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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:

On 06/23/10 the following observations were made:

At approximately 10:40 AM, Observed an unsealed penetration (approximately 1/8"wide) in the Brush Building basement corridor, above the ceiling tile, above the door marked 6870A. This penetration would not prevent the spread of smoke and heat into the corridor wall.


These findings were observed and confirmed by the Facility Maintenance Director during the inspection.

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.

On 06/24/2010, the following observations were made:

1. At approximately 2:41 PM, observed that dry wall was used to seal penetrations in the PACU corridor. Also observed a gap (approximately ½ " x 5 " wide) between the wall and the deck that is not protected by fire stopping material.

These findings were observed and confirmed by the Manager of Plant Operations and Environmental Services and Safety Officer during the inspection.

Based on observation 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 All occupants of the facility.

Findings include:

On 06/24/2010, the following observations were made:

At approximately 11:35 AM, Observed an unsealed penetration (approximately 1/4" wide) in the corridor door leading to the Radiology Reception, across from room G252. This penetration would not prevent the spread of smoke and heat into the corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


27171

Based on observation 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 all occupants of the facility.

Findings include:

On 06/24/2010, the following observations were made:

At approximately 11:14 AM, Observed that the West door to the 10th floor Pantry (Webber South Bldg.) did not fully close to a positive latch.

These findings were observed and confirmed by the Corporate Plant Operations Manager.

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.

On 06/21/2010, the following observations were made:

At approximately 11:14 AM, Observed that the stairwell door HAR-42 is sticking and does not fully close to a positive latch. This penetration would allow smoke and heat to enter the stairwell.

These findings were observed and confirmed by the Corporate Facility Director.


18760

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 06/23/2010, the following observations were made:

At approximately 9:45 AM, Observed an unsealed conduit penetration (approximately 1/2" wide) protruding through the 2-hr fire, wall above the door to exit access stairwell HUH-47 (2nd floor Brush Bldg. This penetration would allow smoke and heat to enter the stairwell.

These findings were observed and confirmed by the Corporate Plant Operations Manager.

At approximately 1:30 PM, Observed that stairwell door HUH-32 (Weber North Building) at room 3502 did not fully close to a positive latch. This deficiency would allow smoke and heat to enter the stairwell.

These findings were observed and confirmed by the Facility Maintenance Director



27171

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 06/21/2010, the following observations were made:

At approximately 11:32 AM, Observed that stairwell door HUH-32 (10th floor, Webber South Bldg.) did not fully close to a positive latch. This deficiency would allow smoke and heat to enter the stairwell.

These findings were observed and confirmed by the Plant Operations Manager.

At approximately 11:36 AM, Observed that stairwell door HUH-36 (10th floor Webber South Bldg.) does not fully close to a positive latch. This deficiency would allow smoke and heat to enter the stairwell.

These findings were observed and confirmed by the Plant Operations Manager.

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:

On 06/23/10, the following observations were made:

At approximately 10:00 AM, Observed an unsealed penetration (Approximately 2"wide) through the cross-corridor smoke barrier wall at room 8601. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 10:37 AM, Observed a 3" x 5" section of missing drywall (above ceiling tile) in the corridor, across from room 8702.

These findings were observed and confirmed by the Facility Maintenance Director.

On 06/21/10, the following observations were made:

At approximately 1:00 PM, Observed three unsealed floor conduits (approximately 2" wide) in the Brush Building Telephone Closet, at the elevator foyer. This deficiency would allow smoke and heat to travel between floors.

These findings were observed and confirmed by the Facility Maintenance Director.


On 06/23/10, the following observations were made:

At approximately 2:02 PM, Observed multiple unsealed wall penetrations (approximately 2" wide) above the cross-corridor smoke barrier doors at room 3712. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility Maintenance Director.


18760

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:

On 06/23/10, the following observations were made:

At approximately 10:00 AM, Observed an unsealed open penetration (approximately 3" x 3") in the 2-hr fire wall, above the ceiling tile, (approximately 3' from the entrance to the Surgical Lounge, on the 2nd floor of the Brush Building). This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Corporate Operations Director.



27171

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:

On 06/21/10, the following observations were made:

At approximately 11:38 AM, Observed an unsealed section of the cable tray, located at the cross- corridor smoke barrier (near the I.C.U. Elevators, on the 10th Floor, Webber South Building) wall.

These findings were observed and confirmed by the Plant Operations Manager.


At approximately 11:42 AM, Observed an unsealed pipe penetration (Approximately 2"wide) through the cross-corridor smoke barrier, (located near 10-I.C.U. Electrical Closet, Webber South Building). This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Plant Operations Manager.


At approximately 1:13 PM, Observed an unsealed conduit penetration in the cross-corridor smoke barrier wall. (located on the east side of the 9th floor nurses station, in the Webber South Building).
This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Plant Operations Manager.


At approximately 1:33 PM, Observed an unsealed section of the cable tray (located at the 9th floor Webber Building cross- corridor smoke barrier, at South entrance to I.C.U.).

