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Based on observation it was determined that the facility failed to provide complete sprinkler coverage and does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could potentially affect 60 occupants of the facility if the steel was not protected against fire.

Findings include:

A. On December 5, 2012, at approximately 11:50 AM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel located in the small comm. closet on A-6 was missing the sprayed on fire proofing.

B. On December 5, 2012, at approximately 12:05 PM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel by the fire/smoke doors between Building A and B at doors CC4108 was missing the sprayed on fire proofing.

C. On December 5, 2012, at approximately 2:52 PM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel in Mechanical room B-1 by back stairwell, F-B1 was missing the sprayed on fire proofing.

D. On December 6, 2012, at approximately 9:48 AM, while conducting a walk through with the Maintenance Director, it was observed that where new structural steel added to Elevator Penthouse of Building C was missing the sprayed on fire proofing.

E. On December 6, 2012, at approximately 1:17 PM, while conducting a walk through with the Maintenance Director, it was observed that room B2373 in the OR did not have any sprinkler protection or ceiling to provide separation.

F. On December 6, 2012, at approximately 3:44 PM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel in the Electrical closet of CDU, was missing the sprayed on fire proofing.

G. On December 7, 2012, at approximately 10:25 AM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel in the basement in room BB220 was missing the sprayed on fire proofing.

H. On December 7, 2012, at approximately 11:22 AM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel in Electrical room, BB132, in the basement was missing the sprayed on fire proofing.

I. On December 7, 2012, at approximately 11:48 AM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel in the old boiler room in basement was missing the sprayed on fire proofing.

These deficiencies were confirmed by the Maintenance Director at the time of discovery.

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 25 occupants of the facility if the corridor did not provide the separation required.

Findings include:

-- On December 6, 2012, at approximately 10:51 AM, while conducting a walk through with the Maintenance Director, it was observed that there were three holes located in the corridor ceiling of Annex 2. This deficiency was confirmed at the time of discovery by the Maintenance Director.

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 40 occupants of the facility if the hazard area failed to provide the required separation for smoke and fire.

Findings include:

A. On December 5, 2012, at approximately, 11:15 AM, while conducting a walk through with the Maintenance Director, it was observed that 2 open conduits penetrating the wall of Comm. closet A7528 on A-7 were not sealed to prevent the spread of smoke or fire. (This deficiency was corrected at the time of discovery with a fire proofing system)

B. On December 5, 2012, at approximately, 11:38 AM, while conducting a walk through with the Maintenance Director, it was observed that 2 open conduits penetrating the wall by/over the smoke barrier doors, CCA6107A, on A-6 were not sealed to prevent the spread of smoke or fire. (This deficiency was corrected at the time of discovery with a fire proofing system)

C. On December 5, 2012, at approximately, 12 noon, while conducting a walk through with the Maintenance Director, it was observed that plywood was stored upon the ductwork of AHU 505 on A-5.

D. On December 5, 2012, at approximately, 12:17 PM, while conducting a walk through with the Maintenance Director, it was observed that a conduit penetrating the ceiling of the large Comm. closet, A3146, on A-3 was not sealed to prevent the spread of smoke or fire. (This deficiency was corrected at the time of discovery with a fire proofing system)

E. On December 5, 2012, at approximately, 1:52 PM, while conducting a walk through with the Maintenance Director, it was observed that there was a hole in the drywall ceiling on the west end of the B-5 penthouse.

F. On December 5, 2012, at approximately, 2:55 PM, while conducting a walk through with the Maintenance Director, it was observed that the open conduit penetrating the Mechanical room, B-1, was not sealed to prevent the spread of smoke or fire. (This deficiency was corrected at the time of discovery with a fire proofing system)

All these deficiencies were confirmed at the time of discovery by the Maintenance Director.

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 75 occupants of the facility if the stairwell did not provide the protection as it was designed.

Findings include:

-- On December 6, 2012, at approximately 11:26 AM, while conducting a walk through with the Maintenance Director, it was observed that the door to stairwell at H-C1 was not latching when closed. This deficiency was confirmed at the time of discovery by the Maintenance Director.

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 40 occupants of the facility if the stairwell failed to provide the protection from smoke and fire as required in Section 7.1.3.2.1(d): Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

Findings include:

-- On December 5, 2012, at approximately 3 PM, while conducting a walk through with the Maintenance Director, it was observed that the Mechanical room B-1, was not separated from the exit stairwell as required under Section 7-1. This deficiency was confirmed at the time of discovery by the Maintenance Director.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect 40 occupants of the facility if the corridor width is made smaller because of an obstruction into the corridor and failure to follow LSC 7.1.10.1.

