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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:

- On April 19, 2010 at 2:44 p.m., observation revealed and confirmed by the facility maintenance director, an open conduit above "Patient Room #264". (1972 Building)

- April 19, 2010 at 12:05 PM, Observation revealed and confirmed by the facility maintenance staff, that there was an unsealed conduit, located by Fourth Floor North Room 412. (1964 Building)

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/ or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all occupants of the facility. Findings include:

- On April 20, 2010 at 10:10 a.m., observation revealed and confirmed by the facility maintenance director, the "CT Scan /CT Holding/Express Care" door not self-closing to provide a positive latch. (1993 Building)

- On April 20, 2010 at 10:11 a.m., observation revealed and confirmed by the facility maintenance director, "Radiology #1" door not self-closing to provide a positive latch. (1993 Building)

- On April 20, 2010 at 1:44 p.m., observation revealed and confirmed by the facility maintenance director, the Electrical Room "door adjacent to smoke barrier doors" #FDMF30 not self-closing to provide a positive latch. (1964 Building)

- On April 20, 2010 at 1:50 p.m., observation revealed and confirmed by the facility maintenance director, the back door to the "Labor & Delivery Nurse Station" had the wired glass cracked. (1993 Building)

- On April 20, 2010 at 9:38 a.m., observation revealed and confirmed by the facility maintenance director, the "Second Floor Histology/Cytology " door from the corridor did not self-close to provide a positive latch. (1993 Building)

- April 20, 2010 at 10:00 AM, Observation revealed and confirmed by the facility maintenance staff, that the door did not close to a positive latch, located at the Third Floor Pre-Op & Recovery/Surgery Clean Utility Room. (1993 Building)

- April 20, 2010 at 10:05 AM, Observation revealed and confirmed by the facility maintenance staff, that the door did not close to a positive latch, located at the Third Floor Pre-Op & Recovery/Surgery Electrical Room. (1993 Building)

- April 21, 2010 at 10:05 AM, Observation revealed and confirmed by the facility maintenance staff, that the door did not close to a positive latch, located in the Equipment Assembly Room to the De-Con corridor. (1993 Building)

- April 21, 2010 at 11:25 AM, Observation revealed and confirmed by the facility maintenance staff, that the door from the Kitchen to the buffet table was hooked in the open position at the door stop, located in the Doctor's Dining Room. (1993 Building)

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. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- April 19, 2010 at 11:55 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an unsealed conduit penetration, located between Fourth Floor North Elevators 6 & 7. (1964 Building)

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 potentially affect all occupants of the facility.

Findings include:

- On April 21, 2010 at 9:14 a.m., observation revealed and confirmed by the facility maintenance director, the Ground Level smoke barrier doors adjacent to the "Physical Plant & Maintenance Office" not self-closing to provide a positive latch. (1964 Building)

- April 21, 2010 at 9:15 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an unsealed conduit penetration, a void in the upper right corner and that the smoke barrier was not sealed tight against the decking/beam. Also, the wallboard joints were not completely sealed, located at Stairwell 17. (1993 Building)

- April 21, 2010 at 10:40 AM, Observation revealed and confirmed by the facility maintenance staff, that there were three unsealed holes in the cross corridor smoke barrier (GR FD 6), located at the intersection of the Concourse and the Health Information Service Corridor. (1993 Building)

- April 21, 2010 at 11:05 AM, Observation revealed and confirmed by the facility maintenance staff, that there were six incomplete seals on pipe/conduit penetrations, located in the Sterilizers Room. (1993 Building)

- April 21, 2010 at 11:15 AM, Observation revealed and confirmed by the facility maintenance staff, that there incomplete seals on pipe/conduit penetrations and the seals around the I-beams are not reasonably smoke tight, located in the Bed Repair Shop. Note: Check all offices, shops and storage rooms in the area for proper seals on beams and penetrations, as some areas were locked. (1993 Building)

- April 21, 2010 at 11:35 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an incomplete seal on a large sleeve, located in the cross corridor smoke barrier (GR FD 1) along the Pharmacy Purchasing side of the corridor. (1993 Building)

- On April 20, 2010 at 1:07 p.m., observation revealed and confirmed by the facility maintenance director, a pipe end not sealed above the smoke barrier doors "#FDMF-22" adjacent to "Patient Room #159". (fixed at the time of inspection) (1972 Building)

