HospitalInspections.org

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:

- March 15, 2010 at 11:55 AM, observation revealed that there was an unsealed conduit, located on the 6th Floor at the Center Nurses Office. (1970 Building #2)
- March 15, 2010 at 12:00 AM, observation revealed that there was an unsealed conduit, located on the 6th Floor across from Room 6804. (1970 Building #2)
- March 15, 2010 at 12:05 AM, Observation revealed that there was an unsealed flexible conduit, located on the 6th Floor in Room 1842 (Interview Room). (1970 Building #2)
- March 15, 2010 at 1:49 PM, observation revealed floating sealing tiles in the 5th Floor North Linen Room, two doors south of Patient Room #51". (1970 Building #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 all occupants of the facility.

Findings include:

- March 16, 2010 at 11:19 AM, observation revealed 3rd Floor South Control Room #3261 door not self-closing to provide a positive latch. (Building #1)

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:

- March 16, 2010 at 9:06 AM, observation revealed the 3rd Floor North Mechanical Equipment Room door across from Patient Room #322 did not self-close to provide a positive latch . (1970 Building #2)
- March 16, 2010 at 10:04 AM, observation revealed 3rd Floor West Patient Room #365 door did not close to a positive latch. . (1956 Building #2)

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:

- March 15, 2010 at 2:36 PM, observation revealed that there were two unsealed floor penetrations (left side), located on the 4th Floor in the PICU - Communication Closet. (1970 Building #2)
- March 16, 2010 at 10:17 AM, observation revealed an open pipe sleeve from the 3rd floor to the 2nd floor in the 3rd Floor South Phone Closet across from the Cardiovascular Neuro Science, Critical Care & MSN Office Coordinator Offices. (1925 Building #2)

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:

- March 15, 2010 at 3:16 PM, observation revealed that a large section of wallboard was missing from the 5th Floor opening in the old elevator shaft, located on the 4th Floor in the Clinical Resources Office. (1981 Building #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 all occupants of the facility.

Findings include:

- March 16, 2010 at 10:20 AM, observation revealed that there was an unsealed large conduit near decking, located on the 4th Floor at the cross corridor smoke barrier near Room 468. (1970 Building #2)
- March 16, 2010 at 10:55 AM, observation revealed that there was an incomplete seal on a wire penetration, located on the 4th Floor at the cross corridor smoke barrier into the Pediatric Wing. (1970 Building #2)
- March 16, 2010 at 11:03 AM, observation revealed that there was a large hole in the smoke barrier wall, located on the 4th Floor, in the Anesthesia On-call Room. (1970 Building #2)
- March 16, 2010 at 11:30 AM, observation revealed that there were two unsealed wire penetrations, located on the 4th Floor at the cross corridor smoke barrier into 4 North (Door 1963). (1970 Building #2)
- March 16, 2010 at 1:15 PM, observation revealed that there was one unsealed wire penetration, and one unsealed pipe penetration (right side), located on the 4th Floor at the cross corridor smoke barrier by Room 435. (1970 Building #2)
- March 16, 2010 at 1:25 PM, observation revealed that there was a large void in the smoke barrier, and one unsealed pipe penetration, located on the 4th Floor at the 4 East Nurse ' s Station located at the end of the rear corridor. (1970 Building #2)
- March 16, 2010 at 1:45 PM, observation revealed that there was a large void in the center of the smoke barrier, and unsealed wire penetrations on the right side of the smoke damper, located on the 4th Floor at the cross corridor smoke barrier (above door 1934) by the Bio-Hazard Room. (1970 Building #2)
- March 16, 2010 at 1:55 PM, observation revealed that there were three unsealed wall penetrations, located on the 4th Floor, in the Storage Room next to Housekeeping. (1970 Building #2)
- March 16, 2010 at 2:40 PM, observation revealed that there were unsealed copper line penetrations on the right side, and incomplete seals on wire penetrations along the bottom, located on the 2nd Floor, at the cross corridor smoke barrier (Door 2237) by G-Wing corridor. (1925 Building #2)
- March 17, 2010 at 11:30 AM, observation revealed that there was an unsealed bracket penetration in the smoke barrier, located on the 1st Floor across from the Marketing and Planning Office. (1956 Building #2)
- March 17, 2010 at 11:40 AM, observation revealed that there was a large unsealed pipe penetration in the smoke barrier wall, located on the 1st Floor, in the corridor by the Dietary Office. (1956 Building #2)
- March 17, 2010 at 1:45 PM, observation revealed that the cross corridor smoke barrier above the doors and along the south wall needs to be reconstructed, located on the 1st Floor, to the entrance of Radiology Administration. (1970 Building #2)
- March 16, 2010 at 2:05 PM, observation revealed that there was an unsealed conduit penetration, located on the 2nd Floor, in Room 2067. (1925 Building #2)
- March 16, 2010 at 2:35 PM, observation revealed that there were unsealed wallboard patches, located on the 2nd Floor, in the corridor by Consultation Room. (1925 Building #2)
- March 17, 2010 at 10:15 AM, observation revealed that there were two unsealed pipe penetrations in the corridor, located on the 2nd Floor across from the " F " Elevators. (1925 Building #2)
- March 17, 2010 at 11:35 AM, observation revealed that there was an unsealed conduit, located on the 1st Floor, above the door to the Dietary Locker Room. (1956 Building #2)
- March 17, 2010 at 1:50 PM, observation revealed that the wallboard seams were unfinished, located on the 1st Floor, between the entrance of Radiology Administration and Cardiac Rehab. (1956 Building #2)
- March 18, 2010 at 10:25 AM, observation revealed that there was an unsealed pipe penetration above doorway, located on the 1st Floor at Room 1631. (1970 Building #2)
- March 18, 2010 at 10:35 AM, observation revealed that there was an unsealed pipe penetration on the north wall, located on the 1st Floor in the Radiology File Room. (1970 Building #2)
- March 15, 2010 at 11:07 AM, observation revealed a pipe sleeve penetration with the caulk coming out above the smoke barrier doors adjacent to Patient Room #733 (right access panel). (1970 Building #2)
- March 15, 2010 at 11:11 AM, observation revealed a pipe sleeve penetration with the caulk coming out above the smoke barrier doors adjacent to the 7th Floor Soiled Utility Room (Right access panel) (1970 Building #2)
- March 15, 2010 at 11:25 AM, observation revealed what appeared to be a layer of drywall removed, pipe penetrations and an unknown white material used to fill the penetrations inside the 7th Floor Med Room across from the Clean Utility Room. (1970 Building #2)
- March 15, 2010 at 11:32 AM, observation revealed pipe penetrations with an unknown white material used to fill the penetrations above the smoke barrier doors adjacent to the 7th Floor Storage Room #2. (1970 Building #2)
- March 15, 2010 at 12:10 PM, observation revealed wire penetrations above the 5th Floor Physician Lounge door (right side) adjacent to "LDR #8". (1970 Building #2)
- March 15, 2010 at 12:29 PM, observation revealed a bundle of wires with the caulk coming out above the 5th Floor East smoke barrier doors across from the 5th Floor North Entrance. (1970 Building #2)
- March 15, 2010 at 12:36 PM, observation revealed pipe and wire penetrations not sealed completely and tape and mud used above the smoke barrier doors at the entry to 5th Floor North. (1970 Building #2)
- March 15, 2010 at 2:40 PM, observation revealed the "EZ Pass" sleeve above the 5th Floor North smoke barrier doors adjacent to Patient Room #576 had the inner component hanging out. (1970 Building #2)
- March 15, 2010 at 3:00 PM, observation revealed a wire penetration above the Third Floor East smoke barrier doors wit the caulk coming apart, adjacent to Patient Room #334. (1970 Building #2)
- March 16, 2010 at 9:11 AM, observation revealed penetrations from the 3rd Floor North Mechanical Room into the Third Floor North Electrical Room. (1970 Building #2)
- March 16, 2010 at 9:59 AM, observation revealed a pipe penetration above the 3rd Floor West smoke barrier doors, unknown white material used to seal the penetration. (1970 Building #2)
- March 16, 2010 at 10:35 AM, observation revealed what appears to be a flexible tube penetration above the 3rd Floor South smoke barrier doors adjacent to the G - Connector. (1925 Building #2)
- March 16, 2010 at 10:36 AM, observation revealed a drywall patch that was not sealed above the 3rd Floor South smoke barrier doors adjacent to the "Medical Director Office & Family Consultation Office". (1925 Building #2)
- March 18, 2010 at 9:50 AM, observation revealed an open pipe sleeve on the east wall above the "Med Gas Alarm Box" inside the Basement MER #11. (1925 Building #2)
- March 18, 2010 at 9:51 AM, observation revealed the block broke out on the north east corner where pipes pass thru the 1 hour wall inside the Basement MER #11. (1925 Building #2)

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:

- March 16, 2010 at 2:45 PM, observation revealed that the smoke barrier was unsealed at the deck (left side), located on the 2nd Floor, into the G-Wing corridor. (1981 Building #1)
- March 17, 2010 at 9:35 AM, observation revealed that there were two unsealed wire penetrations above Door 2762, located on the 2nd Floor at the cross corridor smoke barrier into Endoscopy. (1981 Building #1)
- March 17, 2010 at 10:20 AM, observation revealed that there were incomplete seals on penetrations (both sides of cross corridor smoke barrier), located on the 2nd Floor at the cross corridor smoke barrier at the main entrance into the Endoscopy Department Pre OP area. (1981 Building #1)
- March 17, 2010 at 2:25 PM, observation revealed that the smoke barrier wall was not sealed at the decking, located on the 1st Floor in the Medical Clinic Restroom. (1981 Building #1)
- March 17, 2010 at 2:35 PM, observation revealed that the smoke barrier wall was not sealed at the decking, located on the 1st Floor in the Physicians Workroom. (1981 Building #1)
- March 17, 2010 at 2:40 PM, observation revealed that the smoke barrier wall was not sealed at the decking, located on the 1st Floor in the Patient Restroom. (1981 Building #1)
- March 17, 2010 at 2:41 PM, observation revealed that the smoke barrier wall was not sealed at the decking, located on the 1st Floor in the Medical Clinic Exam Room #9. (1981 Building #1)
- March 17, 2010 at 3:00 PM, observation revealed that there were two incomplete sealed pipe penetrations in the cross corridor smoke barrier, located on the 1st Floor by Room 1234. (1981 Building #1)
- March 17, 2010 at 3:20 PM, observation revealed that there were numerous penetrations and the smoke barrier was not sealed at decking, located on the 1st Floor, in the Communication Closet of the Medical Clinic Waiting Room. (1981 Building #1)
- March 17, 2010 at 3:31 PM, observation revealed that the fire rated wall was not sealed where the MRI machine connections went thru the wall, located on the 1st Floor, in Room 1347, the MRI Toshiba Room. (1981 Building #1)
- March 16, 2010 at 10:05 AM, observation revealed that there was exposed mineral wool at decking on two walls, located on the 4-G Wing, in Room 4149. ( 2005 Building #1)
- March 16, 2010 at 9:20 AM, observation revealed that there was an incomplete seal on a conduit penetration, located on the 4th Floor in the Communication Closet 4A next to Audiology. (1981 Building #1)
- March 16, 2010 at 3:00 PM, observation revealed that there were six unsealed wall penetrations, located on the 2nd Floor in the Operating Room Lounge. (1981 Building #1)
- March 16, 2010 at 3:05 PM, observation revealed that there was an unsealed wire penetration above door, located on the 2nd Floor to the Operating Room Lounge. (1981 Building #1)
- March 16, 2010 at 3:10 PM, observation revealed that there was an unsealed wire conduit above door, located on the 2nd Floor in the Electrical Closet in the Endoscopy Department. (1981 Building #1)
- March 17, 2010 at 9:30 AM, observation revealed that there was an unsealed flexible conduit penetration above fire hose cabinet, located on the 2nd Floor by Stairwell #11 (Endoscopy Recovery). (1981 Building #1)
- March 17, 2010 at 9:40 AM, observation revealed that the complete wall into Endoscopy Consultation Offices needs to be fire stopped, located on the 2nd Floor in the Endoscopy Department. (1981 Building #1)
- March 17, 2010 at 9:45 AM, observation revealed that there was an unsealed conduit penetration in the corridor, located on the 2nd Floor at the rear of the Endoscopy Consultation Offices, in the Endoscopy Department. (1981 Building #1)
- March 17, 2010 at 10:20 AM, observation revealed that there were incomplete seals on a conduit penetration, an unsealed conduit, and an incomplete seal on a wall board hole, located on the 2nd Floor, in the De-bulking Room. (1981 Building #1)
- March 17, 2010 at 2:43 PM, observation revealed that there was an unsealed conduit, located on the 1st Floor, in the Medical Clinic Soiled Holding Room. (1981 Building #1)
- March 17, 2010 at 2:55 PM, observation revealed that there were multiple unsealed penetrations at the decking, located on the 1st Floor, in Room 1234. (1981 Building #1)
- March 17, 2010 at 3:05 PM, observation revealed that there were three unsealed conduits, located on the 1st Floor, in the Clinical File Room. (1981 Building #1)
- March 17, 2010 at 3:09 PM, observation revealed that there were two unsealed conduits on the File Room wall, located on the 1st Floor, in the Medical Clinic Nurses Station. (1981 Building #1)
- March 17, 2010 at 3:15 PM, observation revealed that there were numerous unsealed wire and conduit penetrations, located on the 1st Floor, in the Medical Clinic Electrical Room. (1981 Building #1)
- March 17, 2010 at 3:35 PM, observation revealed that there was an unsealed wire penetration and an unsealed conduit penetration, located on the 1st Floor, in Room 1348. (1981 Building #1)
- March 18, 2010 at 9:45 AM, observation revealed that there was an unsealed wall above doorway, located on the 1st Floor, in Room 1337. (1981 Building #1)
- March 18, 2010 at 10:00 AM, observation revealed that the fire rated wall was not sealed at the decking in the corridor, located on the 1st Floor, at the Storage Room next to Joe ' s Coffee. (1981 Building #1)
- March 18, 2010 at 10:15 AM, observation revealed that there were incomplete seals on pipe penetrations in the corridor, located on the 1st Floor by Rooms 1531 and 1523. (1981 Building #1)
- March 16, 2010 at 10:45 AM, observation revealed pipe and wire penetrations that the caulk was pulled out above the 3rd Floor South smoke barrier doors adjacent to Central Monitoring #3211. (1981 Building #1)
- March 16, 2010 at 10:50 AM, observation revealed pipe and wire penetrations sealed with tape and mud and an unknown brown material used as well as a drywall patch not sealed in the 1 hour wall in the 3rd Floor South Staff Lounge #3212. (1981 Building #1)
- March 16, 2010 at 11:02 AM, observation revealed tape and mud used to seal around a duct in the 1 hour wall in the corridor between 3rd Floor South Dictation Room #3258 and the entry to "Echo". (1981 Building #1)
- March 18, 2010 at 9:59 AM, observation revealed the "Basement Fire Pump Room" rated walls are not tight to the deck above, mineral wool is visible. (1981 Building #1)
- March 18, 2010 at 10:07 AM, observation revealed pipe penetrations not sealed completely on the north east wall, unknown pink material used on the 2 hour wall in the "Basement MER #20 Electrical Sub Station". (1981 Building #1)
- March 18, 2010 at 10:08 AM, observation revealed an electrical wire trey in the 2 hour wall not sealed in the "Basement MER #20 Electrical Sub Station". (1981 Building #1)
- March 18, 2010 at 10:18 AM, observation revealed pipe ends not sealed above the entry door to the "Basement MER", "G - Building" adjacent to "Lab Staff Room". (2005 Building #1)

