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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 all occupants of the facility. Findings include:

On November 15, 2012 the following observation was made:

1) Observed that the facility did not have documentation providing the construction type of the hospital.

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 all occupants of the facility. Findings include:

On November 19, 2012 the following observation was made:

1) Observed that the facility did not have documentation providing the construction type of the facility.

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

On November 13, 2012 at approximately 11:07 AM, the following observations were made:

1) Observed that there was a ceiling tile missing, located in Room 727.
2) Observed that there was a ceiling tile missing, located in Room 680.
3) Observed that there was an unsealed hole in the wallboard in back of the bed as well as a hole in the ceiling in the shower, located in Room 651.
4) Observed that there was a ceiling tile missing, located in Room 665.
5) Observed that there was a ceiling tile missing, located in Room 673.
6) Observed an unsealed hole in the wallboard behind the door, located in Room 527.
7) Observed that there was a ceiling tile missing, located in Room 579.

On November 14, 2012 at approximately 8:05 AM, the following observations were made:

1) Observed an unsealed 2" hole in the ceiling tile, located in Room 421.
2) Observed a hole in the ceiling tile and two ceiling tiles out of place, located in Room 349.
3) Observed that were two ceiling tiles missing, located in "On Call" Room 397 e.
4) Observed that there was a ceiling tile missing, located in Room 395.
5) Observed a hole in the ceiling tile, located in Room 374.
6) Observed that there was a ceiling tile missing, located in Room 373.
7) Observed that there was a ceiling tile missing, located in Room 211 B.
8) Observed there were six ceiling tiles missing, located in Room 238.
9) Observed there were two ceiling tiles missing, located in the CT Scanner Room.

On November 15, 2012 at approximately 12:45 PM, the following observations were made:

1) Observed that there was a ceiling tile missing, located in Room G-12.
2) Observed that were three ceiling tiles missing, located in Room G-06.

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 November 13, 2012 at approximately 10:30 AM, the following observations were made:

1) Observed that the door did not close to a positive latch, located at the west door of Room 732.
2) Observed that the door did not close to a positive latch, located at Room 756.
3) Observed that the door did not close to a positive latch, located at Room 504.
4) Observed that the door did not close to a positive latch, located at Room 511.
5) Observed that the door was missing the door latching hardware, located in Room 545.
6) Observed that the door did not create a smoke tight seal at the frame, located in Room 315.

On November 14, 2012 at approximately 10:18 AM, the following observations were made:

1) Observed that the door to the corridor was blocked in the open position with a heavy box of batteries, located in Room 393.
2) Observed the door to the corridor was blocked in the open position, located in the Pathology Department Break Room.
3) Observed the door hardware was malfunctioning (unable to open from inside room), located in Waiting Room 130. Note: door hardware was repaired at time of inspection.
4) Observed that the door did not close to a positive latch due to tape applied to the lockset, located in Room 131 C. Note: tape was removed at time of inspection.
5) Observed the door did not close to a positive latch, located in the Patient Access area.

On November 15, 2012 at approximately 10:27 AM, the following observations were made:

1) Observed the door hardware needed to be repaired, located at the cross corridor smoke barrier into the Morgue.
2) Observed a deadbolt lockset on the door, located in the Staff Lounge/Conference Room in the Radiation Oncology Department.

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 November 19, 2012 at approximately 10:36 AM, the following observation was made:

1) Observed that the door did not create a smoke tight seal at the frame, located in the Urgent care Manager's Office.

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 November 13, 2012 at approximately 10:45 AM, the following observations were made:

1) Observed that there were two unsealed conduits, two unsealed air vents and gaps around the I-beam and the air duct, located in the smoke barrier rated wall in Room 701.
2) Observed that there was an incomplete seal around the I-beam, located at the cross corridor smoke barrier into the North Unit on the 7th Floor.3) Observed that the cross corridor doors did not close to a positive latch, located at the west door into 7 - South Wing.
4) Observed that there was an unsealed hole in the wallboard and an incomplete seal around an I-beam, located at the cross corridor smoke barrier by Room 780.
5) Observed that the wall was not smoke tight to the deck, located in Room 769.
6) Observed that there was an unsealed large diameter hot water pipe penetration in the smoke barrier wall, located in Room 773.
7) Observed that there was some unsealed stud work in the smoke barrier wall, located in back of the column by the southwest cross corridor smoke barrier doors on the 6th Floor.
8) Observed two unsealed wire penetrations in the smoke barrier wall, located above west door of Room 675.
9) Observed two unsealed wire penetrations and one unsealed flexible conduit penetration in the smoke barrier wall, located in Room 671.
10) Observed one unsealed conduit penetration in the smoke barrier wall, located in Room 673.
11) Observed three unsealed wire penetrations and three unsealed conduit penetrations in the smoke barrier walls, located in Room 632.
12) Observed an incomplete seal around the I-beam in the smoke barrier wall, located in Room 601.
13) Observed an unsealed pipe penetration in the smoke barrier wall, located in Room 637.
14) Observed an unsealed conduit penetration in the (north) smoke barrier wall, located in Room 532.

