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Based on observation it was determined 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 19.1.1.4.1, 19.1.1.4.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed no fire stopping at the top of the 2 hour fire separation between the hospital and the Carl's building.

Observed wall penetrations around the pipes/ducts in the ground floor 2-hour wall at rooms 202 & 205.

Observed large wall penetrations around pipes/ ducts above the doors to the Ambulatory Care Center at room 2A219.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/ or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed no exit sign above the cross corridor doors near room 683.

Observed no exit at the end of the corridor near room 1K70.

Observed no directional exit sign is posted at the E/D Main nurse station.

Based on observation 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 all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed penetrations of wiring of the smoke barrier near room 625 and the barrier is not properly sealed to the deck above and the sides.

Observed a penetration of the smoke barrier near room 6G44 by wiring.

Observed a duct penetrating a smoke barrier near the 5th floor east nutrition room is not properly fire stopped. On 2-8-10, at about 1:40 PM, observed the gap between the smoke barrier doors near room 5G38 is greater than 1/8 " .

Observed wires penetrating a smoke barrier near stairway #6, 1st floor, are not properly fire stopped.

Observed the Orthopedics corridor wall is a smoke barrier wall but non-rated glazing is installed.

Observed wall penetrations above the cross-corridor smoke barrier doors at room 4C09.

Observed wall penetrations in O.R. Corridor wall across from stair CHM-08.

Observed wall penetrations above cross-corridor smoke barrier doors at O.R. # 6.

Observed the windows in the corridor wall at MRI waiting room are not rated.

Observed a wall penetration to the left of the fire alarm strobe in the back O.R. corridor.

Observed wall penetrations above fire doors next to ground floor elevators.

Observed that there was an incomplete seal on a wire penetration, located at cross corridor smoke barrier # 10055.

Observed that there was an incomplete seal on an air duct penetration, located at cross corridor smoke barrier #10107.

Observed that there was an incomplete wallboard seal, located at cross corridor smoke barrier #10139.

Observed that there was an incomplete wire penetration seal, located above the door to Room 651.

Observed that there was an unsealed pipe penetration at the cross corridor smoke barrier, located near Room 3N47.

Observed that there was an incomplete seal on the wallboard at the structural cross member, a hole in the wallboard near the double junction boxes, and an electrical conduit that has separated near the door to the corridor, located in Room 3B45A.

Observed that there was a gap around the air duct that penetrates the fire barrier, located in Room 3B45B.

Observed that there were numerous unsealed penetrations, located in the Telephone Room across from Room 3T55.

Observed that there was a missing ceiling tile, located in Room 3T61.

Observed that there was an unsealed conduit, located at Stairwell CHM-04.

Observed that there were two unsealed pipe penetrations and that there smoke barrier was not tight to the deck, located in Room 3K22.

Observed that the cross corridor smoke barrier had a gap between the doors located at the South entrance to the Carl ' s Building.

Observed that there was an unsealed conduit penetration, and the fire barrier was not tight against the deck, located in Room 3G33.

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed the cross-corridor smoke barrier doors at the Family Lounge blocked by a cleaning cart.

Observed that the astragal on the cross-corridor smoke barrier door at room 436 is damaged.

Based on observation 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 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed a storage room at the west end of the7th floor corridor is not constructed as required.

Observed the following at the 7th floor Child Life storage room:
A. The door to the room is not identified. Staff did not know ownership of the room.
B. Only Security had a key to the room.
C. Observed excessive storage of combustible materials, creating a high fire loading, inside the room.
D. The pathway into the room is obstructed with storage on the floor.
E. Storage is located within 18 " of the sprinkler deflectors.

Observed the room west of the 7th floor elevator lobby is not labeled to show ownership and no staff had a key to enter the room. The room was broken into.

Observed many holes and penetrations of the storage room located 7th floor elevator lobby, west of the elevator.

Observed a rag stuffed into the door frame portion of the door latch mechanism of trash storage room 5G49.

Observed multiple penetrations and holes of the furnace room in 1R40.

Observed the linen storage closet door in the Family Waiting Room does have a self-closer.

Observed the ceiling tile in the Lab Hub storage room is missing.

Observed missing ceiling tile in room 2J28.

Observed that the door handle to the pre-op soiled utility room is sticking.

Observed the janitor's closet door at the back O.R. desk doesn't self-latch.

Observed the door between PACU & anesthesia workroom doesn't self-latch.

Observed ceiling penetration in janitor's closet at stair-01.

Observed missing ceiling tile in soiled utility room GA098.

Observed that there were missing ceiling tiles, located at Room 5G25, housekeeping closet.

