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Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 19.1.1.4.1, 19.1.1.4.2. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On September 20, 2011 the following observations were made:

1. At approximately 11:05 AM, observed that the south fire rated door near auditorium is "C" rated in a 2 hour fire separation.

2. At approximately 11:05 AM, observed the coordinator for the south fire rated door near the auditorium does not operate correctly and the door does not close as required.

Based on observation it was determined that the facility failed to provide complete sprinkler coverage and does not meet the construction type in accordance with the LSC, sections 18.1.6.2, 18, 18.1.6.3, 18.2.5.1. This deficient practice could potentially affect 15 occupants of the facility. Findings include:

On September 20, 2011 the following observation was made:

1. At approximately 11:10 AM, observed that the structural fire insulating material is missing on some of the steel structural members in the electrical room.

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 12 occupants of the facility. Findings include:

On September 19, 2011 the following observations were made:

1. At approximately 10:30 AM, observed that the drop ceiling and the walls of room 4121 are not smoke resistant. Ceiling tiles are missing or are damaged and the walls have unsealed penetrations.

2. Between 10:40 AM and 10:50 AM, observed that the corridor linen closet doors for rooms 474, 465 and 473 were over filled and could not close to latch.

3. At approximately 11:15 AM, observed the drop ceiling and walls of the communication room near room 465 are not smoke resistant. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

4. At approximately 1:45 PM, observed that the ceiling and walls of the communications room near room 311 are not smoke resistant. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

5. At approximately 2:15 PM, the ceiling and walls of the communications room in the west linen room is not smoke resistant. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

6. At approximately 2:20 PM, observed that no ceiling is installed in the communications room inside the linen room on the south side of elevator 12 and the linen room walls are not smoke resistant above the ceiling.

On September 20, 2011 the following observations were made:

7. At approximately 9:20 AM, observed ceiling tiles missing and the walls are not smoke resistant in the communications room near room 211. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

8. At approximately 9:45 AM, observed in the communications room near room 234, holes in the ceiling tiles and the walls are not smoke resistant.

9. At approximately 10:05 AM, observed ceiling tile missing and the walls are not smoke resistant in the equipment storage room near room 242.

10. At approximately 10:30 AM, observed the penetration of 2 wire conduits through the corridor wall, across from the liquid oxygen room, are not smoke resistant.

11. At approximately 11:00 AM, observed the Endoscopy reception desk sliding glass panel is not smoke resistant and is open to the corridor. The area is not open 24 hours per day.

12. At approximately 11:15 AM, observed holes in the ceiling and the walls of the electric room near the Out Patient Services are not smoke resistant. Ceiling tiles are missing or damaged and the walls have penetrations.


On September 21, 2011 the following observation was made:

13. At approximately 9:15 AM, observed that the ceiling tile is missing and the walls are not smoke resistant in the janitor closet near elevator 12.

On September 22, 2011 the following observations were made:

14. At approximately 12:50 PM, observed that the ceiling and walls of the fire alarm main panel room are not smoke resistant. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

15. At approximately 1:50 PM, observed the the ceiling and walls of the communication room across from the Environmental Service office are not smoke resistant. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

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 30 occupants of the facility. Findings include:

On September 19, 2011 the following observations were made:

1. At approximately 1:50 PM, observed that the door to room 317 does not positively latch when closed.

2. At approximately 1:55 PM, observed that the door to the storage across from room 323 does not positively latch when closed.

3. At approximately 2 :10 PM, observed that the door to the 3rd floor storage room near stairway 6 does not positively latch when closed.

4. At approximately 2:10 PM, observed the cross corridor doors to the Cardio Suite do not positively latch when closed.

5. At approximately 2:30 PM, observed that the door to room 377 does not positively latch when closed.


On September 21, 2011 the following observation was made:

6. At approximately 10:15 AM, observed a drop leg door holder on the 1st responder room door in the Emergency Department.

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 100 occupants of the facility. Findings include:

On September 19, 2011 the following observation was made:

1. At approximately 2:25 PM, observed penetrations and holes of the shaft wall located south of the 3rd floor west nurse's station.

Based on observation the facility failed to provide for doors hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 100 occupants of the facility. Findings include:

On September 22, 2011 the following observation was made:

1. At approximately 9:25 AM by review of facility records, observed that various cross corridor doors did not release to close during night fire drills.

Based on observation the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect 30 occupants of the facility. Findings include:

On September 19, 2011 the following observation was made:

1. At approximately 1:30 PM, observed that the exit sign at stairway 14 is only one sided. It should be dual sided so it can be viewed from both sides.

