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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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

* Observed an unsealed wall penetration in the door frame to room S683B.

* Observed multiple unsealed wall and ceiling penetrations in communication closet M615C.

* Observed an unsealed ceiling penetration in room M615.

* Observed that the drywall patch needed to be repaired to meet the rating in the ceiling in closet W30E.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed the doors to room E185 were not smoke tight when closed.

· Observed the doors to the Rehab area did not close to a smoke tight seal. The doors need a coordinator to allow the doors to close properly.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed the cross corridor doors, WG36, do not close to a smoke tight seal due to the air pressure within the unit.

· Observed that the required smoke barrier door 2G21F has been removed.

· Observed an unapproved hold-open device on the smoke barrier door SG02-2 to Express Care.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed the door to the storage area in the NICU needs a closer. This area is being used for storage which requires a closer on the door.

· Observed that the 2nd floor clean utility storage room is not sprinkled or properly rated.

· Observed that the door to the storage room at elevator 11 does not self-close and latch.

· Observed a large ceiling and wall penetrations in janitor's closet located inside room M205.

· Observed a large unsealed wall penetration in mechanical room M245.

· Observed wood pallets being stored in soiled utility room M249.

· Observed unsealed wall penetrations in electrical closet M243.

· Observed an unsealed ceiling penetration around pipes in janitor's closet JC W204.

· Observed an unsealed penetration above the door to the Joint Plus center.

· Observed unsealed penetrations and missing pieces of block, 2nd floor, in the 2- hour wall adjacent the elevator in the small closet.

· Observed the door to the utility closet W10F did not latch when closed.

· Observed the leaf door to the OR equipment storage room does not latch to the floor or the upper jam.

· Observed wood and other combustibles being stored in the electrical room inside the janitor's closet across from elevator 11.

· Observed that the door to the janitor's closet at elevator 11 does not self-close and latch.

· Observed an unsealed wall penetration above door 2G21F.

· Observed unsealed wall penetrations in electrical closet MG25D.

· Observed that the door to mechanical room MG23 does not self-close and latch.

· Observed paints, solvents and combustibles being stored in the 6-west mechanical room.

· Observed missing ceiling tiles in the soiled utility room communication closet M615C.

· Observed ceiling tile missing in room M625.

· Observed the door to the storage area in the NICU needs a closer. This area is being used for storage which requires a closer on the door.

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

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed cleaning supplies being stored in stairwell SGH-07.

· Observed the light in the stairwell, SCH07 5th floor, was not illuminated.

· Observed that stairwell door SGH-16 did not self-latch when tested.

· Observed the light in stairwell SGH03 was not illuminated when inspected. CORRECTED

· Observed the door handle on the secondary exit door was loose on the interior side of the door.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed patient beds obstructing the door to stairwell SGH-10.

· Observed the corridor at rehab stairs W20A was obstructed by equipment.

Based on observation the facility failed to provide lighting in accordance with the LSC section 19.2.8. This deficient practice could potentially affect all occupants of the facility. Findings include:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed the light in the electrical room was not working at time of inspection.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed that the catherization OR's don't have battery operated emergency lights as required where the patient is under anesthesia and incapable of self-preservation.

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

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed an exit sign in the 6-west mechanical room not illuminated.

· Observed that an additional exit sign is needed above cross-corridor smoke barrier door 2GC33.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed that former patient room E670 has been converted into a 6-person office space and does not have a fire alarm audio/visual device.

· Observed that the smoke detector in room E40B was in alarm but was not showing on panel.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed that the sprinkler head was taped in electrical closet M243.

· Observed that the sprinkler head at the cross-corridor smoke barrier doors SGC26 is obstructed by the lay-in ceiling and doesn't provide complete coverage.

· Observed that mechanical room MG23 is not sprinkler protected.

· Observed unsealed wall penetrations in electrical closet MG25D.

· Observed room MG25G is not sprinkler protected.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect all occupants of the facility. Findings include:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

Upon review of records the following deficiencies were noted on the Fire Defense kitchen hood inspection report:

· Ducts not welded
· Hood missing filter
· Nozzles out of adjustment
· Tanks rusted
· Incorrectly sized pipe
· Not all systems are UL 300 compliant

Based on observation the facility failed to provide protection of flammable and combustible liquids in accordance with NFPA 30/99. This deficient practice could potentially affect all occupants of the facility. Findings include:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed flammable liquids in the dialysis work room not properly stored.

· Observed an unsecured tank in the storage area of Great Lakes Coffee.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed a junction box missing its protective cover plate in data closet 6ME1.

· Observed a non-code compliant extension cord in use on a fan in the kitchenette area of the Psych ward.

· Observed an open junction box above 5 West doors, entry doors to unit.

· Observed an open junction box on the East wall by the West passenger elevators.

· Observed an open junction box in room E30D.

· Observed an open junction box next to the cable box in room E10E.

· Observed the light in the electrical room was not working at time of inspection.

· Observed the magnetic hold open device on the doors within the ICU unit was not secured to the wall.

· Observed an open junction box above the cross corridor doors by office WG36.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

* Observed an unsealed wall penetration in the door frame to room S683B.

