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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 18.1.1.4.1, 18.1.1.4.2. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observation was made:

1. Observed a penetration in the fire wall between the occupied building and non-occupied building in Office 158 for the fire suppression line.

This finding was also observed by the maintenance director at the time of inspection.

Based on observation, the facility failed to provide a 2-hour fire resistive separation (connecting four stories or more) or 1-hour fire resistive separation (single story building and sprinklered buildings up to three stories in height) for the vertical openings in accordance with the LSC section 18.3.1.1. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observation was made:

1. Observed two large penetrations approximately, 1 foot x 2 foot, cut into the 2-hour mechanical shaft above the ceiling in the serving line area of the kitchen at the center hatch access.

This finding was also observed by the maintenance director at the time of inspection.

Based on observation, the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed an additional exit sign was needed for stairwell B in the corridor on the first floor.

2. The exit sign at the nurse's station should be a two sided sign.

These findings were also observed by the maintenance director at the time of inspection.

Based on observation, the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed a conduit above the 1 South cross corridor doors in the smoke barrier wall was not completely sealed.

2. Observed an unsealed penetration above room A130 in the smoke barrier wall.

3. Observed a large hole cut in the smoke barrier wall in the kitchen serving line area above the east access hatch.

4. Observed an unsealed penetration for data lines above the 2nd floor west corridor smoke barrier doors.

5. Observed an unsealed penetration for cables and power above the TV in the day room in the smoke barrier wall.

These findings were also observed by the maintenance director 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 18.3.2.1. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed an unsealed penetration in soiled utility room A131.

2. Observed unsealed penetrations for the condensation lines in the rated kitchen wall in central supply, at the northwest corner of wall.

These findings were also observed by the maintenance director at the time of inspection.

Based on observation, the facility failed to provide the required one-hour fire resistance rating (buildings less than four stories), or the required two-hour fire resistance rating (buildings four stories or more) for the exit component in accordance with the LSC sections 8.2.5.4, 18.3.11. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed an unsealed penetration for data lines in stairwell A on the 2nd floor.

2. Observed an unsealed penetration for a sprinkler line in stairwell B on the 1st floor.

These findings were also observed by the maintenance director at the time of inspection.

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 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed the panic hardware for stairwell A on the 3rd floor was damaged.

2. Observed the panic hardware for the cross corridor doors, northwest 4th floor was damaged.

3. Observed the egress door from the patient floor to the elevator lobby on the 4th floor had a damaged door frame and was binding at the top of the door.

These findings were also observed by the maintenance director at the time of inspection.

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 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observation was made:

1. Observed the weekly visual inspection of the generator was not being logged as completed.

This finding was also observed by the maintenance director at the time of inspection.

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 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed an open junction box above the ceiling in the corridor by room A130.

2. Observed an open junction box above the ceiling in the chart room.

These findings were also observed by the maintenance director at the time of inspection.

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 18.1.1.4.1, 18.1.1.4.2. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observation was made:

1. Observed a penetration in the fire wall between the occupied building and non-occupied building in Office 158 for the fire suppression line.

This finding was also observed by the maintenance director at the time of inspection.

Based on observation, the facility failed to provide a 2-hour fire resistive separation (connecting four stories or more) or 1-hour fire resistive separation (single story building and sprinklered buildings up to three stories in height) for the vertical openings in accordance with the LSC section 18.3.1.1. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observation was made:

1. Observed two large penetrations approximately, 1 foot x 2 foot, cut into the 2-hour mechanical shaft above the ceiling in the serving line area of the kitchen at the center hatch access.

This finding was also observed by the maintenance director at the time of inspection.

Based on observation, the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed an additional exit sign was needed for stairwell B in the corridor on the first floor.

2. The exit sign at the nurse's station should be a two sided sign.

These findings were also observed by the maintenance director at the time of inspection.

Based on observation, the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed a conduit above the 1 South cross corridor doors in the smoke barrier wall was not completely sealed.

2. Observed an unsealed penetration above room A130 in the smoke barrier wall.

3. Observed a large hole cut in the smoke barrier wall in the kitchen serving line area above the east access hatch.

4. Observed an unsealed penetration for data lines above the 2nd floor west corridor smoke barrier doors.

5. Observed an unsealed penetration for cables and power above the TV in the day room in the smoke barrier wall.

These findings were also observed by the maintenance director 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 18.3.2.1. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed an unsealed penetration in soiled utility room A131.

2. Observed unsealed penetrations for the condensation lines in the rated kitchen wall in central supply, at the northwest corner of wall.

These findings were also observed by the maintenance director at the time of inspection.

Based on observation, the facility failed to provide the required one-hour fire resistance rating (buildings less than four stories), or the required two-hour fire resistance rating (buildings four stories or more) for the exit component in accordance with the LSC sections 8.2.5.4, 18.3.11. This deficient practice could potentially affect 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed an unsealed penetration for data lines in stairwell A on the 2nd floor.

2. Observed an unsealed penetration for a sprinkler line in stairwell B on the 1st floor.

These findings were also observed by the maintenance director at the time of inspection.

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 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed the panic hardware for stairwell A on the 3rd floor was damaged.

2. Observed the panic hardware for the cross corridor doors, northwest 4th floor was damaged.

3. Observed the egress door from the patient floor to the elevator lobby on the 4th floor had a damaged door frame and was binding at the top of the door.

These findings were also observed by the maintenance director at the time of inspection.

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 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observation was made:

1. Observed the weekly visual inspection of the generator was not being logged as completed.

This finding was also observed by the maintenance director at the time of inspection.

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 104 occupants of the facility. Findings include:

During the survey conducted November 12-13, 2014, the following observations were made:

1. Observed an open junction box above the ceiling in the corridor by room A130.

2. Observed an open junction box above the ceiling in the chart room.

These findings were also observed by the maintenance director at the time of inspection.