridor in accordance with LSC Sections 19.3.7.3 and 19.3.7.5. This deficient practice could potentially affect all three occupants of the facility, all of the staff and any visitors present at the time of a potential incident if smoke and fire were allowed to transfer from one smoke compartment to another.

Findings Include:

On 10/26/16 at approximately 11:43 AM during facility tour with the Maintenance Director observation of penetrations of the smoke barrier wall in the mechanical room in the X-Ray corridor failed to be properly sealed. This finding was verified with the Maintenance Director at the time of discovery and this inspector was advised that they missed this one while installing new data line.

Based on observation and interview, the facility failed to provide illuminated exit and directional signs in accordance with LSC Sections 19.2.10.1 and 7.10 in the lower level at the Purchasing Department. This deficient practice could potentially affect an isolated number of occupants, staff and visitors.

Findings Include:

On 10/26/16 at approximately 11:29 AM during facility tour with the Maintenance Director, observation of the exit sign in the lower level at the Purchasing Department failed to be illuminated. When queried, he Maintenance Director stated that he was unaware of the situation and would have it repaired immediately.

Based on record review and staff interview, the facility failed to provide an approved fire alarm system in accordance with LSC Sections 19.3.4 and 9.6 by failing to have documentation of the required sensitivity testing of the smoke detection and failing to have documentation of the required quarterly dialer testing of the fire alarm system. This deficient practice could potentially affect all three occupants, staff and any visitors that may be in the facility.

Findings Include:

On 10/26/16 at approximately 10:37 AM during record review and interview of the Maintenance Director the facility was unable to provide documentation of the last sensitivity testing of the facilities smoke detection system. The Maintenance Director advised that he was unaware of this requirement and would have it completed immediately.

On 10/26/16 at approximately 10:52 AM during record review and interview of the Maintenance Director the facility was unable to provide documentation of the required quarterly fire alarm dialer testing report. The Maintenance Director advised he was unaware of this requirement and would begin the process to complete this requirement.

Based on observation and interview, the facility failed to provide the electrical system in accordance with LSC Sections 19.5.1 and 9.1.2 by using a multi-plug adapter for permanent wiring in the Laboratory. This deficient practice could potentially affect isolated number of occupants including staff and visitors.

Findings Include:

On 10/26/16 at approximately 11:38 AM during facility tour with the Maintenance Director, observation in the Laboratory revealed the facility failed to remove a multi-plug adapter that was being used for permanent wiring. When queried, the Maintenance Director stated that he was unaware of this situation and would have it removed immediately.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with LSC Section 19.3.6.3 in the lower level leading to the tunnel. This deficient practice could potentially affect an isolated number of occupants, staff and visitors.

Findings Include:

On 10/26/16 at approximately 11:27 AM during facility tour with the Maintenance Director, observation of the door in the lower level leading to the tunnel revealed it failed to properly close and latch when tested. When queried, the Maintenance Director indicated that he was unaware of this situation and would have it repaired.

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 the mechanical room in the X-Ray corridor in accordance with LSC Sections 19.3.7.3 and 19.3.7.5. This deficient practice could potentially affect all three occupants of the facility, all of the staff and any visitors present at the time of a potential incident if smoke and fire were allowed to transfer from one smoke compartment to another.

Findings Include:

On 10/26/16 at approximately 11:43 AM during facility tour with the Maintenance Director observation of penetrations of the smoke barrier wall in the mechanical room in the X-Ray corridor failed to be properly sealed. This finding was verified with the Maintenance Director at the time of discovery and this inspector was advised that they missed this one while installing new data line.

Based on observation and interview, the facility failed to provide illuminated exit and directional signs in accordance with LSC Sections 19.2.10.1 and 7.10 in the lower level at the Purchasing Department. This deficient practice could potentially affect an isolated number of occupants, staff and visitors.

Findings Include:

On 10/26/16 at approximately 11:29 AM during facility tour with the Maintenance Director, observation of the exit sign in the lower level at the Purchasing Department failed to be illuminated. When queried, he Maintenance Director stated that he was unaware of the situation and would have it repaired immediately.

Based on record review and staff interview, the facility failed to provide an approved fire alarm system in accordance with LSC Sections 19.3.4 and 9.6 by failing to have documentation of the required sensitivity testing of the smoke detection and failing to have documentation of the required quarterly dialer testing of the fire alarm system. This deficient practice could potentially affect all three occupants, staff and any visitors that may be in the facility.

Findings Include:

On 10/26/16 at approximately 10:37 AM during record review and interview of the Maintenance Director the facility was unable to provide documentation of the last sensitivity testing of the facilities smoke detection system. The Maintenance Director advised that he was unaware of this requirement and would have it completed immediately.

On 10/26/16 at approximately 10:52 AM during record review and interview of the Maintenance Director the facility was unable to provide documentation of the required quarterly fire alarm dialer testing report. The Maintenance Director advised he was unaware of this requirement and would begin the process to complete this requirement.

Based on observation and interview, the facility failed to provide the electrical system in accordance with LSC Sections 19.5.1 and 9.1.2 by using a multi-plug adapter for permanent wiring in the Laboratory. This deficient practice could potentially affect isolated number of occupants including staff and visitors.

Findings Include:

On 10/26/16 at approximately 11:38 AM during facility tour with the Maintenance Director, observation in the Laboratory revealed the facility failed to remove a multi-plug adapter that was being used for permanent wiring. When queried, the Maintenance Director stated that he was unaware of this situation and would have it removed immediately.