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Based on observation the facility failed to provide smoke compartments in accordance with the LSC section 19.3.7.1. This deficient practice could potentially affect 202 occupants of the facility. Findings include:

On December 10, 2012 the following observation was made:

- At approximately 1:00 PM, observed that there are no current floor plans available to review to determine if the size and location of the smoke zones are correct. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.1.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

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 202 occupants of the facility. Findings include:

On December 11, 2012 the following observations were made:

- At approximately 9:30 AM, observed that there are two 4 - inch open conduits penetrating the smoke barrier in the basement phone room # B-78 that are not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- At approximately 10:05 AM, observed that there is a ¼ - inch wall through penetration in the smoke barrier wall above the ceiling tiles, above the smoke barrier doors by room B-68 that is not seal with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- At approximately 12:10 PM, observed that there is a 1/2 - inch wall through penetration in the smoke barrier wall above the smoke barrier doors on the second floor by room # 213 that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- At approximately 1:02 PM, observed that there is a 1/8 - inch wall through penetration in the smoke barrier wall above the smoke barrier doors on the third floor by room # 344 that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- At approximately 1:20 PM, observed that there is a 1/2 - inch wall through penetration in the smoke barrier wall above the smoke barrier doors on the fifth floor by room # 513 that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

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 202 occupants of the facility. Findings include:

On December 11, 2012 the following observations were made:

- At approximately 10:15 AM, observed that there is a 12-inch by 12-inch ceiling penetration in the fire rated ceiling in the basement janitor closet B-15A that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 8.4.1 and/or 19.3.5.4

- At approximately 10:30 AM, observed that there are several cases of bottled water marked "Emergency Water". This room is not one hour fire rated constructed or automatic sprinkler protected. The doors are not 3/4 hour rated doors. This deficiency is not in accordance with the 2000 Edition LSC 8.4.1 and/or 19.3.5.4

These findings were observed and confirmed by the maintenance staff at the time of the 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 the staff occupants of the facility. Findings include:

On December 11, 2012 the following observation was made:

- At approximately 9:55 AM, observed that the emergency light unit in the main storage room has one lamp broken. This deficiency is not in accordance with the 2000 Edition LSC 7.9 19.2.9.1

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

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 209 occupants of the facility. Findings include:

On December 11, 2012 the following observation was made:

- At approximately 1:45 PM, observed that combustible storage is being stored within 18-inches of the automatic sprinkler head in janitor closet # 613. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

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 202 occupants of the facility. Findings include:

On December 10, 2012 the following observations were made:

- At approximately 1:35 PM, observed that the hand held portable CO-2 fire extinguisher located in the 7th Floor Chiller Area of the Maintenance Area was placed on the floor and not mounted to the wall. This deficiency is not in accordance with the 2000 Edition LSC 9.7.4.1. 19.3.5.6, NFPA 10.

- At approximately 1:35 PM, observed that the hand held portable fire extinguisher located in the Basement Storage Room B-68 is obstructed by storage boxes. This deficiency is not in accordance with the 2000 Edition LSC 9.7.4.1. 19.3.5.6, NFPA 10.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

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 202 occupants of the facility. Findings include:

On December 10, 2012 the following observations were made:

- At approximately 1:25 PM, observed that there is an electrical junction box located in the 7 th Floor East Elevator Room that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 1:55 PM, observed that there is an extension cord being used in lieu of permanent wiring for the machine that drains the oil for the chiller unit. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

On December 11, 2012 the following observations were made:

- At approximately 9:45 AM, observed that there is an electrical junction box located in the Main Storage Room that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 10:20 AM, observed that there is an unsecured electrical outlet extension cord being utilized for a coffee maker in lieu of permanent wiring in the Basement Clean Linen Room. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 10:40 AM, observed that there is an electrical junction box located on the 1st Floor above the ceiling tile, above the smoke barrier doors by room # 180 that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 10:50 AM, observed that there is an electrical outlet cover not secured to the junction box causing electrical wires to be exposed in a 1st Floor phone closet across from room #164. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 11:00 AM, observed that there is an electrical junction box located on the 1st Floor connecting west ramp between the Hospital and the Admin Building above the ceiling tile, above the fire rated doors that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 12:20 PM, observed that there is an electrical junction box located on the 2nd Floor above the ceiling tile, above the smoke barrier doors by room # 237 that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 1:30 PM, observed that there is an electrical junction box located on the 6 th Floor above the ceiling tile, above the smoke barrier doors by room # 618 that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

Based on observation the facility failed to provide smoke compartments in accordance with the LSC section 19.3.7.1. This deficient practice could potentially affect 202 occupants of the facility. Findings include:

On December 10, 2012 the following observation was made:

- At approximately 1:00 PM, observed that there are no current floor plans available to review to determine if the size and location of the smoke zones are correct. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.1.

