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The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the LSC.

1. On 03/07/11 at 1:55 PM, the surveyor, while accompanied by the Director of Engineering & Facilities Development and a Engineering Technician, observed that the access door to the pipe chase, located in the storage room/closet nearest Room # 908 in High Building-Floor 9, was damaged and would not close properly; i.e. listed & approved access door-physically damaged, top latch broken, door bent, self-closing device broken-will not self-close and positively latch any longer.

2. On 03/09/11 at 1:00 PM, the surveyor, while accompanied by the Assistant Engineering Director and the Fire Safety Technician, observed that the access door to the pipe chase, located in the Emergency Department, High Building-1st Floor nearest Room # 1003, was not provided with a self closing device that worked properly; i.e. the arm was removed from the hydraulic closer.

The facility did not ensure that the facility ' s air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems as required by the referenced LSC.

On 03/10/11 at 09:15 AM, the surveyor was not provided with documentation from the Director of Engineering & Facilities Development that indicated the mechanical fire dampers that were identified as needing repairs on the JGlaski Damper Inspection Report of September 2009 were repaired; i.e. fire damper repairs still required at Donnelly, Core & South Buildings

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 03/07 - 03/10/11 at 09:30 AM and at other times throughout the survey, the surveyors along with the Facility Fire Marshal, and the Director of Engineering & Facilities Development observed that throughout the Core, Bliss, High and South Buildings soiled linen and trash collection receptacles that had capacity greater than 32 gallons were placed in lobbies, back corridors, and egress corridors both stationary and wheeled i.e. receptacles with capacities greater than 32 gallons are required to be stored in rooms protected as hazardous areas according to the LSC 19.7.5.5.

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the LSC.

1. On 03/07/11 at 1:55 PM, the surveyor, while accompanied by the Director of Engineering & Facilities Development and a Engineering Technician, observed that the access door to the pipe chase, located in the storage room/closet nearest Room # 908 in High Building-Floor 9, was damaged and would not close properly; i.e. listed & approved access door-physically damaged, top latch broken, door bent, self-closing device broken-will not self-close and positively latch any longer.

2. On 03/09/11 at 1:00 PM, the surveyor, while accompanied by the Assistant Engineering Director and the Fire Safety Technician, observed that the access door to the pipe chase, located in the Emergency Department, High Building-1st Floor nearest Room # 1003, was not provided with a self closing device that worked properly; i.e. the arm was removed from the hydraulic closer.

The facility did not ensure that the facility ' s air conditioning and ventilation equipment was in accordance with NFPA 90A: Standard for the Installation of Air Conditioning and Ventilation Systems as required by the referenced LSC.

On 03/10/11 at 09:15 AM, the surveyor was not provided with documentation from the Director of Engineering & Facilities Development that indicated the mechanical fire dampers that were identified as needing repairs on the JGlaski Damper Inspection Report of September 2009 were repaired; i.e. fire damper repairs still required at Donnelly, Core & South Buildings

The facility did not ensure that solid linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended as required by the referenced LSC.

On 03/07 - 03/10/11 at 09:30 AM and at other times throughout the survey, the surveyors along with the Facility Fire Marshal, and the Director of Engineering & Facilities Development observed that throughout the Core, Bliss, High and South Buildings soiled linen and trash collection receptacles that had capacity greater than 32 gallons were placed in lobbies, back corridors, and egress corridors both stationary and wheeled i.e. receptacles with capacities greater than 32 gallons are required to be stored in rooms protected as hazardous areas according to the LSC 19.7.5.5.