2. At approximately 1:35 PM, observed that there was no exit sign on the south side of the cross corridor doors near room 301.


On September 20, 2011 the following observations were made:

3. At approximately 9:05 AM, observed that the doors to the 2nd floor exterior patio are not posted with a "no exit" sign.

4. At approximately 10:15 AM, observed that the exit sign near room 250 is blocked in both directions.

5. At approximately 10:50 AM, observed that there was no exit sign on the south side of the door in the corridor east of Endoscopy.

6. At approximately 10:55, observed that there was no dual directional exit sign in the corridor near elevator 6 when coming through the above mentioned door.

7. At approximately 11:30 AM, observed that there was no exit sign at the west end of the Radiology corridor behind the X-ray rooms.


On September 21, 2011 the following observation was made:

8. At approximately 9:00 AM, observed that an exit sign blocked by a mirror at the cross corridors near elevator 6.


On September 22, 2011 the following observations were made:

9. At approximately 10:45 AM, observed that the exit near the O.R. Anesthesia office is blocked by a ceiling mounted mirror.

10. At approximately 11:05 AM observed no exit signs at the following locations:

A. The north side of the cross corridor near the nurse/scheduling desk.
B. A directional sign in the west corridor between rooms O.R.1 and Cystology 2.

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 50 occupants of the facility. Findings include:

On September 20, 2011 the following observation was made:

1. At approximately 10:20 AM, observed a penetration of the smoke barrier on the 2nd floor above the doors near stairway 7 that is not properly fire stopped.


On September 21, 2011 the following observations were made:

2. At approximately 9:20 AM, observed a conduit penetrating the smoke barrier above the cross corridor doors at the south end of Pathology that is not properly fire stopped.

3. At approximately 10:20 AM, observed unprotected penetrations of the smoke barrier on the south side of the Emergency Dept entry doors.


On September 22, 2011 the following observations were made:

4. At approximately 10:40 AM, observed penetrations of the smoke barrier above the cross corridor doors near Pre-Op 11 that are not properly fire stopped.

5. At approximately 11:00 AM, observed penetrations of wire and piping through the smoke barrier near PACU1 that are not properly fire stopped.

6. At approximately 12:30 PM, observed penetrations of the smoke barrier above the doors near elevator #11 that are not properly fire stopped.

7. At approximately 1:10 PM, observed penetrations of the smoke barrier near the basement dry goods storage room that are not properly fire stopped.

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 35 occupants of the facility. Findings include:

On September 19, 2011 the following observations were made:

1. At approximately 11:00 AM, observed the drop ceiling and walls of the janitor closet near room 4135 are not smoke resistant. The ceiling tiles are missing or damaged and the walls have unsealed penetrations.

2. At approximately 11:30 AM, observed the door to the soiled linen room near room 4137 does not close to positive latch.

On September 20, 2011 the following observations were made:

3. At approximately 9:30 AM, observed the patient bath/shower room across from room 223 is used for storage.

4. At approximately 10:40 AM, observed a mechanical space near the Endoscopy staff lounge is not smoke resistant. The ceiling tiles are missing or damaged and the walls have unsealed through penetrations.

On September 21, 2011 the following observations were made:

5. At approximately 10:40 AM, observed the Emergency Department soiled linen room is not constructed to a 1 hour fire separation. Penetrations of the walls are not properly fire stopped.

6. At approximately 10:45 AM, observed the Emergency Department supply room is not constructed to a 1 hour fire separation. Penetrations of the walls are not properly fire stopped.

7. At approximately 10:50 AM, observed the east Emergency Department soiled is not constructed to a 1 hour fire separation. Holes and penetrations of the walls are not properly fire stopped.

On September 22, 2011 the following observation was made:

8. At approximately 12:45 PM, observed the door elevator #11 mechanical room does not close to positive latch.

On September 23, 2011 the following observation was made:

9. At approximately 9:40 AM, observed a conduit and wire penetrating the corridor wall of Steve's electrical storage room is not fire stopped.

Based on observation the facility failed to provide laboratory protection in accordance with the LSC sections 19.3.2.2, 19.3.2.1, 8.4.4. This deficient practice could potentially affect 100 occupants of the facility. Findings include:

On September 21, 2011 the following observation was made:

1. At approximately 11:20 AM, observed that the Cytology Laboratory rear door and the walls are not constructed to provide a 1 hour fire separation. The rear door is not fire rated and the walls do not comply with an approved fire stop design.

