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Based on observations, the facility has failed to maintain the 2-hour fire separation between the I occupancy and B occupancy on several levels of the facility. This deficient practice could affect the safety of all patients, staff and visitors in the event of a fire, as fire and smoke could pass from one occupancy to the other.

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM,

1. It was observed that there was no 2 hour fire separation wall above the 90 minute fire doors between the Group I, hospital occupancy, and Group B Plinsky Building.

2. The horizontal exit located on West Level 0 has penetrations around conduits,

3. There was no 2 hour fire separation wall between the I-2 occupancy (maintenance shop) and the S-2 occupancy (garage) located on Level 0,

4. The 2 hr fire separation wall of the Printer Tech office located on Level 0 has penetrations in the wall and around piping.


This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observation the rating of the paneling on the interior walls of the 6th floor doctors lounge could not be determined. This deficient practice could effect all occupants on the floor.

Findings include:

During the facility tour on 8-8-11 at 3:30 PM it was observed that the fire rating of the paneling on the interior walls of the 6th floor doctors lounge could not be determined as required by LSC(00) 19.3.3.2.

This deficient practice was confirmed by escort (KO) at the time of discovery.

Based on observation a sheet metal plate is covering a hole in old duct work on the 6th floor. This deficient practice could effect all occupants of the floor.

Findings include:

During the facility tour on 8-8-11 at approximately 3:35 PM it was observed that an existing hole in a vertical shaft on the 6th floor surgery area has been covered with a non-rated metal plate. This does not meet the requirements of LSC(00) 19.3.1.1

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

Based on observation, the facility had a horizontal exit door without approved, readily visible exit signs. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM, it was observed that the horizontal exit located on Level 0 was not marked with an approved exit sign.

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observation and interview, the facility failed to provide 2 out of 3 smoke barrier walls construction that meets the requirements of NFPA 101 - 2000 edition, Sections 19.3.7.3 and 8.3. This deficient practice could affect out of 98 residents including, staff and visitors

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM,

1. It was observed that the smoke barrier wall on Level 0 above the ceiling in office B9029 had penetrations around piping and conduits and,

2. The smoke barrier above the kitchen door located on Level L had penetrations sealed with a non-rated foam material.

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observations on the 6th floor the following items were also noted related to smoke barriers.

Findings include:

1. The penetrations listed below have not been properly repaired:

A. Above beds 1 & 2 in Pre op.
B Above door 6911
C. Above the door to OR #11
D. SB wall across from OR #6
E. In the SB wall between office 69634 & 69631
F. SB door 69010 also did not properly latch

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observations, the facility has failed to provide proper protection from 5 hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this room could enter the corridor making it untenable.

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM,

1. The waste room located on the 5th floor has a 5" X 5" square hole in the wall,

2. The trash chute room located on Level 0 had a vertical 2" opening around conduit,

3. The generator/mechanical room located on Level 0 had a penetration filled with a non fire rated foam material above the 90-minute door,

4. Soiled linen room # L9003 had a 4" penetration in wall above the ceiling tile,

5. The west elevator # 41 located on level L had a steel assembly that was not covered with a fire rated material,

6. Penetrations from 02 room wall on the 6th floor.

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observation on the 6th floor the wall by stairway 6-1 does not extend to the roof deck above and penetrations were observed into stairwell 6-3 that have not been properly repaired. This deficient practice could effect all occupants on the floor.

Findings include:

During the facility tour on 8-8-11 at approximately 3:40pm, it was observed:

1. That the wall between surgery and stairway 6-1 does not extend completely to the roof deck above.
2. It was further observed that penetrations into stairwell 6-3 have not been properly repaired as required by LSC(00) 19. 3.1.1

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

Based on observations some doors on the 6th floor surgery area require two motions to release. This deficient practice could effect all occupants on the area, in the event the doors needed to be opened under emergency conditions.