Findings include:

A. On December 6, 2012, at approximately 9:51 AM, while conducting a walk through with the Maintenance Director, it was observed that a Christmas tree had be located in the corridor by the Nurse's station on C-4 reducing the corridor width. (This deficiency was corrected at the time of discovery and tree was relocated in a waiting room area.)

B. On December 6, 2012, at approximately 10:35 AM, while conducting a walk through with the Maintenance Director, it was observed that the facility had mounted a drug disposal unit on the corridor wall of C-2 that extended over 4 inches into the corridor.

C. On December 6, 2012, at approximately 12:35 PM, while conducting a walk through with the Maintenance Director, it was observed that the facility had mounted a drug disposal unit on the corridor wall of D-5 by room 4405 that extended over 4 inches into the corridor.

D. On December 6, 2012, at approximately 12:43 PM, while conducting a walk through with the Maintenance Director, it was observed that the facility had mounted a drug disposal unit on the corridor wall of D-5 by room 4416 that extended over 4 inches into the corridor.

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 20 occupants of the facility if the sprinkler system failed to perform as designed.

Findings include:

A. On December 5, 2012, at approximately 1:45 PM, while conducting a walk through with the Maintenance Director, it was observed that duct work was supported by hanging of the duct work from the sprinkler piping in the Southeast corner of B-5 penthouse.

B. On December 5, 2012, at approximately 1:55 PM, while conducting a walk through with the Maintenance Director, it was observed that the control valve for the sprinkler system to the elevator equipment room was not labeled.

C. On December 6, 2012, at approximately 9:55 AM, while conducting a walk through with the Maintenance Director, it was observed that the Inspector's test valve located in the EVS closet, C4103, on C-4 was not labeled.

D. On December 6, 2012, at approximately 10:27 AM, while conducting a walk through with the Maintenance Director, it was observed that the materials stored in store room C2243 on C-2 was within 18 inches to the sprinklers.

E. On December 6, 2012, at approximately 11:17 AM, while conducting a walk through with the Maintenance Director, it was observed that the Inspector's test valve was not labeled in EVS closet, C1178 on C-1.

F. On December 6, 2012, at approximately 1:10 PM, while conducting a walk through with the Maintenance Director, it was observed that an escutcheon on the sprinkler head in Neuro-Sterile Supply in OR department on 3rd floor was loose.

G. On December 6, 2012, at approximately 1:12 PM, while conducting a walk through with the Maintenance Director, it was observed that an escutcheon on a sprinkler head in the back sterile corridor in surgery on the 3rd floor was loose.

H. On December 6, 2012, at approximately 1:53 PM, while conducting a walk through with the Maintenance Director, it was observed that a sprinkler head was obstructed by a hanging light in EVS store room on ground floor.

I. On December 6, 2012, at approximately 1:57 PM, while conducting a walk through with the Maintenance Director, it was observed that the Inspector's test valve in the EVS store room is not labeled.

J. On December 6, 2012, at approximately 2:19 PM, while conducting a walk through with the Maintenance Director, it was observed that since the storage units for film have been removed, 2 sprinkler heads are now less than 6 feet apart in the old Radiology film storage.

K. On December 6, 2012, at approximately 2:22 PM, while conducting a walk through with the Maintenance Director, it was observed that the Inspector's test valve is not labeled in the EVS closet, BG219.

L. On December 7, 2012, at approximately 10:35 AM, while conducting a walk through with the Maintenance Director, it was observed that in room BB215 part of the ceiling had been removed, no sprinklers had been provided to the space above the ceiling.

M. On December 7, 2012, at approximately 11:01 AM, while conducting a walk through with the Maintenance Director, it was observed that a wire was hung from the sprinkler piping in "B" building basement distribution room.

N. On December 7, 2012, at approximately 11:20 AM, while conducting a walk through with the Maintenance Director, it was observed that the Inspector's test valve in the basement, room BB148, was not labeled.

All of these deficiencies were confirmed at the time of discovery by the Maintenance Director.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 20 occupants of the facility if the tanks are not protected from damage.

Findings include:

-- On December 6, 2012, at approximately 11:24 AM, while conducting a walk through with the Maintenance Director, it was observed that the strapping done to prevent the Nitrogen tanks from dislodging and falling over was not arranged or tight enough to prevent damage to tanks. This deficiency was confirmed by the Maintenance Director at the time of discovery.