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 5 occupants of the facility. Findings include:

On September 19, 2011 the following observation was made:

1. At approximately 12:45 PM, observed that there were no handrails in the stairway leading from the 4th floor to the north mechanical room.

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 60 occupants of the facility. Findings include:

On September 20, 2011 the following observations were made:

1. At approximately 9:20 AM while on the 2nd floor of the east center stairway, observed piping and conduit that does not comply with the Code. 7.1.3.2.1 (e) Piping and conduits passing through the stairway have no purpose in the stairway and are not separated from the stairway as required.

2. At approximately 9:30 AM while on the 2nd floor of the northeast stairway, observed piping and conduit that does not comply with the Code. 7.1.3.2.1 (e) Piping and conduits passing through the stairway have no purpose in the stairway and are not separated from the stairway as required.

On September 21, 2011 the following observation was made:

3. At approximately 11:40 AM, observed the main entrance sliding doors are equipped with thumb turn locks that prevent the door from opening 7.2.1.9

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On September 20, 2011 the following observation was made:

1. At approximately 9:50 AM, observed a crash cart obstructing the corridor, plugged in and charging, across from stairway door 11.

On September 21, 2011 the following observation was made:

2. At approximately 10:55 AM, observed the storage of 5 unused stretchers in the east corridor of the Emergency Department. They will cause an obstruction in an emergency.

On September 22, 2011 the following observation was made:

3. At approximately 11:00 AM, observed the storage of 3 portable x-ray machines in the O.R. egress corridor near Cystology room 2. They will cause an obstruction in an emergency.

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 350 occupants of the facility. Findings include:

On September 22, 2011 the following observation was made:

1. At approximately 9:00 AM by review of facility records, observed that the fire alarm panel has not been tested since 2009.


On September 23, 2011 the following observations were made:

2. At approximately 11:10 AM, observed a strobe light in the 3rd floor, #4 did not operate when tested.

3. At approximately 11:20 AM, observed that a strobe light near room 202 did not operate when tested.

4. At approximately 11:30 AM, observed that the smoke barrier doors near elevator #6 did not release with operation of the fire alarm.

5. At approximately 11:35 AM, observed that the corridor Surgical Services sign is blocking a strobe light.

6. At approximately 11:40 AM, observed that the Surgical Services corridor sliding door still operated as normal while the fire alarm was activated.

7. At approximately 11:45 AM, observed that there is no strobe light within 15' of the end of the corridor near the Gift Shop.

8. At approximately 11:50 AM, observed that there is not a fire alarm pull station at the main lobby exit.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On September 20, 2011 the following observations were made:

1. At approximately 10:10 AM, observed the ceiling tile has been removed form the communications room 231 and the smoke detector has not been properly re-installed. They had removed the ceiling tiles and kept the smoke detector at the same location as the ceiling. They did not move to the deck above.

2. At approximately 11:15 AM, observed that a corridor smoke detector near Radiology room 8 is within 3' of a supply air vent. The detector may not operate as required due to the excessive flow of air. NFPA 72, 2-3.5.1

On September 21, 2011 the following observation was made:

3. At approximately 9:05 AM, observed a corridor smoke detector greater than 5' distance from the smoke barrier cross corridor doors near elevator 12.

On September 22, 2011 the following observations were made:

4. At approximately 10:35 AM, observed the smoke detectors in the Limited Procedures corridor are installed more than 12" beneath the ceiling on wall.

5. At approximately 1:00 PM, observed that the ceiling tiles in the telephone room next to the main fire alarm panel room were removed and that the smoke detector is not properly re-installed beneath the deck above.

6. At approximately 1:20 PM observed the smoke detector in front of the Maintenance shop doors is coated with dust.

Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1. This deficient practice could potentially affect 100 occupants of the facility. Findings include:

On September 20, 2011 the following observations were made:

1. At approximately 9:25 AM, observed that the sprinkler control valve for the communications room near room 211 is not electrically monitored by the fire alarm system.

2. At approximately 9:35 AM, observed that the sprinkler control valve for the electric room near the southeast elevators is not electrically monitored by the fire alarm system.

3. At approximately 10:35 AM, observed that the sprinkler control valve in the 2nd floor west clean utility room is not electrically monitored by the fire alarm system.


On September 22, 2011 the following observations were made:

4. At approximately 12:35 PM, observed a sprinkler control valve at the north wall of the Transportation Department is not connected to the fire alarm for monitoring.

5. At approximately 12:40 PM, observed that the sprinkler control valve for the elevator #11 mechanical room is not connected to the fire alarm for monitoring.

