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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 affect all occupants of the smoke compartment in the event of a fire in one of the rooms with improperly installed or maintained corridor walls.

Findings include:

On 07/17/12, the following observations were made:

- At approximately 10:30 AM observed that in Ultrasound Room #43 there was an penetration in the ceiling approximately 2" x 3" created by IT cables.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could affect all occupants of the smoke compartment in the event of a fire in one of the rooms with improperly installed or maintained corridor doors.

Findings include:

On 07/17/12, the following observations were made:

- At approximately 10:50 AM observed that the Outpatient Recovery Room door had a through penetration of approximately 1/4" diameter rendering the door not reasonably smoke tight.

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 07/17/12, the following observations were made:

- At approximately 10:20 AM observed that the Emergency Room Storage Room #302 door was held in the open position with a plastic wedge.
- At approximately 10:53 AM observed that the Outpatient Infusion Room Storage Room door did not auto-close to a positive latch.
- At approximately 11:07 AM observed that the Med Surgery Clean Utility Room door did not auto-close to a positive latch.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could affect all occupants of the facility in the event of a failure of the electrical equipment, or the exposure to hazardous electrical currents due to improper protection.

Findings include:

On 07/17/12, the following observations were made:

- At approximately 10:40 AM observed that above the corridor ceiling west of the Lab Entrance there was an uncovered electrical work box resulting in exposed electrical wiring connections.

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 affect all occupants of the smoke compartment in the event of a fire in one of the rooms with improperly installed or maintained corridor walls.

Findings include:

On 07/17/12, the following observations were made:

- At approximately 10:30 AM observed that in Ultrasound Room #43 there was an penetration in the ceiling approximately 2" x 3" created by IT cables.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could affect all occupants of the smoke compartment in the event of a fire in one of the rooms with improperly installed or maintained corridor doors.

Findings include:

On 07/17/12, the following observations were made:

- At approximately 10:50 AM observed that the Outpatient Recovery Room door had a through penetration of approximately 1/4" diameter rendering the door not reasonably smoke tight.

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 07/17/12, the following observations were made:

- At approximately 10:20 AM observed that the Emergency Room Storage Room #302 door was held in the open position with a plastic wedge.
- At approximately 10:53 AM observed that the Outpatient Infusion Room Storage Room door did not auto-close to a positive latch.
- At approximately 11:07 AM observed that the Med Surgery Clean Utility Room door did not auto-close to a positive latch.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could affect all occupants of the facility in the event of a failure of the electrical equipment, or the exposure to hazardous electrical currents due to improper protection.

Findings include:

On 07/17/12, the following observations were made:

- At approximately 10:40 AM observed that above the corridor ceiling west of the Lab Entrance there was an uncovered electrical work box resulting in exposed electrical wiring connections.