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Based on observation and interview, the facility has corridor doors that do not meet the requirements of LSC (00) Section 19.3.6.3.2. This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that the door leading from the corridor into the NICU suite does not have a method to latch the door closed.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC (00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that the kitchen tray hoistway doors on the second through eighth floors were left open by facility staff after use. Also, the hoistway door lock on the eighth floor is missing.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the stairway enclosure of this facility does not meet the LSC (00) required two (2) hour fire resistive construction. This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that there is an open penetration around the fire sprinkler pipe on the third floor of Stairwell E.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility has failed to maintain the door locks in accordance with LSC (00) Section 19.2.2.4. This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that the locked mental health unit on the seventh floor does not have a means to automatically unlock the exit doors from a central location. The doors unlock upon a fire alarm activation or by staff at the particular door only.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility's fire alarm system is not maintained in conformance with NFPA 72, (99). This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that:
1. There is no smoke alarm with sounder in the doctor sleeping room(s) 226 and 227,
2. There is no smoke detector near room(s) 240, 258 and the third floor kitchenette. These rooms and areas are open to the corridors,
3. There are smoke detectors located within 36" to a heating, ventilation and air conditioning (HVAC) diffuser in the gift shop, room(s) LL206 and LL17 and the same day surgery PACU bay 10.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observations and interview, the automatic sprinkler system in not installed in accordance with NFPA 13 (99). This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that there is no fire sprinkler head in the eighth floor electrical room near the north chute.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility has failed to inspect and maintain the sprinkler system in accordance with NFPA 13 (99) and NFPA 25 (98). This deficient practice could affect all patients.

Findings include:

During facility tour between 01/07/2013 and 01/10/2013, observation revealed that the fire sprinkler heads in the following locations either are located too far below the ceiling or are located in areas where the walls do not go to the roof deck: Rooms(s) 203B, 215, 232A, 333A, the third floor electrical room near the north chute, the seventh floor electrical room near the south chute and the eighth floor electrical room near the south chute.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observations and interview, the facility has medical gas storage not in compliance with the requirements of NFPA 99 (99). This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that there are several E-sized oxygen tanks improperly stored in the basement medgas storage room.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility has corridor doors that do not meet the requirements of LSC (00) Section 19.3.6.3.2. This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that the door leading from the corridor into the NICU suite does not have a method to latch the door closed.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility failed to maintain vertical openings as required by LSC (00) Section 19.3.1.1. This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that the kitchen tray hoistway doors on the second through eighth floors were left open by facility staff after use. Also, the hoistway door lock on the eighth floor is missing.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the stairway enclosure of this facility does not meet the LSC (00) required two (2) hour fire resistive construction. This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that there is an open penetration around the fire sprinkler pipe on the third floor of Stairwell E.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility has failed to maintain the door locks in accordance with LSC (00) Section 19.2.2.4. This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that the locked mental health unit on the seventh floor does not have a means to automatically unlock the exit doors from a central location. The doors unlock upon a fire alarm activation or by staff at the particular door only.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility's fire alarm system is not maintained in conformance with NFPA 72, (99). This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that:
1. There is no smoke alarm with sounder in the doctor sleeping room(s) 226 and 227,
2. There is no smoke detector near room(s) 240, 258 and the third floor kitchenette. These rooms and areas are open to the corridors,
3. There are smoke detectors located within 36" to a heating, ventilation and air conditioning (HVAC) diffuser in the gift shop, room(s) LL206 and LL17 and the same day surgery PACU bay 10.

These deficient practices were verified by the Director of Facility Services at the time of the inspection.

Based on observations and interview, the automatic sprinkler system in not installed in accordance with NFPA 13 (99). This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that there is no fire sprinkler head in the eighth floor electrical room near the north chute.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observation and interview, the facility has failed to inspect and maintain the sprinkler system in accordance with NFPA 13 (99) and NFPA 25 (98). This deficient practice could affect all patients.

Findings include:

During facility tour between 01/07/2013 and 01/10/2013, observation revealed that the fire sprinkler heads in the following locations either are located too far below the ceiling or are located in areas where the walls do not go to the roof deck: Rooms(s) 203B, 215, 232A, 333A, the third floor electrical room near the north chute, the seventh floor electrical room near the south chute and the eighth floor electrical room near the south chute.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.

Based on observations and interview, the facility has medical gas storage not in compliance with the requirements of NFPA 99 (99). This deficient practice could affect all patients.

Findings include:

On facility tour between 01/07/2013 and 01/10/2013, observation revealed that there are several E-sized oxygen tanks improperly stored in the basement medgas storage room.

This deficient practice was verified by the Director of Facility Services at the time of the inspection.