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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 130 occupants of the facility. Findings include:

On June 5, 2013 at approximately 10:00 AM, observed that the corridor door to the Paramedical Room in the Emergency Room had the latching mechanism removed and the door did not close to a positive latch. This deficiency is not in accordance with the 2000 Edition LSC 19.3.6.3.

On June 5, 2013 at approximately 11:00 AM, observed that the fire rated corridor door to the Morgue did not close to a positive latch. This deficiency is not in accordance with the 2000 Edition LSC 19.3.6.3.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:00 AM, observed that there is a 2-inch wall through penetration around a pipe protruding through the fire rated wall in the 3rd Floor Stairway by Prep Recovery Bay 1-8. This deficiency is not in accordance with the 2000 Edition LSC 8.2.5.6. 19.3.1.1.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:30 AM, observed that there is a 1/2-inch open conduit protruding through the smoke barrier wall above the ceiling tile above the smoke barrier doors by the 3rd Floor Clinical Information Office that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

On June 4, 2013 at approximately 2:45 PM, observed that there is a 1/4-inch wall through penetration around a cable protruding through the smoke barrier wall above the ceiling tile, above the smoke barrier doors by the 1st Floor Clinical Lab that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

On June 5, 2013 at approximately 9:10 AM, observed that there is a 1/2-inch open conduit protruding through the smoke barrier wall above the ceiling tile above the smoke barrier doors by the 1st Floor Surgical Supply Managers Office that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

On June 5, 2013 at approximately 9:15 AM, observed that there is a 1/2-inch open conduit protruding through the smoke barrier wall above the ceiling tile above the smoke barrier doors to 1st Floor Recovery that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:15 AM, observed that the fire rated door to the 3rd Floor Endoscopy Storage Room #2 did not close to a positive latch. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

On June 4, 2013 at approximately 1:40 PM, observed that the fire rated door to the 2nd Floor Clean Utility Storage Room across from room #258 did not close to a positive latch. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

On June 4, 2013 at approximately 2:00 PM, observed that the fire rated door to the 2 North Janitor Closet across from the Nursing Station did not close to a positive latch. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

On June 4, 2013 at approximately 2:25 PM, observed that the fire rated door to the 1st Floor Equipment Room #7 did not close to a positive latch. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

On June 5, 2013 at approximately 1:05 PM, observed that there are two 1/2-inch wall through penetrations in the fire rated corridor wall that are not sealed with a UL Listed fire resistant material in the Basement X-Ray Storage Room. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 2:05 PM, observed that the 2 West exit door to the exit access stairway did not have a sign that indicated that the door would open in 15 seconds. This deficiency is not in accordance with the 2000 Edition LSC 7.1., 19.2.1.

On June 5, 2013 at approximately 10:30 AM, observed that the exit door to the outside in the Basement Mechanical Room did not open to the full open position the door struck to the concrete slab outside the door. This deficiency is not in accordance with the 2000 Edition LSC 7.1., 19.2.1.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 1:45 PM, observed that the battery operated emergency light fixture located in the 2nd Floor Main Mechanical Room did not operate when tested. This deficiency is not in accordance with the 2000 Edition LSC 7.9. 19.2.9.1.

Based on observation the facility failed to provide exit and directional signs in accordance with the LSC section 19.2.10.1. This deficient practice could potentially affect 130 occupants of the facility. Findings include:

On June 5, 2013 at approximately 10:50 AM, observed that the exit sign to the exit door to the outside in the upper level of the Basement Mechanical Room is obstructed by box storage. This deficiency is not in accordance with the 2000 Edition LSC 7.1., 19.2.1

On June 5, 2013 at approximately 11:00 AM, observed that the direction of travel in the rear exit access stairway in the Basement Main Storage Room is not clearly marked as to the direction of travel. This deficiency is not in accordance with the 2000 Edition LSC 19.2.10.1.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 10:50 AM, observed that the fire department connection located on the roof of the facility was not identified with a sign indicating that it was a fire department connection. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

On June 5, 2013 at approximately 10:33 AM, observed that the there are two paint rollers hanging from the Inspection Test Valve in the Paint Storage Room in the Basement Mechanical Room. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

On June 5, 2013 at approximately 12:51 PM, observed that the drain for the automatic sprinkler system is not identified with a sign in Equipment Room # 6. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

On June 6, 2013 at approximately 10:15 AM, by review of the annual inspection/test of the facility automatic sprinkler system. The technician reported that the Inspection Test Valve in Equipment Room # 4 did not activate the facility fire alarm system. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

On June 6, 2013 at approximately 10:35 AM, by review of the annual inspection/test of the facility fire Pump. The technician reported that the fire pump maintains the system pressure on a run timer. A Jockey Pump should be installed to avoid unnecessary wear on the fire pump. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:50 AM, observed that the silver Fire Extinguisher Cabinet located in the 3rd Floor Elevator Lobby was not identified. This deficiency is not in accordance with the 2000 Edition LSC 9.7.4.1. 19.3.5.6, NFPA 10.

