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Based on document review and interview the facility failed to provide for the inspection of fire rated door assemblies in accordance with the LSC section 7.2.1.15.1. and failed to provide for the inspection of fire CO2 fire system in accordance with the LSC section 9.7.3 This deficient practice could potentially affect all occupants of the facility.
Findings include:

On June 27, 2017 at approximately 11:30 am the following observations were made:

1) Requested documentation for the annual inspection of the fire doors was not available for review.

2) Requested documentation for the inspection of the Carbon Dioxide (CO2) extinguishing system in the electrical room was not available for review.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview 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 June 27, 2017 at approximately 10:30 pm the following observations were made:

1) Observed an unsealed penetration in the two hour wall above the double doors by room 105.
2) Observed an unsealed penetration in the two hour wall by the stairs to the admin offices to the left of the hose cabinet.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview the facility failed to provide unobstructed egress in accordance with the LSC section 19.7.3. This deficient practice could potentially affect 50 occupants of the facility.
Findings include:

On June 26, 2017 at approximately 10:50 am the following observations were made:

1) Observed a chair in the corridor by room 725.
2) Observed WOW's (work station on wheels) charging in the corridor by room 522.
3) Observed seating set up in the corridor for 3 south.
4) Observed plastic draped across the corridor by holding room 177.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10. This deficient practice could potentially affect 50 occupants of the facility.
Findings include:

On June 27, 2017 at approximately 11:30 am the following observations were made:

1) Observed the gate at the ground level did not open to the full width of the stairs, stair 5.
2) Observed the gate at the ground level did not self-close, stair 4.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview the facility failed to provide lighting in accordance with the LSC section 19.2.8. This deficient practice could potentially affect 50 occupants of the facility.
Findings include:

On June 26, 2017 at approximately 11:30 am the following observations were made:

1) Observed a light out in the stairwell, floor 5, stair 1.
2) Observed a light out in the stairwell, floor 2, stair 6.
3) Observed a light out in the stairwell, exit door.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview the facility failed to provide building construction in accordance with the LSC section 19.1.6. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On June 27, 2017 at approximately 10:55 am the following observations were made:

1) Observed a large hole in the ceiling at the nurse's station on the 7th floor.
2) Observed missing ceiling tiles in patient room 753.
3) Observed a missing ceiling tile in the exit egress corridor by the nurse manager office 760.
4) Observed missing ceiling tiles in the anti-room for room 561.
5) Observed numerous missing ceiling tiles in the NICU area of the facility.
6) Observed numerous ceiling tiles and drywall on the walls had been removed due to a water leak in the 3 north wing.
7) Observed missing ceiling tiles in the visitor elevator lobby area of the 3rd floor.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview 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 25 occupants of the facility.
Findings include:

On June 27, 2017 at approximately 10:50 am the following observations were made:

1) Observed a penetration in the clean supply/telephone room, 732.
2) Observed missing ceiling tiles in the medication room 774.
3) Observed the fire hatch in the ceiling was open in room 436 storage.
4) Observed the door to the lab 236 had a broken closer.
5) Observed the door to room 175 was held open with a supply cart.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation, document review, and interview the facility failed to provide a fire alarm system in accordance with the LSC section 9.3.4. This deficient practice could potentially affect all occupants of the facility.
Findings include:

On June 27, 2017 at approximately 11:30 am the following observations were made:

1) Observed there were troubles indicating on the fire alarm panel.
2) Requests documentation for the annual inspection of the fire alarm system was not available for review.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation, document review, and interview the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.12. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On June 27, 2017 at approximately 11:30 am the following observations were made:

1) Document review revealed the monthly checks were not completed for the months of April, May and June of 2017
2) Observed a fire extinguisher on a table and not mounted in the lab area.
3) Observed a fire extinguisher on the floor by room 345A.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview 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 25 occupants of the facility.
Findings include:

On June 27, 2017 at approximately 2:30 pm the following observations were made:

1) Observed the door to room 636 did not close to latch.
2) Observed the door to room 345C was held open with a piece of medical equipment.
3) Observed the door to room 3015 was held open with a floor wedge.
4) Observed the door to the conference room across from room 235 did not close to latch.
5) Observed the door to room 238 had tape on the latch preventing latch.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview the facility failed to provide for doors hold open devices in accordance with the LSC section 19.3.7. This deficient practice could potentially affect 25 occupants of the facility.
Findings include:

On June 26, 2017 at approximately 1:30 pm the following observations were made:

1) Observed an unsealed penetration above the SB doors to rooms 513-525, 5 north.
2) Observed an unsealed penetration above the SB doors by the outpatient blood draw room on the 1st floor.

Findings were confirmed with facility maintenance staff HH and II.

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 19.3.7.8. This deficient practice could potentially affect 25 occupants of the facility.
Findings include:

On June 26, 2017 at approximately 11:45 am the following observations were made:

1) Observed the smoke barrier doors by room 641 had paper towel stuffed in the jamb at the top of the door preventing it from closing.
2) Observed the SB doors by room 543 did not close to latch preventing the doors from closing to a smoke tight seal.
3) Observed the SB doors to rooms 501-512 did not close to latch preventing the doors from closing to a smoke tight seal.
4) Observed the SB doors by pt. room 444 did not open when tested.
5) Observed the SB doors by holding 177 had a chair placed in front of them preventing the doors from closing.
6) Observed the SB doors by holding 177 did not close to latch preventing a smoke tight seal.

Findings were confirmed with facility maintenance staff HH and II.

Based on document review and interview the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1. This deficient practice could potentially affect all occupants of the facility.
Findings include:

On June 27, 2017 at approximately 12:30 pm document review revealed:

1) The fire drills were not complete in the documentation required for each drill.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview the facility failed to provide safe use of portable space heaters in accordance with the LSC section 19.7.8. This deficient practice could potentially affect 25 occupants of the facility.
Findings include:

On June 27, 2017 at approximately 10:30 am the following observations were made:

1) Observed a portable space heater in use at the registration desk for holding, 177.


Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview the facility failed to provide construction barriers in accordance with the LSC section 19.7.9. This deficient practice could potentially affect 20 occupants of the facility.
Findings include:

On June 26, 2017 at approximately 10:30 am the following observations were made:

1) Observed a construction area on the 4th floor which did not meet the separation requirements.

Findings were confirmed with facility maintenance staff HH and II.

Based on document review and interview, the facility failed to maintain the emergency generator in accordance with NFPA 110. This deficient practice could potentially affect all occupants of the facility.
Findings Include:

On June 27, 2017 at approximately 11:30 am:

1) Requested documentation of the weekly inspections of the generators was not available for review.
2) Requested documentation of the annual load bank testing of the generators was not available for review.


Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 15 occupants of the facility.
Findings include:

On June 26, 2017 at approximately 11:30 am the following observations were made:

1) Observed 5 missing electrical device plates in the Physician lounge on the 6th floor

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 20 occupants of the facility.
Findings include:

On June 26, 2017 at approximately11:30 am the following observations were made:

1) Observed an extension cord in use for a fan in room 605.
2) Observed an extension cord running up through the ceiling tile in the egress corridor by room 665.

Findings were confirmed with facility maintenance staff HH and II.

Based on observation and interview the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 10 occupants of the facility.

Findings include:

On June 26, 2017 at approximately 3:00 pm the following observations were made:

1) Observed an Oxygen (O2) cylinder which was not secured in room 387.
2) Observed the storage of combustible boxes and Styrofoam in the Med gas storage room on the loading dock.
3) Observed metal carts stored on top of the O2 cylinders in the Med gas storage room on the loading dock.

Findings were confirmed with facility maintenance staff HH and II.