On November 14, 2012 at approximately 8:26 AM, the following observations were made:

1) Observed two unsealed three inch conduits in the smoke barrier wall, located in Room 428.
2) Observed two unsealed wire penetrations and two unsealed conduit penetrations in the smoke barrier wall of Room 430.
3) Observed one unsealed wire penetration and one unsealed 2" conduit, located in Room 475. Also noted that the west wall did not extend to the decking of the fire rated room/smoke barrier wall.
4) Observed an unsealed wire penetration in the cross corridor smoke barrier, located by Room 325.
5) Observed four unsealed conduits in the smoke barrier wall, located in Room 325.
6) Observed an unsealed wire penetration in the cross corridor smoke barrier, located by Room 301.
7) Observed an unsealed conduit in the smoke barrier wall, located in Room 301.
8) Observed an unsealed pipe penetration the south smoke barrier wall, located in Room 218.
9) Observed an unsealed flexible conduit penetration, located at the north cross corridor smoke barrier off the Main Lobby.

On November 15, 2012 at approximately 10:27 AM, the following observations were made:

1) Observed an unsealed pipe penetration, located in the cross corridor smoke barrier leading into the Morgue.
2) Observed an unsealed fire sprinkler pipe penetration, located at the corner of the corridor outside the Morgue smoke barrier wall.
3) Observed an unsealed fire sprinkler pipe penetration, located at the cross corridor smoke barrier by Stairwell #5.
4) Observed an unsealed fire sprinkler pipe penetration in the fire rated/smoke barrier wall, located in Room G-10.
5) Observed an unsealed black pipe penetration in the smoke barrier wall, located in Room G-05.

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 November 14, 2012 at approximately 10:31 AM, the following observations were made:

1) Observed two unsealed wire penetrations, and a large unsealed hole in the wallboard around the clothes dryer vent in the wall, located in Room 477.
2) Observed that the door was blocked in the open position to the corridor with a box, located in the Housekeeping Storage Room on the 3 - Southwest Wing.

On November 15, 2012 at approximately 10:38 AM, the following observation was made:

1) Observed excessive lint build up in the rear of the clothes dryer, located in Room G-55.

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 November 19, 2012 at approximately 10:45 AM, the following observations were made:

1) Observed an unsealed copper pipe penetration and an unsealed wire penetration on the corridor wall, located in the East Mechanical Room.
2) Observed an unsealed conduit penetration, located in the West Mechanical Room.
3) Observed an unsealed conduit penetration, located in the Generator Room.

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 November 14, 2012 at approximately 1:45 PM, the following observations were made:

1) Observed the exterior path of exit discharge was illuminated with a single bulb fixture, located at Stairwell #6.
2) Observed the exterior path of exit discharge was illuminated with a single bulb fixture, located at Stairwell #7.
3) Observed the exterior path of exit discharge was illuminated with a single bulb fixture, located at Stairwell #4.
4) Observed the exterior path of exit discharge was illuminated with a single bulb fixture, located at Stairwell #5.

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 November 15, 2012 at approximately 12:58 PM, the following observation was made:

1) Observed that the corridor did not have signage for the exit, located in the corridor outside the G-car Elevator.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 15, 2012 at approximately 8:15 AM, the following observation was made:

1) Observed during the review of the facility records, that the facility failed to document fire drills for the second and third shifts in the 1st, 2nd, and 3rd quarters of 2012.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 1:05 PM, the following observation was made:

1) Observed during the review of the facility records, that the facility failed to document fire drills during the 4th quarter of 2011 and the 1st quarter of 2012.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 13, 2012 at approximately 11:50 AM, the following observations were made:

1) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #3 on the 7th Floor.
2) Observed that the fire alarm pull station was missing the glass rod, located at Room 506.
3) Observed that the fire alarm pull station was missing the glass rod, located at Room 520.
4) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #2 on the 5th Floor.

On November 14, 2012 at approximately 8:10 AM, the following observations were made:

1) Observed that the fire alarm pull station was missing the glass rod, located at Room 420.
2) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #2 on the 4th Floor.
3) Observed that the fire alarm pull station was missing the glass rod, located at Room 307.
4) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #3 on the 3rd Floor.
5) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #2 on the 2nd Floor.
6) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #7 on the 1st Floor.
7) Observed that the fire alarm pull station was missing the glass rod, located at Room 107.

On November 15, 2012 at approximately 8:10 AM, the following observations were made:

1) Observed during the review of the facility records, the fire alarm system inspection report was out-dated.
2) Observed that the fire alarm pull station was missing the glass rod, located by Room G-55.
3) Observed that the fire alarm pull station was missing the glass rod, located by the entrance to the Cafeteria on the Ground Floor.
4) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #2 on the Ground Floor.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 1:00 PM, the following observation was made:

1) Observed during the review of the facility records, the fire alarm system inspection report was out-dated (June 3, 2010).

