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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 November 26, 2012 at 11:35 a.m., observation revealed and confirmed by the facility maintenance director, the Basement Wheelchair Room door held open with a wheelchair.

- On November 26, 2012 at 11:38 a.m., observation revealed and confirmed by the facility maintenance director, the Telecom Room #015 door held open with a metal plate.

- On November 26, 2012 at 1:40 p.m., observation revealed and confirmed by the facility maintenance director, the Fourth Floor door from Administration to the Kitchen Area did not self-close to provide a positive latch.

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 November 26, 2012 at 12:11 p.m., observation revealed and confirmed by the facility maintenance director, a pipe end not sealed adjacent to the door to the Main Elevator Lobby inside the Shell Space.

- On November 26, 2012 at 12:21 p.m., observation revealed and confirmed by the facility maintenance director, a rectangular hole with a flex wire running through it not sealed in the 1.5 hour wall inside the North Shell Space adjacent to the desk and window.

- On November 26, 2012 at 12:22 p.m., observation revealed and confirmed by the facility maintenance director, a sprinkler pipe penetration not sealed in the 1.5 hour wall inside the North Shell Space adjacent to the desk and window.

- On November 26, 2012 at 1:00 p.m., observation revealed and confirmed by the facility maintenance director, a pipe end not sealed in the 1.5 hour wall inside Soiled Utility #237.

- On November 26, 2012 at 1:08 p.m., observation revealed and confirmed by the facility maintenance director, a 4" pipe sleeve not sealed above Occupational Therapy #241 door.

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 November 26, 2012 at 1:26 p.m., observation revealed and confirmed by the facility maintenance director, a gap larger than 1/8" between the Third Floor smoke barrier doors adjacent to the Nurse Station.

- On November 26, 2012 at 1:53 p.m., observation revealed and confirmed by the facility maintenance director, the Record Storage #563 door in the 2 hour rated wall was not equipped with a self-closing unit.

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 November 26, 2012 at 11:45 a.m., observation revealed and confirmed by the facility maintenance director, stock stored within 18" of the bottom of a sprinkler head deflector inside the Central Supply #011.

By questioning of Kitchen staff, it was observed that staff failed to properly demonstrate the kitchen hood fire suppression system and emergency procedures. This deficient practice could potentially affect all occupants of the facility. Findings Include:

- On November 26, 2012 at 12:39 p.m., observation revealed and confirmed by the facility maintenance director, the cook on duty at the time of inspection was unsure of the operation of the Kitchen hood system and the difference between the ABC extinguisher and the K Class extinguisher.

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 November 26, 2012 at 11:49 a.m., observation revealed and confirmed by the facility maintenance director, an open junction box above ceiling in the corridor just west of Medical Records #010.

- On November 26, 2012 at 12:17 p.m., observation revealed and confirmed by the facility maintenance director, an extension cord used for what appears to be a permanent power source inside First Floor Staff Office.

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 November 26, 2012 at 11:35 a.m., observation revealed and confirmed by the facility maintenance director, the Basement Wheelchair Room door held open with a wheelchair.

- On November 26, 2012 at 11:38 a.m., observation revealed and confirmed by the facility maintenance director, the Telecom Room #015 door held open with a metal plate.

- On November 26, 2012 at 1:40 p.m., observation revealed and confirmed by the facility maintenance director, the Fourth Floor door from Administration to the Kitchen Area did not self-close to provide a positive latch.

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 November 26, 2012 at 12:11 p.m., observation revealed and confirmed by the facility maintenance director, a pipe end not sealed adjacent to the door to the Main Elevator Lobby inside the Shell Space.

- On November 26, 2012 at 12:21 p.m., observation revealed and confirmed by the facility maintenance director, a rectangular hole with a flex wire running through it not sealed in the 1.5 hour wall inside the North Shell Space adjacent to the desk and window.

- On November 26, 2012 at 12:22 p.m., observation revealed and confirmed by the facility maintenance director, a sprinkler pipe penetration not sealed in the 1.5 hour wall inside the North Shell Space adjacent to the desk and window.

- On November 26, 2012 at 1:00 p.m., observation revealed and confirmed by the facility maintenance director, a pipe end not sealed in the 1.5 hour wall inside Soiled Utility #237.

- On November 26, 2012 at 1:08 p.m., observation revealed and confirmed by the facility maintenance director, a 4" pipe sleeve not sealed above Occupational Therapy #241 door.

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 November 26, 2012 at 1:26 p.m., observation revealed and confirmed by the facility maintenance director, a gap larger than 1/8" between the Third Floor smoke barrier doors adjacent to the Nurse Station.

- On November 26, 2012 at 1:53 p.m., observation revealed and confirmed by the facility maintenance director, the Record Storage #563 door in the 2 hour rated wall was not equipped with a self-closing unit.

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 November 26, 2012 at 11:45 a.m., observation revealed and confirmed by the facility maintenance director, stock stored within 18" of the bottom of a sprinkler head deflector inside the Central Supply #011.

By questioning of Kitchen staff, it was observed that staff failed to properly demonstrate the kitchen hood fire suppression system and emergency procedures. This deficient practice could potentially affect all occupants of the facility. Findings Include:

- On November 26, 2012 at 12:39 p.m., observation revealed and confirmed by the facility maintenance director, the cook on duty at the time of inspection was unsure of the operation of the Kitchen hood system and the difference between the ABC extinguisher and the K Class extinguisher.

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 November 26, 2012 at 11:49 a.m., observation revealed and confirmed by the facility maintenance director, an open junction box above ceiling in the corridor just west of Medical Records #010.

- On November 26, 2012 at 12:17 p.m., observation revealed and confirmed by the facility maintenance director, an extension cord used for what appears to be a permanent power source inside First Floor Staff Office.