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Based on observation it was determined that the facility failed to provide complete sprinkler coverage and does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/10/13 at 2:55 PM the following observations were made:

Observed during the review of the facility documents that the facility was unable to provide documentation of the construction rating of the building.

Based on observation and/or review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/09/13 at approximately 1:15 PM, the following observations were made:

Observed during the documentation review, the facility was unable to provide any flame spread rating documentation for their contents and furnishings throught the facility..

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/9/13 at approximately 10:45 AM, the following observations were made:

Observed a former nursing station which was permitted to be open to the egress corridor was now being used as a "Bio Med Office Space". The space was open to the corridor and contained several pieces of computer equipment as well as combustibles. Use areas are not permitted to be open to the corridor unless meeting allowable exceptions. No exceptions were met.

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:

On 10/10/13 at approximately 11:05 AM, the following observations were made:

Observed the staircase door did not close to a positive latch, located in Stairwell #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:

On 10/09/13 at approximately 11:15AM, the following observations were made:

Observed a section of a required smoke barrier wall in room 325 was missing. The wall appeared to be covered on one side but was lacking the complete separation.


27171

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/10/13 at approximately 9:50 AM, the following observations were made:

Observed that the smoke barrier wall was not smoke tight against the decking, located in smoke wall of Room 737.
Observed there were two unsealed conduit penetrations and two unsealed conduits, located in smoke wall of Room 725.
Observed there were two unsealed conduits, located in the smoke wall of Room 744.
Observed the east end of the smoke wall was incomplete, located in Room 601.
Observed the east end of the smoke wall was incomplete, located in Room 501.
Observed there were "Cat 5" wires that were unsealed, located in the smoke wall in Room 525.
Observed there were a row of electrical conduit penetrations that were unsealed, located on the east wall of the Cath Lab Waiting Area on the 2nd Floor.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/09/13 at approximately 1:00PM, the following observations were made:

Observed the former "Antepartum" room was being used for the storage of combustible items. The room is >100 sqft and sprinkler protected but does not have the proper fire separation. The wood doors to the space are non-self-closing and have vision panels making them non fire rated. No UL fire resistance labels were present on the door or glass located within the door.

On 10/09/13 at approximately 1:20PM, the following observations were made:

Observed in the 1st floor entrance to the ER/Urgent Care Suite, a non fire rated piece of glass in a required one hour fire rated wall door which surrounds the suite.

On 10/09/13 at approximately 2:15PM, the following observations were made:

Observed storage room door #168 in the Operating Suite had a towel stuffed in the door keeping it from latching as required.




27171



On 10/10/13 at approximately 1:00 PM, the following observations were made:

Observed the door did not close to a positive latch, located from the office area to the Chiller Room of the Power House.

Based on observation the facility failed to provide approved means of egress in accordance with the LSC section 19.2, 19.2.2.3, 19.2.2.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/9/13 at approximately 11:00 AM, the following observations were made:

Observed "stairwell 7" at level 3 had an unapproved penetration of wiring which was being used for a closed circuit TV system. This is a violation of 7.1.3.2.1.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/09/13 at approximately 1:45 PM, the following observations were made:

Observed during the review of the facility records that the facility failed to document fire drills on the 3rd shift in the 4th quarter of 2012.

Observed during the review of the facility records that the facility failed to document fire drills on the 2nd and 3rd shifts in the 3rd quarter of 2012.

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:

On 10/09/13 at approximately 1:00 PM, the following observations were made:

Observed during the documentation review that the fire alarm inspection report conducted July 8, 2013 by Cintas noted the following deficiencies:

The fire alarm panel is not grounded because it was installed on a bracket and not secured. The facility did not have any documentation that this issue was resolved.

The smoke detector is missing and is in programing, located on the 5 th Floor Rooms 551-568.

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 all occupants of the facility.

