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Based on observation and review of records the facility failed to provide approved interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 03/02/2010, at approximately 11:21 AM, observed a bulletin board without a fire rating next to room 723.

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

1:31 PM, Observed in the 2 hour extended egress hall from stairwell 9 to the exterior near ER an unsealed penetration above the ceiling into the corridor.

8:56 AM, Observed in the corridor near the radiology office #1789 a glass window in the 1 hour rated wall to the corridor with no drop door. Confirmation of the window assembly is needed.

9:56 AM, Observed a penetration above the ceiling to the corridor in the patient registration office.

On 03/03/2010, at approximately 10:39 AM, observed a 1" unsealed penetration on west wall of room 4330.

Based on observation the facility failed to provide corridor doors that would resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 3/3/2010, at approximately 1:49 PM, observed the top half of the dutch door in room 4590 could be attached to the bottom half by a dead bolt and the two halfs did not close and latch in accordance with NFPA 101 Life Safety Code 2000 Edition 19.3.6.3.6.

On 03/02/2010, at approximately 11:07 AM, the clean linen room door failed to close and latch.

On 03/02/2010, at approximately 2:10 PM, observed fire/smoke doors next to room 620 did not close and latch.

On 03/03/2010, at approximately 10:52 AM, observed storage room 4360 door propped open defeating the door closer.

Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 03/08/2010, at approximately 11:34 AM, observed in stairwell # 2, 6th floor a penetration of the stairwell wall by a fire sprinkler without fire stopping.

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:

03/08/2010, at approximately 9:23 AM, observed in the custodial closet on the 7th floor, unsealed penetrations by 7 cables through the smoke barrier wall.

10:36 AM, Observed unsealed penetrations on the 3rd floor smoke barrier wall near the OR Suite separating Patient Pre-op above the ceiling over double doors.

11:36 AM, Observed unsealed penetrations on the 3rd floor above doors near the wound care office.

11:43 AM, Observed unsealed penetrations on the 3rd floor in ICU above the ceiling near room 307.

11:49 AM, Observed an unsealed penetration through the wall on the 3rd floor near ICU next to vending machines.

2:07 PM, Observed an unsealed penetration on the 2nd floor through the wall above the doors to the executive offices.

8:54 AM, -Observed on the 1st floor the smoke barrier doors near the manager office door labeled 1-10-B was not closing due to rubbing on the floor.

9:05 AM, Observed on the 1st floor the smoke barrier wall between the men's bathroom and the lady's bathroom did not extend tight to the deck above to maintain the required separation.

9:18 AM, Observed an unsealed penetration through the 2 hour wall on the 1st floor near the main elevator banks separating the office kitchen and the corridor.

9:21 AM, Observed an unsealed penetration on the 1st floor through the 2 hour wall above the door labeled 1-12-A.

10:17 AM, Observed an unsealed penetration above the roll up doors separating the kitchen servers and the dining room.

10:26 AM, Observed an unsealed penetration through the smoke barrier wall on the 1st floor separating the lobby and the hospital.

10:36 AM, Observed on the 3rd floor the smoke barrier to the OR Suite separating Patient Pre-op, unsealed penetrations above ceiling over double doors.

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 potentially affect all occupants of the facility.

Findings include:

On 03/08/2010 at approximately 10:06 AM observed in the 6th floor soiled utility room, unsealed penetrations by a wet fire sprinkler line.

10:31 AM-Observed on the 3rd floor in the OR area utility room with no separation above ceiling from the patient area and hazardous area.

11:21 AM-Observed on the 3rd floor near SDS 4 in the soiled utility room, unsealed penetrations above ceiling.

2:09 PM-Observed on the 2nd floor executive office area a storage room with improperly sealed penetrations through the wall.

2:14 PM-Observed on the 2nd floor in the executive office area unsealed penetrations in the mechanical room.

8:44 AM-Observed on the 1st floor in storage room near Doctors Chart room an unsealed penetration through wall.

9:03 AM-Observed an improperly sealed penetration through the wall of the telephone room on the 1st floor near elevators.

9:39 AM-Observed an office near the 1st floor kitchen used as storage and the room is not fire rated as required. Also observed an improperly sealed penetration through the 2 hour block wall above the ceiling.

