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Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 1.1.4.1, 19.1.1.4.2.

Findings include:

On 11/17/11 at approximately 11:00 AM during an inspection of separation walls with the Maintenance Supervisor, the following observation was made:

1. Observed electrical conduits through the rated building separation in the basement electrical room to be open around the conduits, leaving holes through the rated building separation.

This deficiency was confirmed with the Maintenance Supervisor.

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.

Findings include:

On 11/16/11 at approximately 9:00 AM during an inspection of vertical openings with the Maintenance Supervisor, the following observation was made:

1. Observed sprinkler line above door to stairwell near the Wound Clinic to be open around the sprinkler pipe, leaving a hole in the rated stairwell wall.

This deficiency was confirmed with the Maintenance Supervisor.

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.

Findings include:

On 11/16/11 between approximately 11:40 AM - 3:00 PM during an inspection of smoke barrier walls with the Maintenance Supervisor, the following observations were made:

1. Observed grey wires through the smoke barrier wall above doors to the Orthopedic Unit open around the wires, leaving a hole through the smoke barrier wall.

2. Observed hole through the smoke barrier wall above doors to the Orthopedic Unit.

3. Observed copper pipe through the smoke barrier wall above doors to the Orthopedic Unit open around the pipe, leaving a hole through the smoke barrier wall.

4. Observed bundle of wires through the smoke barrier wall above doors to the Wound Healing Center open around the wires, leaving a hole through the smoke barrier wall.

5. Observed copper pipe through the smoke barrier wall above doors to the Wound Healing Center open around the pipe, leaving a hole through the smoke barrier wall.

6. Observed sprinkler pipe through the smoke barrier wall above doors to the Surgery Short Stay open around the pipe, leaving a hole through the smoke barrier wall.

7. Observed grey wires through the smoke barrier wall above doors to the OR Suite open around the wires, leaving a hole through the smoke barrier wall.

8. Observed 4"x 4" hole in smoke barrier wall approximately 20' down the wall of the air handler # 2 exit.

9. Observed hole in smoke barrier wall approximately 30' down the wall of the air handler # 2 exit.

10. Observed large hole in the smoke barrier wall above doors to the CT corridor.

11. Observed sprinkler pipe through the smoke barrier wall above doors to the Radiology corridor open around the pipe, leaving a large hole through the smoke barrier wall.

12. Observed large bundle of wires through the smoke barrier wall above doors to the Radiology corridor open around the wires, leaving a large hole through the smoke barrier wall.

13. Observed large bundle of wires through the smoke barrier wall above door to the Mail Room open around the wires, leaving a hole through the smoke barrier wall.

14. Observed sprinkler pipe through the smoke barrier wall above door to the Financial Counselor open around the pipe, leaving a large hole through the smoke barrier wall.

15. Observed a 3" conduit through the smoke barrier wall of the Occupational Health Office to be open on both ends of the conduit, as well as around the conduit, leaving holes through the smoke barrier wall.

These deficiencies were confirmed with the Maintenance Supervisor.

On 11/17/11 between approximately 9:30 AM - 11:00 AM during an inspection of smoke barrier walls with the Maintenance Supervisor, the following observations were made:

1. Observed sprinkler pipe through the smoke barrier wall above doors to the Michigan Room open around the pipe, leaving a large hole through the smoke barrier wall.

2. Observed several wires through the smoke barrier wall above doors to the Michigan Room open around the wires, leaving holes through the smoke barrier wall.

3. Observed several penetrations through the smoke barrier wall above doors to the Materials Management Corridor, leaving holes through the smoke barrier wall.

These deficiencies were confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1.

Findings include:

On 11/16/11 between approximately 3:00 PM - 5:00 PM during an inspection of hazard rooms with the Maintenance Supervisor, the following observations were made:

1. Observed the shower room across from room # 213 being used as a Storage Room. The room does not meet storage room requirements.

2. Observed the door to the Short Stay Clean Linen Room to have several holes through the door.

3. Observed the door to the Short Stay Clean Linen/Storage Room to not have a self-closing device on the door as required.

4. Observed the door to the OR Clean Linen Room not self-close to a positive latch.

5. Observed sprinkler pipe through wall of Volunteer Storage Room open around the pipe, leaving a hole through the rated wall.

6. Observed several penetrations in the rated walls of the M-2 Mechanical Room.

7. Observed several penetrations in the rated walls of Generator Room # 2.

8. Observed copper pipe through the rated wall of the Kitchen Storage Room to be open around the pipe, leaving a hole through the rate wall.

These deficiencies were confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11.

Findings include:

On 11/16/11 at approximately 1:00 PM during an inspection of exits with the Maintenance Supervisor, the following observation was made:

1. Observed the exit stairwell door out of the Operating Suite to stick in the open position.

This deficiency was confirmed with the Maintenance Supervisor.

Based on review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2.

Findings include:

On 11/17/11 at approximately 11:00 AM during a review of records with the Maintenance Supervisor, the following observations were made:

1. No record of fire drill for the first shift of the first quarter as required.

2. No record of fire drill for the second shift of the third quarter as required.

3. No record of fire drill for the third shift of the third quarter as required.

These deficiencies were confirmed with the Maintenance Supervisor.

Based on observation 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.

Findings include:

On 11/16/11 at approximately 8:30 AM during an inspection of the sprinkler system with the Maintenance Supervisor, the following observations were made:

1. Observed Electrical Room across from room # 228 to be missing ceiling tiles. The facility is fully sprinklered and this was common throughout the facility in most Electrical/Data Rooms.

2. Observed the sprinkler head in the janitors closet, next to Director of Impatient Services, to be too high in the dry wall ceiling and to have a hole around the sprinkler head.

These deficiencies were confirmed with the Maintenance Supervisor.

Based on review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99.

Findings include:

On 11/17/11 at approximately 11:30 AM during review of records with the Maintenance Supervisor, the following observation was made:

1. The hours documented on the monthly generator load records do not add up to the correct amount of time to ensure that the emergency generators have been run under load for a minimum of 30 minutes monthly as required.

This deficiency was confirmed with the Maintenance Supervisor.