On June 5, 2013 at approximately 10:10 AM, observed that the fire extinguisher located in the 1st Floor Chemistry Lab is not mounted to the wall. This deficiency is not in accordance with the 2000 Edition LSC 9.7.4.1. 19.3.5.6, NFPA 10.

Based on observation the facility failed to provide protection of hazardous collection receptacles in accordance with the LSC section 19.7.5.5. This deficient practice could potentially affect 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:25 AM, observed that there is a Recyclable Paper Container exceeding the 32 Gal capacity located in the exit access corridor by the 3rd Floor Consultation Office this deficiency is not in accordance with the 2000 Edition of the LSC 19.7.5.5.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:55 AM, observed that E-Type Oxygen Cylinders are being stored to close to combustible medical supplies in Storage Room #323. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect 130 occupants of the facility. Findings include:

On June 6, 2013 at approximately 11:00 AM, observed that by review of the annual inspection/test report on the facility Generator #1 the technician reported that the test had to be stopped due to overheating. The governor is not maintaining engine speed. Recommended new or recoil radiator. This deficiency is not in accordance with NFPA 99. 3.4.4.1.

On June 6, 2013 at approximately 11:10 AM, observed that by review of the annual inspection/test report on the facility Generator # 2 the technician reported that the generator needs a new block heater and batteries. The batteries are 7-years old. This deficiency is not in accordance with NFPA 99. 3.4.4.1.

On June 6, 2013 at approximately 11:30 AM, observed that by review of the annual inspection/test report on the facility Generator # 3 the technician reported that the generator needs new the batteries. This deficiency is not in accordance with NFPA 99. 3.4.4.1.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 10:55 AM, observed that combustible maintenance storage was being stored within 36-inches in front of the electrical panel in the facility Penthouse. This deficiency is not in accordance with the NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 10:57 AM, observed that an electrical power strip was being used in lieu of permanent wiring for radio equipment in the facility Penthouse. There was no documentation to review that the power strip could handle the equipment amperage. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 11:20 AM, observed that two old construction lights with exposed wires were located above the ceiling tile in the 3rd Floor Stairway by the Consultation Office. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 1:15 PM, observed that there is an electrical extension cord above the ceiling tile by Room #278 being used in lieu of permanent wire for an isolation room fan. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 1:15 PM, observed that there are exposed electrical wires above the ceiling tile by Room #278. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 1:15 PM, observed that there is an electrical junction box located above the ceiling tile by Room #278 that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 2:35 PM, observed that there are two electrical junction box located above the ceiling tile, above the entrance doors to the Emergency Room that are missing cover plates. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 5, 2013 at approximately 10:40 AM, observed that there is an extension cord being used for an air compressor for a chiller unit in lieu of permanent wiring in the Basement Mechanical Room. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 5, 2013 at approximately 10:45 AM, observed that there is an electrical junction box located under a vent fan next to the air compressor in the upper level or the Basement Mechanical Room that is missing cover plates. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

Based on observation the facility failed to provide an elevator in accordance with the LSC sections 19.5.3, 9.4.3.2. This deficient practice could potentially affect 130 occupants of the facility. Findings include:

On June 5, 2013 at approximately 12:50 PM, observed that there is oil leaking from the elevator machinery that is being dried up with the use of rags that are placed around the equipment to stop the oil in Elevator Room #6. This deficiency is not in accordance with the 2000 Edition LSC 19.5.3, 9.4.3.2.

On June 5, 2013 at approximately 1:20 PM, observed that there is a 1/2 - inch open conduit protruding through the fire rated ceiling in Elevator Room # 2. This deficiency is not in accordance with the 2000 Edition LSC 19.5.3, 9.4.3.2.