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:

- March 16, 2010 at 10:00 AM, observation revealed a gap larger than 1/8" between the smoke barrier doors at the entry to 3rd Floor West. (1956 Building #2)
- March 17, 2010 at 11:33 AM, observation revealed a gap larger than 1/8" between the Basement smoke barrier doors to the MOB. (1970 Building #2)

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:

- March 16, 2010 at 11:28 AM, observation revealed a gap larger than 1/8" between the 3rd Floor CCU smoke barrier doors at the entry to CCU. (1981 Building #1)
- March 16, 2010 at 1:33 PM, observation revealed the rated gasket between the 2nd Floor G - Wing smoke barrier doors at the entry was torn. ( 2005 Building #1)
- March 16, 2010 at 2:12 PM, observation revealed a gap larger than 1/8" between the 2nd Floor West smoke barrier doors adjacent to Patient Room #289. (1956 Building #1)

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:

- March 15, 2010 at 2:27 PM, observation revealed that there were two unsealed ceiling penetrations, located on the 4th Floor, in the storage room across from Elevator F. (1970 Building #2)
- March 16, 2010 at 11:20 AM, observation revealed that the vent into the storage closet needs to be fire stopped, located on the 4th Floor, in the Peds Mechanical Room. (1970 Building #2)
- March 16, 2010 at 11:22 AM, observation revealed that the HV-11 vent needs to be fire stopped at the bottom, located on the 4th Floor, in the Peds Mechanical Room. (1970 Building #2)
- March 16, 2010 at 11:27 AM, observation revealed that there was an unsealed ceiling conduit penetration above the Electrical Panel 4EM-RP, located on the 4th Floor, in the Peds Mechanical Room. (1970 Building #2)
- March 17, 2010 at 11:00 AM, observation revealed that there was a large unsealed pipe penetration, located on the 1st Floor, in the Storage Room adjacent to the Gift Shop. (1970 Building #2)
- March 15, 2010 at 11:21 AM, observation revealed three (3) holes in 7th Floor Storage Room #2 wall. (1970 Building #2)
- March 15, 2010 at 3:23 PM, observation revealed floating ceiling tiles in the 3rd Floor East Storage Room / Janitor Supply adjacent to the Equipment Storage Room (between east and west) . (Building #2)
- March 16, 2010 at 9:26 AM, observation revealed floating ceiling tiles in the 3rd Floor North Equipment Storage Room across from Patient Room #312. (1970 Building #2)
- March 17, 2010 at 12:00 PM, observation revealed the Basement Storage Room door adjacent to the "Darkroom" in the Telecom Area was missing the self-closing unit. (1970 Building #2)

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:

- March 17, 2010 at 10:27 AM, observation revealed the 1st Floor MRI Prep/Recovery #1331 adjacent to Room #1337 was being used as a storage area. (1981 Building #1)
- March 17, 2010 at 10:30 AM, observation revealed wood pallets used in 1st Floor MRI Prep/Recovery Storage Room #1331. (1981 Building #1)

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:

- March 15, 2010 at 11:50 AM, observation revealed that the corridor handrail was loose, located on the 6th Floor near Stairwell #3. (1970 Building #2)
- March 15, 2010 at 12:25 PM, observation revealed a loose handrail adjacent to the 5th floor east smoke barrier doors and across from the entry to 5th Floor North. (1970 Building #2)

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:

- March 17, 2010 at 11:10 AM, observation revealed the Basement south exit egress in the Data Center was blocked by a mobile computers, totes, tables and wood pallets. (1981 Building #1)
- March 17, 2010 at 11:20 AM, observation revealed the Basement second south exit door in the Data Center was blocked by storage and the door handle was broke off. (1981 Building #1)

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- March 15, 2010 at 11:10 AM, observation revealed that there was trash (boxes, paper etc.) in the corridor, located on the 9th Floor in the Elevator Lobby. (1970 Building #2)

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:

- March 15, 2010 at 3:02 PM, observation revealed a missing smoke detector head in the corridor outside 3rd Floor East Patient Room #335. (1970 Building #2)

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:

- March 17, 2010 at 2:11 PM, observation revealed that there was a smoke detector located above the ceiling tiles, located on the 1st Floor, south of the G-Wing entrance, south of " Staff Only " doorway. (1981 Building #1)

Based on observation and 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:

- March 16, 2010 at 9:11 AM, observation revealed that there was a hole in the ceiling tile, located on the 4th Floor in the Get Well Network Office in the Library. (1981 Building #1)
- March 16, 2010 at 9:13 AM, observation revealed that some of the book shelves were positioned too close to the sprinkler heads, located on the 4th Floor in the Library. (1981 Building #1)
- March 16, 2010 at 9:15 AM, observation revealed that the sprinkler piping was corroded at the hanger, located on the 4th Floor in Stairwell #12. (1981 Building #1)
- March 17, 2010 at 10:26 AM, observation revealed a broken ceiling tile from appears to be from a leak in the First Floor MRI Prep/Recovery #1331 adjacent to Room #1337. (1981 Building #1)

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and 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:

- March 15, 2010 at 11:00 AM, observation revealed that the stand pipe gauge was dated with the year 1969, located on the 10th Floor at the stand pipe. (1970 Building #2)
- March 15, 2010 at 2:03 PM, observation revealed that the stand pipe gauge was dated with the year 1970, located on the 6th Floor at the stand pipe. (1970 Building #2)
- March 15, 2010 at 2:25 PM, Observation revealed that there was paint on the sprinkler head, located on the 4th Floor, in the storage room across from Elevator F. (1970 Building #2)
- March 15, 2010 at 2:26 PM, observation revealed that there were combustibles stored too close to the sprinkler head, located on the 4th Floor, in the storage room across from Elevator F. (1970 Building #2)
- March 16, 2010 at 9:28 AM, observation revealed the 3rd Floor North Standpipe #28 adjacent to 3rd Floor North Equipment Storage Room had a tag attached stating that the stem leaks. (1970 Building #2)

Based on observation and 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:

- March 15, 2010 at 2:00 PM, observation revealed that there was a fire extinguisher improperly stored on the floor, located on the 6th Floor, in Mechanical Room #10. (1970 Building #2)
- March 16, 2010 at 11:10 AM, observation revealed that the fire extinguishers missed the January and February inspections, located on the 4th Floor, in the Mechanical Room in the Pediatric Department. (1970 Building #2)
- March 16, 2010 at 1:50 PM, observation revealed that the fire extinguishers missed the January and February inspections, located on the 4th Floor, in the Therapy Room #2. (1970 Building #2)
- March 16, 2010 at 9:33 AM, observation revealed the fire extinguisher cabinet adjacent to 3rd Floor North Clean Supply had a broken door handle. (1970 Building #2)
- March 16, 2010 at 10:22 AM, observation revealed a missing escutcheon plate outside the Third Floor South Residence Quarters and the F-Elevators. (1925 Building #2)

