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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:

1. On 03/6/12 at 11:04 AM, observation revealed numerous penetrations of the CMU wall separating the corridor from the patient rooms above the ceiling in the surgical wing that were not properly fire stopped using an approved fire stopping system.

2. On 03/6/12 at 11:10 AM, observation revealed numerous penetrations of the CMU wall separating the corridor from the patient rooms above the ceiling in the patient wing that were not properly fire stopped using an approved fire stopping system.

These deficient practices were confirmed by the Facility Manager at the time of discovery.

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 25 occupants of the facility.

Findings include:

On 03/6/12 at 11:14 AM, observation revealed that room #18 was being used as a storage room without the door being self-closing or automatic closing.

This deficient practice was confirmed by the Facility Manager at the time of discovery.

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 10 occupants of the facility.

Findings include:

On 03/6/12 at 11:17 AM, observation revealed the emergency light located in the Sleep Clinic failed to stay lit for 30-seconds when tested.

This deficient practice was confirmed by the Facility Manager at the time of discovery.

Based on observation the facility failed to provide documentation that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 15 occupants of the facility.

Findings include:

On 03/6/12 at 10:44 AM, observation revealed that 5 of 5 sprinkler heads located in Central Supply were turning green in color indicating the head had become corroded. This change indicates that the sprinkler would not function as it was designed to function and may not activate at its designated temperature.

This deficient practice was confirmed by the Facility Manager at the time of discovery.

Based on observation the facility failed to provide portable fire extinguishers in accordance with the LSC section 9.7.4.1. This deficient practice could potentially affect 10 occupants of the facility.

Findings include:

On 03/6/12 at 10:36 AM, observation revealed that the Class K extinguisher located in the kitchen had a manufacturer date of 2006 stamped on it and no 5 year hydrostatic test was completed during the calendar year of 2011. Wet chemical fire extinguishers shall be inspected not less than every 5 years.

This deficient practice was confirmed by the Facility Manager at the time of discovery.

Based on interview of the Facility Manager the facility failed to provide building services in accordance with the LSC sections 19.5.2.1, 9.2, 19.6.2.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 03/6/12 at 9:39 AM, interview of the Facility Manager revealed that a fire damper inspection had not been completed within the previous 4 years.

This deficient practice was confirmed by the Facility Manager at the time of discovery.

Based on observation and review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility.

Findings include:

1. On 03/6/12 at 9:14 AM, review of the document titled "Monthly Generator Full Load Test" revealed that the generator was a diesel generator and was not tested at loads of at least 30% of the nameplate rating, nor were the minimum exhaust temperature ratings recorded in lieu of meeting the 30% requirement, nor did the generator have an annual load bank test completed.
2. On 03/6/12 at 11:32 AM, observation revealed that there was no emergency stop button located outside of the prime mover housing for outside generator.

These deficient practices were confirmed by the Facility Manager at the time of discovery.

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

Findings include:

1. On 03/6/12 at 11:04 AM, observation revealed numerous penetrations of the CMU wall separating the corridor from the patient rooms above the ceiling in the surgical wing that were not properly fire stopped using an approved fire stopping system.

2. On 03/6/12 at 11:10 AM, observation revealed numerous penetrations of the CMU wall separating the corridor from the patient rooms above the ceiling in the patient wing that were not properly fire stopped using an approved fire stopping system.

These deficient practices were confirmed by the Facility Manager at the time of discovery.

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 25 occupants of the facility.

Findings include:

On 03/6/12 at 11:14 AM, observation revealed that room #18 was being used as a storage room without the door being self-closing or automatic closing.

This deficient practice was confirmed by the Facility Manager at the time of discovery.

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 10 occupants of the facility.

Findings include:

On 03/6/12 at 11:17 AM, observation revealed the emergency light located in the Sleep Clinic failed to stay lit for 30-seconds when tested.

This deficient practice was confirmed by the Facility Manager at the time of discovery.

Based on observation the facility failed to provide documentation that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect 15 occupants of the facility.

Findings include:

On 03/6/12 at 10:44 AM, observation revealed that 5 of 5 sprinkler heads located in Central Supply were turning green in color indicating the head had become corroded. This change indicates that the sprinkler would not function as it was designed to function and may not activate at its designated temperature.

This deficient practice was confirmed by the Facility Manager at the time of discovery.

Based on observation the facility failed to provide portable fire extinguishers in accordance with the LSC section 9.7.4.1. This deficient practice could potentially affect 10 occupants of the facility.

Findings include:

On 03/6/12 at 10:36 AM, observation revealed that the Class K extinguisher located in the kitchen had a manufacturer date of 2006 stamped on it and no 5 year hydrostatic test was completed during the calendar year of 2011. Wet chemical fire extinguishers shall be inspected not less than every 5 years.

This deficient practice was confirmed by the Facility Manager at the time of discovery.

Based on interview of the Facility Manager the facility failed to provide building services in accordance with the LSC sections 19.5.2.1, 9.2, 19.6.2.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 03/6/12 at 9:39 AM, interview of the Facility Manager revealed that a fire damper inspection had not been completed within the previous 4 years.

This deficient practice was confirmed by the Facility Manager at the time of discovery.

Based on observation and review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility.

Findings include:

1. On 03/6/12 at 9:14 AM, review of the document titled "Monthly Generator Full Load Test" revealed that the generator was a diesel generator and was not tested at loads of at least 30% of the nameplate rating, nor were the minimum exhaust temperature ratings recorded in lieu of meeting the 30% requirement, nor did the generator have an annual load bank test completed.
2. On 03/6/12 at 11:32 AM, observation revealed that there was no emergency stop button located outside of the prime mover housing for outside generator.

These deficient practices were confirmed by the Facility Manager at the time of discovery.