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 130 occupants of the facility. Findings include:

On June 5, 2013 at approximately 10:00 AM, observed that the corridor door to the Paramedical Room in the Emergency Room had the latching mechanism removed and the door did not close to a positive latch. This deficiency is not in accordance with the 2000 Edition LSC 19.3.6.3.

On June 5, 2013 at approximately 11:00 AM, observed that the fire rated corridor door to the Morgue did not close to a positive latch. This deficiency is not in accordance with the 2000 Edition LSC 19.3.6.3.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:00 AM, observed that there is a 2-inch wall through penetration around a pipe protruding through the fire rated wall in the 3rd Floor Stairway by Prep Recovery Bay 1-8. This deficiency is not in accordance with the 2000 Edition LSC 8.2.5.6. 19.3.1.1.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:30 AM, observed that there is a 1/2-inch open conduit protruding through the smoke barrier wall above the ceiling tile above the smoke barrier doors by the 3rd Floor Clinical Information Office that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

On June 4, 2013 at approximately 2:45 PM, observed that there is a 1/4-inch wall through penetration around a cable protruding through the smoke barrier wall above the ceiling tile, above the smoke barrier doors by the 1st Floor Clinical Lab that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

On June 5, 2013 at approximately 9:10 AM, observed that there is a 1/2-inch open conduit protruding through the smoke barrier wall above the ceiling tile above the smoke barrier doors by the 1st Floor Surgical Supply Managers Office that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

On June 5, 2013 at approximately 9:15 AM, observed that there is a 1/2-inch open conduit protruding through the smoke barrier wall above the ceiling tile above the smoke barrier doors to 1st Floor Recovery that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:15 AM, observed that the fire rated door to the 3rd Floor Endoscopy Storage Room #2 did not close to a positive latch. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

On June 4, 2013 at approximately 1:40 PM, observed that the fire rated door to the 2nd Floor Clean Utility Storage Room across from room #258 did not close to a positive latch. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

On June 4, 2013 at approximately 2:00 PM, observed that the fire rated door to the 2 North Janitor Closet across from the Nursing Station did not close to a positive latch. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

On June 4, 2013 at approximately 2:25 PM, observed that the fire rated door to the 1st Floor Equipment Room #7 did not close to a positive latch. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

On June 5, 2013 at approximately 1:05 PM, observed that there are two 1/2-inch wall through penetrations in the fire rated corridor wall that are not sealed with a UL Listed fire resistant material in the Basement X-Ray Storage Room. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 2:05 PM, observed that the 2 West exit door to the exit access stairway did not have a sign that indicated that the door would open in 15 seconds. This deficiency is not in accordance with the 2000 Edition LSC 7.1., 19.2.1.

On June 5, 2013 at approximately 10:30 AM, observed that the exit door to the outside in the Basement Mechanical Room did not open to the full open position the door struck to the concrete slab outside the door. This deficiency is not in accordance with the 2000 Edition LSC 7.1., 19.2.1.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 1:45 PM, observed that the battery operated emergency light fixture located in the 2nd Floor Main Mechanical Room did not operate when tested. This deficiency is not in accordance with the 2000 Edition LSC 7.9. 19.2.9.1.

Based on observation the facility failed to provide exit and directional signs in accordance with the LSC section 19.2.10.1. This deficient practice could potentially affect 130 occupants of the facility. Findings include:

On June 5, 2013 at approximately 10:50 AM, observed that the exit sign to the exit door to the outside in the upper level of the Basement Mechanical Room is obstructed by box storage. This deficiency is not in accordance with the 2000 Edition LSC 7.1., 19.2.1

On June 5, 2013 at approximately 11:00 AM, observed that the direction of travel in the rear exit access stairway in the Basement Main Storage Room is not clearly marked as to the direction of travel. This deficiency is not in accordance with the 2000 Edition LSC 19.2.10.1.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 10:50 AM, observed that the fire department connection located on the roof of the facility was not identified with a sign indicating that it was a fire department connection. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

On June 5, 2013 at approximately 10:33 AM, observed that the there are two paint rollers hanging from the Inspection Test Valve in the Paint Storage Room in the Basement Mechanical Room. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

On June 5, 2013 at approximately 12:51 PM, observed that the drain for the automatic sprinkler system is not identified with a sign in Equipment Room # 6. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

On June 6, 2013 at approximately 10:15 AM, by review of the annual inspection/test of the facility automatic sprinkler system. The technician reported that the Inspection Test Valve in Equipment Room # 4 did not activate the facility fire alarm system. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

On June 6, 2013 at approximately 10:35 AM, by review of the annual inspection/test of the facility fire Pump. The technician reported that the fire pump maintains the system pressure on a run timer. A Jockey Pump should be installed to avoid unnecessary wear on the fire pump. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:50 AM, observed that the silver Fire Extinguisher Cabinet located in the 3rd Floor Elevator Lobby was not identified. This deficiency is not in accordance with the 2000 Edition LSC 9.7.4.1. 19.3.5.6, NFPA 10.