- On April 20, 2010 at 1:27 p.m., observation revealed and confirmed by the facility maintenance director, what appears to be a drywall patch sealed with tape and mud above the smoke barrier doors adjacent to "OB On-Call Room #102". (1964 Building)

- On April 20, 2010 at 2:52 p.m., observation revealed and confirmed by the facility maintenance director, an unknown white material used to seal penetrations in the 2 hour wall inside the "Director of Radiology Services #E-142". (1993 Building)

- On April 19, 2010 at 2:54 p.m., observation revealed and confirmed by the facility maintenance director, a pipe penetration, a hole cut in the wall for wire and a drywall patch with what appears to be tape and mud used to seal it in the wall between the "Second Floor South Nurse Station " and "Clean Utility Room". (1972 Building)

- On April 19, 2010 at 3:00 p.m., observation revealed and confirmed by the facility maintenance director, pipe and wire penetrations, holes in the wall above and below the duct and an unknown green material used to fill penetrations in the "Second Floor South Charting Room" across from the "Soiled and Clean Utility Rooms" . (1972 Building)

- On April 19, 2010 at 3:22 p.m., observation revealed and confirmed by the facility maintenance director, a penetration above a pipe above the smoke barrier doors adjacent to "Second Floor Cardiac Pulmonary Rehabilitation" . (Second Floor West Professional -1991 Building)

- April 19, 2010 at 11:50 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an incomplete seal on a wire penetration, located above the entrance door into 4 North from 4 Central. (1987 Building)

- April 20, 2010 at 1:10 PM, Observation revealed and confirmed by the facility maintenance staff, that there was an unsealed wire penetration, located at the First Floor cross corridor smoke barrier at the ramp to the North POB. Note: Penetration was corrected at time of inspection. (1991 Building)

- April 20, 2010 at 1:15 PM, Observation revealed and confirmed by the facility maintenance staff, that the smoke barrier was not sealed at the deck, located at First Floor Elevator 16. (1991 Building)

- April 20, 2010 at 1:20 PM, Observation revealed and confirmed by the facility maintenance staff, that the First Floor cross corridor smoke barrier was not sealed (both sides) at the upper corner along the exterior wall, located by the POB North Main Entrance. (1976 Building)

- April 19, 2010 at 2:00 PM, Observation revealed and confirmed by the facility maintenance staff, that there were five unsealed pipe/conduit penetrations and two unsealed conduits in the smoke barrier wall, located in the Third Floor North Staff Restroom. (1964 Building)

- April 19, 2010 at 2:40 PM, Observation revealed and confirmed by the facility maintenance staff, that there was an open Hilti sleeve and incomplete seals on conduit penetrations, located at the Second Floor North cross corridor smoke barrier by Room 202. (1964 Building)

- April 19, 2010 at 3:05 PM, Observation revealed and confirmed by the facility maintenance staff, that there was an unsealed penetration above the U-shaped channel, located at the Second Floor North cross corridor smoke barrier by Room 218. (1964 Building)

- April 20, 2010 at 9:20 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an unsealed penetration in the center of the smoke barrier at the deck level, located at the Third Floor East cross corridor smoke barrier by the Third Floor East Surgical Waiting Room. (1993 Building)

- April 20, 2010 at 9:50 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an unsealed conduit penetration (right side), located at the cross corridor smoke barrier by the Third Floor Elevator 11. (1993 Building)

- April 20, 2010 at 1:00 PM, Observation revealed and confirmed by the facility maintenance staff, that there were two incomplete seals on fire barrier sleeves, located at the First Floor cross corridor smoke barrier to the West Connector. (1964 Building)

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 21, 2010 at 9:31 a.m., observation revealed and confirmed by the facility maintenance director, the Ground Level smoke barrier doors #GRFD16 adjacent to the "Women's Restroom" not self-closing to provide a positive latch. (1987 Building)

- On April 21, 2010 at 9:37 a.m., observation revealed and confirmed by the facility maintenance director, the Ground Level automatic smoke barrier doors across from the "Morgue Cooler" not self-closing to provide a positive latch. (1964 Building)

- On April 21, 2010 at 11:10 a.m., observation revealed and confirmed by the facility maintenance director, Ground Floor smoke barrier doors #GRFD12 across from "Stairwell #7" not self-closing to provide a positive latch. (1964 Building)

- On April 20, 2010 at 10:39 a.m., observation revealed and confirmed by the facility maintenance director, smoke barrier doors "FDMF-10" across from "Stairwell #10" not self-closing to provide a positive latch. (1993 Building)