6. At approximately 1:35 PM, observed the sprinkler control valve for the basement electric equipment room is not electrically connected to the fire alarm system.

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 50 occupants of the facility. Findings include:

On September 19, 2011 the following observation was made:

1. At approximately 10:30 AM, observed that the sprinkler in room 4121 is missing the escutcheon.


On September 20, 2011 the following observations were made:

2. At approximately 9:10 AM, observed a sprinkler eschuseon missing from a sprinkler in the locker room near room 210.

3. At approximately 9:40 AM, observed a defective sprinkler eschuseon in the corridor near the Nursing Education Office.

4. At approximately 9:40 AM, observed that a restroom sign was hung from the ceiling grid on the 2nd floor blocking the sprinkler spray in the corridor near the Epidemiology entrance.

5. At approximately 9:45 AM, observed no sprinkler eschuseon in the communications room near room 234.

6. At approximately 10:10 AM, observed that the ceiling has been removed in the communications room near room 231 and that the sprinkler was not turned up and adjusted.

7. At approximately 10:40 AM, observed the use of an intermediate temperature sprinkler in a mechanical space near the Endoscopy staff lounge.

8. At approximately 11:15 AM, observed a fire sprinkler near the Out Patient Services north door is damaged.

9. At approximately 11:20 AM, observed that a sprinkler in front of elevator 5 on the 1st floor is blocked by a sign.

10. At approximately 11:30 AM, observed a gap in the ceiling tile around the sprinkler eschuseon in the corridor behind Radiology room 3.


On September 21, 2011 the following observations were made:

11. At approximately 9:00 AM, observed a damaged sprinkler at the entrance to the EC locker room.

12. At approximately 9:10 AM, observed a sign hanging from the ceiling grid and blocking the sprinkler spray pattern near elevator 12.

13. At approximately 9:45 AM, observed that the fire department connection is behind foliage and shrubs and difficult to access.

14. At approximately 9:50 AM, observed fire alarm wiring wrapped around a sprinkler in the closet across from the E.R. security desk.

15. At approximately 11:05 AM, observed a damaged sprinkler in the Emergency Department Resuscitation room.

16. At approximately 12:35 PM by review of records, observed that a UL system pressure switch has not been tested.


On September 22, 2011 the following observations were made:

17. At approximately 10:35 AM, observed a damaged sprinkler near the O.R. Phase 2 soiled linen room.

18. At approximately 10:35 AM, observed sprinkler in the O.R. Limited Procedures corridor that is improperly installed.


On September 23, 2011 the following observations were made:

19. At approximately 9:15 AM, observed that the escutcheon is missing for a sprinkler in the Morgue.

20. At approximately 9:50 AM, observed the sprinkler above Pharmacy Pyxis machine is not adjusted properly for the ceiling height.

Based on observation the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10. This deficient practice could potentially affect 100 occupants of the facility. Findings include:

On September 21, 2011 the following observation was made:

1. At approximately 9:40 AM, observed the storage of 4 wheel chairs in the egress access at the exit next to the north Security desk.

Based on observation and/or review of records the facility failed to maintain a safe environment for building occupants. This deficient practice could potentially affect 100 occupants of the facility. Findings include:

On September 22, 2011 the following observation was made:

1. At approximately 11:15 AM, observed combustible waste debris in the pits of elevator #10 and #11.


On September 23, 2011 the following observations were made:

2. At approximately 9:30 AM, observed combustible waste debris in the pit of elevator #7.

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 12 occupants of the facility. Findings include:

On September 21, 2011 the following observation was made:

1. At approximately 11:15 AM, observed a gallon bottle of alcohol on the counter and not in the flammable liquid storage cabinet after the day/shift use containers had been filled in the Cytology Lab.

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 5 occupants of the facility. Findings include:

On September 21, 2011 the following observations were made:

1. At approximately 10:30 AM, observed an open electrical junction box above the ceiling over Emergency Department fast track bed #28.

2. At approximately 11:25 AM, observed the use of an electrical power strip for a refrigerator in the Cytology laboratory instead of plugging the device directly into the wall outlet.

3. At approximately 11:30 AM, observed the use of a residential type extension cord to power a coffee pot in the Registration Department.


On September 23, 2011 the following observations were made:

4. At approximately 9:15 AM, observed that there was no ground fault interrupter GFI electrical outlet near the Morgue sink.