Findings include:

During the facility tour on 8-8-11 between 3:30-5:00 PM it was observed that the following doors, 69640, OR #10, and 2 doors in Pre-op require two distinct operations to open. This does not meet the requirements of LSC(00) 19.2.3.3

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

Based on observation smoke detectors were located within 36 inches of HVAC deflectors on the 6th floor surgery area. This deficient practice could effect all building occupants in the event of a fire emergency and cause delay of the fire alarm activation.

Findings include:

During the facility tour on 8-8-11 between 3:30-5:00 PM it was observed that fire alarm system connected smoke detectors were not located within HVAC deflectors (supply and or return) in the following locations.
1. In OR's 3 & 4
2. 6th floor women's locker room
3. 6th floor doctors lounge.

This practice does not meet the installation requirements of NFPA 72(99).

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

Based on observation a single sprinkler head had residue on it in the 6th floor surgery area. This deficient practice could effect all occupants in the area if the head needed to activate.

Findings include:

During the facility tour on 8-9-11 at 9:00 AM it was observed that a fire sprinkler head in room 69652 had a white residue on it. This does not meet the requirements of LSC(00) 19.3.5 and NFPA 13 & 25.

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

Based on observation and interview, it was determined that the facility has failed to ensure that the automatic fire sprinkler system has been properly maintained in accordance with NFPA 13 The Standard for Sprinkler Systems (1999 edition). This deficient practice could affect all 65 residents, staff and visitors if the sprinkler system failed to function properly.

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM,

1. It was observed in the maintenance shop located on Level 0, that over the main work area there were two quick-response sprinkler heads that had a clear liquid and not the standard red liquid.

2. The Janitor's Closet # B9003 had a fire sprinkler head within 18" inches of buffer pads,

3. It was observed in the maintenance shop on Level 0 that there was equipment hanging from fire sprinkler piping,

4. It was observed that the laboratory located on Level 0 had ceiling tiles missing throughout and,

5. It was observed that the wood shop had dusty fire sprinkler heads and that the 4 sprinkler heads had escutcheon plates missing,

6. Waste Room # L9002 had a ceiling tile missing,

7. It was observed outside the Janitor's closet in the corridor that there were 2-3 inch gaps in ceiling tiles around sprinkler piping,

8. It was observed that the walk-in freezer # 5 on Level L had fire sprinklers that did not have an 18" clearance and above the freezer had a sprinkler hanger rod not mounted to the ceiling.



This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

It was also observed that a trim ring was missing around the pendent fire sprinkler head across from OR #4.

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

During an interview with the facility ' s maintenance manager, he stated that facility does not currently have a Type I Essential Electrical System as required by NFPA 76 (67), Chapter 3. The facility was required to comply with NFPA 76, 1967 edition. This deficient practice could affect all occupants of the facility in the event of a normal utility power outage.

Findings include: During an interview with the maintenance manager on 8-10-11 at approximately 4:20 pm, it was determined that the facility ' s essential electrical system is not divided into an emergency electrical system and critical electrical system as detailed in Chapter 3 of NFPA 76 (67). This deficient practice was confirmed by the facility administration team during the exit interview.

Based on observation and interview the facility failed to provide signage in areas where oxygen is used or stored in accordance with LSC (00) section 19.3.2.4.

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM,

1. It was observed that the 2nd floor oxygen storage room, # 29238A, contained 16 tanks but did not have the required "No Smoking" signage and,

2. It was observed that the 1st floor oxygen storage room, #19140, contained 16 tanks but did not have the required no smoking signage.

This deficient practice was confirmed by the facility administration team during the exit interview.

Based on observation the facility failed to install Alcohol Based Hand Rub (ABHR) dispensers in accordance with CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623 and 485.623. This deficient practice could affect all occupants.

Findings include:

During the facility tour on 8-8-11 between approximately 3:00-5:00 PM it was observed that Alcohol Based Hand Rub dispensers had been installed adjacent to ignition sources in OR's 2 & 4. The dispensers are not at least 12 inches from light switches and above electrical outlets.