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

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 202 occupants of the facility. Findings include:

On December 11, 2012 the following observations were made:

- At approximately 9:30 AM, observed that there are two 4 - inch open conduits penetrating the smoke barrier in the basement phone room # B-78 that are not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- At approximately 10:05 AM, observed that there is a ¼ - inch wall through penetration in the smoke barrier wall above the ceiling tiles, above the smoke barrier doors by room B-68 that is not seal with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- At approximately 12:10 PM, observed that there is a 1/2 - inch wall through penetration in the smoke barrier wall above the smoke barrier doors on the second floor by room # 213 that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- At approximately 1:02 PM, observed that there is a 1/8 - inch wall through penetration in the smoke barrier wall above the smoke barrier doors on the third floor by room # 344 that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

- At approximately 1:20 PM, observed that there is a 1/2 - inch wall through penetration in the smoke barrier wall above the smoke barrier doors on the fifth floor by room # 513 that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

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 202 occupants of the facility. Findings include:

On December 11, 2012 the following observations were made:

- At approximately 10:15 AM, observed that there is a 12-inch by 12-inch ceiling penetration in the fire rated ceiling in the basement janitor closet B-15A that is not sealed with a UL Listed fire resistant material. This deficiency is not in accordance with the 2000 Edition LSC 8.4.1 and/or 19.3.5.4

- At approximately 10:30 AM, observed that there are several cases of bottled water marked "Emergency Water". This room is not one hour fire rated constructed or automatic sprinkler protected. The doors are not 3/4 hour rated doors. This deficiency is not in accordance with the 2000 Edition LSC 8.4.1 and/or 19.3.5.4

These findings were observed and confirmed by the maintenance staff at the time of the 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 the staff occupants of the facility. Findings include:

On December 11, 2012 the following observation was made:

- At approximately 9:55 AM, observed that the emergency light unit in the main storage room has one lamp broken. This deficiency is not in accordance with the 2000 Edition LSC 7.9 19.2.9.1

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

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 209 occupants of the facility. Findings include:

On December 11, 2012 the following observation was made:

- At approximately 1:45 PM, observed that combustible storage is being stored within 18-inches of the automatic sprinkler head in janitor closet # 613. This deficiency is not in accordance with the 2000 Edition LSC 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

This finding was observed and confirmed by the maintenance staff at the time of the inspection.

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 202 occupants of the facility. Findings include:

On December 10, 2012 the following observations were made:

- At approximately 1:35 PM, observed that the hand held portable CO-2 fire extinguisher located in the 7th Floor Chiller Area of the Maintenance Area was placed on the floor and not mounted to the wall. This deficiency is not in accordance with the 2000 Edition LSC 9.7.4.1. 19.3.5.6, NFPA 10.

- At approximately 1:35 PM, observed that the hand held portable fire extinguisher located in the Basement Storage Room B-68 is obstructed by storage boxes. This deficiency is not in accordance with the 2000 Edition LSC 9.7.4.1. 19.3.5.6, NFPA 10.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.

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 202 occupants of the facility. Findings include:

On December 10, 2012 the following observations were made:

- At approximately 1:25 PM, observed that there is an electrical junction box located in the 7 th Floor East Elevator Room that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 1:55 PM, observed that there is an extension cord being used in lieu of permanent wiring for the machine that drains the oil for the chiller unit. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

On December 11, 2012 the following observations were made:

- At approximately 9:45 AM, observed that there is an electrical junction box located in the Main Storage Room that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 10:20 AM, observed that there is an unsecured electrical outlet extension cord being utilized for a coffee maker in lieu of permanent wiring in the Basement Clean Linen Room. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 10:40 AM, observed that there is an electrical junction box located on the 1st Floor above the ceiling tile, above the smoke barrier doors by room # 180 that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 10:50 AM, observed that there is an electrical outlet cover not secured to the junction box causing electrical wires to be exposed in a 1st Floor phone closet across from room #164. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 11:00 AM, observed that there is an electrical junction box located on the 1st Floor connecting west ramp between the Hospital and the Admin Building above the ceiling tile, above the fire rated doors that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 12:20 PM, observed that there is an electrical junction box located on the 2nd Floor above the ceiling tile, above the smoke barrier doors by room # 237 that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

- At approximately 1:30 PM, observed that there is an electrical junction box located on the 6 th Floor above the ceiling tile, above the smoke barrier doors by room # 618 that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2.

These findings were observed and confirmed by the maintenance staff at the time of the inspection.