On June 5, 2013 at approximately 10:10 AM, observed that the fire extinguisher located in the 1st Floor Chemistry Lab is not mounted to the wall. This deficiency is not in accordance with the 2000 Edition LSC 9.7.4.1. 19.3.5.6, NFPA 10.

Based on observation the facility failed to provide protection of hazardous collection receptacles in accordance with the LSC section 19.7.5.5. This deficient practice could potentially affect 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:25 AM, observed that there is a Recyclable Paper Container exceeding the 32 Gal capacity located in the exit access corridor by the 3rd Floor Consultation Office this deficiency is not in accordance with the 2000 Edition of the LSC 19.7.5.5.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 11:55 AM, observed that E-Type Oxygen Cylinders are being stored to close to combustible medical supplies in Storage Room #323. This deficiency is not in accordance with NFPA 99, Standards for Health Care Facilities.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect 130 occupants of the facility. Findings include:

On June 6, 2013 at approximately 11:00 AM, observed that by review of the annual inspection/test report on the facility Generator #1 the technician reported that the test had to be stopped due to overheating. The governor is not maintaining engine speed. Recommended new or recoil radiator. This deficiency is not in accordance with NFPA 99. 3.4.4.1.

On June 6, 2013 at approximately 11:10 AM, observed that by review of the annual inspection/test report on the facility Generator # 2 the technician reported that the generator needs a new block heater and batteries. The batteries are 7-years old. This deficiency is not in accordance with NFPA 99. 3.4.4.1.

On June 6, 2013 at approximately 11:30 AM, observed that by review of the annual inspection/test report on the facility Generator # 3 the technician reported that the generator needs new the batteries. This deficiency is not in accordance with NFPA 99. 3.4.4.1.

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 130 occupants of the facility. Findings include:

On June 4, 2013 at approximately 10:55 AM, observed that combustible maintenance storage was being stored within 36-inches in front of the electrical panel in the facility Penthouse. This deficiency is not in accordance with the NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 10:57 AM, observed that an electrical power strip was being used in lieu of permanent wiring for radio equipment in the facility Penthouse. There was no documentation to review that the power strip could handle the equipment amperage. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 11:20 AM, observed that two old construction lights with exposed wires were located above the ceiling tile in the 3rd Floor Stairway by the Consultation Office. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 1:15 PM, observed that there is an electrical extension cord above the ceiling tile by Room #278 being used in lieu of permanent wire for an isolation room fan. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 1:15 PM, observed that there are exposed electrical wires above the ceiling tile by Room #278. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 1:15 PM, observed that there is an electrical junction box located above the ceiling tile by Room #278 that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 4, 2013 at approximately 2:35 PM, observed that there are two electrical junction box located above the ceiling tile, above the entrance doors to the Emergency Room that are missing cover plates. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 5, 2013 at approximately 10:40 AM, observed that there is an extension cord being used for an air compressor for a chiller unit in lieu of permanent wiring in the Basement Mechanical Room. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

On June 5, 2013 at approximately 10:45 AM, observed that there is an electrical junction box located under a vent fan next to the air compressor in the upper level or the Basement Mechanical Room that is missing cover plates. This deficiency is not in accordance with NFPA 70, National Electrical Code 9.1.2.

Based on observation the facility failed to provide an elevator in accordance with the LSC sections 19.5.3, 9.4.3.2. This deficient practice could potentially affect 130 occupants of the facility. Findings include:

On June 5, 2013 at approximately 12:50 PM, observed that there is oil leaking from the elevator machinery that is being dried up with the use of rags that are placed around the equipment to stop the oil in Elevator Room #6. This deficiency is not in accordance with the 2000 Edition LSC 19.5.3, 9.4.3.2.

On June 5, 2013 at approximately 1:20 PM, observed that there is a 1/2 - inch open conduit protruding through the fire rated ceiling in Elevator Room # 2. This deficiency is not in accordance with the 2000 Edition LSC 19.5.3, 9.4.3.2.