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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 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 2:30 PM, the following observation was made and observed by facility maintenance staff that the self-closer for the door to the pipe chase in room 137 was disconnected and the door did not close to a positive latch.

On 04/13/10 at approximately 2:00 PM, the following observation was made and observed by facility maintenance staff that the there is a 1/2 - inch open conduit above the ceiling tile, above the door to the stairway by room # 625. (Corrected)

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 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 1:10 PM, the following observation was made and observed by facility maintenance staff that there are two 1/4 - inch penetrations around two conduits protruding through the rear wall to the Communication Closet located in the Basement Warehouse. (Corrected)

On 04/12/10 at approximately 2:35 PM, the following observation was made and observed by facility maintenance staff that there is a 1/2 - inch penetration above the ceiling tile above the smoke barrier doors by room B-40. (Corrected)

On 04/13/10 at approximately 12:45 PM, the following observation was made and observed by facility maintenance staff that the there is a 1/8 - inch penetration around a pipe protruding through the smoke barrier wall above the ceiling tile, above the smoke barrier doors by room # 433B. (Corrected)

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 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 12:45 PM, the following observation was made and observed by facility maintenance staff that the magnetic door hold openers for the smoke barrier doors by room B-40 do not operator.

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 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 1:00 PM, the following observation was made and observed by facility maintenance staff that there is a 1/4 - inch penetration around a sprinkler pipe protruding through the rear wall in the Basement Medical Records Storage Room. (Corrected)

On 04/12/10 at approximately 1:20 PM, the following observation was made and observed by facility maintenance staff that there is a 3 - inch penetration around a pipe protruding through the ceiling in the Basement Snack Storage Room. (Corrected)

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 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 2: 55 PM, the following observation was made and observed by facility maintenance staff that the exit door to the outside by room 155 sticks in the door frame and is difficult to open. (Corrected)

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 Staff occupants of the facility.

Findings include:

On 04/12/10 at approximately 2:00 PM, the following observation was made and observed by facility maintenance staff that the direction of travel in the Housekeeping Storage Room is not marked as to the direction of travel to the exit access corridor. (Corrected)

Based on observation and/or review of records the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6. This deficient practice could potentially affect 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 10:35 AM, the following observation was made and observed by facility maintenance staff that by review of the annual inspection/test records the fire alarm technician reported that the fire phones did not operate and were in need of repair.

On 04/13/10 at approximately 2:45 PM the following observation was made and observed by facility maintenance staff that the fire alarm pull station located by the 6th floor West Stairway is coming loose from the wall.

04/14/10 at approximately 10:30 AM the following observations was made and observed by facility maintenance staff that a staff person when asked to operate the fire alarm manual pull station on the 1st floor had difficultly with the key that operated the manual pull station.

Based on observation the facility failed to provide chutes that are not in accordance with the LSC sections 9.5, 9.7, 8.4. This deficient practice could potentially affect 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 2:00 PM, the following observation was made and observed by facility maintenance staff that the door to the Trash Chute in room # 130 did not close to a positive latch.

On 04/13/10 at approximately 10:15 AM, the following observation was made and observed by facility maintenance staff that the door to the Trash Chute in room # 230 did not close to a positive latch.

On 04/13/10 at approximately 11:00 AM, the following observation was made and observed by facility maintenance staff that the door to the Trash Chute in room # 330 did not close to a positive latch.

On 04/13/10 at approximately 12:55 PM, the following observation was made and observed by facility maintenance staff that the door to the Trash Chute in room # 430 did not close to a positive latch.

On 04/13/10 at approximately 1:30 PM, the following observation was made and observed by facility maintenance staff that the door to the Trash Chute in room # 530 did not close to a positive latch.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 12:30 PM, the following observation was made and observed by facility maintenance staff that E-Type oxygen cylinders are being stored in a closet in the Control Center. The closet is not sprinkler protected and the enclosure is not separated with a 1-hour fire resistance barrier.

On 04/12/10 at approximately 1:35 PM, the following observation was made and observed by facility maintenance staff that E-Type Oxygen Cylinders are not secured in the Basement Oxygen Storage Room. (Corrected).

On 04/12/10 at approximately 1:45 PM, the following observation was made and observed by facility maintenance staff that there in a 1 - foot - by 2 - foot penetration in the lower left wall of the Basement Oxygen Storage Room.

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 231 occupants of the facility.

Findings Include:

On 04/12/10 at approximately 11:25 AM, the following observation was made and observed by facility maintenance staff that by review of the annual inspection/test records for the Power House generator the technician reported that the batteries need to be replaced.

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 occupants of the facility.

Findings include:

On 04/12/10 at approximately 1:25 PM, the following observation was made and observed by facility maintenance staff that there are two electrical junction boxes located in the Communication Closet in the Warehouse that are missing cover plates. (Corrected)

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 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 2:30 PM, the following observation was made and observed by facility maintenance staff that the self-closer for the door to the pipe chase in room 137 was disconnected and the door did not close to a positive latch.