Based on observation it was determined that the facility failed to provide complete sprinkler coverage and does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could potentially affect 60 occupants of the facility if the steel was not protected against fire.

Findings include:

A. On December 5, 2012, at approximately 11:50 AM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel located in the small comm. closet on A-6 was missing the sprayed on fire proofing.

B. On December 5, 2012, at approximately 12:05 PM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel by the fire/smoke doors between Building A and B at doors CC4108 was missing the sprayed on fire proofing.

C. On December 5, 2012, at approximately 2:52 PM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel in Mechanical room B-1 by back stairwell, F-B1 was missing the sprayed on fire proofing.

D. On December 6, 2012, at approximately 9:48 AM, while conducting a walk through with the Maintenance Director, it was observed that where new structural steel added to Elevator Penthouse of Building C was missing the sprayed on fire proofing.

E. On December 6, 2012, at approximately 1:17 PM, while conducting a walk through with the Maintenance Director, it was observed that room B2373 in the OR did not have any sprinkler protection or ceiling to provide separation.

F. On December 6, 2012, at approximately 3:44 PM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel in the Electrical closet of CDU, was missing the sprayed on fire proofing.

G. On December 7, 2012, at approximately 10:25 AM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel in the basement in room BB220 was missing the sprayed on fire proofing.

H. On December 7, 2012, at approximately 11:22 AM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel in Electrical room, BB132, in the basement was missing the sprayed on fire proofing.

I. On December 7, 2012, at approximately 11:48 AM, while conducting a walk through with the Maintenance Director, it was observed that the structural steel in the old boiler room in basement was missing the sprayed on fire proofing.

These deficiencies were confirmed by the Maintenance Director at the time of discovery.

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 25 occupants of the facility if the corridor did not provide the separation required.

Findings include:

-- On December 6, 2012, at approximately 10:51 AM, while conducting a walk through with the Maintenance Director, it was observed that there were three holes located in the corridor ceiling of Annex 2. This deficiency was confirmed at the time of discovery by the Maintenance Director.

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 40 occupants of the facility if the hazard area failed to provide the required separation for smoke and fire.

Findings include:

A. On December 5, 2012, at approximately, 11:15 AM, while conducting a walk through with the Maintenance Director, it was observed that 2 open conduits penetrating the wall of Comm. closet A7528 on A-7 were not sealed to prevent the spread of smoke or fire. (This deficiency was corrected at the time of discovery with a fire proofing system)

B. On December 5, 2012, at approximately, 11:38 AM, while conducting a walk through with the Maintenance Director, it was observed that 2 open conduits penetrating the wall by/over the smoke barrier doors, CCA6107A, on A-6 were not sealed to prevent the spread of smoke or fire. (This deficiency was corrected at the time of discovery with a fire proofing system)

C. On December 5, 2012, at approximately, 12 noon, while conducting a walk through with the Maintenance Director, it was observed that plywood was stored upon the ductwork of AHU 505 on A-5.

D. On December 5, 2012, at approximately, 12:17 PM, while conducting a walk through with the Maintenance Director, it was observed that a conduit penetrating the ceiling of the large Comm. closet, A3146, on A-3 was not sealed to prevent the spread of smoke or fire. (This deficiency was corrected at the time of discovery with a fire proofing system)

E. On December 5, 2012, at approximately, 1:52 PM, while conducting a walk through with the Maintenance Director, it was observed that there was a hole in the drywall ceiling on the west end of the B-5 penthouse.

F. On December 5, 2012, at approximately, 2:55 PM, while conducting a walk through with the Maintenance Director, it was observed that the open conduit penetrating the Mechanical room, B-1, was not sealed to prevent the spread of smoke or fire. (This deficiency was corrected at the time of discovery with a fire proofing system)

All these deficiencies were confirmed at the time of discovery by the Maintenance Director.

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 75 occupants of the facility if the stairwell did not provide the protection as it was designed.

Findings include:

-- On December 6, 2012, at approximately 11:26 AM, while conducting a walk through with the Maintenance Director, it was observed that the door to stairwell at H-C1 was not latching when closed. This deficiency was confirmed at the time of discovery by the Maintenance Director.

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 40 occupants of the facility if the stairwell failed to provide the protection from smoke and fire as required in Section 7.1.3.2.1(d): Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

Findings include:

-- On December 5, 2012, at approximately 3 PM, while conducting a walk through with the Maintenance Director, it was observed that the Mechanical room B-1, was not separated from the exit stairwell as required under Section 7-1. This deficiency was confirmed at the time of discovery by the Maintenance Director.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect 40 occupants of the facility if the corridor width is made smaller because of an obstruction into the corridor and failure to follow LSC 7.1.10.1.