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 November 19, 2012 at approximately 10:26 AM, the following observations were made:

1) Observed an unsealed hole in the ceiling tile, located in the Soiled Utility Room of the Urgent Care Unit.
2) Observed that the mesh at the top of the patient curtain was too small to allow proper fire sprinkler coverage, located in the Cardiac Room C-1.
3) Observed that there was a ceiling tile missing, located in the Radiology Storage Room.

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 November 13, 2012 at approximately 11:09 AM, the following observations were made:

1) Observed that the pendant fire sprinkler head did not extend below the required one inch spacing of the ceiling, located at the 7 - North Nursing Station.
2) Observed that the fire sprinkler head was missing an escutcheon plate, located at the 6 - North Nursing Station.

On November 14, 2012 at approximately 9:10 AM, the following observations were made:

1) Observed a fire sprinkler head covered with lint, located in the Med Room of the 4 - North Wing.
2) Observed there were items stored within the required eighteen inch clearance of a fire sprinkler head, located in the Housekeeping Storage Room on the 3 - Southwest Wing.
3) Observed a fire sprinkler head covered with lint, located in Room 149.
4) Observed at 3:00 PM that the fire sprinkler system was out of service. Speaking with the Director of Operations, he stated the fire sprinkler system has been out of service for about two months. There is approximately eight-hundred and thirty feet of piping that is being replaced on the Ground Floor due to numerous leaks. At that time the facility was placed on Fire Watch detail until fire sprinkler system is back in service. Note: the fire sprinkler system was back in-service on November 16, 2012 at approximately 1:00 PM. The Bureau of Fire Services and the local fire department were not notified of the fire sprinkler system being out of service.

On November 15, 2012 at approximately 8:20 AM, the following observations were made:

1) Observed during the review of the facility records, that the facility failed to document quarterly water flows of the fire sprinkler system in 2012.
2) Observed electrical wiring attached to the fire sprinkler piping, located outside Linen Supply Room.

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 November 13, 2012 at approximately 11:55 AM, the following observation was made:

1) Observed that the fire extinguisher missed the monthly inspections since August of 2012, located in Room 747.

On November 14, 2012 at approximately 11:48 AM, the following observations were made:

1) Observed the fire extinguisher missed the monthly inspections in April and May of 2012, located in the Cardiac Cath. Department.
2) Observed the fire extinguisher did not have an inspection tag attached, located in the Mechanical Room 222.

On November 15, 2012 at approximately 9:45 AM, the following observations were made:

1) Observed a carbon dioxide fire extinguisher missed monthly inspections since April of 2012, also the extinguisher needed to be recharged and mounted, located in the Chiller Room of the Power House.
2) Observed the fire extinguisher needed to be mounted, located in the Boiler Room of the Power House.
3) Observed the fire extinguisher needed to be mounted, located in the Generator Room of the
Power House.

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 November 15, 2012 at approximately 8:25 AM, the following observations were made:

1) Observed during the review of the facility records, that the facility failed to document a semi annual inspection of the kitchen hood suppression system report for the 1st half of 2012. Note: an inspection report dated for October 18, 2012 was provided.

Based on observation the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 14, 2012 at approximately 12:10 PM, the following observations were made:

1) Observed an electrical space heater in the office, located in the Pathology Department.
2) Observed two electrical space heaters, located in the Patient Access area.
3) Observed an electrical space heater in the office, located in the Security Radio Room.

Based on observation the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 10:31 AM, the following observations were made:

1) Observed an electrical space heater, located at the Reception Desk.
2) Observed two electrical space heaters, located in the Administration Front Office.
3) Observed an electrical space heater, located in the Staff Office of the Physical Therapy Department.
4) Observed an electrical space heater, located in the IT Room of the Physical Therapy Department.
5) Observed three electrical space heaters, located in the Patient Therapy Room of the Physical Therapy Department.

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

On November 13, 2012 at approximately 11:10 AM, the following observations were made:

1) Observed that there were five large size boxes stored in the corridor, located outside Room 744.
2) Observed that there were three chairs, an exam table, bed mattress and a table stored in the southeast corridor of the 6 - South Wing.
3) Observed that the wall mounted charting station in the corridor did not self close, located at Room 555.
4) Observed that the wall mounted charting station in the corridor did not self close, located at Room 564.
5) Observed that the wall mounted charting station in the corridor did not self close, located at Room 565.

On November 14, 2012 at approximately 9:20 AM, the following observations were made:

1) Observed that a large quantity of chairs, a file cabinet and a bed were stored in the corridor, located by the Main Elevators.
2) Observed four beds and four chairs stored in the corridor, located by the 3 - North Nurses Station.
3) Observed numerous beds, monitors, and wooden pallets were stored in the corridor, located by Room 393.
4) Observed chairs, a table, and a filling cabinet were stored in the corridor, located by Room 372.
5) Observed a housekeeping cart was stored in the stairwell, located in Stairwell #7, on the 2nd Floor.