5. At approximately 9:55 AM, observed that there was no GFI outlets near the sinks in the Pharmacy.

Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 19.1.1.4.1, 19.1.1.4.2. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On September 20, 2011 the following observations were made:

1. At approximately 11:05 AM, observed that the south fire rated door near auditorium is "C" rated in a 2 hour fire separation.

2. At approximately 11:05 AM, observed the coordinator for the south fire rated door near the auditorium does not operate correctly and the door does not close as required.

Based on observation it was determined that the facility failed to provide complete sprinkler coverage and does not meet the construction type in accordance with the LSC, sections 18.1.6.2, 18, 18.1.6.3, 18.2.5.1. This deficient practice could potentially affect 15 occupants of the facility. Findings include:

On September 20, 2011 the following observation was made:

1. At approximately 11:10 AM, observed that the structural fire insulating material is missing on some of the steel structural members in the electrical room.

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 12 occupants of the facility. Findings include:

On September 19, 2011 the following observations were made:

1. At approximately 10:30 AM, observed that the drop ceiling and the walls of room 4121 are not smoke resistant. Ceiling tiles are missing or are damaged and the walls have unsealed penetrations.

2. Between 10:40 AM and 10:50 AM, observed that the corridor linen closet doors for rooms 474, 465 and 473 were over filled and could not close to latch.

3. At approximately 11:15 AM, observed the drop ceiling and walls of the communication room near room 465 are not smoke resistant. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

4. At approximately 1:45 PM, observed that the ceiling and walls of the communications room near room 311 are not smoke resistant. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

5. At approximately 2:15 PM, the ceiling and walls of the communications room in the west linen room is not smoke resistant. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

6. At approximately 2:20 PM, observed that no ceiling is installed in the communications room inside the linen room on the south side of elevator 12 and the linen room walls are not smoke resistant above the ceiling.

On September 20, 2011 the following observations were made:

7. At approximately 9:20 AM, observed ceiling tiles missing and the walls are not smoke resistant in the communications room near room 211. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

8. At approximately 9:45 AM, observed in the communications room near room 234, holes in the ceiling tiles and the walls are not smoke resistant.

9. At approximately 10:05 AM, observed ceiling tile missing and the walls are not smoke resistant in the equipment storage room near room 242.

10. At approximately 10:30 AM, observed the penetration of 2 wire conduits through the corridor wall, across from the liquid oxygen room, are not smoke resistant.

11. At approximately 11:00 AM, observed the Endoscopy reception desk sliding glass panel is not smoke resistant and is open to the corridor. The area is not open 24 hours per day.

12. At approximately 11:15 AM, observed holes in the ceiling and the walls of the electric room near the Out Patient Services are not smoke resistant. Ceiling tiles are missing or damaged and the walls have penetrations.


On September 21, 2011 the following observation was made:

13. At approximately 9:15 AM, observed that the ceiling tile is missing and the walls are not smoke resistant in the janitor closet near elevator 12.

On September 22, 2011 the following observations were made:

14. At approximately 12:50 PM, observed that the ceiling and walls of the fire alarm main panel room are not smoke resistant. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

15. At approximately 1:50 PM, observed the the ceiling and walls of the communication room across from the Environmental Service office are not smoke resistant. Ceiling tiles are missing or damaged and the walls have unsealed penetrations.

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 30 occupants of the facility. Findings include:

On September 19, 2011 the following observations were made:

1. At approximately 1:50 PM, observed that the door to room 317 does not positively latch when closed.

2. At approximately 1:55 PM, observed that the door to the storage across from room 323 does not positively latch when closed.

3. At approximately 2 :10 PM, observed that the door to the 3rd floor storage room near stairway 6 does not positively latch when closed.

4. At approximately 2:10 PM, observed the cross corridor doors to the Cardio Suite do not positively latch when closed.

5. At approximately 2:30 PM, observed that the door to room 377 does not positively latch when closed.


On September 21, 2011 the following observation was made:

6. At approximately 10:15 AM, observed a drop leg door holder on the 1st responder room door in the Emergency Department.

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 100 occupants of the facility. Findings include:

On September 19, 2011 the following observation was made:

1. At approximately 2:25 PM, observed penetrations and holes of the shaft wall located south of the 3rd floor west nurse's station.

Based on observation the facility failed to provide for doors hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 100 occupants of the facility. Findings include:

On September 22, 2011 the following observation was made:

1. At approximately 9:25 AM by review of facility records, observed that various cross corridor doors did not release to close during night fire drills.

Based on observation the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect 30 occupants of the facility. Findings include:

On September 19, 2011 the following observation was made:

1. At approximately 1:30 PM, observed that the exit sign at stairway 14 is only one sided. It should be dual sided so it can be viewed from both sides.