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:

- March 17, 2010 at 10:40 AM, observation revealed the 1st Floor fire extinguisher cabinet across from the Electrical Room and two doors down from Ultra Sound Staff #1541, cabinet is not labeled and blends in with the wall. (1981 Building #1)

Based on observation the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- March 15, 2010 at 3:17 PM, observation revealed that there was an electrical space heater, located on the 4th Floor in the Medical Education Program Director ' s Office. (1981 Building #1)
- March 15, 2010 at 3:20 PM, observation revealed that there was an electrical space heater, located on the 4th Floor in the Medical Education Dr. Badshah ' s Office. (1981 Building #1)
- March 15, 2010 at 3:45 PM, observation revealed that there was an electrical space heater, located on the 4th Floor in C. Parliament ' s Office. (1981 Building #1)

Based on observation the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- March 16, 2010 at 10:15 AM, observation revealed that there was an electrical space heater, located on the 4th Floor in Clinical Informatics Office. (1970 Building #2)
- March 16, 2010 at 11:35 AM, observation revealed that there was an electrical space heater, located on the 4th Floor in Peds Hospitality Office, across from the Nurses Station. (1970 Building #2)

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:

- March 15, 2010 at 11:06 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 9th Floor in the corridor by Stairwell #5. (1970 Building #2)
- March 15, 2010 at 11:56 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 6th Floor at the Center Nurses Office near the corridor (NW corner). (1925 Building #2)
- March 15, 2010 at 1:55 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 6th Floor, at Mechanical Room #10, located in Elevator B Machine Room. (1970 Building #2)
- March 15, 2010 at 2:10 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 6th Floor, in Mechanical Room #13 near Bar Code 1389. (1970 Building #2)
- March 15, 2010 at 2:35 PM, Observation revealed that there was an electrical junction box missing a cover plate, located on the 4th Floor in the PICU - Communication Closet. (1970 Building #2)
- March 16, 2010 at 10:21 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 4th Floor at the cross corridor smoke barrier near Room 468. (1970 Building #2)
March 16, 2010 at 10:40 AM, Observation revealed that there was an electrical extension cord in use, located on the 4th Floor, in Room 487. (1970 Building #2)
- March 16, 2010 at 10:45 AM, observation revealed that there were two electrical power strips daisy chained together, located on the 4th Floor in Kim Allen ' s Office. (1970 Building #2)
- March 16, 2010 at 10:50 AM, observation revealed that there was an electrical extension cord in use, located on the 4th Floor, in Respiratory Managers Office. (1970 Building #2)
- March 16, 2010 at 10:51 AM, observation revealed that there were two electrical power strips daisy chained together, located on the 4th Floor in Director of Rehab Services Office. (1970 Building #2)
- March 16, 2010 at 11:00 AM, observation revealed that there was an electrical extension cord in use, located on the 4th Floor, in the Anesthesia On-call Room. (1970 Building #2)
- March 16, 2010 at 11:25 AM, observation revealed that there was an electrical junction box missing a cover plate above HV-11 fan, located on the 4th Floor, in the Peds Mechanical Room. (1970 Building #2)
- March 17, 2010 at 11:25 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor in the Dietary corridor near the Dietary Elevator. (1956 Building #2)
- March 18, 2010 at 10:50 AM, observation revealed that there were two electrical junction boxes missing a cover plates, located on the 1st Floor in the Interventional Radiology Control Room. (1970 Building #2)
- March 15, 2010 at 12:11 PM, observation revealed a half open junction box above the bed in 5th Floor LDR #8. (1970 Building #2)
- March 16, 2010 at 10:11 AM, observation revealed a open junction box above the 3rd Floor South smoke barrier doors adjacent to the CINE View Room. (1925 Building #2)
- March 18, 2010 at 9:48 AM, observation revealed two (2) open junction boxes on the east wall above the chilled water valve #12 and #14 inside Basement MER #11. (1925 Building #2)

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:

- March 15, 2010 at 3:00 PM, observation revealed that there were two electrical power strips daisy chained together, located on the 4th Floor in the Clinical Resource Coordinators Office. (1981 Building #1)
- March 15, 2010 at 3:05 PM, observation revealed that there was an electrical extension cord in use, located on the 4th Floor in the Educational Services (back office). (1981 Building #1)
- March 15, 2010 at 3:15 PM, observation revealed that there was numerous electrical power strips daisy chained together, located on the 4th Floor in the Medical Education Offices. (1981 Building #1)
- March 15, 2010 at 3:21 PM, observation revealed that there were two electrical power strips daisy chained together, located on the 4th Floor in the Clinical Health Initiatives Director ' s Offices. (1981 Building #1)
- March 15, 2010 at 3:22 PM, observation revealed that there were two electrical power strips daisy chained together, located on the 4th Floor in Melanie Zaleski ' s Office. (1981 Building #1)
- March 15, 2010 at 3:23 PM, observation revealed that there was an electrical space heater, located on the 4th Floor in Melanie Zaleski ' s Office. (1981 Building #1)
- March 15, 2010 at 3:24 PM, observation revealed that there was an electrical extension cord in use, located on the 4th Floor in Melanie Zaleski ' s Office. (1981 Building #1)
- March 15, 2010 at 3:25 PM, observation revealed that there was numerous electrical power strips daisy chained together, located on the 4th Floor in the Case Manager ' s Offices. (1981 Building #1)
- March 16, 2010 at 9:25 AM, observation revealed that there were numerous electrical power strips daisy chained together, located on the 4th Floor in the Computer Training Room. (1981 Building #1)
- March 16, 2010 at 9:30 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 4th Floor at the cross corridor smoke barrier by Stairwell #9. (1981 Building #1)
- March 16, 2010 at 3:10 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 2nd Floor in the Electrical Closet in the Endoscopy Department. (1981 Building #1)
- March 17, 2010 at 10:00 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 2nd Floor at the cross corridor smoke barrier from the Endoscopy Department into Pre OP. (1981 Building #1)
- March 17, 2010 at 1:55 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor, at the cross corridor smoke barrier, on the south wall to G-Wing entrance. (2005 Building #1)
- March 17, 2010 at 2:00 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor, south of the G-Wing entrance. (TH - 1981 Building #1)
- March 17, 2010 at 2:05 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor, south of the G-Wing entrance above " Staff Only " doorway. (1981 Building #1)
- March 17, 2010 at 2:10 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor, south of the G-Wing entrance, south of " Staff Only " doorway. (1981 Building #1)
- March 17, 2010 at 3:30 PM, observation revealed that there were three electrical junction boxes missing a cover plates, located on the 1st Floor, in Room 1347 (the MRI Toshiba Room). (1981 Building #1)
- March 18, 2010 at 9:50 AM, observation revealed that there were two electrical junction boxes missing a cover plates, located on the 1st Floor, at Stairwell #11. (1990 Building #1)
- March 18, 2010 at 9:55 AM, observation revealed that there was an electrical junction box missing a cover plate on the above decking, located on the 1st Floor, at Stairwell #10. (1990 Building #1)
- March 18, 2010 at 10:05 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor, in Room 1365. (1981 Building #1)
- March 16, 2010 at 1:12 PM, observation revealed an open junction box in the "3rd Floor Connector Communication Room #3208". (2005 Building #1)
- March 17, 2010 at 11:07 AM, observation revealed boxes stored in front of the electrical panel on the center support beam in the Basement Data Center. (1981 Building #1)

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:

- March 15, 2010 at 11:55 AM, observation revealed that there was an unsealed conduit, located on the 6th Floor at the Center Nurses Office. (1970 Building #2)
- March 15, 2010 at 12:00 AM, observation revealed that there was an unsealed conduit, located on the 6th Floor across from Room 6804. (1970 Building #2)
- March 15, 2010 at 12:05 AM, Observation revealed that there was an unsealed flexible conduit, located on the 6th Floor in Room 1842 (Interview Room). (1970 Building #2)
- March 15, 2010 at 1:49 PM, observation revealed floating sealing tiles in the 5th Floor North Linen Room, two doors south of Patient Room #51". (1970 Building #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 all occupants of the facility.