Observed that there was a missing ceiling tile, located in Room 3T61.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed the penetration through stairway 2 of electrical conduit, 3rd floor.

Observed the unapproved penetration of piping through stairway 3, at the 3rd floor.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed wall chart boxes are open and used to hold isolation equipment at rooms 527 and 532.

Observed 3 computers-on-wheels not in use and charging in the egress corridor near rooms 534 and 528.

Observed that there was furniture items (chair, table and a wagon) parked in the corridor near Stairwell CHM-07.

Observed that there was a " Crash Cart " parked in the corridor near room 3B45A.

Based on observation and/or review of records the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6. This deficient practice could potentially affect All occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed that the E/R "Quiet waiting room" requires a fire alarm visual device.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed a smoke detector in the Kitchen dish wash area is hanging from the wiring.

Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed that the sprinkler control valve for the "Dumbwaiter" at stair CHM-05 is not supervised.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed the unused top shelves of the storage racks in the 7th floor gift shop storage room are blocking the sprinkler discharge pattern.

Observed the sprinkler discharge pattern in room 3J17 is blocked by storage on the cabinets in the room.

Observed storage blocking the sprinkler discharge pattern in room 3X68.

Observed sprinklers are not installed in the clothes and storage closets in room 3X16.

Observed no sprinkler in the closet in room 1N20.

Observed storage in the closets in Board room D and in room 1N40A is within 18 " of the sprinklers.

Observed storage in the closet of the room next the above room is blocked by storage.

Observed the IT closet in the Medical Records office is not enclosed or sprinkler protected.

Observed no sprinkler in the Kitchen dairy cooler.

Observed no sprinkler in the Family Waiting Room linen closet.

Observed that the sprinkler in the ICU staff lounge 4E21 is dust loaded.

Observed missing sprinkler escutcheon plate in soiled utility room GA098.

Observed ceiling tiles around sprinkler head missing in "Turtle Phone Closet".

Observed that the orifice on the sprinkler inspector's test valve in janitor's closet GA182 is wrong size.

Observed sprinkler heads in ambulance bay are dust loaded.

Observed that the sprinkler in the " Stat Lab " cooler is corroded.

Observed a missing sprinkler escutcheon plate at room GA095.

Observed a missing sprinkler escutcheon plate in the back corridor near room 3L23.

Observed a missing sprinkler escutcheon plate in the supply closet 3B61.

Based on observation and/or review of records the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed that the fire extinguisher cabinet door at room GA181 is secured and does not allow safe immediate access.

Observed a fire extinguisher in the back corridor near conference room 3L29 not labeled.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed in the Kitchen grill area, the wok hood suppression system discharge nozzles are not aligned correctly to protect the equipment.

Observed the hamburger grill grease filters are dirty and grease is dripping form the filter frame and the hood.

Based on observation the facility failed to provide anesthetizing locations in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:


Observed oxygen cylinders within 5' of combustibles in storage room 4N50.

Observed unsecured oxygen cylinders in storage room 410.

Observed that the oxygen stored in room 4E19 appears to exceed the allowable quantity.

Observed oxygen stored in an unapproved (E/R- Marina) room.

Observed two large helium tanks unsecured in room 3N81A.

Based on observation and/or review of records the facility failed to provide approved construction materials in accordance with the LSC section 19.1.6.3. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed a large hole in the ceiling of the Board Room AIT closet.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of the facility.
Findings include:

On 2/08-11/2010 between the hours of 9:00am and 4:00PM the following was observed:

Observed combustibles being stored on transformers at unit GE-15.

Observed exposed wired above door to Radiology.

Observed an open electrical junction box above ceiling to the right of room 2B126.

Observed an open electrical junction box at door to room 2E100.

Observed an open electrical junction box above the cross-corridor smoke barrier doors at room 4H200B.

Observed that there were two electrical junction boxes missing cover plates, located in the corridor near the Elevator #1 and #2 Mechanical Room.

Observed that there was an electrical junction box missing a cover plate, located above Elevator #8.

Observed that there were two electrical junction boxes missing cover plates, located at Stairwell CHM-06.

Observed that there was a large electrical junction box missing a cover plate, located at Stairwell CHM-02.

Observed that there were electrical power strips " daisy chained " together, located in Room C-555.

Observed that there was an electrical extension cord in use, located in Room 3L23 (Lab.).

Observed that there was an electrical junction box missing a cover plate, Room 3G33.

Observed that there was an electrical junction box missing a cover plate, located at the cross corridor smoke barrier near Room 3X36B.

Observed that there were electrical power strips " daisy chained " together, located in Room 3A116.