2. At approximately 1:35 PM, observed that there was no exit sign on the south side of the cross corridor doors near room 301.


On September 20, 2011 the following observations were made:

3. At approximately 9:05 AM, observed that the doors to the 2nd floor exterior patio are not posted with a "no exit" sign.

4. At approximately 10:15 AM, observed that the exit sign near room 250 is blocked in both directions.

5. At approximately 10:50 AM, observed that there was no exit sign on the south side of the door in the corridor east of Endoscopy.

6. At approximately 10:55, observed that there was no dual directional exit sign in the corridor near elevator 6 when coming through the above mentioned door.

7. At approximately 11:30 AM, observed that there was no exit sign at the west end of the Radiology corridor behind the X-ray rooms.


On September 21, 2011 the following observation was made:

8. At approximately 9:00 AM, observed that an exit sign blocked by a mirror at the cross corridors near elevator 6.


On September 22, 2011 the following observations were made:

9. At approximately 10:45 AM, observed that the exit near the O.R. Anesthesia office is blocked by a ceiling mounted mirror.

10. At approximately 11:05 AM observed no exit signs at the following locations:

A. The north side of the cross corridor near the nurse/scheduling desk.
B. A directional sign in the west corridor between rooms O.R.1 and Cystology 2.

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 50 occupants of the facility. Findings include:

On September 20, 2011 the following observation was made:

1. At approximately 10:20 AM, observed a penetration of the smoke barrier on the 2nd floor above the doors near stairway 7 that is not properly fire stopped.


On September 21, 2011 the following observations were made:

2. At approximately 9:20 AM, observed a conduit penetrating the smoke barrier above the cross corridor doors at the south end of Pathology that is not properly fire stopped.

3. At approximately 10:20 AM, observed unprotected penetrations of the smoke barrier on the south side of the Emergency Dept entry doors.


On September 22, 2011 the following observations were made:

4. At approximately 10:40 AM, observed penetrations of the smoke barrier above the cross corridor doors near Pre-Op 11 that are not properly fire stopped.

5. At approximately 11:00 AM, observed penetrations of wire and piping through the smoke barrier near PACU1 that are not properly fire stopped.

6. At approximately 12:30 PM, observed penetrations of the smoke barrier above the doors near elevator #11 that are not properly fire stopped.

7. At approximately 1:10 PM, observed penetrations of the smoke barrier near the basement dry goods storage room that are not properly fire stopped.

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 35 occupants of the facility. Findings include:

On September 19, 2011 the following observations were made:

1. At approximately 11:00 AM, observed the drop ceiling and walls of the janitor closet near room 4135 are not smoke resistant. The ceiling tiles are missing or damaged and the walls have unsealed penetrations.

2. At approximately 11:30 AM, observed the door to the soiled linen room near room 4137 does not close to positive latch.

On September 20, 2011 the following observations were made:

3. At approximately 9:30 AM, observed the patient bath/shower room across from room 223 is used for storage.

4. At approximately 10:40 AM, observed a mechanical space near the Endoscopy staff lounge is not smoke resistant. The ceiling tiles are missing or damaged and the walls have unsealed through penetrations.

On September 21, 2011 the following observations were made:

5. At approximately 10:40 AM, observed the Emergency Department soiled linen room is not constructed to a 1 hour fire separation. Penetrations of the walls are not properly fire stopped.

6. At approximately 10:45 AM, observed the Emergency Department supply room is not constructed to a 1 hour fire separation. Penetrations of the walls are not properly fire stopped.

7. At approximately 10:50 AM, observed the east Emergency Department soiled is not constructed to a 1 hour fire separation. Holes and penetrations of the walls are not properly fire stopped.

On September 22, 2011 the following observation was made:

8. At approximately 12:45 PM, observed the door elevator #11 mechanical room does not close to positive latch.

On September 23, 2011 the following observation was made:

9. At approximately 9:40 AM, observed a conduit and wire penetrating the corridor wall of Steve's electrical storage room is not fire stopped.

Based on observation the facility failed to provide laboratory protection in accordance with the LSC sections 19.3.2.2, 19.3.2.1, 8.4.4. This deficient practice could potentially affect 100 occupants of the facility. Findings include:

On September 21, 2011 the following observation was made:

1. At approximately 11:20 AM, observed that the Cytology Laboratory rear door and the walls are not constructed to provide a 1 hour fire separation. The rear door is not fire rated and the walls do not comply with an approved fire stop design.