10:05 AM-Observed on the 1st floor in the water meter room an unsealed penetration above the ceiling in the corridor.

10:46 AM-Observed an unsealed penetration on the 1st floor in the soiled linen room to laundry.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 03/02/2010, at approximately 9:13 AM, observed an approximate 1 foot area missing the required fire proofing on the structural beam in the stairwell.

On 03/03/2010, at approximately 9:03 AM, observed unsealed penetrations above the fire doors nearest the elevator doors on the fifth floor.

Based on observation the facility failed to provide approved means of egress in accordance with the LSC section 19.2.2.3, 19.2.2.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 03/08/2010, at approximately 11:12 AM, observed on the 3rd floor in stairwell #4 storage in the stairwell.

1:45 PM, Observed on the 2nd floor in stairwell #4 storage in stairwell, also exiting to the roof not clear of snow and ice to other stairs.

2:02 PM, Observed on the 2nd floor stairwell #6 was not clear of ice and snow when you exited to the roof.

2:17 PM, Observed on the 2nd floor Stairwell #7 was not clear of ice and snow when you exited to the roof.

9:13 AM, Observed on the 1st floor stairwell 3 empties out onto the 1st floor from floors 2 and 3 this stairwell must be maintained 1 hour to an exit. Confirm wall construction in this area.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 03/03/2010, at approximately 10:58 AM, observed that the chart box near room 453 and a chart box near room 429, when placed in the writing position did not automatically close.

On 03/02/2010, at approximately 11:47 AM, observed that the chart box near room 750, when placed in the writing position did not automatically close.

On 03/02/2010, at approximately 1:44 AM, observed that the chart box near room 745 and a chart box near room 743, when placed in the writing position did not automatically close.

On 03/02/2010, at approximately 2:43 PM, observed that 2 computer on wheels units were plugged into wall sockets in the corridor across from room 5190.

On 03/02/2010, at approximately 2:40 PM, observed that the chart box near room 518 when placed in the writing position did not automatically close.

On 03/02/2010, at approximately 2:25 PM, observed patient chart boxes next to room 618 & 620 did not automatically close when opened for use.

1:48 PM, During Fire Alarm testing it was observed the delayed egress locks on the 2nd floor to stairwell #8 near room 250 failed to release the locking mechanism. Also observed this on door 2440.

2:01 PM, During the fire alarm activation in the psych ward staff was asked to provide a key to the stairwell, staff was misinformed on the proper key and could not find the key quickly and in a timely manner. Staff was also confused on the proper key for the fire alarm pull station. Some Staff did not have their keys with them, they used other staff keys.

On 03/02/2010, at approximately 11:05 AM, observed patient chart box next to room 719 did not automatically close when opened for use.

On 03/02/2010, at approximately 11:20 AM, observed patient chart box next to room 720 did not automatically close when opened for use.

On 03/02/2010, at approximately 11:35 AM, observed patient chart box next to room 645 did not automatically close when opened for use.

On 03/02/2010, at approximately 12:35 AM, observed patient chart box next to room 648, and 652 did not automatically close when opened for use.

On 03/02/2010, at approximately 12:20 PM, observed patient chart box next to room 611 did not automatically close when opened for use.

On 03/02/2010, at approximately 12:25 PM, observed patient chart box next to room 615 did not automatically close when opened for use.

On 03/02/2010, at approximately 12: 26 PM, observed Computer on wheels blocking egress in the corridor next to room 617.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.5. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 03/01/2010, at approximately 9:01 AM, observed the exit door near the mobile scanner # 24 had the wrong door swing. The door opened against egress.

Based on observation the facility failed to provide lighting in accordance with the LSC section 19.2.8. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 3/03/2010, at approximately 1:58 PM, observed an emergency exit sign burned out near room 1516.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 03/03/2010, at approximately 2:05 PM, observed in the Emergency generator room an EBU that is inoperable.

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 all occupants of the facility.

Findings include:

On 03/09/2010, at approximately 1:03 PM, observed that the facility failed to produce an annual fire alarm test in accordance with National Fire Alarm Code Hand book 7-5.2.2 - 7-5.4.

Based on observation and review of records the facility failed to provide and maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 3/03/2010, at approximately 2:40 PM, observed that the pressure gauge in basement riser number 4, gauge was not calibrated.