On November 15, 2012 at approximately 9:50 AM, the following observations were made:

1) Observed the exit was blocked with barrels and carts, located in the Boiler Room of the Power House.
2) Observed a copying machine and table in the corridor, located by G-car Elevator at the Ground Floor.

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 November 15, 2012 at approximately 1:39 PM, the following observation was made:

1) Observed an unsecured helium cylinder, located in the Gift Shop.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 15, 2012 at approximately 8:12 AM, the following observations were made:

1) Observed during the review of the facility documents, that the monthly load bank testing dated 11-1-12 noted that the 100 KW switch does not work to load generator (the switch next to the 200 KW) for both generators #1 and #2. The facility did not provide documentation that this issue had been resolved.
2) Observed during the review of the facility documents, that the monthly load bank testing dated 10-2-12 noted that the 100 KW switch does not work to load generator #2. The facility did not provide documentation that this issue had been resolved.
3) Observed during the review of the facility documents, that the monthly load bank testing Generator #1 dated 1-16-12, 2-16-12, 3-13-12, 4-27-12, 5-9-12, 6-5-12 noted high amp readings on legs #1 and #2. The facility did not provide documentation that this issue had been resolved.
4) Observed during the review of the facility documents, that the monthly load bank testing Generator #2 dated 1-2-12, 2-20-12, 3-13-12, 4-27-12, 5-10-12, 6-6-12 noted high amp readings on legs #1 and #2. On load bank test dated 1-18-12, it was noted high amp readings only on leg #2. The facility did not provide documentation that this issue had been resolved.
5) Observed during the review of the facility documents, that the facility failed to document monthly load bank testing for the months of July and August of 2012.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 1:10 PM, the following observation was made:

1) Observed during the review of the facility records, that the facility failed to document a monthly load test of the generator for the month of October 2012.

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 November 13, 2012 at approximately 10:35 AM, the following observations were made:

1) Observed that the 110 V wiring was not encased in conduit, located above the ceiling in Room 730.
2) Observed an electrical junction box was missing a cover plate, located in Room 736.
3) Observed an electrical junction box was missing a cover plate, located in Room 762.
4) Observed an electrical junction box was missing a cover plate, located in Room 651.
5) Observed an electrical junction box was missing a cover plate, located in Room 666 above Bed #1.
6) Observed that the 110 V wiring was not encased in conduit, located in Room 637.
7) Observed that the 110 V wiring did not terminate in a junction box, located in Room 638.
8) Observed an electrical extension cord in use, located in Room 527.

On November 14, 2012 at approximately 8:25 AM, the following observations were made:

1) Observed that the electrical panel was missing a filler blank, located in Room 429.
2) Observed an electrical extension cord in use, located in Room 470.
3) Observed an electrical outlet missing a cover plate, located in Room 226 A.
4) Observed two electrical extension cords in use, located in Room 164.
5) Observed two electrical junction boxes missing cover plates and a light switch missing a cover plate, located in the CT Scanner Room.
6) Observed an electrical junction box was missing a cover plate, located at the cross corridor smoke barrier, off the Main Lobby.

On November 15, 2012 at approximately 9:40 AM, the following observations were made:

1) Observed the front cover of the electrical panel was missing and temporary wiring was attached to the panel, located in the Chiller Room of the Power House.
2) Observed an electrical extension cord in use, located in Room G-55.
3) Observed that the 110 V wiring did not terminate in a junction box, located in Room G-54.
4) Observed an electrical extension cord in use, located in Room G-06 B.
5) Observed an electrical extension cord in use, located in Room G-10.
6) Observed two electrical extension cords in use, located in Out Patient Endoscopy Department.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 15, 2012 at approximately 8:50 AM, the following observation was made:

1) During the review of the facility documents, the facility failed to provide a document for notifying the Bureau of Fire Services should an outage of the fire sprinkler system occur for more than four hours in a twenty four hour period.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 1:15 PM, the following observation was made:

1) During the review of the facility documents, the facility failed to provide a document for notifying the Bureau of Fire Services should an outage of the fire sprinkler system occur for more than four hours in a twenty four hour period.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 15, 2012 at approximately 8:55 AM, the following observation was made:

1) During the review of the facility documents, the facility failed to provide a document for notifying the Bureau of Fire Services should an outage of the fire alarm system occur for more than four hours in a twenty four hour period.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 1:16 PM, the following observation was made:

1) During the review of the facility documents, the facility failed to provide a document for notifying the Bureau of Fire Services should an outage of the fire alarm system occur for more than four hours in a twenty four hour period.