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 5 occupants of the facility. Findings include:

On September 19, 2011 the following observation was made:

1. At approximately 12:45 PM, observed that there were no handrails in the stairway leading from the 4th floor to the north mechanical room.

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 60 occupants of the facility. Findings include:

On September 20, 2011 the following observations were made:

1. At approximately 9:20 AM while on the 2nd floor of the east center stairway, observed piping and conduit that does not comply with the Code. 7.1.3.2.1 (e) Piping and conduits passing through the stairway have no purpose in the stairway and are not separated from the stairway as required.

2. At approximately 9:30 AM while on the 2nd floor of the northeast stairway, observed piping and conduit that does not comply with the Code. 7.1.3.2.1 (e) Piping and conduits passing through the stairway have no purpose in the stairway and are not separated from the stairway as required.

On September 21, 2011 the following observation was made:

3. At approximately 11:40 AM, observed the main entrance sliding doors are equipped with thumb turn locks that prevent the door from opening 7.2.1.9

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On September 20, 2011 the following observation was made:

1. At approximately 9:50 AM, observed a crash cart obstructing the corridor, plugged in and charging, across from stairway door 11.

On September 21, 2011 the following observation was made:

2. At approximately 10:55 AM, observed the storage of 5 unused stretchers in the east corridor of the Emergency Department. They will cause an obstruction in an emergency.

On September 22, 2011 the following observation was made:

3. At approximately 11:00 AM, observed the storage of 3 portable x-ray machines in the O.R. egress corridor near Cystology room 2. They will cause an obstruction in an emergency.

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 350 occupants of the facility. Findings include:

On September 22, 2011 the following observation was made:

1. At approximately 9:00 AM by review of facility records, observed that the fire alarm panel has not been tested since 2009.


On September 23, 2011 the following observations were made:

2. At approximately 11:10 AM, observed a strobe light in the 3rd floor, #4 did not operate when tested.

3. At approximately 11:20 AM, observed that a strobe light near room 202 did not operate when tested.

4. At approximately 11:30 AM, observed that the smoke barrier doors near elevator #6 did not release with operation of the fire alarm.

5. At approximately 11:35 AM, observed that the corridor Surgical Services sign is blocking a strobe light.

6. At approximately 11:40 AM, observed that the Surgical Services corridor sliding door still operated as normal while the fire alarm was activated.

7. At approximately 11:45 AM, observed that there is no strobe light within 15' of the end of the corridor near the Gift Shop.

8. At approximately 11:50 AM, observed that there is not a fire alarm pull station at the main lobby exit.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect 50 occupants of the facility. Findings include:

On September 20, 2011 the following observations were made:

1. At approximately 10:10 AM, observed the ceiling tile has been removed form the communications room 231 and the smoke detector has not been properly re-installed. They had removed the ceiling tiles and kept the smoke detector at the same location as the ceiling. They did not move to the deck above.

2. At approximately 11:15 AM, observed that a corridor smoke detector near Radiology room 8 is within 3' of a supply air vent. The detector may not operate as required due to the excessive flow of air. NFPA 72, 2-3.5.1

On September 21, 2011 the following observation was made:

3. At approximately 9:05 AM, observed a corridor smoke detector greater than 5' distance from the smoke barrier cross corridor doors near elevator 12.

On September 22, 2011 the following observations were made:

4. At approximately 10:35 AM, observed the smoke detectors in the Limited Procedures corridor are installed more than 12" beneath the ceiling on wall.

5. At approximately 1:00 PM, observed that the ceiling tiles in the telephone room next to the main fire alarm panel room were removed and that the smoke detector is not properly re-installed beneath the deck above.

6. At approximately 1:20 PM observed the smoke detector in front of the Maintenance shop doors is coated with dust.

Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1. This deficient practice could potentially affect 100 occupants of the facility. Findings include:

On September 20, 2011 the following observations were made:

1. At approximately 9:25 AM, observed that the sprinkler control valve for the communications room near room 211 is not electrically monitored by the fire alarm system.

2. At approximately 9:35 AM, observed that the sprinkler control valve for the electric room near the southeast elevators is not electrically monitored by the fire alarm system.

3. At approximately 10:35 AM, observed that the sprinkler control valve in the 2nd floor west clean utility room is not electrically monitored by the fire alarm system.


On September 22, 2011 the following observations were made:

4. At approximately 12:35 PM, observed a sprinkler control valve at the north wall of the Transportation Department is not connected to the fire alarm for monitoring.

5. At approximately 12:40 PM, observed that the sprinkler control valve for the elevator #11 mechanical room is not connected to the fire alarm for monitoring.