- On April 20, 2010 at 1:29 p.m., observation revealed and confirmed by the facility maintenance director, the smoke barrier doors adjacent to the "OB On-Call Room #102" not self-closing to provide a positive latch. (1964 Building)

- On April 19, 2010 at 3:12 p.m., observation revealed and confirmed by the facility maintenance director, the smoke barrier doors adjacent to the "Second Floor Retirement Services/Education Center/Satellite Laboratory" not self-closing to provide a positive latch. (Second Floor West Connector) (1991 Building)

- On April 19, 2010 at 3:28 p.m., observation revealed and confirmed by the facility maintenance director, the smoke barrier doors across from "Second Floor Cardiology Waiting Room" not self-closing to provide a positive latch. (Second Floor West Professional-1991 Building)

- April 20, 2010 at 9:21 AM, Observation revealed and confirmed by the facility maintenance staff, that the cross corridor smoke barrier doors (FD3E-1) did not close to a positive latch, located by the Third Floor East Surgical Waiting Room. (1993 Building)

- April 20, 2010 at 10:10 AM, Observation revealed and confirmed by the facility maintenance staff, that the door ' s metal astragal was loose on the lower portion of the door, located at the cross corridor smoke barrier into the Third Floor Pre-Op & Recovery/Surgery Sterile Corridor. (1993 Building)

- April 21, 2010 at 9:38AM, Observation revealed and confirmed by the facility maintenance staff, that the cross corridor smoke barrier doors did not close to a positive latch, located at the cross corridor smoke barrier (GR FD 8) at the East Entrance Tunnel. (1993 Building)

- April 21, 2010 at 10:05 AM, Observation revealed and confirmed by the facility maintenance staff, that the door did not close to a positive latch, located in the Elevator Mechanical Room 11. (1993 Building)

- April 21, 2010 at 10:50 AM, Observation revealed and confirmed by the facility maintenance staff, that the cross corridor smoke barrier doors (GR FD 5) closed extremely slow, located at the intersection of the Concourse and Central Services Corridor. (1993 Building)

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 all occupants of the facility.

Findings include:

- On April 21, 2010 at 9:43 a.m., observation revealed and confirmed by the facility maintenance director, the ceiling access panel open in the Ground Floor "EVS Soiled Linen Cart Storage Room". (1964 Building)

- On April 21, 2010 at 9:44 a.m., observation revealed and confirmed by the facility maintenance director, four holes in the wall of the Ground Floor "EVS Soiled Linen Cart Storage Room". (1964 Building)

- On April 20, 2010 at 1:18 p.m., observation revealed and confirmed by the facility maintenance director, the "Storage Room" door adjacent to the "Conference Room" and across from "Patient Room #172" did not self-close and latch. (1972 Building)

- On April 19, 2010 at 1:43 p.m., observation revealed and confirmed by the facility maintenance director, the dryer vent disconnected in the "Third Floor South Laundry Room" across from "Patient Room #367". (1972 Building)

- On April 19, 2010 at 1:54 p.m., observation revealed and confirmed by the facility maintenance director, a hole in the "Third Floor South Clean Utility Room" adjacent to the smoke barrier doors and across from the "Storage Room". (1972 Building)

- April 19, 2010 at 2:55 PM, Observation revealed and confirmed by the facility maintenance staff, that there were three holes in the ceiling, located in the Second Floor North Clean Linen Closet by Room 214. (1964 Building)

- April 19, 2010 at 3:15 PM, Observation revealed and confirmed by the facility maintenance staff, that there were two incomplete seals on conduit penetrations, located in the Second Floor North Electrical Closet. (1991 Building)

- April 19, 2010 at 3:20 PM, Observation revealed and confirmed by the facility maintenance staff, that there were two incomplete seals on conduit penetrations and one unsealed conduit, located in the Second Floor North Electrical/Telephone Closet, in the Satellite Lab by Stairwell 15. (1991 Building)

- April 20, 2010 at 9:35 AM, Observation revealed and confirmed by the facility maintenance staff, that the door did not close to a positive latch, located at the Environmental Services Closet by the Third Floor Pre-Op Nurses Station. (1993 Building)

- April 20, 2010 at 9:45 AM, Observation revealed and confirmed by the facility maintenance staff, that there was a hole in the wallboard behind the door, located in the Third Floor Post-Op Soiled Utility Room. (1993 Building)