These findings were observed and confirmed by the Plant Operations Manager.


At approximately 1:40 PM, Observed an unsealed section of cable tray. Located at the cross- corridor smoke barrier wall, near I.C.U. Room 8522.

These findings were observed and confirmed by the Plant Operations Manager.

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 19.2.2.2.6. This deficient practice could potentially affect All occupants of the facility.

Findings include:

On 06/23/10, the following observations were made:

At approximately 2:02 PM, Observed that the coordinator on the cross-corridor smoke barrier doors, located at room 5719, did not function when tested. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility Maintenance Director.

At Approximately 12:22 PM, Observed an approximately 1/8" gap between the edges of the cross-corridor smoke barrier doors, adjacent to room 3820. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility Maintenance Director.


On 06/21/10, the following observations were made:

At approximately 11:27 AM, Observed that the cross-corridor smoke barrier doors (Located adjacent to the 10th floor Webber- South I.C.U. entrance) did not fully close. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 1:20 PM, Observed that the cross-corridor smoke barrier wall (Located at the 9th floor, Webber South nurse's station) did not extend to the ceiling. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility 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 all occupants of the facility.

Findings include:

On 06/21/10, the following observations were made:

At approximately 12:46 PM, Observed that the door to clean utility room/ storage room 3627 requires a self-closer. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 10:01 AM, Observed an unapproved trash receptacle in the Brush Center corridor at room 3820.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 2:46 PM, Observed that the door to supply room 8701 does not meet the 45-minute rating requirement.

These findings were observed and confirmed by the Facility Maintenance Director.

At approximately 2:46 PM, Observed an unsealed wall penetration between the corridor and room 8701. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 2:49 PM, Observed that he door to supply room 8712 does not meet the minimum 45-minute rating requirement.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 12:46 PM, Observed that the door to Janitor's Closet 7702 does not self-close and latch. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 12:46 PM, Observed an unsealed wall penetration (Approximately 1" x 2" wide) above the door to Janitor's Closet 7702. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director.

At approximately 2:49 PM, Observed that the storage room door, at entrance to 6-Brush Center, is not rated.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 2:55 PM, Observed that the door to the storage closet at room 6812 is not rated.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 2:49 PM, Observed that the door to storage room 6605A does not have a self-closer.

These findings were observed and confirmed by the Facility Maintenance Director.

At approximately 2:19 PM, Observed that the dimensions of the clean linen/ storage room 5718 exceed 100 square feet and is not sprinkler protected.

These findings were observed and confirmed by the Facility Maintenance Director.

At approximately 2:57 PM, Observed heat producing appliances were observed in staff lounge 5708. This room is not sprinkled or have a rated door with closer. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director

At approximately 2:58 PM, Observed wiring and combustibles not properly secured inside of Mechanical closet 2627.

These findings were observed and confirmed by the Facility Maintenance Director


18760

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 06/21/10, the following observations were made:

At approximately 11:32 AM, Observed that the door to the Soiled Linen Room marked G114/1114A did not close to a positive latch. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 11:50 AM, Observed that the door to the Weber Building O.R. janitor's closet did not close to a positive latch. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 1:25 PM, Observed that the door to the Wendy's kitchen janitor's closet did not close to a positive latch. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 1:35 PM, Observed ceiling tiles missing in the Webber Building ground floor service elevator area.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 10:20 AM, Observed an unsealed wall penetration (Approximately 3" x 3" in diameter) in the Brush Building Upper Café janitor's closet. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 10:25 AM, Observed that the door to the Upper Café Storage Room in the Brush Building did not close to a positive latch.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 10:40 AM, Observed that the ceiling tile in the 1st floor Brush Building Hospitality Storage room is missing.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 10:55 AM, Observed an unsealed penetration (Approximately 1" x 6" in diameter)in the Brush Basement EVA Storage Room. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 11:00 AM, Observed an unsealed conduit (Approximately 1" in diameter) protruding through the corridor wall, in the Brush Building basement kitchen. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 11:00 AM, Observed a concrete block missing (Approximately 6" x 12") missing from the corridor wall in the Brush Building basement kitchen storage room. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 1:05 PM, Observed that the 4th floor Weber North clean linen room door did not close to a positive latch.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 11:00 AM, Observed an unsealed penetration around a pipe (Approximately 1" in diameter) protruding through the rear wall of the 4th floor Weber South janitor's closet, adjacent to room 4445. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector















27171

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 06/21/10, the following observations were made:

At approximately 10:57 AM, Observed an unsealed conduit penetration (Approximately 1" in diameter) next to the HVAC duct in the 11th floor North Penthouse Plumbers Shop. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director


At approximately 1:50 PM, Observed missing ceiling tiles at the HVAC unit in room 8450 in the Webber South Building.

These findings were observed and confirmed by the Facility Maintenance Director


At approximately 2:26 PM, Observed two unsealed large diameter conduit penetrations (Approximately 4" in diameter) in Room 5444, Webber South Building. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility 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 All occupants of the facility.

Findings include:

On 06/23/10, the following observations were made:

At approximately 11:00 AM, Observed that the door to the "Old Sump Room" was secured with a clasp and pad lock, that prevents the door from being opened from the egress side.

These findings were observed and confirmed by the Facility Maintenance Director

At approximately 10:05 AM, Observed exit access at the 2nd floor Brush Surgical Suite was obstructed by a 6-ft slab of ¾ - inch plywood laid across the stairway.

These findings were observed and confirmed by the Facility Maintenance Director


At approximately 10:25 AM, Observed that the exit door at the 1st floor Doctors Dinning Room in the Brush Building was obstructed by chairs.

These findings were observed and confirmed by the Facility Maintenance Director

At approximately 10:35 AM, Observed that the rear door to the exit access corridor, in the Brush Building Upper Café, has a dead bolt lock.

These findings were observed and confirmed by the Facility Maintenance Director


At approximately 10:40 AM, Observed that the door to the exit access corridor in the Brush Building basement EVA Equipment Storage Room has a dead bolt lock.

These findings were observed and confirmed by the Facility Maintenance Director

At approximately 11:20 AM, Observed that the door to the exit access corridor in the Brush Building Basement Stretcher Equipment Storage Room has a dead bolt lock.

These findings were observed and confirmed by the Facility 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 all occupants of the facility.

On 06/23/2010, the following observation was made:

1. At approximately 11:04 AM, observed a scale and shelving units extending more than 6" into the Emergency Department corridor.

These findings were observed and confirmed by the Manager of Plant Operations and Environmental Services and Safety Officer during the inspection.

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 all occupants of the facility.

Findings include:

On 06/23/10, the following observations were made:

At approximately 1:15 PM, Observed a patient bed being stored in the corridor, by Room 9411, in the Webber South Building.

These findings were observed and confirmed by the Facility Maintenance Director.

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 06/23/2010, the following observation was made:

1. At approximately 11:47 AM, observed a light fixture at the receiving dock exit with a single bulb. Failure of the single bulb could have the potential to leave the area un-illuminated.

These findings were observed and confirmed by the Vice President of Operations/Patient Care Services, the Manager of Plant Operations and Environmental Services and Safety Officer during the inspection.

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 06/23/10, the following observations were made:

At approximately 11:10 AM, Observed that the emergency lighting in the Brush Building Basement Sub-Station # 1 exit access stairway did not operate when tested.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

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 potentially affect All occupants of the facility.

Findings include:

On 06/23/10, the following observations were made:

At approximately 10:55 AM, Observed that there is no exit directional signs located in the Weber Building Sub-Basement to identify the direction of travel.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


At approximately 11:00 AM, Observed that the exit door from the Weber Building "Old Sump Room" is not identified with a exit sign.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


On 06/23/10, the following observations were made:

At approximately 11:20 AM, Observed that there are no directional signs in the Weber Sub-Basement Tunnel and the exit door by the "Old Am-Cart" elevator is not identified with an exit sign.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

On 06/23/10, the following observations were made:

At approximately 10:10 AM, Observed that the exit door to the Administration Suite, located in the 2nd floor stairway marked HUH - 4C, does not have an exit sign.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


On 06/23/10, the following observations were made:

At approximately 11:10 AM, observed there are no exit directional signs from the Brush Building Basement Sub-Station # 1 to the exit access stairway.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

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 potentially affect all occupants of the facility.

Findings include:

On 06/23/2010, the following observations were made:

1. At approximately 12:29 PM, observed that the facility did not have at least 2 types of spare sprinkler heads for each type of sprinkler head in service at the facility.

2. At approximately 12:37 PM, observed that hydraulic name plates are not attached to the North and South sprinkler systems.

3. At approximately 12:41 PM, observed that the pressure gauge on the North sprinkler system is out of calibration and is more than 5 years old.

4. At approximately 12:52 PM, observed that the North and South sprinkler systems were possibly over 10 years old; therefore, the quick response heads shall be tested per NFPA 25 5.3.1.1.1.2, 2002 Edition.

These findings were observed and confirmed by the Manager of Plant Operations and Environmental Services and Safety Officer during the inspection.

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 all occupants of the facility.

Findings include:

On 06/21/10, the following observations were made:

At approximately 10:46 AM, Observed a Central Brand recalled sprinkler head in the corridor at room 8622.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


At approximately 10:00 AM, Observed a large gap (Approximately 1") around the sprinkler head in room 7841.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


At approximately 2:34 PM, Observed that the data room sprinkler head is not within 12" of ceiling.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


18760

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 All occupants of the facility.

Findings include:

On 06/21/10, the following observations were made:

At approximately 10:45 AM, Observed that the automatic sprinkler valve drain located in the Weber Building Sub-Basement did not have a sign to identify its purpose.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

At approximately 1:30 PM, Observed that combustible storage was within 18" of the automatic sprinkler heads in the Weber Building Pharmacy Storage Room.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


At approximately 1:25 PM, Observed that the automatic sprinkler head located in the Weber North Building room 3435 is missing an escutcheon plate

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

Based on observation and/or 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 06/23/10, the following observations were made:

At approximately 1:10 PM, Observed that the portable fire extinguisher located in the Wendy's restaurant kitchen was not mounted to the wall.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 10:05 AM, Observed the portable fire extinguisher located in the 1st floor Brush Center Doctors Dinning Room was not mounted to the wall.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 11:10 AM, Observed the portable fire extinguisher located in the Brush Building Basement De-Con Mechanical/Electrical Room is not mounted to the wall.

These findings were observed and confirmed by the Facility Maintenance Director.

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 06/21/10, the following observations were made:

At approximately 1:20 PM, Observed the manual station for the Wendy's hood suppression system was damaged and the seal was broken.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

At approximately 1:25 PM, Observed that the kitchen hood grease filters in the Wendy's restaurant were not installed properly and had an approximate two 1/4" gaps between the filters.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

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:

On 06/21/10, the following observations were made:

At approximately 1:46 PM, Observed an unsecured oxygen Cylinder in room 3809.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 2:34 PM, Observed an unsecured oxygen cylinder in soiled utility room 3616.

These findings were observed and confirmed by the Facility Maintenance Director.


18760

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:

On 06/21/10, the following observations were made:

At approximately 1:10 PM, Observed two unsecured oxygen cylinders in the 4th floor Weber North Clean Linen Room.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

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 06/21/10, the following observations were made:

At approximately 2:46 PM, Observed an electrical junction box missing a cover plate at room 8702.

These findings were observed and confirmed by the Facility maintenance director.


18760

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 06/21/10, the following observations were made:

At approximately 10:45 AM, Observed an electrical junction box, located in the Weber South basement, missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

At approximately 11:20 AM, Observed that there is an electrical junction box located above the ceiling tile, above the smoke barrier doors by room G207 in Weber Building Radiology that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 11:25 AM, observed by the Corporate Fire Safety Inspector that there is an electrical junction box located above the ceiling tile, above the smoke barrier doors by room G234 in Weber Building Radiology that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 9:45 AM, Observed that there is an electrical junction box above the ceiling tile, above the door to the stairway marked HUH-47 on the 2nd Floor of the Brush Building that is missing a cover plate..

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 10:03 AM, observed that there is exposed wiring to a construction light located above the ceiling tile, above the entrance to the Surgical Lounge, on the 2nd Floor of the Brush Building.
These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 10:50 AM, observed an electrical junction box in the Brush Building Basement storage room next to stairway marked HUH-40 that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 10:50 AM, Observed an electrical junction box in the Brush Building Basement above the ceiling tile above the smoke barrier doors by the Pharmacy Entrance that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 10:55 AM, Observed that there is a damaged 220 volt electrical outlet located in the Brush Building Basement Kitchen Storage Room.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 11:00 AM, observed an electrical junction box located in the Brush Building Basement Kitchen Storage Room that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 11:00 AM, Observed an electrical junction box located in the Fire Sprinkler Cabinet in the Brush Building Basement Grey Tunnel that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 1:30 PM, Observed an electrical junction box located in the 3rd floor Weber North Building Electrical Room # 3236 that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector







27171

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 06/21/10, the following observations were made:

At approximately 10:41 AM, Observed an electrical junction box missing a cover plate, located in Substation 6 on the 11th Floor Penthouse North.

These findings were observed and confirmed by the Plant Operations Manager.

At approximately 10:43 AM, Observed that there were two electrical panels missing filler blanks (Panels RP-112 and RP-113) located in the 11th Floor Penthouse North.

These findings were observed and confirmed by the Plant Operations Manager.

At approximately 11:01 AM, Observed that there was an electrical junction box missing a cover plate, located in the Mechanical/Control Room, located on the 11th Floor Penthouse North.

These findings were observed and confirmed by the Plant Operations Manager.

At approximately 11:20 AM, Observed that there was an electrical panel missing filler blanks, located in Room 10443, on the 10th Floor of Webber South Building.

These findings were observed and confirmed by the Plant Operations Manager.

At approximately 2:26 PM, Observed that there were two electrical junction boxes missing cover plates, located in the Mechanical Room near air conditioning units 9 and 10, on the 6th Floor - Webber North Building.

These findings were observed and confirmed by the Plant Operations Manager.

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 06/23/2010, the following observation was made:

1. At approximately 11:00 AM, observed that the wiring above the door to Room 1100 was spliced together and not in an electrical box.

These findings were observed and confirmed by the Vice President Operations/Patient Care services, Manager of Plant Operations and Environmental Services and Safety Officer during the inspection.

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:

On 06/23/10 the following observations were made:

At approximately 10:40 AM, Observed an unsealed penetration (approximately 1/8"wide) in the Brush Building basement corridor, above the ceiling tile, above the door marked 6870A. This penetration would not prevent the spread of smoke and heat into the corridor wall.


These findings were observed and confirmed by the Facility Maintenance Director during the inspection.

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.

On 06/24/2010, the following observations were made:

1. At approximately 2:41 PM, observed that dry wall was used to seal penetrations in the PACU corridor. Also observed a gap (approximately ½ " x 5 " wide) between the wall and the deck that is not protected by fire stopping material.

These findings were observed and confirmed by the Manager of Plant Operations and Environmental Services and Safety Officer during the inspection.

Based on observation 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 All occupants of the facility.

Findings include:

On 06/24/2010, the following observations were made:

At approximately 11:35 AM, Observed an unsealed penetration (approximately 1/4" wide) in the corridor door leading to the Radiology Reception, across from room G252. This penetration would not prevent the spread of smoke and heat into the corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


27171

Based on observation 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 all occupants of the facility.

Findings include:

On 06/24/2010, the following observations were made:

At approximately 11:14 AM, Observed that the West door to the 10th floor Pantry (Webber South Bldg.) did not fully close to a positive latch.

These findings were observed and confirmed by the Corporate Plant Operations Manager.

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.

On 06/21/2010, the following observations were made:

At approximately 11:14 AM, Observed that the stairwell door HAR-42 is sticking and does not fully close to a positive latch. This penetration would allow smoke and heat to enter the stairwell.

These findings were observed and confirmed by the Corporate Facility Director.


18760

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 06/23/2010, the following observations were made:

At approximately 9:45 AM, Observed an unsealed conduit penetration (approximately 1/2" wide) protruding through the 2-hr fire, wall above the door to exit access stairwell HUH-47 (2nd floor Brush Bldg. This penetration would allow smoke and heat to enter the stairwell.

These findings were observed and confirmed by the Corporate Plant Operations Manager.

At approximately 1:30 PM, Observed that stairwell door HUH-32 (Weber North Building) at room 3502 did not fully close to a positive latch. This deficiency would allow smoke and heat to enter the stairwell.

These findings were observed and confirmed by the Facility Maintenance Director



27171

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 06/21/2010, the following observations were made:

At approximately 11:32 AM, Observed that stairwell door HUH-32 (10th floor, Webber South Bldg.) did not fully close to a positive latch. This deficiency would allow smoke and heat to enter the stairwell.

These findings were observed and confirmed by the Plant Operations Manager.

At approximately 11:36 AM, Observed that stairwell door HUH-36 (10th floor Webber South Bldg.) does not fully close to a positive latch. This deficiency would allow smoke and heat to enter the stairwell.

These findings were observed and confirmed by the Plant Operations Manager.

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:

On 06/23/10, the following observations were made:

At approximately 10:00 AM, Observed an unsealed penetration (Approximately 2"wide) through the cross-corridor smoke barrier wall at room 8601. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 10:37 AM, Observed a 3" x 5" section of missing drywall (above ceiling tile) in the corridor, across from room 8702.

These findings were observed and confirmed by the Facility Maintenance Director.

On 06/21/10, the following observations were made:

At approximately 1:00 PM, Observed three unsealed floor conduits (approximately 2" wide) in the Brush Building Telephone Closet, at the elevator foyer. This deficiency would allow smoke and heat to travel between floors.

These findings were observed and confirmed by the Facility Maintenance Director.


On 06/23/10, the following observations were made:

At approximately 2:02 PM, Observed multiple unsealed wall penetrations (approximately 2" wide) above the cross-corridor smoke barrier doors at room 3712. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility Maintenance Director.


18760

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:

On 06/23/10, the following observations were made:

At approximately 10:00 AM, Observed an unsealed open penetration (approximately 3" x 3") in the 2-hr fire wall, above the ceiling tile, (approximately 3' from the entrance to the Surgical Lounge, on the 2nd floor of the Brush Building). This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Corporate Operations Director.



27171

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:

On 06/21/10, the following observations were made:

At approximately 11:38 AM, Observed an unsealed section of the cable tray, located at the cross- corridor smoke barrier (near the I.C.U. Elevators, on the 10th Floor, Webber South Building) wall.

These findings were observed and confirmed by the Plant Operations Manager.


At approximately 11:42 AM, Observed an unsealed pipe penetration (Approximately 2"wide) through the cross-corridor smoke barrier, (located near 10-I.C.U. Electrical Closet, Webber South Building). This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Plant Operations Manager.


At approximately 1:13 PM, Observed an unsealed conduit penetration in the cross-corridor smoke barrier wall. (located on the east side of the 9th floor nurses station, in the Webber South Building).
This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Plant Operations Manager.


At approximately 1:33 PM, Observed an unsealed section of the cable tray (located at the 9th floor Webber Building cross- corridor smoke barrier, at South entrance to I.C.U.).

These findings were observed and confirmed by the Plant Operations Manager.


At approximately 1:40 PM, Observed an unsealed section of cable tray. Located at the cross- corridor smoke barrier wall, near I.C.U. Room 8522.

These findings were observed and confirmed by the Plant Operations Manager.

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 19.2.2.2.6. This deficient practice could potentially affect All occupants of the facility.

Findings include:

On 06/23/10, the following observations were made:

At approximately 2:02 PM, Observed that the coordinator on the cross-corridor smoke barrier doors, located at room 5719, did not function when tested. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility Maintenance Director.

At Approximately 12:22 PM, Observed an approximately 1/8" gap between the edges of the cross-corridor smoke barrier doors, adjacent to room 3820. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility Maintenance Director.


On 06/21/10, the following observations were made:

At approximately 11:27 AM, Observed that the cross-corridor smoke barrier doors (Located adjacent to the 10th floor Webber- South I.C.U. entrance) did not fully close. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 1:20 PM, Observed that the cross-corridor smoke barrier wall (Located at the 9th floor, Webber South nurse's station) did not extend to the ceiling. This deficiency would allow smoke and heat to travel between smoke compartments.

These findings were observed and confirmed by the Facility 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 all occupants of the facility.

Findings include:

On 06/21/10, the following observations were made:

At approximately 12:46 PM, Observed that the door to clean utility room/ storage room 3627 requires a self-closer. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 10:01 AM, Observed an unapproved trash receptacle in the Brush Center corridor at room 3820.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 2:46 PM, Observed that the door to supply room 8701 does not meet the 45-minute rating requirement.

These findings were observed and confirmed by the Facility Maintenance Director.

At approximately 2:46 PM, Observed an unsealed wall penetration between the corridor and room 8701. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 2:49 PM, Observed that he door to supply room 8712 does not meet the minimum 45-minute rating requirement.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 12:46 PM, Observed that the door to Janitor's Closet 7702 does not self-close and latch. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 12:46 PM, Observed an unsealed wall penetration (Approximately 1" x 2" wide) above the door to Janitor's Closet 7702. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director.

At approximately 2:49 PM, Observed that the storage room door, at entrance to 6-Brush Center, is not rated.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 2:55 PM, Observed that the door to the storage closet at room 6812 is not rated.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 2:49 PM, Observed that the door to storage room 6605A does not have a self-closer.

These findings were observed and confirmed by the Facility Maintenance Director.

At approximately 2:19 PM, Observed that the dimensions of the clean linen/ storage room 5718 exceed 100 square feet and is not sprinkler protected.

These findings were observed and confirmed by the Facility Maintenance Director.

At approximately 2:57 PM, Observed heat producing appliances were observed in staff lounge 5708. This room is not sprinkled or have a rated door with closer. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director

At approximately 2:58 PM, Observed wiring and combustibles not properly secured inside of Mechanical closet 2627.

These findings were observed and confirmed by the Facility Maintenance Director


18760

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 06/21/10, the following observations were made:

At approximately 11:32 AM, Observed that the door to the Soiled Linen Room marked G114/1114A did not close to a positive latch. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 11:50 AM, Observed that the door to the Weber Building O.R. janitor's closet did not close to a positive latch. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 1:25 PM, Observed that the door to the Wendy's kitchen janitor's closet did not close to a positive latch. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 1:35 PM, Observed ceiling tiles missing in the Webber Building ground floor service elevator area.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 10:20 AM, Observed an unsealed wall penetration (Approximately 3" x 3" in diameter) in the Brush Building Upper Café janitor's closet. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 10:25 AM, Observed that the door to the Upper Café Storage Room in the Brush Building did not close to a positive latch.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 10:40 AM, Observed that the ceiling tile in the 1st floor Brush Building Hospitality Storage room is missing.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 10:55 AM, Observed an unsealed penetration (Approximately 1" x 6" in diameter)in the Brush Basement EVA Storage Room. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 11:00 AM, Observed an unsealed conduit (Approximately 1" in diameter) protruding through the corridor wall, in the Brush Building basement kitchen. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 11:00 AM, Observed a concrete block missing (Approximately 6" x 12") missing from the corridor wall in the Brush Building basement kitchen storage room. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 1:05 PM, Observed that the 4th floor Weber North clean linen room door did not close to a positive latch.

These findings were observed and confirmed by the Corporate Fire Safety Inspector


At approximately 11:00 AM, Observed an unsealed penetration around a pipe (Approximately 1" in diameter) protruding through the rear wall of the 4th floor Weber South janitor's closet, adjacent to room 4445. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Corporate Fire Safety Inspector















27171

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 06/21/10, the following observations were made:

At approximately 10:57 AM, Observed an unsealed conduit penetration (Approximately 1" in diameter) next to the HVAC duct in the 11th floor North Penthouse Plumbers Shop. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility Maintenance Director


At approximately 1:50 PM, Observed missing ceiling tiles at the HVAC unit in room 8450 in the Webber South Building.

These findings were observed and confirmed by the Facility Maintenance Director


At approximately 2:26 PM, Observed two unsealed large diameter conduit penetrations (Approximately 4" in diameter) in Room 5444, Webber South Building. This deficiency would allow smoke and heat to enter the exit corridor.

These findings were observed and confirmed by the Facility 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 All occupants of the facility.

Findings include:

On 06/23/10, the following observations were made:

At approximately 11:00 AM, Observed that the door to the "Old Sump Room" was secured with a clasp and pad lock, that prevents the door from being opened from the egress side.

These findings were observed and confirmed by the Facility Maintenance Director

At approximately 10:05 AM, Observed exit access at the 2nd floor Brush Surgical Suite was obstructed by a 6-ft slab of ¾ - inch plywood laid across the stairway.

These findings were observed and confirmed by the Facility Maintenance Director


At approximately 10:25 AM, Observed that the exit door at the 1st floor Doctors Dinning Room in the Brush Building was obstructed by chairs.

These findings were observed and confirmed by the Facility Maintenance Director

At approximately 10:35 AM, Observed that the rear door to the exit access corridor, in the Brush Building Upper Café, has a dead bolt lock.

These findings were observed and confirmed by the Facility Maintenance Director


At approximately 10:40 AM, Observed that the door to the exit access corridor in the Brush Building basement EVA Equipment Storage Room has a dead bolt lock.

These findings were observed and confirmed by the Facility Maintenance Director

At approximately 11:20 AM, Observed that the door to the exit access corridor in the Brush Building Basement Stretcher Equipment Storage Room has a dead bolt lock.

These findings were observed and confirmed by the Facility 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 all occupants of the facility.

On 06/23/2010, the following observation was made:

1. At approximately 11:04 AM, observed a scale and shelving units extending more than 6" into the Emergency Department corridor.

These findings were observed and confirmed by the Manager of Plant Operations and Environmental Services and Safety Officer during the inspection.

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 all occupants of the facility.

Findings include:

On 06/23/10, the following observations were made:

At approximately 1:15 PM, Observed a patient bed being stored in the corridor, by Room 9411, in the Webber South Building.

These findings were observed and confirmed by the Facility Maintenance Director.

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 06/23/2010, the following observation was made:

1. At approximately 11:47 AM, observed a light fixture at the receiving dock exit with a single bulb. Failure of the single bulb could have the potential to leave the area un-illuminated.

These findings were observed and confirmed by the Vice President of Operations/Patient Care Services, the Manager of Plant Operations and Environmental Services and Safety Officer during the inspection.

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 06/23/10, the following observations were made:

At approximately 11:10 AM, Observed that the emergency lighting in the Brush Building Basement Sub-Station # 1 exit access stairway did not operate when tested.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

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 potentially affect All occupants of the facility.

Findings include:

On 06/23/10, the following observations were made:

At approximately 10:55 AM, Observed that there is no exit directional signs located in the Weber Building Sub-Basement to identify the direction of travel.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


At approximately 11:00 AM, Observed that the exit door from the Weber Building "Old Sump Room" is not identified with a exit sign.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


On 06/23/10, the following observations were made:

At approximately 11:20 AM, Observed that there are no directional signs in the Weber Sub-Basement Tunnel and the exit door by the "Old Am-Cart" elevator is not identified with an exit sign.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

On 06/23/10, the following observations were made:

At approximately 10:10 AM, Observed that the exit door to the Administration Suite, located in the 2nd floor stairway marked HUH - 4C, does not have an exit sign.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


On 06/23/10, the following observations were made:

At approximately 11:10 AM, observed there are no exit directional signs from the Brush Building Basement Sub-Station # 1 to the exit access stairway.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

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 potentially affect all occupants of the facility.

Findings include:

On 06/23/2010, the following observations were made:

1. At approximately 12:29 PM, observed that the facility did not have at least 2 types of spare sprinkler heads for each type of sprinkler head in service at the facility.

2. At approximately 12:37 PM, observed that hydraulic name plates are not attached to the North and South sprinkler systems.

3. At approximately 12:41 PM, observed that the pressure gauge on the North sprinkler system is out of calibration and is more than 5 years old.

4. At approximately 12:52 PM, observed that the North and South sprinkler systems were possibly over 10 years old; therefore, the quick response heads shall be tested per NFPA 25 5.3.1.1.1.2, 2002 Edition.

These findings were observed and confirmed by the Manager of Plant Operations and Environmental Services and Safety Officer during the inspection.

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 all occupants of the facility.

Findings include:

On 06/21/10, the following observations were made:

At approximately 10:46 AM, Observed a Central Brand recalled sprinkler head in the corridor at room 8622.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


At approximately 10:00 AM, Observed a large gap (Approximately 1") around the sprinkler head in room 7841.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


At approximately 2:34 PM, Observed that the data room sprinkler head is not within 12" of ceiling.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


18760

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 All occupants of the facility.

Findings include:

On 06/21/10, the following observations were made:

At approximately 10:45 AM, Observed that the automatic sprinkler valve drain located in the Weber Building Sub-Basement did not have a sign to identify its purpose.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

At approximately 1:30 PM, Observed that combustible storage was within 18" of the automatic sprinkler heads in the Weber Building Pharmacy Storage Room.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.


At approximately 1:25 PM, Observed that the automatic sprinkler head located in the Weber North Building room 3435 is missing an escutcheon plate

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

Based on observation and/or 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 06/23/10, the following observations were made:

At approximately 1:10 PM, Observed that the portable fire extinguisher located in the Wendy's restaurant kitchen was not mounted to the wall.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 10:05 AM, Observed the portable fire extinguisher located in the 1st floor Brush Center Doctors Dinning Room was not mounted to the wall.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 11:10 AM, Observed the portable fire extinguisher located in the Brush Building Basement De-Con Mechanical/Electrical Room is not mounted to the wall.

These findings were observed and confirmed by the Facility Maintenance Director.

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 06/21/10, the following observations were made:

At approximately 1:20 PM, Observed the manual station for the Wendy's hood suppression system was damaged and the seal was broken.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

At approximately 1:25 PM, Observed that the kitchen hood grease filters in the Wendy's restaurant were not installed properly and had an approximate two 1/4" gaps between the filters.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

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:

On 06/21/10, the following observations were made:

At approximately 1:46 PM, Observed an unsecured oxygen Cylinder in room 3809.

These findings were observed and confirmed by the Facility Maintenance Director.


At approximately 2:34 PM, Observed an unsecured oxygen cylinder in soiled utility room 3616.

These findings were observed and confirmed by the Facility Maintenance Director.


18760

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:

On 06/21/10, the following observations were made:

At approximately 1:10 PM, Observed two unsecured oxygen cylinders in the 4th floor Weber North Clean Linen Room.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

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 06/21/10, the following observations were made:

At approximately 2:46 PM, Observed an electrical junction box missing a cover plate at room 8702.

These findings were observed and confirmed by the Facility maintenance director.


18760

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 06/21/10, the following observations were made:

At approximately 10:45 AM, Observed an electrical junction box, located in the Weber South basement, missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector.

At approximately 11:20 AM, Observed that there is an electrical junction box located above the ceiling tile, above the smoke barrier doors by room G207 in Weber Building Radiology that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 11:25 AM, observed by the Corporate Fire Safety Inspector that there is an electrical junction box located above the ceiling tile, above the smoke barrier doors by room G234 in Weber Building Radiology that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 9:45 AM, Observed that there is an electrical junction box above the ceiling tile, above the door to the stairway marked HUH-47 on the 2nd Floor of the Brush Building that is missing a cover plate..

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 10:03 AM, observed that there is exposed wiring to a construction light located above the ceiling tile, above the entrance to the Surgical Lounge, on the 2nd Floor of the Brush Building.
These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 10:50 AM, observed an electrical junction box in the Brush Building Basement storage room next to stairway marked HUH-40 that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 10:50 AM, Observed an electrical junction box in the Brush Building Basement above the ceiling tile above the smoke barrier doors by the Pharmacy Entrance that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 10:55 AM, Observed that there is a damaged 220 volt electrical outlet located in the Brush Building Basement Kitchen Storage Room.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 11:00 AM, observed an electrical junction box located in the Brush Building Basement Kitchen Storage Room that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 11:00 AM, Observed an electrical junction box located in the Fire Sprinkler Cabinet in the Brush Building Basement Grey Tunnel that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector

At approximately 1:30 PM, Observed an electrical junction box located in the 3rd floor Weber North Building Electrical Room # 3236 that is missing a cover plate.

These findings were observed and confirmed by the Corporate Fire Safety Inspector







27171

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 06/21/10, the following observations were made:

At approximately 10:41 AM, Observed an electrical junction box missing a cover plate, located in Substation 6 on the 11th Floor Penthouse North.

These findings were observed and confirmed by the Plant Operations Manager.

At approximately 10:43 AM, Observed that there were two electrical panels missing filler blanks (Panels RP-112 and RP-113) located in the 11th Floor Penthouse North.

These findings were observed and confirmed by the Plant Operations Manager.

At approximately 11:01 AM, Observed that there was an electrical junction box missing a cover plate, located in the Mechanical/Control Room, located on the 11th Floor Penthouse North.

These findings were observed and confirmed by the Plant Operations Manager.

At approximately 11:20 AM, Observed that there was an electrical panel missing filler blanks, located in Room 10443, on the 10th Floor of Webber South Building.

These findings were observed and confirmed by the Plant Operations Manager.

At approximately 2:26 PM, Observed that there were two electrical junction boxes missing cover plates, located in the Mechanical Room near air conditioning units 9 and 10, on the 6th Floor - Webber North Building.

These findings were observed and confirmed by the Plant Operations Manager.

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 06/23/2010, the following observation was made:

1. At approximately 11:00 AM, observed that the wiring above the door to Room 1100 was spliced together and not in an electrical box.

These findings were observed and confirmed by the Vice President Operations/Patient Care services, Manager of Plant Operations and Environmental Services and Safety Officer during the inspection.