Findings include:

- March 16, 2010 at 11:19 AM, observation revealed 3rd Floor South Control Room #3261 door not self-closing to provide a positive latch. (Building #1)

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:

- March 16, 2010 at 9:06 AM, observation revealed the 3rd Floor North Mechanical Equipment Room door across from Patient Room #322 did not self-close to provide a positive latch . (1970 Building #2)
- March 16, 2010 at 10:04 AM, observation revealed 3rd Floor West Patient Room #365 door did not close to a positive latch. . (1956 Building #2)

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:

- March 15, 2010 at 2:36 PM, observation revealed that there were two unsealed floor penetrations (left side), located on the 4th Floor in the PICU - Communication Closet. (1970 Building #2)
- March 16, 2010 at 10:17 AM, observation revealed an open pipe sleeve from the 3rd floor to the 2nd floor in the 3rd Floor South Phone Closet across from the Cardiovascular Neuro Science, Critical Care & MSN Office Coordinator Offices. (1925 Building #2)

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:

- March 15, 2010 at 3:16 PM, observation revealed that a large section of wallboard was missing from the 5th Floor opening in the old elevator shaft, located on the 4th Floor in the Clinical Resources Office. (1981 Building #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 all occupants of the facility.

Findings include:

- March 16, 2010 at 10:20 AM, observation revealed that there was an unsealed large conduit near decking, located on the 4th Floor at the cross corridor smoke barrier near Room 468. (1970 Building #2)
- March 16, 2010 at 10:55 AM, observation revealed that there was an incomplete seal on a wire penetration, located on the 4th Floor at the cross corridor smoke barrier into the Pediatric Wing. (1970 Building #2)
- March 16, 2010 at 11:03 AM, observation revealed that there was a large hole in the smoke barrier wall, located on the 4th Floor, in the Anesthesia On-call Room. (1970 Building #2)
- March 16, 2010 at 11:30 AM, observation revealed that there were two unsealed wire penetrations, located on the 4th Floor at the cross corridor smoke barrier into 4 North (Door 1963). (1970 Building #2)
- March 16, 2010 at 1:15 PM, observation revealed that there was one unsealed wire penetration, and one unsealed pipe penetration (right side), located on the 4th Floor at the cross corridor smoke barrier by Room 435. (1970 Building #2)
- March 16, 2010 at 1:25 PM, observation revealed that there was a large void in the smoke barrier, and one unsealed pipe penetration, located on the 4th Floor at the 4 East Nurse ' s Station located at the end of the rear corridor. (1970 Building #2)
- March 16, 2010 at 1:45 PM, observation revealed that there was a large void in the center of the smoke barrier, and unsealed wire penetrations on the right side of the smoke damper, located on the 4th Floor at the cross corridor smoke barrier (above door 1934) by the Bio-Hazard Room. (1970 Building #2)
- March 16, 2010 at 1:55 PM, observation revealed that there were three unsealed wall penetrations, located on the 4th Floor, in the Storage Room next to Housekeeping. (1970 Building #2)
- March 16, 2010 at 2:40 PM, observation revealed that there were unsealed copper line penetrations on the right side, and incomplete seals on wire penetrations along the bottom, located on the 2nd Floor, at the cross corridor smoke barrier (Door 2237) by G-Wing corridor. (1925 Building #2)
- March 17, 2010 at 11:30 AM, observation revealed that there was an unsealed bracket penetration in the smoke barrier, located on the 1st Floor across from the Marketing and Planning Office. (1956 Building #2)
- March 17, 2010 at 11:40 AM, observation revealed that there was a large unsealed pipe penetration in the smoke barrier wall, located on the 1st Floor, in the corridor by the Dietary Office. (1956 Building #2)
- March 17, 2010 at 1:45 PM, observation revealed that the cross corridor smoke barrier above the doors and along the south wall needs to be reconstructed, located on the 1st Floor, to the entrance of Radiology Administration. (1970 Building #2)
- March 16, 2010 at 2:05 PM, observation revealed that there was an unsealed conduit penetration, located on the 2nd Floor, in Room 2067. (1925 Building #2)
- March 16, 2010 at 2:35 PM, observation revealed that there were unsealed wallboard patches, located on the 2nd Floor, in the corridor by Consultation Room. (1925 Building #2)
- March 17, 2010 at 10:15 AM, observation revealed that there were two unsealed pipe penetrations in the corridor, located on the 2nd Floor across from the " F " Elevators. (1925 Building #2)
- March 17, 2010 at 11:35 AM, observation revealed that there was an unsealed conduit, located on the 1st Floor, above the door to the Dietary Locker Room. (1956 Building #2)
- March 17, 2010 at 1:50 PM, observation revealed that the wallboard seams were unfinished, located on the 1st Floor, between the entrance of Radiology Administration and Cardiac Rehab. (1956 Building #2)
- March 18, 2010 at 10:25 AM, observation revealed that there was an unsealed pipe penetration above doorway, located on the 1st Floor at Room 1631. (1970 Building #2)
- March 18, 2010 at 10:35 AM, observation revealed that there was an unsealed pipe penetration on the north wall, located on the 1st Floor in the Radiology File Room. (1970 Building #2)
- March 15, 2010 at 11:07 AM, observation revealed a pipe sleeve penetration with the caulk coming out above the smoke barrier doors adjacent to Patient Room #733 (right access panel). (1970 Building #2)
- March 15, 2010 at 11:11 AM, observation revealed a pipe sleeve penetration with the caulk coming out above the smoke barrier doors adjacent to the 7th Floor Soiled Utility Room (Right access panel) (1970 Building #2)
- March 15, 2010 at 11:25 AM, observation revealed what appeared to be a layer of drywall removed, pipe penetrations and an unknown white material used to fill the penetrations inside the 7th Floor Med Room across from the Clean Utility Room. (1970 Building #2)
- March 15, 2010 at 11:32 AM, observation revealed pipe penetrations with an unknown white material used to fill the penetrations above the smoke barrier doors adjacent to the 7th Floor Storage Room #2. (1970 Building #2)
- March 15, 2010 at 12:10 PM, observation revealed wire penetrations above the 5th Floor Physician Lounge door (right side) adjacent to "LDR #8". (1970 Building #2)
- March 15, 2010 at 12:29 PM, observation revealed a bundle of wires with the caulk coming out above the 5th Floor East smoke barrier doors across from the 5th Floor North Entrance. (1970 Building #2)
- March 15, 2010 at 12:36 PM, observation revealed pipe and wire penetrations not sealed completely and tape and mud used above the smoke barrier doors at the entry to 5th Floor North. (1970 Building #2)
- March 15, 2010 at 2:40 PM, observation revealed the "EZ Pass" sleeve above the 5th Floor North smoke barrier doors adjacent to Patient Room #576 had the inner component hanging out. (1970 Building #2)
- March 15, 2010 at 3:00 PM, observation revealed a wire penetration above the Third Floor East smoke barrier doors wit the caulk coming apart, adjacent to Patient Room #334. (1970 Building #2)
- March 16, 2010 at 9:11 AM, observation revealed penetrations from the 3rd Floor North Mechanical Room into the Third Floor North Electrical Room. (1970 Building #2)
- March 16, 2010 at 9:59 AM, observation revealed a pipe penetration above the 3rd Floor West smoke barrier doors, unknown white material used to seal the penetration. (1970 Building #2)
- March 16, 2010 at 10:35 AM, observation revealed what appears to be a flexible tube penetration above the 3rd Floor South smoke barrier doors adjacent to the G - Connector. (1925 Building #2)
- March 16, 2010 at 10:36 AM, observation revealed a drywall patch that was not sealed above the 3rd Floor South smoke barrier doors adjacent to the "Medical Director Office & Family Consultation Office". (1925 Building #2)
- March 18, 2010 at 9:50 AM, observation revealed an open pipe sleeve on the east wall above the "Med Gas Alarm Box" inside the Basement MER #11. (1925 Building #2)
- March 18, 2010 at 9:51 AM, observation revealed the block broke out on the north east corner where pipes pass thru the 1 hour wall inside the Basement MER #11. (1925 Building #2)

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:

- March 16, 2010 at 2:45 PM, observation revealed that the smoke barrier was unsealed at the deck (left side), located on the 2nd Floor, into the G-Wing corridor. (1981 Building #1)
- March 17, 2010 at 9:35 AM, observation revealed that there were two unsealed wire penetrations above Door 2762, located on the 2nd Floor at the cross corridor smoke barrier into Endoscopy. (1981 Building #1)
- March 17, 2010 at 10:20 AM, observation revealed that there were incomplete seals on penetrations (both sides of cross corridor smoke barrier), located on the 2nd Floor at the cross corridor smoke barrier at the main entrance into the Endoscopy Department Pre OP area. (1981 Building #1)
- March 17, 2010 at 2:25 PM, observation revealed that the smoke barrier wall was not sealed at the decking, located on the 1st Floor in the Medical Clinic Restroom. (1981 Building #1)
- March 17, 2010 at 2:35 PM, observation revealed that the smoke barrier wall was not sealed at the decking, located on the 1st Floor in the Physicians Workroom. (1981 Building #1)
- March 17, 2010 at 2:40 PM, observation revealed that the smoke barrier wall was not sealed at the decking, located on the 1st Floor in the Patient Restroom. (1981 Building #1)
- March 17, 2010 at 2:41 PM, observation revealed that the smoke barrier wall was not sealed at the decking, located on the 1st Floor in the Medical Clinic Exam Room #9. (1981 Building #1)
- March 17, 2010 at 3:00 PM, observation revealed that there were two incomplete sealed pipe penetrations in the cross corridor smoke barrier, located on the 1st Floor by Room 1234. (1981 Building #1)
- March 17, 2010 at 3:20 PM, observation revealed that there were numerous penetrations and the smoke barrier was not sealed at decking, located on the 1st Floor, in the Communication Closet of the Medical Clinic Waiting Room. (1981 Building #1)
- March 17, 2010 at 3:31 PM, observation revealed that the fire rated wall was not sealed where the MRI machine connections went thru the wall, located on the 1st Floor, in Room 1347, the MRI Toshiba Room. (1981 Building #1)
- March 16, 2010 at 10:05 AM, observation revealed that there was exposed mineral wool at decking on two walls, located on the 4-G Wing, in Room 4149. ( 2005 Building #1)
- March 16, 2010 at 9:20 AM, observation revealed that there was an incomplete seal on a conduit penetration, located on the 4th Floor in the Communication Closet 4A next to Audiology. (1981 Building #1)
- March 16, 2010 at 3:00 PM, observation revealed that there were six unsealed wall penetrations, located on the 2nd Floor in the Operating Room Lounge. (1981 Building #1)
- March 16, 2010 at 3:05 PM, observation revealed that there was an unsealed wire penetration above door, located on the 2nd Floor to the Operating Room Lounge. (1981 Building #1)
- March 16, 2010 at 3:10 PM, observation revealed that there was an unsealed wire conduit above door, located on the 2nd Floor in the Electrical Closet in the Endoscopy Department. (1981 Building #1)
- March 17, 2010 at 9:30 AM, observation revealed that there was an unsealed flexible conduit penetration above fire hose cabinet, located on the 2nd Floor by Stairwell #11 (Endoscopy Recovery). (1981 Building #1)
- March 17, 2010 at 9:40 AM, observation revealed that the complete wall into Endoscopy Consultation Offices needs to be fire stopped, located on the 2nd Floor in the Endoscopy Department. (1981 Building #1)
- March 17, 2010 at 9:45 AM, observation revealed that there was an unsealed conduit penetration in the corridor, located on the 2nd Floor at the rear of the Endoscopy Consultation Offices, in the Endoscopy Department. (1981 Building #1)
- March 17, 2010 at 10:20 AM, observation revealed that there were incomplete seals on a conduit penetration, an unsealed conduit, and an incomplete seal on a wall board hole, located on the 2nd Floor, in the De-bulking Room. (1981 Building #1)
- March 17, 2010 at 2:43 PM, observation revealed that there was an unsealed conduit, located on the 1st Floor, in the Medical Clinic Soiled Holding Room. (1981 Building #1)
- March 17, 2010 at 2:55 PM, observation revealed that there were multiple unsealed penetrations at the decking, located on the 1st Floor, in Room 1234. (1981 Building #1)
- March 17, 2010 at 3:05 PM, observation revealed that there were three unsealed conduits, located on the 1st Floor, in the Clinical File Room. (1981 Building #1)
- March 17, 2010 at 3:09 PM, observation revealed that there were two unsealed conduits on the File Room wall, located on the 1st Floor, in the Medical Clinic Nurses Station. (1981 Building #1)
- March 17, 2010 at 3:15 PM, observation revealed that there were numerous unsealed wire and conduit penetrations, located on the 1st Floor, in the Medical Clinic Electrical Room. (1981 Building #1)
- March 17, 2010 at 3:35 PM, observation revealed that there was an unsealed wire penetration and an unsealed conduit penetration, located on the 1st Floor, in Room 1348. (1981 Building #1)
- March 18, 2010 at 9:45 AM, observation revealed that there was an unsealed wall above doorway, located on the 1st Floor, in Room 1337. (1981 Building #1)
- March 18, 2010 at 10:00 AM, observation revealed that the fire rated wall was not sealed at the decking in the corridor, located on the 1st Floor, at the Storage Room next to Joe ' s Coffee. (1981 Building #1)
- March 18, 2010 at 10:15 AM, observation revealed that there were incomplete seals on pipe penetrations in the corridor, located on the 1st Floor by Rooms 1531 and 1523. (1981 Building #1)
- March 16, 2010 at 10:45 AM, observation revealed pipe and wire penetrations that the caulk was pulled out above the 3rd Floor South smoke barrier doors adjacent to Central Monitoring #3211. (1981 Building #1)
- March 16, 2010 at 10:50 AM, observation revealed pipe and wire penetrations sealed with tape and mud and an unknown brown material used as well as a drywall patch not sealed in the 1 hour wall in the 3rd Floor South Staff Lounge #3212. (1981 Building #1)
- March 16, 2010 at 11:02 AM, observation revealed tape and mud used to seal around a duct in the 1 hour wall in the corridor between 3rd Floor South Dictation Room #3258 and the entry to "Echo". (1981 Building #1)
- March 18, 2010 at 9:59 AM, observation revealed the "Basement Fire Pump Room" rated walls are not tight to the deck above, mineral wool is visible. (1981 Building #1)
- March 18, 2010 at 10:07 AM, observation revealed pipe penetrations not sealed completely on the north east wall, unknown pink material used on the 2 hour wall in the "Basement MER #20 Electrical Sub Station". (1981 Building #1)
- March 18, 2010 at 10:08 AM, observation revealed an electrical wire trey in the 2 hour wall not sealed in the "Basement MER #20 Electrical Sub Station". (1981 Building #1)
- March 18, 2010 at 10:18 AM, observation revealed pipe ends not sealed above the entry door to the "Basement MER", "G - Building" adjacent to "Lab Staff Room". (2005 Building #1)

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:

- March 16, 2010 at 10:00 AM, observation revealed a gap larger than 1/8" between the smoke barrier doors at the entry to 3rd Floor West. (1956 Building #2)
- March 17, 2010 at 11:33 AM, observation revealed a gap larger than 1/8" between the Basement smoke barrier doors to the MOB. (1970 Building #2)

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:

- March 16, 2010 at 11:28 AM, observation revealed a gap larger than 1/8" between the 3rd Floor CCU smoke barrier doors at the entry to CCU. (1981 Building #1)
- March 16, 2010 at 1:33 PM, observation revealed the rated gasket between the 2nd Floor G - Wing smoke barrier doors at the entry was torn. ( 2005 Building #1)
- March 16, 2010 at 2:12 PM, observation revealed a gap larger than 1/8" between the 2nd Floor West smoke barrier doors adjacent to Patient Room #289. (1956 Building #1)

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:

- March 15, 2010 at 2:27 PM, observation revealed that there were two unsealed ceiling penetrations, located on the 4th Floor, in the storage room across from Elevator F. (1970 Building #2)
- March 16, 2010 at 11:20 AM, observation revealed that the vent into the storage closet needs to be fire stopped, located on the 4th Floor, in the Peds Mechanical Room. (1970 Building #2)
- March 16, 2010 at 11:22 AM, observation revealed that the HV-11 vent needs to be fire stopped at the bottom, located on the 4th Floor, in the Peds Mechanical Room. (1970 Building #2)
- March 16, 2010 at 11:27 AM, observation revealed that there was an unsealed ceiling conduit penetration above the Electrical Panel 4EM-RP, located on the 4th Floor, in the Peds Mechanical Room. (1970 Building #2)
- March 17, 2010 at 11:00 AM, observation revealed that there was a large unsealed pipe penetration, located on the 1st Floor, in the Storage Room adjacent to the Gift Shop. (1970 Building #2)
- March 15, 2010 at 11:21 AM, observation revealed three (3) holes in 7th Floor Storage Room #2 wall. (1970 Building #2)
- March 15, 2010 at 3:23 PM, observation revealed floating ceiling tiles in the 3rd Floor East Storage Room / Janitor Supply adjacent to the Equipment Storage Room (between east and west) . (Building #2)
- March 16, 2010 at 9:26 AM, observation revealed floating ceiling tiles in the 3rd Floor North Equipment Storage Room across from Patient Room #312. (1970 Building #2)
- March 17, 2010 at 12:00 PM, observation revealed the Basement Storage Room door adjacent to the "Darkroom" in the Telecom Area was missing the self-closing unit. (1970 Building #2)

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:

- March 17, 2010 at 10:27 AM, observation revealed the 1st Floor MRI Prep/Recovery #1331 adjacent to Room #1337 was being used as a storage area. (1981 Building #1)
- March 17, 2010 at 10:30 AM, observation revealed wood pallets used in 1st Floor MRI Prep/Recovery Storage Room #1331. (1981 Building #1)

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:

- March 15, 2010 at 11:50 AM, observation revealed that the corridor handrail was loose, located on the 6th Floor near Stairwell #3. (1970 Building #2)
- March 15, 2010 at 12:25 PM, observation revealed a loose handrail adjacent to the 5th floor east smoke barrier doors and across from the entry to 5th Floor North. (1970 Building #2)

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:

- March 17, 2010 at 11:10 AM, observation revealed the Basement south exit egress in the Data Center was blocked by a mobile computers, totes, tables and wood pallets. (1981 Building #1)
- March 17, 2010 at 11:20 AM, observation revealed the Basement second south exit door in the Data Center was blocked by storage and the door handle was broke off. (1981 Building #1)

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- March 15, 2010 at 11:10 AM, observation revealed that there was trash (boxes, paper etc.) in the corridor, located on the 9th Floor in the Elevator Lobby. (1970 Building #2)

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:

- March 15, 2010 at 3:02 PM, observation revealed a missing smoke detector head in the corridor outside 3rd Floor East Patient Room #335. (1970 Building #2)

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:

- March 17, 2010 at 2:11 PM, observation revealed that there was a smoke detector located above the ceiling tiles, located on the 1st Floor, south of the G-Wing entrance, south of " Staff Only " doorway. (1981 Building #1)

Based on observation and 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:

- March 16, 2010 at 9:11 AM, observation revealed that there was a hole in the ceiling tile, located on the 4th Floor in the Get Well Network Office in the Library. (1981 Building #1)
- March 16, 2010 at 9:13 AM, observation revealed that some of the book shelves were positioned too close to the sprinkler heads, located on the 4th Floor in the Library. (1981 Building #1)
- March 16, 2010 at 9:15 AM, observation revealed that the sprinkler piping was corroded at the hanger, located on the 4th Floor in Stairwell #12. (1981 Building #1)
- March 17, 2010 at 10:26 AM, observation revealed a broken ceiling tile from appears to be from a leak in the First Floor MRI Prep/Recovery #1331 adjacent to Room #1337. (1981 Building #1)

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and 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:

- March 15, 2010 at 11:00 AM, observation revealed that the stand pipe gauge was dated with the year 1969, located on the 10th Floor at the stand pipe. (1970 Building #2)
- March 15, 2010 at 2:03 PM, observation revealed that the stand pipe gauge was dated with the year 1970, located on the 6th Floor at the stand pipe. (1970 Building #2)
- March 15, 2010 at 2:25 PM, Observation revealed that there was paint on the sprinkler head, located on the 4th Floor, in the storage room across from Elevator F. (1970 Building #2)
- March 15, 2010 at 2:26 PM, observation revealed that there were combustibles stored too close to the sprinkler head, located on the 4th Floor, in the storage room across from Elevator F. (1970 Building #2)
- March 16, 2010 at 9:28 AM, observation revealed the 3rd Floor North Standpipe #28 adjacent to 3rd Floor North Equipment Storage Room had a tag attached stating that the stem leaks. (1970 Building #2)

Based on observation and 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:

- March 15, 2010 at 2:00 PM, observation revealed that there was a fire extinguisher improperly stored on the floor, located on the 6th Floor, in Mechanical Room #10. (1970 Building #2)
- March 16, 2010 at 11:10 AM, observation revealed that the fire extinguishers missed the January and February inspections, located on the 4th Floor, in the Mechanical Room in the Pediatric Department. (1970 Building #2)
- March 16, 2010 at 1:50 PM, observation revealed that the fire extinguishers missed the January and February inspections, located on the 4th Floor, in the Therapy Room #2. (1970 Building #2)
- March 16, 2010 at 9:33 AM, observation revealed the fire extinguisher cabinet adjacent to 3rd Floor North Clean Supply had a broken door handle. (1970 Building #2)
- March 16, 2010 at 10:22 AM, observation revealed a missing escutcheon plate outside the Third Floor South Residence Quarters and the F-Elevators. (1925 Building #2)

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:

- March 17, 2010 at 10:40 AM, observation revealed the 1st Floor fire extinguisher cabinet across from the Electrical Room and two doors down from Ultra Sound Staff #1541, cabinet is not labeled and blends in with the wall. (1981 Building #1)

Based on observation the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- March 15, 2010 at 3:17 PM, observation revealed that there was an electrical space heater, located on the 4th Floor in the Medical Education Program Director ' s Office. (1981 Building #1)
- March 15, 2010 at 3:20 PM, observation revealed that there was an electrical space heater, located on the 4th Floor in the Medical Education Dr. Badshah ' s Office. (1981 Building #1)
- March 15, 2010 at 3:45 PM, observation revealed that there was an electrical space heater, located on the 4th Floor in C. Parliament ' s Office. (1981 Building #1)

Based on observation the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect all occupants of the facility.

Findings include:

- March 16, 2010 at 10:15 AM, observation revealed that there was an electrical space heater, located on the 4th Floor in Clinical Informatics Office. (1970 Building #2)
- March 16, 2010 at 11:35 AM, observation revealed that there was an electrical space heater, located on the 4th Floor in Peds Hospitality Office, across from the Nurses Station. (1970 Building #2)

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:

- March 15, 2010 at 11:06 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 9th Floor in the corridor by Stairwell #5. (1970 Building #2)
- March 15, 2010 at 11:56 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 6th Floor at the Center Nurses Office near the corridor (NW corner). (1925 Building #2)
- March 15, 2010 at 1:55 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 6th Floor, at Mechanical Room #10, located in Elevator B Machine Room. (1970 Building #2)
- March 15, 2010 at 2:10 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 6th Floor, in Mechanical Room #13 near Bar Code 1389. (1970 Building #2)
- March 15, 2010 at 2:35 PM, Observation revealed that there was an electrical junction box missing a cover plate, located on the 4th Floor in the PICU - Communication Closet. (1970 Building #2)
- March 16, 2010 at 10:21 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 4th Floor at the cross corridor smoke barrier near Room 468. (1970 Building #2)
March 16, 2010 at 10:40 AM, Observation revealed that there was an electrical extension cord in use, located on the 4th Floor, in Room 487. (1970 Building #2)
- March 16, 2010 at 10:45 AM, observation revealed that there were two electrical power strips daisy chained together, located on the 4th Floor in Kim Allen ' s Office. (1970 Building #2)
- March 16, 2010 at 10:50 AM, observation revealed that there was an electrical extension cord in use, located on the 4th Floor, in Respiratory Managers Office. (1970 Building #2)
- March 16, 2010 at 10:51 AM, observation revealed that there were two electrical power strips daisy chained together, located on the 4th Floor in Director of Rehab Services Office. (1970 Building #2)
- March 16, 2010 at 11:00 AM, observation revealed that there was an electrical extension cord in use, located on the 4th Floor, in the Anesthesia On-call Room. (1970 Building #2)
- March 16, 2010 at 11:25 AM, observation revealed that there was an electrical junction box missing a cover plate above HV-11 fan, located on the 4th Floor, in the Peds Mechanical Room. (1970 Building #2)
- March 17, 2010 at 11:25 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor in the Dietary corridor near the Dietary Elevator. (1956 Building #2)
- March 18, 2010 at 10:50 AM, observation revealed that there were two electrical junction boxes missing a cover plates, located on the 1st Floor in the Interventional Radiology Control Room. (1970 Building #2)
- March 15, 2010 at 12:11 PM, observation revealed a half open junction box above the bed in 5th Floor LDR #8. (1970 Building #2)
- March 16, 2010 at 10:11 AM, observation revealed a open junction box above the 3rd Floor South smoke barrier doors adjacent to the CINE View Room. (1925 Building #2)
- March 18, 2010 at 9:48 AM, observation revealed two (2) open junction boxes on the east wall above the chilled water valve #12 and #14 inside Basement MER #11. (1925 Building #2)

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:

- March 15, 2010 at 3:00 PM, observation revealed that there were two electrical power strips daisy chained together, located on the 4th Floor in the Clinical Resource Coordinators Office. (1981 Building #1)
- March 15, 2010 at 3:05 PM, observation revealed that there was an electrical extension cord in use, located on the 4th Floor in the Educational Services (back office). (1981 Building #1)
- March 15, 2010 at 3:15 PM, observation revealed that there was numerous electrical power strips daisy chained together, located on the 4th Floor in the Medical Education Offices. (1981 Building #1)
- March 15, 2010 at 3:21 PM, observation revealed that there were two electrical power strips daisy chained together, located on the 4th Floor in the Clinical Health Initiatives Director ' s Offices. (1981 Building #1)
- March 15, 2010 at 3:22 PM, observation revealed that there were two electrical power strips daisy chained together, located on the 4th Floor in Melanie Zaleski ' s Office. (1981 Building #1)
- March 15, 2010 at 3:23 PM, observation revealed that there was an electrical space heater, located on the 4th Floor in Melanie Zaleski ' s Office. (1981 Building #1)
- March 15, 2010 at 3:24 PM, observation revealed that there was an electrical extension cord in use, located on the 4th Floor in Melanie Zaleski ' s Office. (1981 Building #1)
- March 15, 2010 at 3:25 PM, observation revealed that there was numerous electrical power strips daisy chained together, located on the 4th Floor in the Case Manager ' s Offices. (1981 Building #1)
- March 16, 2010 at 9:25 AM, observation revealed that there were numerous electrical power strips daisy chained together, located on the 4th Floor in the Computer Training Room. (1981 Building #1)
- March 16, 2010 at 9:30 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 4th Floor at the cross corridor smoke barrier by Stairwell #9. (1981 Building #1)
- March 16, 2010 at 3:10 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 2nd Floor in the Electrical Closet in the Endoscopy Department. (1981 Building #1)
- March 17, 2010 at 10:00 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 2nd Floor at the cross corridor smoke barrier from the Endoscopy Department into Pre OP. (1981 Building #1)
- March 17, 2010 at 1:55 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor, at the cross corridor smoke barrier, on the south wall to G-Wing entrance. (2005 Building #1)
- March 17, 2010 at 2:00 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor, south of the G-Wing entrance. (TH - 1981 Building #1)
- March 17, 2010 at 2:05 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor, south of the G-Wing entrance above " Staff Only " doorway. (1981 Building #1)
- March 17, 2010 at 2:10 PM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor, south of the G-Wing entrance, south of " Staff Only " doorway. (1981 Building #1)
- March 17, 2010 at 3:30 PM, observation revealed that there were three electrical junction boxes missing a cover plates, located on the 1st Floor, in Room 1347 (the MRI Toshiba Room). (1981 Building #1)
- March 18, 2010 at 9:50 AM, observation revealed that there were two electrical junction boxes missing a cover plates, located on the 1st Floor, at Stairwell #11. (1990 Building #1)
- March 18, 2010 at 9:55 AM, observation revealed that there was an electrical junction box missing a cover plate on the above decking, located on the 1st Floor, at Stairwell #10. (1990 Building #1)
- March 18, 2010 at 10:05 AM, observation revealed that there was an electrical junction box missing a cover plate, located on the 1st Floor, in Room 1365. (1981 Building #1)
- March 16, 2010 at 1:12 PM, observation revealed an open junction box in the "3rd Floor Connector Communication Room #3208". (2005 Building #1)
- March 17, 2010 at 11:07 AM, observation revealed boxes stored in front of the electrical panel on the center support beam in the Basement Data Center. (1981 Building #1)