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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 25 occupants of the facility.

Findings include:

On 12/01/15 at approximately 10:05 AM, the following observations were made:

Observed there was an incomplete seal on an approximate two inch diameter conduit, located in the corridor, above the door to Room 403.

Observed there was an unsealed flexible conduit and blue wire penetration of the fire rated wall, located in the corridor, right side of the door to Room 404.

All of the above citations were discussed with the maintenance director.

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 2 occupants of the facility.

Findings include:

On 12/01/15 at approximately 1:30 PM, the following observations were made;

Observed there was an unsealed pipe penetration and an unsealed copper pipe, located in the Elevator Mechanical Room on the first floor. This deficiency was discussed with the maintenance director.

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 15 occupants of the facility.

Findings include:

On 12/01/15 at approximately 10:35 AM, the following observations were made:

Observed the emergency lighting fixture did not work when tested, located in Room 539, Post-op Bay #4.

Observed the emergency lighting fixture did not work when tested, located in the Main Electrical Room in the Basement.

The above deficiency were discussed with the maintenance director.

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 46 occupants of the facility.

Findings include:

On 12/01/15 at approximately 9:30 AM, the following was learned during record reviews.

During document review of the fire alarm inspection report from Security Corp, dated November 24, 2015, noted the Load Voltage and Discharge test were unable to be performed. "Auxiliary panels will not run on batteries only, Siemens to investigate".

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect 2 occupants of the facility.

Findings include:

On 12/01/15 at approximately 10:00 AM, the following observations were made:

Observed there was paint on the fire sprinkler head, located in the I.T. Closet, Room 404.

Observed there was paint on the fire sprinkler head, located in Stairwell #3 on the fourth floor.

The above deficiencies were discussed with the maintenance director.

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 25 occupants of the facility.

Findings include:

On 12/01/15 at approximately 10:05 AM, the following observations were made:

Observed there was an incomplete seal on an approximate two inch diameter conduit, located in the corridor, above the door to Room 403.

Observed there was an unsealed flexible conduit and blue wire penetration of the fire rated wall, located in the corridor, right side of the door to Room 404.

All of the above citations were discussed with the maintenance director.

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 2 occupants of the facility.

Findings include:

On 12/01/15 at approximately 1:30 PM, the following observations were made;

Observed there was an unsealed pipe penetration and an unsealed copper pipe, located in the Elevator Mechanical Room on the first floor. This deficiency was discussed with the maintenance director.

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 15 occupants of the facility.

Findings include:

On 12/01/15 at approximately 10:35 AM, the following observations were made:

Observed the emergency lighting fixture did not work when tested, located in Room 539, Post-op Bay #4.

Observed the emergency lighting fixture did not work when tested, located in the Main Electrical Room in the Basement.

The above deficiency were discussed with the maintenance director.

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 46 occupants of the facility.

Findings include:

On 12/01/15 at approximately 9:30 AM, the following was learned during record reviews.

During document review of the fire alarm inspection report from Security Corp, dated November 24, 2015, noted the Load Voltage and Discharge test were unable to be performed. "Auxiliary panels will not run on batteries only, Siemens to investigate".

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect 2 occupants of the facility.

Findings include:

On 12/01/15 at approximately 10:00 AM, the following observations were made:

Observed there was paint on the fire sprinkler head, located in the I.T. Closet, Room 404.

Observed there was paint on the fire sprinkler head, located in Stairwell #3 on the fourth floor.

The above deficiencies were discussed with the maintenance director.