* Observed multiple unsealed wall and ceiling penetrations in communication closet M615C.

* Observed an unsealed ceiling penetration in room M615.

* Observed that the drywall patch needed to be repaired to meet the rating in the ceiling in closet W30E.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed the doors to room E185 were not smoke tight when closed.

· Observed the doors to the Rehab area did not close to a smoke tight seal. The doors need a coordinator to allow the doors to close properly.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed the cross corridor doors, WG36, do not close to a smoke tight seal due to the air pressure within the unit.

· Observed that the required smoke barrier door 2G21F has been removed.

· Observed an unapproved hold-open device on the smoke barrier door SG02-2 to Express Care.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed the door to the storage area in the NICU needs a closer. This area is being used for storage which requires a closer on the door.

· Observed that the 2nd floor clean utility storage room is not sprinkled or properly rated.

· Observed that the door to the storage room at elevator 11 does not self-close and latch.

· Observed a large ceiling and wall penetrations in janitor's closet located inside room M205.

· Observed a large unsealed wall penetration in mechanical room M245.

· Observed wood pallets being stored in soiled utility room M249.

· Observed unsealed wall penetrations in electrical closet M243.

· Observed an unsealed ceiling penetration around pipes in janitor's closet JC W204.

· Observed an unsealed penetration above the door to the Joint Plus center.

· Observed unsealed penetrations and missing pieces of block, 2nd floor, in the 2- hour wall adjacent the elevator in the small closet.

· Observed the door to the utility closet W10F did not latch when closed.

· Observed the leaf door to the OR equipment storage room does not latch to the floor or the upper jam.

· Observed wood and other combustibles being stored in the electrical room inside the janitor's closet across from elevator 11.

· Observed that the door to the janitor's closet at elevator 11 does not self-close and latch.

· Observed an unsealed wall penetration above door 2G21F.

· Observed unsealed wall penetrations in electrical closet MG25D.

· Observed that the door to mechanical room MG23 does not self-close and latch.

· Observed paints, solvents and combustibles being stored in the 6-west mechanical room.

· Observed missing ceiling tiles in the soiled utility room communication closet M615C.

· Observed ceiling tile missing in room M625.

· Observed the door to the storage area in the NICU needs a closer. This area is being used for storage which requires a closer on the door.

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

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed cleaning supplies being stored in stairwell SGH-07.

· Observed the light in the stairwell, SCH07 5th floor, was not illuminated.

· Observed that stairwell door SGH-16 did not self-latch when tested.

· Observed the light in stairwell SGH03 was not illuminated when inspected. CORRECTED

· Observed the door handle on the secondary exit door was loose on the interior side of the door.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed patient beds obstructing the door to stairwell SGH-10.

· Observed the corridor at rehab stairs W20A was obstructed by equipment.

Based on observation the facility failed to provide lighting in accordance with the LSC section 19.2.8. This deficient practice could potentially affect all occupants of the facility. Findings include:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed the light in the electrical room was not working at time of inspection.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed that the catherization OR's don't have battery operated emergency lights as required where the patient is under anesthesia and incapable of self-preservation.

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

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed an exit sign in the 6-west mechanical room not illuminated.

· Observed that an additional exit sign is needed above cross-corridor smoke barrier door 2GC33.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed that former patient room E670 has been converted into a 6-person office space and does not have a fire alarm audio/visual device.

· Observed that the smoke detector in room E40B was in alarm but was not showing on panel.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed that the sprinkler head was taped in electrical closet M243.

· Observed that the sprinkler head at the cross-corridor smoke barrier doors SGC26 is obstructed by the lay-in ceiling and doesn't provide complete coverage.

· Observed that mechanical room MG23 is not sprinkler protected.

· Observed unsealed wall penetrations in electrical closet MG25D.

· Observed room MG25G is not sprinkler protected.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect all occupants of the facility. Findings include:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

Upon review of records the following deficiencies were noted on the Fire Defense kitchen hood inspection report:

· Ducts not welded
· Hood missing filter
· Nozzles out of adjustment
· Tanks rusted
· Incorrectly sized pipe
· Not all systems are UL 300 compliant

Based on observation the facility failed to provide protection of flammable and combustible liquids in accordance with NFPA 30/99. This deficient practice could potentially affect all occupants of the facility. Findings include:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed flammable liquids in the dialysis work room not properly stored.

· Observed an unsecured tank in the storage area of Great Lakes Coffee.

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:

The following violations were noted during a validation inspection conduct on November 19, 2012 and November 20, 2012 between the hours of 9:00 AM and 5:00 PM. These findings were observed and confirmed by the facility maintenance director during the inspection.

· Observed a junction box missing its protective cover plate in data closet 6ME1.

· Observed a non-code compliant extension cord in use on a fan in the kitchenette area of the Psych ward.

· Observed an open junction box above 5 West doors, entry doors to unit.

· Observed an open junction box on the East wall by the West passenger elevators.

· Observed an open junction box in room E30D.

· Observed an open junction box next to the cable box in room E10E.

· Observed the light in the electrical room was not working at time of inspection.

· Observed the magnetic hold open device on the doors within the ICU unit was not secured to the wall.

· Observed an open junction box above the cross corridor doors by office WG36.