This deficient practice was confirmed by the maintenance supervisor (KO) at the time of discovery.

Based on observations, the facility has failed to maintain the 2-hour fire separation between the I occupancy and B occupancy on several levels of the facility. This deficient practice could affect the safety of all patients, staff and visitors in the event of a fire, as fire and smoke could pass from one occupancy to the other.

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM,

1. It was observed that there was no 2 hour fire separation wall above the 90 minute fire doors between the Group I, hospital occupancy, and Group B Plinsky Building.

2. The horizontal exit located on West Level 0 has penetrations around conduits,

3. There was no 2 hour fire separation wall between the I-2 occupancy (maintenance shop) and the S-2 occupancy (garage) located on Level 0,

4. The 2 hr fire separation wall of the Printer Tech office located on Level 0 has penetrations in the wall and around piping.


This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observation the rating of the paneling on the interior walls of the 6th floor doctors lounge could not be determined. This deficient practice could effect all occupants on the floor.

Findings include:

During the facility tour on 8-8-11 at 3:30 PM it was observed that the fire rating of the paneling on the interior walls of the 6th floor doctors lounge could not be determined as required by LSC(00) 19.3.3.2.

This deficient practice was confirmed by escort (KO) at the time of discovery.

Based on observation a sheet metal plate is covering a hole in old duct work on the 6th floor. This deficient practice could effect all occupants of the floor.

Findings include:

During the facility tour on 8-8-11 at approximately 3:35 PM it was observed that an existing hole in a vertical shaft on the 6th floor surgery area has been covered with a non-rated metal plate. This does not meet the requirements of LSC(00) 19.3.1.1

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

Based on observation, the facility had a horizontal exit door without approved, readily visible exit signs. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM, it was observed that the horizontal exit located on Level 0 was not marked with an approved exit sign.

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observation and interview, the facility failed to provide 2 out of 3 smoke barrier walls construction that meets the requirements of NFPA 101 - 2000 edition, Sections 19.3.7.3 and 8.3. This deficient practice could affect out of 98 residents including, staff and visitors

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM,

1. It was observed that the smoke barrier wall on Level 0 above the ceiling in office B9029 had penetrations around piping and conduits and,

2. The smoke barrier above the kitchen door located on Level L had penetrations sealed with a non-rated foam material.

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observations on the 6th floor the following items were also noted related to smoke barriers.

Findings include:

1. The penetrations listed below have not been properly repaired:

A. Above beds 1 & 2 in Pre op.
B Above door 6911
C. Above the door to OR #11
D. SB wall across from OR #6
E. In the SB wall between office 69634 & 69631
F. SB door 69010 also did not properly latch

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observations, the facility has failed to provide proper protection from 5 hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. This deficient practice could affect all patients, staff and visitors as smoke from a fire in this room could enter the corridor making it untenable.

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM,

1. The waste room located on the 5th floor has a 5" X 5" square hole in the wall,

2. The trash chute room located on Level 0 had a vertical 2" opening around conduit,

3. The generator/mechanical room located on Level 0 had a penetration filled with a non fire rated foam material above the 90-minute door,

4. Soiled linen room # L9003 had a 4" penetration in wall above the ceiling tile,

5. The west elevator # 41 located on level L had a steel assembly that was not covered with a fire rated material,

6. Penetrations from 02 room wall on the 6th floor.

This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

Based on observation on the 6th floor the wall by stairway 6-1 does not extend to the roof deck above and penetrations were observed into stairwell 6-3 that have not been properly repaired. This deficient practice could effect all occupants on the floor.

Findings include:

During the facility tour on 8-8-11 at approximately 3:40pm, it was observed:

1. That the wall between surgery and stairway 6-1 does not extend completely to the roof deck above.
2. It was further observed that penetrations into stairwell 6-3 have not been properly repaired as required by LSC(00) 19. 3.1.1

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

Based on observations some doors on the 6th floor surgery area require two motions to release. This deficient practice could effect all occupants on the area, in the event the doors needed to be opened under emergency conditions.

Findings include:

During the facility tour on 8-8-11 between 3:30-5:00 PM it was observed that the following doors, 69640, OR #10, and 2 doors in Pre-op require two distinct operations to open. This does not meet the requirements of LSC(00) 19.2.3.3

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

Based on observation smoke detectors were located within 36 inches of HVAC deflectors on the 6th floor surgery area. This deficient practice could effect all building occupants in the event of a fire emergency and cause delay of the fire alarm activation.

Findings include:

During the facility tour on 8-8-11 between 3:30-5:00 PM it was observed that fire alarm system connected smoke detectors were not located within HVAC deflectors (supply and or return) in the following locations.
1. In OR's 3 & 4
2. 6th floor women's locker room
3. 6th floor doctors lounge.

This practice does not meet the installation requirements of NFPA 72(99).

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

Based on observation a single sprinkler head had residue on it in the 6th floor surgery area. This deficient practice could effect all occupants in the area if the head needed to activate.

Findings include:

During the facility tour on 8-9-11 at 9:00 AM it was observed that a fire sprinkler head in room 69652 had a white residue on it. This does not meet the requirements of LSC(00) 19.3.5 and NFPA 13 & 25.

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

Based on observation and interview, it was determined that the facility has failed to ensure that the automatic fire sprinkler system has been properly maintained in accordance with NFPA 13 The Standard for Sprinkler Systems (1999 edition). This deficient practice could affect all 65 residents, staff and visitors if the sprinkler system failed to function properly.

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM,

1. It was observed in the maintenance shop located on Level 0, that over the main work area there were two quick-response sprinkler heads that had a clear liquid and not the standard red liquid.

2. The Janitor's Closet # B9003 had a fire sprinkler head within 18" inches of buffer pads,

3. It was observed in the maintenance shop on Level 0 that there was equipment hanging from fire sprinkler piping,

4. It was observed that the laboratory located on Level 0 had ceiling tiles missing throughout and,

5. It was observed that the wood shop had dusty fire sprinkler heads and that the 4 sprinkler heads had escutcheon plates missing,

6. Waste Room # L9002 had a ceiling tile missing,

7. It was observed outside the Janitor's closet in the corridor that there were 2-3 inch gaps in ceiling tiles around sprinkler piping,

8. It was observed that the walk-in freezer # 5 on Level L had fire sprinklers that did not have an 18" clearance and above the freezer had a sprinkler hanger rod not mounted to the ceiling.



This deficient practice was confirmed by the Director of Facilities Services (KJ) at the time of discovery,

It was also observed that a trim ring was missing around the pendent fire sprinkler head across from OR #4.

This deficient practice was confirmed by facility escort (KO) at the time of discovery.

During an interview with the facility ' s maintenance manager, he stated that facility does not currently have a Type I Essential Electrical System as required by NFPA 76 (67), Chapter 3. The facility was required to comply with NFPA 76, 1967 edition. This deficient practice could affect all occupants of the facility in the event of a normal utility power outage.

Findings include: During an interview with the maintenance manager on 8-10-11 at approximately 4:20 pm, it was determined that the facility ' s essential electrical system is not divided into an emergency electrical system and critical electrical system as detailed in Chapter 3 of NFPA 76 (67). This deficient practice was confirmed by the facility administration team during the exit interview.

Based on observation and interview the facility failed to provide signage in areas where oxygen is used or stored in accordance with LSC (00) section 19.3.2.4.

Findings include:

Based on observations during the facility tour on 8/8/11 at 2:30 PM and 8/11/11 at 10:30 AM,

1. It was observed that the 2nd floor oxygen storage room, # 29238A, contained 16 tanks but did not have the required "No Smoking" signage and,

2. It was observed that the 1st floor oxygen storage room, #19140, contained 16 tanks but did not have the required no smoking signage.

This deficient practice was confirmed by the facility administration team during the exit interview.