Findings include:

A. On December 6, 2012, at approximately 9:51 AM, while conducting a walk through with the Maintenance Director, it was observed that a Christmas tree had be located in the corridor by the Nurse's station on C-4 reducing the corridor width. (This deficiency was corrected at the time of discovery and tree was relocated in a waiting room area.)

B. On December 6, 2012, at approximately 10:35 AM, while conducting a walk through with the Maintenance Director, it was observed that the facility had mounted a drug disposal unit on the corridor wall of C-2 that extended over 4 inches into the corridor.

C. On December 6, 2012, at approximately 12:35 PM, while conducting a walk through with the Maintenance Director, it was observed that the facility had mounted a drug disposal unit on the corridor wall of D-5 by room 4405 that extended over 4 inches into the corridor.

D. On December 6, 2012, at approximately 12:43 PM, while conducting a walk through with the Maintenance Director, it was observed that the facility had mounted a drug disposal unit on the corridor wall of D-5 by room 4416 that extended over 4 inches into the corridor.

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 20 occupants of the facility if the sprinkler system failed to perform as designed.

Findings include:

A. On December 5, 2012, at approximately 1:45 PM, while conducting a walk through with the Maintenance Director, it was observed that duct work was supported by hanging of the duct work from the sprinkler piping in the Southeast corner of B-5 penthouse.

B. On December 5, 2012, at approximately 1:55 PM, while conducting a walk through with the Maintenance Director, it was observed that the control valve for the sprinkler system to the elevator equipment room was not labeled.

C. On December 6, 2012, at approximately 9:55 AM, while conducting a walk through with the Maintenance Director, it was observed that the Inspector's test valve located in the EVS closet, C4103, on C-4 was not labeled.

D. On December 6, 2012, at approximately 10:27 AM, while conducting a walk through with the Maintenance Director, it was observed that the materials stored in store room C2243 on C-2 was within 18 inches to the sprinklers.

E. On December 6, 2012, at approximately 11:17 AM, while conducting a walk through with the Maintenance Director, it was observed that the Inspector's test valve was not labeled in EVS closet, C1178 on C-1.

F. On December 6, 2012, at approximately 1:10 PM, while conducting a walk through with the Maintenance Director, it was observed that an escutcheon on the sprinkler head in Neuro-Sterile Supply in OR department on 3rd floor was loose.

G. On December 6, 2012, at approximately 1:12 PM, while conducting a walk through with the Maintenance Director, it was observed that an escutcheon on a sprinkler head in the back sterile corridor in surgery on the 3rd floor was loose.

H. On December 6, 2012, at approximately 1:53 PM, while conducting a walk through with the Maintenance Director, it was observed that a sprinkler head was obstructed by a hanging light in EVS store room on ground floor.

I. On December 6, 2012, at approximately 1:57 PM, while conducting a walk through with the Maintenance Director, it was observed that the Inspector's test valve in the EVS store room is not labeled.

J. On December 6, 2012, at approximately 2:19 PM, while conducting a walk through with the Maintenance Director, it was observed that since the storage units for film have been removed, 2 sprinkler heads are now less than 6 feet apart in the old Radiology film storage.

K. On December 6, 2012, at approximately 2:22 PM, while conducting a walk through with the Maintenance Director, it was observed that the Inspector's test valve is not labeled in the EVS closet, BG219.

L. On December 7, 2012, at approximately 10:35 AM, while conducting a walk through with the Maintenance Director, it was observed that in room BB215 part of the ceiling had been removed, no sprinklers had been provided to the space above the ceiling.

M. On December 7, 2012, at approximately 11:01 AM, while conducting a walk through with the Maintenance Director, it was observed that a wire was hung from the sprinkler piping in "B" building basement distribution room.

N. On December 7, 2012, at approximately 11:20 AM, while conducting a walk through with the Maintenance Director, it was observed that the Inspector's test valve in the basement, room BB148, was not labeled.

All of these deficiencies were confirmed at the time of discovery by the Maintenance Director.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 20 occupants of the facility if the tanks are not protected from damage.

Findings include:

-- On December 6, 2012, at approximately 11:24 AM, while conducting a walk through with the Maintenance Director, it was observed that the strapping done to prevent the Nitrogen tanks from dislodging and falling over was not arranged or tight enough to prevent damage to tanks. This deficiency was confirmed by the Maintenance Director at the time of discovery.