6. At approximately 1:35 PM, observed the sprinkler control valve for the basement electric equipment room is not electrically connected to the fire alarm system.

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 50 occupants of the facility. Findings include:

On September 19, 2011 the following observation was made:

1. At approximately 10:30 AM, observed that the sprinkler in room 4121 is missing the escutcheon.


On September 20, 2011 the following observations were made:

2. At approximately 9:10 AM, observed a sprinkler eschuseon missing from a sprinkler in the locker room near room 210.

3. At approximately 9:40 AM, observed a defective sprinkler eschuseon in the corridor near the Nursing Education Office.

4. At approximately 9:40 AM, observed that a restroom sign was hung from the ceiling grid on the 2nd floor blocking the sprinkler spray in the corridor near the Epidemiology entrance.

5. At approximately 9:45 AM, observed no sprinkler eschuseon in the communications room near room 234.

6. At approximately 10:10 AM, observed that the ceiling has been removed in the communications room near room 231 and that the sprinkler was not turned up and adjusted.

7. At approximately 10:40 AM, observed the use of an intermediate temperature sprinkler in a mechanical space near the Endoscopy staff lounge.

8. At approximately 11:15 AM, observed a fire sprinkler near the Out Patient Services north door is damaged.

9. At approximately 11:20 AM, observed that a sprinkler in front of elevator 5 on the 1st floor is blocked by a sign.

10. At approximately 11:30 AM, observed a gap in the ceiling tile around the sprinkler eschuseon in the corridor behind Radiology room 3.


On September 21, 2011 the following observations were made:

11. At approximately 9:00 AM, observed a damaged sprinkler at the entrance to the EC locker room.

12. At approximately 9:10 AM, observed a sign hanging from the ceiling grid and blocking the sprinkler spray pattern near elevator 12.

13. At approximately 9:45 AM, observed that the fire department connection is behind foliage and shrubs and difficult to access.

14. At approximately 9:50 AM, observed fire alarm wiring wrapped around a sprinkler in the closet across from the E.R. security desk.

15. At approximately 11:05 AM, observed a damaged sprinkler in the Emergency Department Resuscitation room.

16. At approximately 12:35 PM by review of records, observed that a UL system pressure switch has not been tested.


On September 22, 2011 the following observations were made:

17. At approximately 10:35 AM, observed a damaged sprinkler near the O.R. Phase 2 soiled linen room.

18. At approximately 10:35 AM, observed sprinkler in the O.R. Limited Procedures corridor that is improperly installed.


On September 23, 2011 the following observations were made:

19. At approximately 9:15 AM, observed that the escutcheon is missing for a sprinkler in the Morgue.

20. At approximately 9:50 AM, observed the sprinkler above Pharmacy Pyxis machine is not adjusted properly for the ceiling height.

Based on observation the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10. This deficient practice could potentially affect 100 occupants of the facility. Findings include:

On September 21, 2011 the following observation was made:

1. At approximately 9:40 AM, observed the storage of 4 wheel chairs in the egress access at the exit next to the north Security desk.

Based on observation and/or review of records the facility failed to maintain a safe environment for building occupants. This deficient practice could potentially affect 100 occupants of the facility. Findings include:

On September 22, 2011 the following observation was made:

1. At approximately 11:15 AM, observed combustible waste debris in the pits of elevator #10 and #11.


On September 23, 2011 the following observations were made:

2. At approximately 9:30 AM, observed combustible waste debris in the pit of elevator #7.

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 12 occupants of the facility. Findings include:

On September 21, 2011 the following observation was made:

1. At approximately 11:15 AM, observed a gallon bottle of alcohol on the counter and not in the flammable liquid storage cabinet after the day/shift use containers had been filled in the Cytology Lab.

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 5 occupants of the facility. Findings include:

On September 21, 2011 the following observations were made:

1. At approximately 10:30 AM, observed an open electrical junction box above the ceiling over Emergency Department fast track bed #28.

2. At approximately 11:25 AM, observed the use of an electrical power strip for a refrigerator in the Cytology laboratory instead of plugging the device directly into the wall outlet.

3. At approximately 11:30 AM, observed the use of a residential type extension cord to power a coffee pot in the Registration Department.


On September 23, 2011 the following observations were made:

4. At approximately 9:15 AM, observed that there was no ground fault interrupter GFI electrical outlet near the Morgue sink.

5. At approximately 9:55 AM, observed that there was no GFI outlets near the sinks in the Pharmacy.