Findings include:

On 10/10/13 at approximately 2:15 PM, the following observations were made:

Observed the mesh at the top of the patient privacy curtains was too small, located in the Exam
Room #10.
Observed the mesh at the top of the patient privacy curtains was too small, located in the Exam Bay #6.
Observed the mesh at the top of the patient privacy curtains was too small, located in the Mammogram Room.

The mesh noted in the above deficiencies does not meet the minimum size requirements under NFPA 19.3.5.5

Observed that items were stored within the required eighteen inch clearance to a fire sprinkler head, located in the back storage room.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/09/13 at approximately 1:30 PM, the following observations were made;

Observed during the review of the facility documents, that the facility did not have documentation for a quarterly water flow of the fire sprinkler system for the first quarter of 2013.

Observed during the review of the facility documents, that the facility did not have documentation regarding the required fire sprinkler system gauges replacement or calibration.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/10/13 at approximately 2:30 PM, the following observations were made:

Observed during the review of the facility's documents, the facility was unable to provide quarterly water flow documents for the 1st quarter of 2013 and the 3rd and 4th quarters of 2012.

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:

On 10/10/13 at approximately 2:55 AM, the following observations were made:

Observed all of the fire extinguishers throughout the facility missed the monthly inspection for the months of August and September 2013.

Based on observation and/or review of records the facility failed to provide building services in accordance with the LSC sections 19.5.2.1, 9.2, This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/09/13 at approximately 10:00 AM, the following observations were made:

Observed clothes washers and dryers and ducts had been installed on floors 5, 6, and 7. The facility could not provide documentation the units had been installed in accordance with NFPA Section 9.2 Documentation could not be provided verifying if the installation contractor had obtained the required permits.

Further observation revealed the units on the lower levels had the ventilation tied into other facility exhaust ducts.

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

Findings include:

On 10/9/13 at approximately 2:00PM, the following observations were made:

Observed 8 oxygen E Tanks being stored in clean linen room #178. Staff U, the Operating Room Nurse Manager was questioned as to how many of those tanks would be used on any given day. Her response was 3 tanks would likely be used on the busiest day of operations. The room does not meet the storage requirements of NFPA 99 and more than a one day supply was present in the non rated clean linen room.

The facility failed to protect fire/smoke wall duct penetrations in accordance with LSC 101:8.3.5. Findings include: (NOTE 19.3.7.3, EXCEPTION NO. 2, which allows dampers to be omitted.) This deficient practice could potentially affect all occupants of the facility.


FACILITY: It was observed that the facility did not have protection of duct openings as required in referenced codes.

Findings include:

On 10/09/13 at approximately 2:00 PM, the following observations were made:

Observed during the review of the facility's documents, the facility did not have documentation for the inspection/testing of the fusible link/fire damper system.

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 all occupants of the facility.

Findings include:

On 10/09/13 at approximately 1:40 PM, the following observations were made;

Observed during the review of the facility records that the facility did not document the required weekly visual inspections of the generators.

Observed during the review of the facility records that the facility's generator #1 was out of service due to a bad voltage regulator from June 20, 2013 to September 20, 2013.

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 all occupants of the facility.

Findings include:

On 10/10/13 at approximately 2:45 PM, the following observations were made:

Observed during the review of the facility documents, the facility was unable to provide a current generator inspection document.

Observed during the review of the facility documents, the facility was unable to provide the required weekly visual inspections of the generator.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/10/13 at approximately 11:25 AM, the following observations were made:

Observed the 110 volt electrical wiring was not encased in electrical conduit, located in the Elevator Corridor on the 2nd Floor.
Observed there was an electrical junction box missing a cover plate, located in the southeast corner of the South Mechanical Room.
Observed the 110 volt electrical wiring was not encased in electrical conduit, located in the corridor outside the South Mechanical Room on the 2nd Floor.
Observed there was an electrical junction box missing a cover plate, located in the southeast corner of the Chiller Room in the Power House.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/10/13 at approximately 2:32 PM, the following observations were made:

Observed a large electrical junction box was missing a cover plate, located in the back mechanical room.
Observed there was an electrical extension cord in use, located in the Manager's Office.