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 all occupants of the facility. Findings include:

On November 15, 2012 the following observation was made:

1) Observed that the facility did not have documentation providing the construction type of the hospital.

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 all occupants of the facility. Findings include:

On November 19, 2012 the following observation was made:

1) Observed that the facility did not have documentation providing the construction type of the facility.

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

On November 13, 2012 at approximately 11:07 AM, the following observations were made:

1) Observed that there was a ceiling tile missing, located in Room 727.
2) Observed that there was a ceiling tile missing, located in Room 680.
3) Observed that there was an unsealed hole in the wallboard in back of the bed as well as a hole in the ceiling in the shower, located in Room 651.
4) Observed that there was a ceiling tile missing, located in Room 665.
5) Observed that there was a ceiling tile missing, located in Room 673.
6) Observed an unsealed hole in the wallboard behind the door, located in Room 527.
7) Observed that there was a ceiling tile missing, located in Room 579.

On November 14, 2012 at approximately 8:05 AM, the following observations were made:

1) Observed an unsealed 2" hole in the ceiling tile, located in Room 421.
2) Observed a hole in the ceiling tile and two ceiling tiles out of place, located in Room 349.
3) Observed that were two ceiling tiles missing, located in "On Call" Room 397 e.
4) Observed that there was a ceiling tile missing, located in Room 395.
5) Observed a hole in the ceiling tile, located in Room 374.
6) Observed that there was a ceiling tile missing, located in Room 373.
7) Observed that there was a ceiling tile missing, located in Room 211 B.
8) Observed there were six ceiling tiles missing, located in Room 238.
9) Observed there were two ceiling tiles missing, located in the CT Scanner Room.

On November 15, 2012 at approximately 12:45 PM, the following observations were made:

1) Observed that there was a ceiling tile missing, located in Room G-12.
2) Observed that were three ceiling tiles missing, located in Room G-06.

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 November 13, 2012 at approximately 10:30 AM, the following observations were made:

1) Observed that the door did not close to a positive latch, located at the west door of Room 732.
2) Observed that the door did not close to a positive latch, located at Room 756.
3) Observed that the door did not close to a positive latch, located at Room 504.
4) Observed that the door did not close to a positive latch, located at Room 511.
5) Observed that the door was missing the door latching hardware, located in Room 545.
6) Observed that the door did not create a smoke tight seal at the frame, located in Room 315.

On November 14, 2012 at approximately 10:18 AM, the following observations were made:

1) Observed that the door to the corridor was blocked in the open position with a heavy box of batteries, located in Room 393.
2) Observed the door to the corridor was blocked in the open position, located in the Pathology Department Break Room.
3) Observed the door hardware was malfunctioning (unable to open from inside room), located in Waiting Room 130. Note: door hardware was repaired at time of inspection.
4) Observed that the door did not close to a positive latch due to tape applied to the lockset, located in Room 131 C. Note: tape was removed at time of inspection.
5) Observed the door did not close to a positive latch, located in the Patient Access area.

On November 15, 2012 at approximately 10:27 AM, the following observations were made:

1) Observed the door hardware needed to be repaired, located at the cross corridor smoke barrier into the Morgue.
2) Observed a deadbolt lockset on the door, located in the Staff Lounge/Conference Room in the Radiation Oncology Department.

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 November 19, 2012 at approximately 10:36 AM, the following observation was made:

1) Observed that the door did not create a smoke tight seal at the frame, located in the Urgent care Manager's Office.

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 November 13, 2012 at approximately 10:45 AM, the following observations were made:

1) Observed that there were two unsealed conduits, two unsealed air vents and gaps around the I-beam and the air duct, located in the smoke barrier rated wall in Room 701.
2) Observed that there was an incomplete seal around the I-beam, located at the cross corridor smoke barrier into the North Unit on the 7th Floor.3) Observed that the cross corridor doors did not close to a positive latch, located at the west door into 7 - South Wing.
4) Observed that there was an unsealed hole in the wallboard and an incomplete seal around an I-beam, located at the cross corridor smoke barrier by Room 780.
5) Observed that the wall was not smoke tight to the deck, located in Room 769.
6) Observed that there was an unsealed large diameter hot water pipe penetration in the smoke barrier wall, located in Room 773.
7) Observed that there was some unsealed stud work in the smoke barrier wall, located in back of the column by the southwest cross corridor smoke barrier doors on the 6th Floor.
8) Observed two unsealed wire penetrations in the smoke barrier wall, located above west door of Room 675.
9) Observed two unsealed wire penetrations and one unsealed flexible conduit penetration in the smoke barrier wall, located in Room 671.
10) Observed one unsealed conduit penetration in the smoke barrier wall, located in Room 673.
11) Observed three unsealed wire penetrations and three unsealed conduit penetrations in the smoke barrier walls, located in Room 632.
12) Observed an incomplete seal around the I-beam in the smoke barrier wall, located in Room 601.
13) Observed an unsealed pipe penetration in the smoke barrier wall, located in Room 637.
14) Observed an unsealed conduit penetration in the (north) smoke barrier wall, located in Room 532.

