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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 affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly maintained dampers.

Findings include:

On 08/26/10, the following observations were made:

- At approximately 1:40 PM observed by review of records that damper maintenance records for 11 of 31 dampers were not available for review at the time of inspection.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could affect an undetermined number of occupants in the event of a fire within the hazardous area enclosure where the products of combustion are allowed to spread to the means of egress due to improperly installed or maintained hazardous room doors.

Findings include:

On 08/26/10, the following observations were made:

- At approximately 1:00 PM observed that the Outpatient Janitor Closet door was not equipped with a self-closing device.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could affect all building occupants in the event of a delay in occupant notification due to improperly located fire alarm system components.

Findings include:

On 08/26/10, the following observations were made:

- At approximately 12:42 PM observed that in the Ultra Sound Corridor there were ceiling mounted smoke detectors that were located within 3 feet of an HVAC duct opening.
- At approximately 12:50 PM observed that in the Lab Hallway near the smoke barrier doors there was a ceiling mounted smoke detector located within 3 feet of an HVAC duct opening.
- At approximately 1:30 PM observed that in the Surgery Hallway there was a ceiling mounted smoke detector located within 3 feet of an HVAC duct opening.
- At approximately 1:50 PM observed by review of records that a Smoke Detector Sensitivity Test conducted in 2009 revealed that detectors #4, #11, & #16 were out of tolerance. It was verified by maintenance that these detectors had not yet been serviced or replaced.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could affect all building occupants in the event of a fire where the early suppression of the fire does not occur due to the improperly maintained fire suppression system.

Findings include:

On 08/26/10, the following observations were made:

- At approximately 12:30 PM observed by review of records that the fire sprinkler system was overdue for its annual system inspection.
- At approximately 1:55 PM observed by review of records that Hose Station Hose Testing records were not available for review at the time of inspection.

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 affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly maintained dampers.

Findings include:

On 08/26/10, the following observations were made:

- At approximately 1:40 PM observed by review of records that damper maintenance records for 11 of 31 dampers were not available for review at the time of inspection.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could affect an undetermined number of occupants in the event of a fire within the hazardous area enclosure where the products of combustion are allowed to spread to the means of egress due to improperly installed or maintained hazardous room doors.

Findings include:

On 08/26/10, the following observations were made:

- At approximately 1:00 PM observed that the Outpatient Janitor Closet door was not equipped with a self-closing device.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could affect all building occupants in the event of a delay in occupant notification due to improperly located fire alarm system components.

Findings include:

On 08/26/10, the following observations were made:

- At approximately 12:42 PM observed that in the Ultra Sound Corridor there were ceiling mounted smoke detectors that were located within 3 feet of an HVAC duct opening.
- At approximately 12:50 PM observed that in the Lab Hallway near the smoke barrier doors there was a ceiling mounted smoke detector located within 3 feet of an HVAC duct opening.
- At approximately 1:30 PM observed that in the Surgery Hallway there was a ceiling mounted smoke detector located within 3 feet of an HVAC duct opening.
- At approximately 1:50 PM observed by review of records that a Smoke Detector Sensitivity Test conducted in 2009 revealed that detectors #4, #11, & #16 were out of tolerance. It was verified by maintenance that these detectors had not yet been serviced or replaced.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could affect all building occupants in the event of a fire where the early suppression of the fire does not occur due to the improperly maintained fire suppression system.

Findings include:

On 08/26/10, the following observations were made:

- At approximately 12:30 PM observed by review of records that the fire sprinkler system was overdue for its annual system inspection.
- At approximately 1:55 PM observed by review of records that Hose Station Hose Testing records were not available for review at the time of inspection.