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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 18.1.1.4.1, 18.1.1.4.2. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On 7-7-11 between the hours of 10:30 AM and 1:30 PM, the following observation was made:

1. Observation revealed the required 2 hour fire separation is missing or has been penetrated the length of the wall. The required wall was absent above the lay in ceiling between that and the deck above.

Based on observation it was determined that the facility failed to meet the construction type in accordance with the LSC, sections 18.1.6.2, 18, 18.1.6.3, 18.2.5.1. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On 7-7-11 at approximately 10:50 AM, the following observation was made:

1. The fire protective coating on the construction beam above the ceiling near room C304 has been chipped away to install wiring.

On 7-12-11 at approximately 12:35 PM, the following observation was made:

1. The fire protective coating installed on construction girders and beams in the basement mechanical rooms has been chipped and is missing.

Based on observation 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 potentially affect 10 occupants of the facility. Findings include:

On 7-7-11 at approximately 10:30 AM, the following observation was made:

1. The future Pharmacy sliding corridor window is not smoke resistant. Air could be felt passing through the opening between the glazing into the corridor.

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 18.3.6.3.6. This deficient practice could potentially affect 35 occupants of the facility. Findings include:

On 7-7-11 at approximately 1:45 PM, the following observation was made:

1. Observed the new patient room doors are not reasonably smoke resistant.

Based on observation the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect 15 occupants of the facility. Findings include:

On 7-7-11 the following observations were made:

1. At approximately 12:20 PM, observation revealed no exit sign at the exit door in west center stairway.

2. At approximately 1:30 PM, observation revealed the exit sign in the stairway, located near room 310, was inoperative.

Based on observation 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 potentially affect 45 occupants of the facility. Findings include:

On 7-7-11 the following observations were made:

1. At approximately 10:45 AM, observed the smoke barrier near room C304 was not properly fire stopped.

2. At approximately 11:45 AM, observed penetrations of the smoke barrier near room B326 by wires and piping that were not properly fire stopped.

Based on observation 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 potentially affect 10 occupants of the facility. Findings include:

On 7-7-11 at approximately 1:40 PM, the following observation was made:

1. Observed the self closing device on storage room C306 door is broken.

Based on observation the facility failed to provide approved means of egress in accordance with the LSC section 18.2.2.4. and 7.2. This deficient practice could potentially affect 35 occupants of the facility. Findings include:

On 7-7-11 the following observations were made:

1. At approximately 1:25 PM, in the stairway near janitor closet C325 observed wires and sprinkler piping penetrating the stairway that are not fire stopped.

2. At approximately 1:35 PM, observed the exterior exit door for the stairway located near room 310 was difficult to open.

Based on observation the facility failed to provide lighting in accordance with the LSC section 18.2.8. This deficient practice could potentially affect 35 occupants of the facility. Findings include:

On 7-7-11 the following observations were made:

1. At approximately 12:10 PM, observed the lighting not operating at the level of exit discharge in the west center stairway.

2. At approximately 12:25 PM, observed some of the lights in the stairway near janitor closet C325 were inoperative.

3. At approximately 1:30 PM, observed some of the lights in the stairway near room 310 were inoperative.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect 15 occupants of the facility. Findings include:

On 7-7-11 at approximately 11:55 AM, the following observation was made:

1. Observed a broken fire alarm pull station in the center corridor, at west stairway exit.

On 7-12-11 at approximately 10:25 AM, the following observation was made:

1. The facility could not provide any fire alarm inspection/test records.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could potentially affect 35 occupants of the facility. Findings include:

On 7-7-11 at approximately 1:25 PM, the following observation was made:

1. Observed a painted sprinkler in electric room A322.

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 50 occupants of the facility. Findings include:

On 7-12-11 the following observations were made:

1. At approximately 11:55 AM, observed the 2 sprinkler control valves at the city supply pipe are not electrically supervised or monitored by the fire alarm.

2. At approximately 11:50 AM, observed that the fire alarm panel did not receive a supervisory signal when a valve was moved toward the closed position. The valve was turned 7 full turns.

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 18.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 40 occupants of the facility. Findings include:

On 7-7-11 at approximately 10:00 AM, the following observations were made:

1. Observed that the fire department connection in the front of the building is not free spinning as required..

2. Observed that the fire department connection in the front of the building is difficult to reach due to a large bush planted in front of the connection.

On 7-12-11 at approximately 10:20 AM, the following observations were made:

1. By review of records, observed the hydraulic calculations were not posted for the sprinkler system.

2. By observation and by review of records, no sprinkler wrench was present.

Based on observation and/or review of records the facility failed to maintain compliance with NFPA 101. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On 7-7-11 and 7-12-11 at approximately 10:00 AM on both dates, 1:10 PM on 7-7-11 and 2:00 PM on both dates the following observations were made:

1. Automobiles parked beneath the 2nd floor area, at the front entrance to the building. This is not a sprinkler protected area. It also appears that "no parking" signs have been removed by observation of empty sign posts. 19.3.5

On 7-7-11 at approximately 1:50 PM, the following observation was made:

1. Observed no device at the level of exit discharge to prevent persons from going below the level of exit in the stairway near A331. 7.7.3

Based on observation and/or review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On 7-12-11 the following observation was made:

1. At approximately 10:10 AM, the facility could not provide annual inspection, testing or load bank test for the emergency generator.

2. At approximately 12:15 PM, observed conduit passing through the emergency generator room into the electrical room is not fire stopped at the wall.