On November 14, 2012 at approximately 8:26 AM, the following observations were made:

1) Observed two unsealed three inch conduits in the smoke barrier wall, located in Room 428.
2) Observed two unsealed wire penetrations and two unsealed conduit penetrations in the smoke barrier wall of Room 430.
3) Observed one unsealed wire penetration and one unsealed 2" conduit, located in Room 475. Also noted that the west wall did not extend to the decking of the fire rated room/smoke barrier wall.
4) Observed an unsealed wire penetration in the cross corridor smoke barrier, located by Room 325.
5) Observed four unsealed conduits in the smoke barrier wall, located in Room 325.
6) Observed an unsealed wire penetration in the cross corridor smoke barrier, located by Room 301.
7) Observed an unsealed conduit in the smoke barrier wall, located in Room 301.
8) Observed an unsealed pipe penetration the south smoke barrier wall, located in Room 218.
9) Observed an unsealed flexible conduit penetration, located at the north cross corridor smoke barrier off the Main Lobby.

On November 15, 2012 at approximately 10:27 AM, the following observations were made:

1) Observed an unsealed pipe penetration, located in the cross corridor smoke barrier leading into the Morgue.
2) Observed an unsealed fire sprinkler pipe penetration, located at the corner of the corridor outside the Morgue smoke barrier wall.
3) Observed an unsealed fire sprinkler pipe penetration, located at the cross corridor smoke barrier by Stairwell #5.
4) Observed an unsealed fire sprinkler pipe penetration in the fire rated/smoke barrier wall, located in Room G-10.
5) Observed an unsealed black pipe penetration in the smoke barrier wall, located in Room G-05.

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 November 14, 2012 at approximately 10:31 AM, the following observations were made:

1) Observed two unsealed wire penetrations, and a large unsealed hole in the wallboard around the clothes dryer vent in the wall, located in Room 477.
2) Observed that the door was blocked in the open position to the corridor with a box, located in the Housekeeping Storage Room on the 3 - Southwest Wing.

On November 15, 2012 at approximately 10:38 AM, the following observation was made:

1) Observed excessive lint build up in the rear of the clothes dryer, located in Room G-55.

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 November 19, 2012 at approximately 10:45 AM, the following observations were made:

1) Observed an unsealed copper pipe penetration and an unsealed wire penetration on the corridor wall, located in the East Mechanical Room.
2) Observed an unsealed conduit penetration, located in the West Mechanical Room.
3) Observed an unsealed conduit penetration, located in the Generator Room.

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 November 14, 2012 at approximately 1:45 PM, the following observations were made:

1) Observed the exterior path of exit discharge was illuminated with a single bulb fixture, located at Stairwell #6.
2) Observed the exterior path of exit discharge was illuminated with a single bulb fixture, located at Stairwell #7.
3) Observed the exterior path of exit discharge was illuminated with a single bulb fixture, located at Stairwell #4.
4) Observed the exterior path of exit discharge was illuminated with a single bulb fixture, located at Stairwell #5.

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 November 15, 2012 at approximately 12:58 PM, the following observation was made:

1) Observed that the corridor did not have signage for the exit, located in the corridor outside the G-car Elevator.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 15, 2012 at approximately 8:15 AM, the following observation was made:

1) Observed during the review of the facility records, that the facility failed to document fire drills for the second and third shifts in the 1st, 2nd, and 3rd quarters of 2012.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 1:05 PM, the following observation was made:

1) Observed during the review of the facility records, that the facility failed to document fire drills during the 4th quarter of 2011 and the 1st quarter of 2012.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 13, 2012 at approximately 11:50 AM, the following observations were made:

1) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #3 on the 7th Floor.
2) Observed that the fire alarm pull station was missing the glass rod, located at Room 506.
3) Observed that the fire alarm pull station was missing the glass rod, located at Room 520.
4) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #2 on the 5th Floor.

On November 14, 2012 at approximately 8:10 AM, the following observations were made:

1) Observed that the fire alarm pull station was missing the glass rod, located at Room 420.
2) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #2 on the 4th Floor.
3) Observed that the fire alarm pull station was missing the glass rod, located at Room 307.
4) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #3 on the 3rd Floor.
5) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #2 on the 2nd Floor.
6) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #7 on the 1st Floor.
7) Observed that the fire alarm pull station was missing the glass rod, located at Room 107.

On November 15, 2012 at approximately 8:10 AM, the following observations were made:

1) Observed during the review of the facility records, the fire alarm system inspection report was out-dated.
2) Observed that the fire alarm pull station was missing the glass rod, located by Room G-55.
3) Observed that the fire alarm pull station was missing the glass rod, located by the entrance to the Cafeteria on the Ground Floor.
4) Observed that the fire alarm pull station was missing the glass rod, located at Stairwell #2 on the Ground Floor.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 1:00 PM, the following observation was made:

1) Observed during the review of the facility records, the fire alarm system inspection report was out-dated (June 3, 2010).

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 November 19, 2012 at approximately 10:26 AM, the following observations were made:

1) Observed an unsealed hole in the ceiling tile, located in the Soiled Utility Room of the Urgent Care Unit.
2) Observed that the mesh at the top of the patient curtain was too small to allow proper fire sprinkler coverage, located in the Cardiac Room C-1.
3) Observed that there was a ceiling tile missing, located in the Radiology Storage Room.

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 November 13, 2012 at approximately 11:09 AM, the following observations were made:

1) Observed that the pendant fire sprinkler head did not extend below the required one inch spacing of the ceiling, located at the 7 - North Nursing Station.
2) Observed that the fire sprinkler head was missing an escutcheon plate, located at the 6 - North Nursing Station.

On November 14, 2012 at approximately 9:10 AM, the following observations were made:

1) Observed a fire sprinkler head covered with lint, located in the Med Room of the 4 - North Wing.
2) Observed there were items stored within the required eighteen inch clearance of a fire sprinkler head, located in the Housekeeping Storage Room on the 3 - Southwest Wing.
3) Observed a fire sprinkler head covered with lint, located in Room 149.
4) Observed at 3:00 PM that the fire sprinkler system was out of service. Speaking with the Director of Operations, he stated the fire sprinkler system has been out of service for about two months. There is approximately eight-hundred and thirty feet of piping that is being replaced on the Ground Floor due to numerous leaks. At that time the facility was placed on Fire Watch detail until fire sprinkler system is back in service. Note: the fire sprinkler system was back in-service on November 16, 2012 at approximately 1:00 PM. The Bureau of Fire Services and the local fire department were not notified of the fire sprinkler system being out of service.

On November 15, 2012 at approximately 8:20 AM, the following observations were made:

1) Observed during the review of the facility records, that the facility failed to document quarterly water flows of the fire sprinkler system in 2012.
2) Observed electrical wiring attached to the fire sprinkler piping, located outside Linen Supply Room.

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 November 13, 2012 at approximately 11:55 AM, the following observation was made:

1) Observed that the fire extinguisher missed the monthly inspections since August of 2012, located in Room 747.

On November 14, 2012 at approximately 11:48 AM, the following observations were made:

1) Observed the fire extinguisher missed the monthly inspections in April and May of 2012, located in the Cardiac Cath. Department.
2) Observed the fire extinguisher did not have an inspection tag attached, located in the Mechanical Room 222.

On November 15, 2012 at approximately 9:45 AM, the following observations were made:

1) Observed a carbon dioxide fire extinguisher missed monthly inspections since April of 2012, also the extinguisher needed to be recharged and mounted, located in the Chiller Room of the Power House.
2) Observed the fire extinguisher needed to be mounted, located in the Boiler Room of the Power House.
3) Observed the fire extinguisher needed to be mounted, located in the Generator Room of the
Power House.

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 November 15, 2012 at approximately 8:25 AM, the following observations were made:

1) Observed during the review of the facility records, that the facility failed to document a semi annual inspection of the kitchen hood suppression system report for the 1st half of 2012. Note: an inspection report dated for October 18, 2012 was provided.

Based on observation the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 14, 2012 at approximately 12:10 PM, the following observations were made:

1) Observed an electrical space heater in the office, located in the Pathology Department.
2) Observed two electrical space heaters, located in the Patient Access area.
3) Observed an electrical space heater in the office, located in the Security Radio Room.

Based on observation the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 10:31 AM, the following observations were made:

1) Observed an electrical space heater, located at the Reception Desk.
2) Observed two electrical space heaters, located in the Administration Front Office.
3) Observed an electrical space heater, located in the Staff Office of the Physical Therapy Department.
4) Observed an electrical space heater, located in the IT Room of the Physical Therapy Department.
5) Observed three electrical space heaters, located in the Patient Therapy Room of the Physical Therapy Department.

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

On November 13, 2012 at approximately 11:10 AM, the following observations were made:

1) Observed that there were five large size boxes stored in the corridor, located outside Room 744.
2) Observed that there were three chairs, an exam table, bed mattress and a table stored in the southeast corridor of the 6 - South Wing.
3) Observed that the wall mounted charting station in the corridor did not self close, located at Room 555.
4) Observed that the wall mounted charting station in the corridor did not self close, located at Room 564.
5) Observed that the wall mounted charting station in the corridor did not self close, located at Room 565.

