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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 1.1.4.1, 19.1.1.4.2. This deficient practice could affect all occupants in the event of a fire in the non-conforming building where the products of combustion are allowed to transmit throughout the facility due to an improperly maintained 2 hour separation.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 2:00 PM observed that the rating label for Buyer's Office Door in the 2 hour separation wall was not legible.
- At approximately 2:03 PM observed that the Buyer's Office Door in the 2 hour separation wall would not self-close to a positive latch.
- At approximately 1:10 PM observed that the ER door east leaf contained 2 holes creating an unsealed through penetration in the 2 hour separation.
- At approximately 1:12 PM observed that the ER door west leaf contained 2 holes creating an unsealed through penetration in the 2 hour separation.

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 affect occupants of the affected smoke compartment in the event of a fire within the hazardous area enclosure where the products of combustion are allowed to spread to the means of egress due to improperly maintained hazardous room enclosures.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 12:10 PM observed that Special Procedures Storage Room walls did not provide a one hour separation rating.
- At approximately 12:40 PM observed that the Radiology/ER Condensate Room located next to the Janitor's Closet contained 2 electrical conduits penetrating the wall creating 2 unsealed through penetrations.
- At approximately 12:50 PM observed that the ER Soiled Utility door did not latch.

Based on observation the facility failed to provide horizontal exits in accordance with the LSC section 19.2.2.5. This deficient practice could affect an all occupants in the event of a fire where the products of combustion are allowed to transmit throughout an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure due to improper automatic closing of doors.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 1:00 PM observed that the Ambulance Bay power assisted exit access doors in the 2 hour rated wall were not equipped to close including the power assist mechanism ceasing to function upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72. NFPA 101 Section 7.2.1.9.2

Based on observation the facility failed to provide exit and directional signs in accordance with the LSC section 19.2.10.1. This deficient practice could affect room occupants in the event of an emergency where the rapid evacuation of the room is necessary, but is delayed due to improperly maintained exit signs.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 2:14 PM observed that the Cardio Pulmonary Rehab "Exit" sign was not illuminated.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 18.7.1.2. Findings include:

On 04/30/13, the following observations were made:

- At approximately 9:00 AM observed that fire drill records for 2012 2nd, 3rd, and 4th quarters were available for review, but the shift conducted could not be identified due to incomplete time of day recording.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 9:00 AM observed that fire drill records for 2012 2nd, 3rd, and 4th quarters were available for review, but the shift conducted could not be identified due to incomplete time of day recording.

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 affect all building occupants in the event of a fire where the early suppression of the fire does not occur due to incomplete sprinkler system protection.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 3:00 PM observed that the Radiology rooftop air handing unit was not provided with an automatic sprinkler system. Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system. Section 18.3.5.1
- At approximately 3:15 PM observed that the Entryway rooftop air handling unit was not provided with an automatic sprinkler system. Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system. Section 18.3.5.1

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 19.3.5. This deficient practice could affect all occupants of the affected smoke compartment in the event of a fire where the early suppression of the fire does not occur due to the improperly maintained fire sprinkler system.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 12:30 PM observed that in the Radiology Maintenance Room there was missing ceiling tile, creating a space not provided with sprinkler protection.
- At approximately 4:15 PM observed that in the Medical Records Storage Room there were file storage units that placed stored items closer than 18" to the bottom of the sprinkler deflectors.

Based on observation the facility failed to provide signs where oxygen is used or stored in accordance with NFPA 99. This deficient practice could affect occupants of the smoke compartment in the event of a fire where improperly signed oxygen storage rooms contribute to a delay in control of a fire in that area.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 11:15 AM observed that the 2nd Floor Med Storage Room was being used for oxygen storage, and a precautionary sign, readable from a distance of 5 ft (1.5 m), conspicuously displayed on each door or gate of the storage room or enclosure was not provided. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

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 1.1.4.1, 19.1.1.4.2. This deficient practice could affect all occupants in the event of a fire in the non-conforming building where the products of combustion are allowed to transmit throughout the facility due to an improperly maintained 2 hour separation.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 2:00 PM observed that the rating label for Buyer's Office Door in the 2 hour separation wall was not legible.
- At approximately 2:03 PM observed that the Buyer's Office Door in the 2 hour separation wall would not self-close to a positive latch.
- At approximately 1:10 PM observed that the ER door east leaf contained 2 holes creating an unsealed through penetration in the 2 hour separation.
- At approximately 1:12 PM observed that the ER door west leaf contained 2 holes creating an unsealed through penetration in the 2 hour separation.

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 affect occupants of the affected smoke compartment in the event of a fire within the hazardous area enclosure where the products of combustion are allowed to spread to the means of egress due to improperly maintained hazardous room enclosures.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 12:10 PM observed that Special Procedures Storage Room walls did not provide a one hour separation rating.
- At approximately 12:40 PM observed that the Radiology/ER Condensate Room located next to the Janitor's Closet contained 2 electrical conduits penetrating the wall creating 2 unsealed through penetrations.
- At approximately 12:50 PM observed that the ER Soiled Utility door did not latch.

Based on observation the facility failed to provide horizontal exits in accordance with the LSC section 19.2.2.5. This deficient practice could affect an all occupants in the event of a fire where the products of combustion are allowed to transmit throughout an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure due to improper automatic closing of doors.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 1:00 PM observed that the Ambulance Bay power assisted exit access doors in the 2 hour rated wall were not equipped to close including the power assist mechanism ceasing to function upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72. NFPA 101 Section 7.2.1.9.2

Based on observation the facility failed to provide exit and directional signs in accordance with the LSC section 19.2.10.1. This deficient practice could affect room occupants in the event of an emergency where the rapid evacuation of the room is necessary, but is delayed due to improperly maintained exit signs.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 2:14 PM observed that the Cardio Pulmonary Rehab "Exit" sign was not illuminated.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 18.7.1.2. Findings include:

On 04/30/13, the following observations were made:

- At approximately 9:00 AM observed that fire drill records for 2012 2nd, 3rd, and 4th quarters were available for review, but the shift conducted could not be identified due to incomplete time of day recording.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 9:00 AM observed that fire drill records for 2012 2nd, 3rd, and 4th quarters were available for review, but the shift conducted could not be identified due to incomplete time of day recording.

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 affect all building occupants in the event of a fire where the early suppression of the fire does not occur due to incomplete sprinkler system protection.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 3:00 PM observed that the Radiology rooftop air handing unit was not provided with an automatic sprinkler system. Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system. Section 18.3.5.1
- At approximately 3:15 PM observed that the Entryway rooftop air handling unit was not provided with an automatic sprinkler system. Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system. Section 18.3.5.1

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 19.3.5. This deficient practice could affect all occupants of the affected smoke compartment in the event of a fire where the early suppression of the fire does not occur due to the improperly maintained fire sprinkler system.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 12:30 PM observed that in the Radiology Maintenance Room there was missing ceiling tile, creating a space not provided with sprinkler protection.
- At approximately 4:15 PM observed that in the Medical Records Storage Room there were file storage units that placed stored items closer than 18" to the bottom of the sprinkler deflectors.

Based on observation the facility failed to provide signs where oxygen is used or stored in accordance with NFPA 99. This deficient practice could affect occupants of the smoke compartment in the event of a fire where improperly signed oxygen storage rooms contribute to a delay in control of a fire in that area.

Findings include:

On 04/30/13, the following observations were made:

- At approximately 11:15 AM observed that the 2nd Floor Med Storage Room was being used for oxygen storage, and a precautionary sign, readable from a distance of 5 ft (1.5 m), conspicuously displayed on each door or gate of the storage room or enclosure was not provided. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING