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Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 18.1.1.4.1, 18.1.1.4.2. This deficient practice could affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the adjacent smoke compartments due to improperly maintained fire separations.

Findings include:

On 03/14/12, the following observations were made:

- At approximately 10:00 AM observed that at the 3 hour rated wall above the Physical Therapy Corridor doors there was a through penetration caused by a black cable that was not sealed.
- At approximately 12:15 PM observed that at the 3 hour rated wall above the Admitting Corridor doors there was a through penetration caused by a conduit that was not sealed.

Based on observation the facility failed to provide smoke barriers that would provide at least a one hour fire resistance rating in accordance with the LSC sections 18.3.7.3, 18.3.7.5, 18.1.6.3. This deficient practice could affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly sealed penetrations.

Findings include:

On 03/14/12, the following observations were made:

- At approximately 11:30 AM observed that above the Emergency Department Entrance Doors there were through penetrations caused by 2 conduits that did not have sealed ends.
- At approximately 11:40 AM observed that at the smoke barrier wall above the ceiling in the Quiet Room there was a through penetration caused by a 2 inch wire chase that did not have a sealed end.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could affect all occupants of the affected smoke compartment in the event of a fire within the hazardous area enclosure where the products of combustion are allowed to spread to the means of egress due to improperly installed or maintained hazardous area doors.

Findings include:

On 03/14/12, the following observations were made:

- At approximately 11:40 AM observed that the Lab Entry Door #1104 did not auto close to a positive latch.

Based on observation and/or review of records the facility failed to provide building services in accordance with the LSC sections 9.2, 18.5.2.1, 18.5.2.2. This deficient practice could affect all occupants of the affected smoke compartment in the event of a failure of the clothes dryer exhaust system which may contribute to the start of a fire.

Findings include:

On 03/14/12, the following observations were made:

- At approximately 10:25 AM observed that the Physical Therapy Clothes Dryer exhaust duct work was sealed with a cloth type duct tape. Tape, if used, shall be rated for that purpose.