- April 20, 2010 at 9:55 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an incomplete seal on a large conduit (both ends), located in the Third Floor Pre-Op & Recovery/Surgery Telephone Room next to the OR Pharmacy. (1993 Building)

- April 20, 2010 at 2:00 PM, Observation revealed and confirmed by the facility maintenance staff, that there was a dead bolt lock installed on the First Floor Clean Utility Room, located in the PACU. (1991 Building)

- April 21, 2010 at 10:15 AM, Observation revealed and confirmed by the facility maintenance staff, that there were two incomplete seals on conduit penetrations, located in the Elevator Mechanical Room 11. (1993 Building)

- April 21, 2010 at 11:35 AM, Observation revealed and confirmed by the facility maintenance staff, that there were three unsealed copper pipes, located in the Pharmacy Storage Room. (1993 Building)

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. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 21, 2010 at 9:43 a.m., observation revealed and confirmed by the facility maintenance director, cleaning supplies stored under the stairs in Ground Floor "Stairwell #7" across from the "Food & Nutrition Department". (1964 Building)

- April 21, 2010 at 10:25 AM, Observation revealed and confirmed by the facility maintenance staff, that there was a "Greenlee Wire Cart" stored in the stairwell, located at Stairwell 16. (1993 Building)

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- On April 21, 2010 at 9:51 a.m., observation revealed and confirmed by the facility maintenance director, the marked exit door blocked by a sharps container cart in the Ground Floor "EVS Clean Linen Storage Room". (1964 Building)

- On April 21, 2010 at 10:00 a.m., and confirmed by the facility maintenance director, observation revealed an exit sign in the Ground Floor " Electricians Room " directing egress out to an equipment well that has a ladder and a metal grate over the well. Exit sign should be over the door exiting the "Electricians Room" to the corridor where "Stairwell #14" is immediately outside the door. (1991 Building)

- On April 20, 2010 at 10:15 a.m., observation revealed and confirmed by the facility maintenance director, a patient bed stored in the corridor between "Radiology #2" and "Emergency Department X-Ray". (1993 Building)

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- April 19, 2010 at 10:55 AM, Observation revealed and confirmed by the facility maintenance staff, that the smoke detector was positioned within the required three foot spacing from an air vent, located by Fifth Floor North Elevator 6 & 7. (1964 Building)

- April 19, 2010 at 1:45 PM, Observation revealed and confirmed by the facility maintenance staff, that the smoke detector was positioned within the required three foot spacing from an air vent, located by Third Floor North Elevator 6 & 7. (1964 Building)

- April 20, 2010 at 1:13 PM, Observation revealed and confirmed by the facility maintenance staff, that the smoke detector was positioned within the required three foot spacing from an air vent, located by First Floor Elevator 16. (1991 Building)

- April 21, 2010 at 9:25 AM, Observation revealed and confirmed by the facility maintenance staff, that the required pull station device was missing, located next to Stairwell 17. (1993 Building)

Based on observation and/or review of records 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. This deficient practice could potentially affect all occupants of the facility. Findings include:

- April 20, 2010 at 2:40 PM, Observation revealed and confirmed by the facility maintenance staff, that the closet was missing a sprinkler head, located by the SET Department. (1968 Building)

- April 20, 2010 at 3:20 PM, Observation revealed and confirmed by the facility maintenance staff, that the deflectors on the sprinkler head were bent located in the Mr. Henning's Office. (1968 Building)

Based on observation and/or review of records the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect all occupants of the facility. Findings include:

- April 20, 2010 at 1:35 PM, Observation revealed and confirmed by the facility maintenance staff, the fire extinguisher was found on the floor and had only two monthly inspections since July 2009, located in the First Floor North POB Elevator Equipment Room. (1976 Building)

Oxygen storage of 3000 cubic feet or less is permitted to be in a storage area containing combustible materials, per 1999 NFPA 99, 8-3.1.11.2(c), if the tanks are a minimum of 20 feet from combustibles. A minimum separation of 5 feet is required where the storage area is NFPA 13 sprinklered (Fully Suppressed) This deficient practice could potentially affect all occupants of the facility. Findings Include:

- On April 21, 2010 at 9:54 a.m., observation revealed and confirmed by the facility maintenance director, oxygen, nitrous, compressed air and carbon dioxide cylinders stored within five feet of combustibles in the Ground Floor "Equipment Storage Room" across from "Elevator #16". (1991 Building)