3. At approximately 12:15 PM, observed insufficient battery powered emergency lighting in the emergency generator room.

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 18.1.1.4.1, 18.1.1.4.2. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On 7-7-11 between the hours of 10:30 AM and 1:30 PM, the following observation was made:

1. Observation revealed the required 2 hour fire separation is missing or has been penetrated the length of the wall. The required wall was absent above the lay in ceiling between that and the deck above.

Based on observation it was determined that the facility failed to meet the construction type in accordance with the LSC, sections 18.1.6.2, 18, 18.1.6.3, 18.2.5.1. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On 7-7-11 at approximately 10:50 AM, the following observation was made:

1. The fire protective coating on the construction beam above the ceiling near room C304 has been chipped away to install wiring.

On 7-12-11 at approximately 12:35 PM, the following observation was made:

1. The fire protective coating installed on construction girders and beams in the basement mechanical rooms has been chipped and is missing.

Based on observation 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 potentially affect 10 occupants of the facility. Findings include:

On 7-7-11 at approximately 10:30 AM, the following observation was made:

1. The future Pharmacy sliding corridor window is not smoke resistant. Air could be felt passing through the opening between the glazing into the corridor.

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 18.3.6.3.6. This deficient practice could potentially affect 35 occupants of the facility. Findings include:

On 7-7-11 at approximately 1:45 PM, the following observation was made:

1. Observed the new patient room doors are not reasonably smoke resistant.

Based on observation the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect 15 occupants of the facility. Findings include:

On 7-7-11 the following observations were made:

1. At approximately 12:20 PM, observation revealed no exit sign at the exit door in west center stairway.

2. At approximately 1:30 PM, observation revealed the exit sign in the stairway, located near room 310, was inoperative.

Based on observation 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 potentially affect 45 occupants of the facility. Findings include:

On 7-7-11 the following observations were made:

1. At approximately 10:45 AM, observed the smoke barrier near room C304 was not properly fire stopped.

2. At approximately 11:45 AM, observed penetrations of the smoke barrier near room B326 by wires and piping that were not properly fire stopped.

Based on observation 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 potentially affect 10 occupants of the facility. Findings include:

On 7-7-11 at approximately 1:40 PM, the following observation was made:

1. Observed the self closing device on storage room C306 door is broken.

Based on observation the facility failed to provide approved means of egress in accordance with the LSC section 18.2.2.4. and 7.2. This deficient practice could potentially affect 35 occupants of the facility. Findings include:

On 7-7-11 the following observations were made:

1. At approximately 1:25 PM, in the stairway near janitor closet C325 observed wires and sprinkler piping penetrating the stairway that are not fire stopped.

2. At approximately 1:35 PM, observed the exterior exit door for the stairway located near room 310 was difficult to open.

Based on observation the facility failed to provide lighting in accordance with the LSC section 18.2.8. This deficient practice could potentially affect 35 occupants of the facility. Findings include:

On 7-7-11 the following observations were made:

1. At approximately 12:10 PM, observed the lighting not operating at the level of exit discharge in the west center stairway.

2. At approximately 12:25 PM, observed some of the lights in the stairway near janitor closet C325 were inoperative.

3. At approximately 1:30 PM, observed some of the lights in the stairway near room 310 were inoperative.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect 15 occupants of the facility. Findings include:

On 7-7-11 at approximately 11:55 AM, the following observation was made:

1. Observed a broken fire alarm pull station in the center corridor, at west stairway exit.

On 7-12-11 at approximately 10:25 AM, the following observation was made:

1. The facility could not provide any fire alarm inspection/test records.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could potentially affect 35 occupants of the facility. Findings include:

On 7-7-11 at approximately 1:25 PM, the following observation was made:

1. Observed a painted sprinkler in electric room A322.

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 50 occupants of the facility. Findings include:

On 7-12-11 the following observations were made:

1. At approximately 11:55 AM, observed the 2 sprinkler control valves at the city supply pipe are not electrically supervised or monitored by the fire alarm.

2. At approximately 11:50 AM, observed that the fire alarm panel did not receive a supervisory signal when a valve was moved toward the closed position. The valve was turned 7 full turns.

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 18.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 40 occupants of the facility. Findings include:

On 7-7-11 at approximately 10:00 AM, the following observations were made:

1. Observed that the fire department connection in the front of the building is not free spinning as required..

2. Observed that the fire department connection in the front of the building is difficult to reach due to a large bush planted in front of the connection.

On 7-12-11 at approximately 10:20 AM, the following observations were made:

1. By review of records, observed the hydraulic calculations were not posted for the sprinkler system.

2. By observation and by review of records, no sprinkler wrench was present.

Based on observation and/or review of records the facility failed to maintain compliance with NFPA 101. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On 7-7-11 and 7-12-11 at approximately 10:00 AM on both dates, 1:10 PM on 7-7-11 and 2:00 PM on both dates the following observations were made:

1. Automobiles parked beneath the 2nd floor area, at the front entrance to the building. This is not a sprinkler protected area. It also appears that "no parking" signs have been removed by observation of empty sign posts. 19.3.5

On 7-7-11 at approximately 1:50 PM, the following observation was made:

1. Observed no device at the level of exit discharge to prevent persons from going below the level of exit in the stairway near A331. 7.7.3

Based on observation and/or review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On 7-12-11 the following observation was made:

1. At approximately 10:10 AM, the facility could not provide annual inspection, testing or load bank test for the emergency generator.

2. At approximately 12:15 PM, observed conduit passing through the emergency generator room into the electrical room is not fire stopped at the wall.

3. At approximately 12:15 PM, observed insufficient battery powered emergency lighting in the emergency generator room.