On November 14, 2012 at approximately 9:20 AM, the following observations were made:

1) Observed that a large quantity of chairs, a file cabinet and a bed were stored in the corridor, located by the Main Elevators.
2) Observed four beds and four chairs stored in the corridor, located by the 3 - North Nurses Station.
3) Observed numerous beds, monitors, and wooden pallets were stored in the corridor, located by Room 393.
4) Observed chairs, a table, and a filling cabinet were stored in the corridor, located by Room 372.
5) Observed a housekeeping cart was stored in the stairwell, located in Stairwell #7, on the 2nd Floor.

On November 15, 2012 at approximately 9:50 AM, the following observations were made:

1) Observed the exit was blocked with barrels and carts, located in the Boiler Room of the Power House.
2) Observed a copying machine and table in the corridor, located by G-car Elevator at the Ground Floor.

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 November 15, 2012 at approximately 1:39 PM, the following observation was made:

1) Observed an unsecured helium cylinder, located in the Gift Shop.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 15, 2012 at approximately 8:12 AM, the following observations were made:

1) Observed during the review of the facility documents, that the monthly load bank testing dated 11-1-12 noted that the 100 KW switch does not work to load generator (the switch next to the 200 KW) for both generators #1 and #2. The facility did not provide documentation that this issue had been resolved.
2) Observed during the review of the facility documents, that the monthly load bank testing dated 10-2-12 noted that the 100 KW switch does not work to load generator #2. The facility did not provide documentation that this issue had been resolved.
3) Observed during the review of the facility documents, that the monthly load bank testing Generator #1 dated 1-16-12, 2-16-12, 3-13-12, 4-27-12, 5-9-12, 6-5-12 noted high amp readings on legs #1 and #2. The facility did not provide documentation that this issue had been resolved.
4) Observed during the review of the facility documents, that the monthly load bank testing Generator #2 dated 1-2-12, 2-20-12, 3-13-12, 4-27-12, 5-10-12, 6-6-12 noted high amp readings on legs #1 and #2. On load bank test dated 1-18-12, it was noted high amp readings only on leg #2. The facility did not provide documentation that this issue had been resolved.
5) Observed during the review of the facility documents, that the facility failed to document monthly load bank testing for the months of July and August of 2012.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 1:10 PM, the following observation was made:

1) Observed during the review of the facility records, that the facility failed to document a monthly load test of the generator for the month of October 2012.

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 November 13, 2012 at approximately 10:35 AM, the following observations were made:

1) Observed that the 110 V wiring was not encased in conduit, located above the ceiling in Room 730.
2) Observed an electrical junction box was missing a cover plate, located in Room 736.
3) Observed an electrical junction box was missing a cover plate, located in Room 762.
4) Observed an electrical junction box was missing a cover plate, located in Room 651.
5) Observed an electrical junction box was missing a cover plate, located in Room 666 above Bed #1.
6) Observed that the 110 V wiring was not encased in conduit, located in Room 637.
7) Observed that the 110 V wiring did not terminate in a junction box, located in Room 638.
8) Observed an electrical extension cord in use, located in Room 527.

On November 14, 2012 at approximately 8:25 AM, the following observations were made:

1) Observed that the electrical panel was missing a filler blank, located in Room 429.
2) Observed an electrical extension cord in use, located in Room 470.
3) Observed an electrical outlet missing a cover plate, located in Room 226 A.
4) Observed two electrical extension cords in use, located in Room 164.
5) Observed two electrical junction boxes missing cover plates and a light switch missing a cover plate, located in the CT Scanner Room.
6) Observed an electrical junction box was missing a cover plate, located at the cross corridor smoke barrier, off the Main Lobby.

On November 15, 2012 at approximately 9:40 AM, the following observations were made:

1) Observed the front cover of the electrical panel was missing and temporary wiring was attached to the panel, located in the Chiller Room of the Power House.
2) Observed an electrical extension cord in use, located in Room G-55.
3) Observed that the 110 V wiring did not terminate in a junction box, located in Room G-54.
4) Observed an electrical extension cord in use, located in Room G-06 B.
5) Observed an electrical extension cord in use, located in Room G-10.
6) Observed two electrical extension cords in use, located in Out Patient Endoscopy Department.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 15, 2012 at approximately 8:50 AM, the following observation was made:

1) During the review of the facility documents, the facility failed to provide a document for notifying the Bureau of Fire Services should an outage of the fire sprinkler system occur for more than four hours in a twenty four hour period.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 1:15 PM, the following observation was made:

1) During the review of the facility documents, the facility failed to provide a document for notifying the Bureau of Fire Services should an outage of the fire sprinkler system occur for more than four hours in a twenty four hour period.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 15, 2012 at approximately 8:55 AM, the following observation was made:

1) During the review of the facility documents, the facility failed to provide a document for notifying the Bureau of Fire Services should an outage of the fire alarm system occur for more than four hours in a twenty four hour period.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On November 19, 2012 at approximately 1:16 PM, the following observation was made:

1) During the review of the facility documents, the facility failed to provide a document for notifying the Bureau of Fire Services should an outage of the fire alarm system occur for more than four hours in a twenty four hour period.