Based on observation it was determined that the facility failed to provide complete sprinkler coverage and does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/10/13 at 2:55 PM the following observations were made:

Observed during the review of the facility documents that the facility was unable to provide documentation of the construction rating of the building.

Based on observation and/or review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/09/13 at approximately 1:15 PM, the following observations were made:

Observed during the documentation review, the facility was unable to provide any flame spread rating documentation for their contents and furnishings throught the facility..

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/9/13 at approximately 10:45 AM, the following observations were made:

Observed a former nursing station which was permitted to be open to the egress corridor was now being used as a "Bio Med Office Space". The space was open to the corridor and contained several pieces of computer equipment as well as combustibles. Use areas are not permitted to be open to the corridor unless meeting allowable exceptions. No exceptions were met.

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:

On 10/10/13 at approximately 11:05 AM, the following observations were made:

Observed the staircase door did not close to a positive latch, located in Stairwell #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:

On 10/09/13 at approximately 11:15AM, the following observations were made:

Observed a section of a required smoke barrier wall in room 325 was missing. The wall appeared to be covered on one side but was lacking the complete separation.


27171

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/10/13 at approximately 9:50 AM, the following observations were made:

Observed that the smoke barrier wall was not smoke tight against the decking, located in smoke wall of Room 737.
Observed there were two unsealed conduit penetrations and two unsealed conduits, located in smoke wall of Room 725.
Observed there were two unsealed conduits, located in the smoke wall of Room 744.
Observed the east end of the smoke wall was incomplete, located in Room 601.
Observed the east end of the smoke wall was incomplete, located in Room 501.
Observed there were "Cat 5" wires that were unsealed, located in the smoke wall in Room 525.
Observed there were a row of electrical conduit penetrations that were unsealed, located on the east wall of the Cath Lab Waiting Area on the 2nd Floor.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/09/13 at approximately 1:00PM, the following observations were made:

Observed the former "Antepartum" room was being used for the storage of combustible items. The room is >100 sqft and sprinkler protected but does not have the proper fire separation. The wood doors to the space are non-self-closing and have vision panels making them non fire rated. No UL fire resistance labels were present on the door or glass located within the door.

On 10/09/13 at approximately 1:20PM, the following observations were made:

Observed in the 1st floor entrance to the ER/Urgent Care Suite, a non fire rated piece of glass in a required one hour fire rated wall door which surrounds the suite.

On 10/09/13 at approximately 2:15PM, the following observations were made:

Observed storage room door #168 in the Operating Suite had a towel stuffed in the door keeping it from latching as required.




27171



On 10/10/13 at approximately 1:00 PM, the following observations were made:

Observed the door did not close to a positive latch, located from the office area to the Chiller Room of the Power House.

Based on observation the facility failed to provide approved means of egress in accordance with the LSC section 19.2, 19.2.2.3, 19.2.2.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/9/13 at approximately 11:00 AM, the following observations were made:

Observed "stairwell 7" at level 3 had an unapproved penetration of wiring which was being used for a closed circuit TV system. This is a violation of 7.1.3.2.1.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/09/13 at approximately 1:45 PM, the following observations were made:

Observed during the review of the facility records that the facility failed to document fire drills on the 3rd shift in the 4th quarter of 2012.

Observed during the review of the facility records that the facility failed to document fire drills on the 2nd and 3rd shifts in the 3rd quarter of 2012.

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:

On 10/09/13 at approximately 1:00 PM, the following observations were made:

Observed during the documentation review that the fire alarm inspection report conducted July 8, 2013 by Cintas noted the following deficiencies:

The fire alarm panel is not grounded because it was installed on a bracket and not secured. The facility did not have any documentation that this issue was resolved.

The smoke detector is missing and is in programing, located on the 5 th Floor Rooms 551-568.

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 all occupants of the facility.

