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Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. . This deficient practice could potentially affect patients, staff and visitors in 4 of 8 smoke compartments due to smoke and/or fire entering the corridor system.

Findings include:

On 1/29/13 between 11:00am and 1:00pm during the physical inspection of the facility, the corridor doors to the Ambulatory Care Suite and the Obstetrics Suite were not equipped with latching hardware on the doors. This condition was noted with the Facilities Director present.

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 patients, staff, and visitors in 2 of 8 smoke compartments in the event of smoke not being contained to the smoke compartment of origin.

Findings include:

On 1/29/13 at approximately 12:19pm, the door to the Pharmacy Corridor failed to self-close and latch as designed. This door comprises both a smoke barrier and a corridor separation. This condition was noted with the Facilities Director present.

Based on observation the facility failed to maintain exit and directional signs in accordance with the LSC section 19.2.10.1. This deficient practice could potentially affect staff in the noted area in the event of an evacuation emergency.

Findings include:

On 1/29/13 at approximately 12:44pm, the exit sign in the Lab Office was observed to not be illuminated. This condition was noted with the Facilities Director present.

Based on observation the facility failed to ensure that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect patients, staff, and visitors in 2 of 8 smoke compartments in the event of a delay in the operation or effectiveness of the sprinkler system.

Findings include:

On 1/29/13 at approximately 12:05pm, items were observed to be stored within 18 inches of the sprinkler head in the MRT Storage Room. This condition was noted with the Facilities Director present.

On 1/29/13 at approximately 12:42pm, a ceiling tile in the Garden Level Lab Corridor was observed to have a hole approximately 1/2 inch larger than the sprinkler escutcheon. This condition would allow heat to bypass the sprinkler head and delay it's activation. This condition was noted with the Facilities Director present.

Based on 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 staff in the kitchen area in the event of a cooking fire that is not quickly suppressed.

Findings include:

On 1/29/13 between 10:00am and 11:00am during records review, the facility documentation showed that the appliances in the kitchen were protected by a water spray system. This system is not UL-300 compliant as required by NFPA 96, Section 7.2.2. This condition was noted with the Facilities Director present.

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 staff in the noted room in the event of an electrical malfunction.

Findings include:

On 1/29/13 at approximately 12:36pm, an L-bend on a control box was observed to be missing the cover plate and exposed wires. This condition was noted with the Facilities Director present.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. . This deficient practice could potentially affect patients, staff and visitors in 4 of 8 smoke compartments due to smoke and/or fire entering the corridor system.

Findings include:

On 1/29/13 between 11:00am and 1:00pm during the physical inspection of the facility, the corridor doors to the Ambulatory Care Suite and the Obstetrics Suite were not equipped with latching hardware on the doors. This condition was noted with the Facilities Director present.

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 patients, staff, and visitors in 2 of 8 smoke compartments in the event of smoke not being contained to the smoke compartment of origin.

Findings include:

On 1/29/13 at approximately 12:19pm, the door to the Pharmacy Corridor failed to self-close and latch as designed. This door comprises both a smoke barrier and a corridor separation. This condition was noted with the Facilities Director present.

Based on observation the facility failed to maintain exit and directional signs in accordance with the LSC section 19.2.10.1. This deficient practice could potentially affect staff in the noted area in the event of an evacuation emergency.

Findings include:

On 1/29/13 at approximately 12:44pm, the exit sign in the Lab Office was observed to not be illuminated. This condition was noted with the Facilities Director present.

Based on observation the facility failed to ensure that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect patients, staff, and visitors in 2 of 8 smoke compartments in the event of a delay in the operation or effectiveness of the sprinkler system.

Findings include:

On 1/29/13 at approximately 12:05pm, items were observed to be stored within 18 inches of the sprinkler head in the MRT Storage Room. This condition was noted with the Facilities Director present.

On 1/29/13 at approximately 12:42pm, a ceiling tile in the Garden Level Lab Corridor was observed to have a hole approximately 1/2 inch larger than the sprinkler escutcheon. This condition would allow heat to bypass the sprinkler head and delay it's activation. This condition was noted with the Facilities Director present.

Based on 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 staff in the kitchen area in the event of a cooking fire that is not quickly suppressed.

Findings include:

On 1/29/13 between 10:00am and 11:00am during records review, the facility documentation showed that the appliances in the kitchen were protected by a water spray system. This system is not UL-300 compliant as required by NFPA 96, Section 7.2.2. This condition was noted with the Facilities Director present.

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 staff in the noted room in the event of an electrical malfunction.

Findings include:

On 1/29/13 at approximately 12:36pm, an L-bend on a control box was observed to be missing the cover plate and exposed wires. This condition was noted with the Facilities Director present.