On 3/03/2010, at approximately 12:35 PM, observed that the pressure gauge in stairwell 11 across from room 471 is past its calibration date.

03/02/2010, at approximately 11:55 AM, observed an escutcheon ring missing from sprinkler head in the nurse's station near room 748.

On 03/02/2010, at approximately 11: 07 AM, observed that the inspectors test valve with no tag or labeled in room 740.

11:26 AM, Observed in the clean storage OR a sprinkler head to far from a wall for proper coverage. A distance of over 13 feet was observed.

11:40 AM, Observed an escutcheon ring missing from sprinkler head in room 1024.

1:54 PM, Observed an escutcheon ring missing from sprinkler head in room 1516.

8:53 AM, Observed in the shipping and receiving area an inspectors test valve in the corner with the valve handle broken off.

On 3/01/2010, at approximately 11:12 AM, observed that the sprinkler system located in the basement mechanical room does not have a hydraulic name plate attached to the riser, the wet sprinkler system pressure gauge has not been calibrated within 5 years.

On 03/02/2010, at approximately 11:25 AM, observed an escutcheon ring missing from the sprinkler head in the corridor next to room 723.

On 03/02/2010, at approximately 12: 05 PM, observed that the inspectors test valve in room 6400 had no tag or label.

On 03/02/2010, at approximately 2:58 PM, observed control valve #4 was leaking.

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 all occupants of the facility.

Findings include:

On 03/02/2010, at approximately 2:56 PM, observed that control valve #4 in the pump room did not have a tamper switch installed.

Based on observation and review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and 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 03/08/2010, at approximately 9:48 AM, observed in stairwell #1, 7th floor that the pressure gauge has not been calibrated within 5 years.

10:38 AM, Observed on the 3rd floor in the Phase 1 recovery area a curtain track installed over a sprinkler head.

10:43 AM, Observed on the 3rd floor in the OR equipment storage room had inadequate sprinkler head coverage for the number of heads provided.

10:46 AM, Observed on the 3rd floor in the OR area the doctors charting area a missing escutcheon ring.

1:53 PM, Observed on the 2nd floor in the custodial closet a large gap around the sprinkler head through the ceiling tile.

9:49 AM, Observed on the 1st floor in the receiving area, the hallway door to the storage room has the wrong type of sprinkler head installed.

Based on observation and review of records the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 3/1/2010, at approximately 9:30 AM, Observed a fire extinguisher near room 1901 blocked by a corridor door In the held open position. When the fire alarm is activated the door shuts and reveals the extinguisher cabinet.

On 03/01/2010, at approximately 1:28 PM, observed that the K class fire extinguishers in the kitchen were not visible from all directions and were installed at a height over 6'.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 3/01/2010 at approximately 9:50 AM observed the fire suppression system covering the grill in the kitchen was loose and appeared to be off center from the grill, the filters for the hood system were grease laden, the fusible links were covered with grease and a tar like substance.

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

Findings include:

2:02 PM, Observed in the Medical gas storage room near room 1610 oxygen gas stored with combustibles and other storage equipment, along with unsealed penetrations into the room, and the room not labeled for oxygen storage.

2:14 PM, Observed in the medical oxygen storage room near the trash dumpster, penetrations into the room and the room not labeled for oxygen storage.

Based on observation and review of records the facility failed to comply with NFPA 101 Life Safety Code 2000 edition 4.2.1,and 4.6.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 03/01/2010, at approximately 10:58 AM, observed two O2 tanks unsecured in the basement gas storage room.

2:10 PM, Observed in the Boiler Room four H tanks stored in the room secured only with a bungee to a mobile sign. Storage of the pressurized cylinders is inadequate.

8:49 AM, Observed in the electrical room 1787 combustible boxes stored next to the electrical panels.

On 3/03/2010, at approximately 2:45 PM, observed in the corridor next to the carpenter shop a large drum of stored used batteries, the batteries terminals were not covered and due to the positions of the batteries positive terminals touching positive terminals and negative touching negative terminals creating a short condition and fire hazard, some of the batteries were warm to the touch.

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 03/01/2010, at approximately 9:40 AM, observed the electrical circuit for the Kitchen hood fire suppression not clearly marked in the electrical panel.