- On April 19, 2010 at 2:47 p.m., observation revealed and confirmed by the facility maintenance director, oxygen stored and not labeled full or empty in the "Equipment Room" across from "Patient Room #265". (1972 Building)

- April 19, 2010 at 3:00 PM, Observation revealed and confirmed by the facility maintenance staff, that there were oxygen tanks stored too close to combustible materials, located in the Second Floor North Equipment Storage Room by Room 217. (1964 Building)

- April 20, 2010 at 10:55 AM, Observation revealed and confirmed by the facility maintenance staff, that there were two unsecured tanks of Nitrous Oxide and four unsecured tanks of Nitrogen, located in the Tank Room in the Fourth Floor East Penthouse. (1993 Building)

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 all occupants of the facility.

Findings include:

- On April 21, 2010 at 9:25 a.m., observation revealed and confirmed by the facility maintenance director, a nitrogen cylinder and a maintenance cart stored in front of "Transformer Bay-1A & Bay 1 MBE" on the Ground Level. (1987 Building)

- On April 20, 2010 at 10:56 a.m., observation revealed and confirmed by the facility maintenance director, an open junction box above the double doors to "Room #167 and #172 East/West Corridor". (1972 Building)

- On April 20, 2010 at 12:57 p.m., observation revealed and confirmed by the facility maintenance director, a hole in the ceiling tile that is too large for the cover plate outside the "Critical Care Pharmacist Office". (1972 Building)

- On April 19, 2010 at 1:35 p.m., observation revealed and confirmed by the facility maintenance director, an open junction box above the "Third Floor South" smoke barrier doors "#FD3S-4" adjacent to "Office #358A". (1972 Building)

- On April 21, 2010 at 10:13 a.m., observation revealed and confirmed by the facility maintenance director, an open junction box in the Ground Floor "Support Tower Mechanical Room" adjacent to the "Fire Pump Room". (1987 Building)

- April 19, 2010 at 11:02 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an electrical extension cord in use, located in the North Penthouse Mechanical Room. (1964 Building)

- April 19, 2010 at 11:05 AM, Observation revealed and confirmed by the facility maintenance staff, that there were two flexible conduits separated from the junction boxes, located in the North Penthouse Mechanical Room at Air Handling Unit #3. (1964 Building)

- April 19, 2010 at 12:00 PM, Observation revealed and confirmed by the facility maintenance staff, that there was an electrical junction box missing a cover plate, located by the Fourth Floor North Laundry Room, adjacent to Room 412. (1964 Building)

- April 20, 2010 at 10:50 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an electrical junction box missing a cover plate, located above the duct work for Unit AC-6 in the Fourth Floor East Penthouse. (1993 Building)

- April 20, 2010 at 10:52 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an electrical junction box missing a cover plate, located above the duct work for Unit AC-3E in the Fourth Floor East Penthouse. (1993 Building)

- April 21, 2010 at 10:00 AM, Observation revealed and confirmed by the facility maintenance staff, that there were two electrical power strips daisy chained together, located in the Equipment Assembly Room. (1993 Building)

- April 20, 2010 at 1:00 PM, Observation revealed and confirmed by the facility maintenance staff, that there were two electrical junction boxes missing cover plates (one on each side of smoke barrier), located at the First Floor cross corridor smoke barrier to the West Connector. (1964 Building)

- April 20, 2010 at 1:00 PM, Observation revealed and confirmed by the facility maintenance staff, that two electrical junction boxes missing cover plates (one on each side of smoke barrier), located at the First Floor cross corridor smoke barrier to the West Connector. (1964 Building)

- April 20, 2010 at 2:05 PM, Observation revealed and confirmed by the facility maintenance staff, that there was an electrical junction box missing a cover plate, located in the First Floor Electrical Room near PACU. (1991 Building)

- April 20, 2010 at 2:10 PM, Observation revealed and confirmed by the facility maintenance staff, an electrical junction box was missing a cover plate, located at the cross corridor smoke barrier doors (FD MF 35) entering into the Endo Department. (1991 Building)

- April 21, 2010 at 9:35 AM, Observation revealed and confirmed by the facility maintenance staff, that there was an electrical junction box missing a cover plate, located at the cross corridor smoke barrier (GR FD 8) at the East Entrance Tunnel. (1993 Building)