Findings include:

On 10/10/13 at approximately 2:15 PM, the following observations were made:

Observed the mesh at the top of the patient privacy curtains was too small, located in the Exam
Room #10.
Observed the mesh at the top of the patient privacy curtains was too small, located in the Exam Bay #6.
Observed the mesh at the top of the patient privacy curtains was too small, located in the Mammogram Room.

The mesh noted in the above deficiencies does not meet the minimum size requirements under NFPA 19.3.5.5

Observed that items were stored within the required eighteen inch clearance to a fire sprinkler head, located in the back storage room.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/09/13 at approximately 1:30 PM, the following observations were made;

Observed during the review of the facility documents, that the facility did not have documentation for a quarterly water flow of the fire sprinkler system for the first quarter of 2013.

Observed during the review of the facility documents, that the facility did not have documentation regarding the required fire sprinkler system gauges replacement or calibration.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/10/13 at approximately 2:30 PM, the following observations were made:

Observed during the review of the facility's documents, the facility was unable to provide quarterly water flow documents for the 1st quarter of 2013 and the 3rd and 4th quarters of 2012.

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:

On 10/10/13 at approximately 2:55 AM, the following observations were made:

Observed all of the fire extinguishers throughout the facility missed the monthly inspection for the months of August and September 2013.

Based on observation and/or review of records the facility failed to provide building services in accordance with the LSC sections 19.5.2.1, 9.2, This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/09/13 at approximately 10:00 AM, the following observations were made:

Observed clothes washers and dryers and ducts had been installed on floors 5, 6, and 7. The facility could not provide documentation the units had been installed in accordance with NFPA Section 9.2 Documentation could not be provided verifying if the installation contractor had obtained the required permits.

Further observation revealed the units on the lower levels had the ventilation tied into other facility exhaust ducts.

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

Findings include:

On 10/9/13 at approximately 2:00PM, the following observations were made:

Observed 8 oxygen E Tanks being stored in clean linen room #178. Staff U, the Operating Room Nurse Manager was questioned as to how many of those tanks would be used on any given day. Her response was 3 tanks would likely be used on the busiest day of operations. The room does not meet the storage requirements of NFPA 99 and more than a one day supply was present in the non rated clean linen room.

The facility failed to protect fire/smoke wall duct penetrations in accordance with LSC 101:8.3.5. Findings include: (NOTE 19.3.7.3, EXCEPTION NO. 2, which allows dampers to be omitted.) This deficient practice could potentially affect all occupants of the facility.


FACILITY: It was observed that the facility did not have protection of duct openings as required in referenced codes.

Findings include:

On 10/09/13 at approximately 2:00 PM, the following observations were made:

Observed during the review of the facility's documents, the facility did not have documentation for the inspection/testing of the fusible link/fire damper system.

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 all occupants of the facility.

Findings include:

On 10/09/13 at approximately 1:40 PM, the following observations were made;

Observed during the review of the facility records that the facility did not document the required weekly visual inspections of the generators.

Observed during the review of the facility records that the facility's generator #1 was out of service due to a bad voltage regulator from June 20, 2013 to September 20, 2013.

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 all occupants of the facility.

Findings include:

On 10/10/13 at approximately 2:45 PM, the following observations were made:

Observed during the review of the facility documents, the facility was unable to provide a current generator inspection document.

Observed during the review of the facility documents, the facility was unable to provide the required weekly visual inspections of the generator.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/10/13 at approximately 11:25 AM, the following observations were made:

Observed the 110 volt electrical wiring was not encased in electrical conduit, located in the Elevator Corridor on the 2nd Floor.
Observed there was an electrical junction box missing a cover plate, located in the southeast corner of the South Mechanical Room.
Observed the 110 volt electrical wiring was not encased in electrical conduit, located in the corridor outside the South Mechanical Room on the 2nd Floor.
Observed there was an electrical junction box missing a cover plate, located in the southeast corner of the Chiller Room in the Power House.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 10/10/13 at approximately 2:32 PM, the following observations were made:

Observed a large electrical junction box was missing a cover plate, located in the back mechanical room.
Observed there was an electrical extension cord in use, located in the Manager's Office.