On 04/13/10 at approximately 2:00 PM, the following observation was made and observed by facility maintenance staff that the there is a 1/2 - inch open conduit above the ceiling tile, above the door to the stairway by room # 625. (Corrected)

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 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 1:10 PM, the following observation was made and observed by facility maintenance staff that there are two 1/4 - inch penetrations around two conduits protruding through the rear wall to the Communication Closet located in the Basement Warehouse. (Corrected)

On 04/12/10 at approximately 2:35 PM, the following observation was made and observed by facility maintenance staff that there is a 1/2 - inch penetration above the ceiling tile above the smoke barrier doors by room B-40. (Corrected)

On 04/13/10 at approximately 12:45 PM, the following observation was made and observed by facility maintenance staff that the there is a 1/8 - inch penetration around a pipe protruding through the smoke barrier wall above the ceiling tile, above the smoke barrier doors by room # 433B. (Corrected)

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 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 12:45 PM, the following observation was made and observed by facility maintenance staff that the magnetic door hold openers for the smoke barrier doors by room B-40 do not operator.

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 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 1:00 PM, the following observation was made and observed by facility maintenance staff that there is a 1/4 - inch penetration around a sprinkler pipe protruding through the rear wall in the Basement Medical Records Storage Room. (Corrected)

On 04/12/10 at approximately 1:20 PM, the following observation was made and observed by facility maintenance staff that there is a 3 - inch penetration around a pipe protruding through the ceiling in the Basement Snack Storage Room. (Corrected)

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 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 2: 55 PM, the following observation was made and observed by facility maintenance staff that the exit door to the outside by room 155 sticks in the door frame and is difficult to open. (Corrected)

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 Staff occupants of the facility.

Findings include:

On 04/12/10 at approximately 2:00 PM, the following observation was made and observed by facility maintenance staff that the direction of travel in the Housekeeping Storage Room is not marked as to the direction of travel to the exit access corridor. (Corrected)

Based on observation and/or review of records the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6. This deficient practice could potentially affect 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 10:35 AM, the following observation was made and observed by facility maintenance staff that by review of the annual inspection/test records the fire alarm technician reported that the fire phones did not operate and were in need of repair.

On 04/13/10 at approximately 2:45 PM the following observation was made and observed by facility maintenance staff that the fire alarm pull station located by the 6th floor West Stairway is coming loose from the wall.

04/14/10 at approximately 10:30 AM the following observations was made and observed by facility maintenance staff that a staff person when asked to operate the fire alarm manual pull station on the 1st floor had difficultly with the key that operated the manual pull station.

Based on observation the facility failed to provide chutes that are not in accordance with the LSC sections 9.5, 9.7, 8.4. This deficient practice could potentially affect 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 2:00 PM, the following observation was made and observed by facility maintenance staff that the door to the Trash Chute in room # 130 did not close to a positive latch.

On 04/13/10 at approximately 10:15 AM, the following observation was made and observed by facility maintenance staff that the door to the Trash Chute in room # 230 did not close to a positive latch.

On 04/13/10 at approximately 11:00 AM, the following observation was made and observed by facility maintenance staff that the door to the Trash Chute in room # 330 did not close to a positive latch.

On 04/13/10 at approximately 12:55 PM, the following observation was made and observed by facility maintenance staff that the door to the Trash Chute in room # 430 did not close to a positive latch.

On 04/13/10 at approximately 1:30 PM, the following observation was made and observed by facility maintenance staff that the door to the Trash Chute in room # 530 did not close to a positive latch.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 231 occupants of the facility.

Findings include:

On 04/12/10 at approximately 12:30 PM, the following observation was made and observed by facility maintenance staff that E-Type oxygen cylinders are being stored in a closet in the Control Center. The closet is not sprinkler protected and the enclosure is not separated with a 1-hour fire resistance barrier.

On 04/12/10 at approximately 1:35 PM, the following observation was made and observed by facility maintenance staff that E-Type Oxygen Cylinders are not secured in the Basement Oxygen Storage Room. (Corrected).

On 04/12/10 at approximately 1:45 PM, the following observation was made and observed by facility maintenance staff that there in a 1 - foot - by 2 - foot penetration in the lower left wall of the Basement Oxygen Storage Room.

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 231 occupants of the facility.

Findings Include:

On 04/12/10 at approximately 11:25 AM, the following observation was made and observed by facility maintenance staff that by review of the annual inspection/test records for the Power House generator the technician reported that the batteries need to be replaced.

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 occupants of the facility.

Findings include:

On 04/12/10 at approximately 1:25 PM, the following observation was made and observed by facility maintenance staff that there are two electrical junction boxes located in the Communication Closet in the Warehouse that are missing cover plates. (Corrected)