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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 1.1.4.1, 19.1.1.4.2.

Findings include:

On 02/01/12 at approximately 8:30 AM during an inspection of separation walls with the Maintenance Supervisor, the following observation was made:

1. The door in the two hour fire wall in the basement, between the medical office building and the hospital, did not self-close to a positive latch.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11.

Findings include:

On 02/01/12 at approximately 9:50 AM during an inspection of exits with the Maintenance Supervisor, the following observation was made:

1. Observed exit stairwell # 4 to have a gap between the corridor wall, not providing a separation from the corridor.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide lighting in accordance with the LSC section 19.2.8.

Findings include:

On 02/01/12 between approximately 9:00 AM - 2:00 PM during an inspection of exits with the Maintenance Supervisor, the following observation was made:

1. The Maintenance Supervisor could not provide documentation that the emergency lighting provided at the required exits was adequate lighting to the public way in compliance with LSC section 19.2.8. Emergency lighting shall be provided along sidewalks for a distance of at least 50 feet from the building, or to the public way. Required emergency lighting facilities shall be provided with 2 bulbs per each fixture or multiple overlapping fixtures arranged such that the loss of any single light will not leave the area in darkness, and arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux) measured along the path of egress at floor level.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1.

Findings include:

On 02/01/12 at approximately 2:30 PM during review of emergency lighting records with the Maintenance Supervisor, the following observation was made:

1. The facility did not complete 90 minute tests of battery emergency lights throughout the facility during 2011.

This deficiency was confirmed with the Maintenance Supervisor.

Based on review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1.

Findings include:

On 02/01/12 at approximately 2:10 PM during review of records with the Maintenance Supervisor, the following observations were made:

1. The fire evacuation plan provided for review did not address evacuation of residents from one smoke compartment to another.

2. The fire evacuation plan provided for review did not address who was responsible or when staff was to call the fire department.

These deficiencies were confirmed with the Maintenance Supervisor.

Based on review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2.

Findings include:

On 02/01/12 at approximately 2:00 PM during a review of fire drill records with the Maintenance Supervisor, the following observation was made:

1. The fire drills that were conducted for the PM shift of 2011 were not completed at varying times and conditions. Three of the four drills were completed between 7:35 PM & 8:00 PM.

This deficiency was confirmed with the Maintenance Supervisor.

Based on review of records the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4.

Findings include:

On 02/01/12 at approximately 2:00 PM during an inspection of fire alarm records with the Maintenance Supervisor, the following observation was made:

1. The fire alarm report from Siemens dated 5-16-11 listed under violations that the fire alarm strobes in the facility do not flash in synchronization as required.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1.

Findings include:

On 02/01/12 at approximately 8:45 AM during an inspection of the sprinkler system with the Maintenance Supervisor, the following observation was made:

1. Observed the PIV outside the administration entrance not equipped with approved tamper switch supervised through the building fire alarm system.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to maintain the automatic sprinkler system in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5.

Findings include:

On 02/01/12 at approximately 11:20 AM during inspection of the sprinkler system with the Maintenance Supervisor, the following observation was made:

1. Observed blue cables attached to the sprinkler lines above the ceiling of the Lab.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide smoke dampers in accordance with the LSC section 8.3.5.

Findings include:

On 02/01/12 at approximately 1:00 PM during an inspection of smoke barriers with the Maintenance Supervisor, the following observations were made:

1. Observed duct penetrations of smoke barrier walls; with openings on both sides of the smoke barrier walls, not protected at the following locations:

A. Above the cross-corridor smoke barrier doors near the pharmacy.

B. Above the cross-corridor smoke barrier doors near the entrance to the OB.

C. Above the cross-corridor smoke barrier doors next to room # 240.

These deficiencies were confirmed with the Maintenance Supervisor.

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 1.1.4.1, 19.1.1.4.2.

Findings include:

On 02/01/12 at approximately 8:30 AM during an inspection of separation walls with the Maintenance Supervisor, the following observation was made:

1. The door in the two hour fire wall in the basement, between the medical office building and the hospital, did not self-close to a positive latch.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11.

Findings include:

On 02/01/12 at approximately 9:50 AM during an inspection of exits with the Maintenance Supervisor, the following observation was made:

1. Observed exit stairwell # 4 to have a gap between the corridor wall, not providing a separation from the corridor.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide lighting in accordance with the LSC section 19.2.8.

Findings include:

On 02/01/12 between approximately 9:00 AM - 2:00 PM during an inspection of exits with the Maintenance Supervisor, the following observation was made:

1. The Maintenance Supervisor could not provide documentation that the emergency lighting provided at the required exits was adequate lighting to the public way in compliance with LSC section 19.2.8. Emergency lighting shall be provided along sidewalks for a distance of at least 50 feet from the building, or to the public way. Required emergency lighting facilities shall be provided with 2 bulbs per each fixture or multiple overlapping fixtures arranged such that the loss of any single light will not leave the area in darkness, and arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux) measured along the path of egress at floor level.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1.

Findings include:

On 02/01/12 at approximately 2:30 PM during review of emergency lighting records with the Maintenance Supervisor, the following observation was made:

1. The facility did not complete 90 minute tests of battery emergency lights throughout the facility during 2011.

This deficiency was confirmed with the Maintenance Supervisor.

Based on review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1.

Findings include:

On 02/01/12 at approximately 2:10 PM during review of records with the Maintenance Supervisor, the following observations were made:

1. The fire evacuation plan provided for review did not address evacuation of residents from one smoke compartment to another.

2. The fire evacuation plan provided for review did not address who was responsible or when staff was to call the fire department.

These deficiencies were confirmed with the Maintenance Supervisor.

Based on review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2.

Findings include:

On 02/01/12 at approximately 2:00 PM during a review of fire drill records with the Maintenance Supervisor, the following observation was made:

1. The fire drills that were conducted for the PM shift of 2011 were not completed at varying times and conditions. Three of the four drills were completed between 7:35 PM & 8:00 PM.

This deficiency was confirmed with the Maintenance Supervisor.

Based on review of records the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4.

Findings include:

On 02/01/12 at approximately 2:00 PM during an inspection of fire alarm records with the Maintenance Supervisor, the following observation was made:

1. The fire alarm report from Siemens dated 5-16-11 listed under violations that the fire alarm strobes in the facility do not flash in synchronization as required.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide approved supervision for sprinkler valves in accordance with the LSC section 9.7.2.1.

Findings include:

On 02/01/12 at approximately 8:45 AM during an inspection of the sprinkler system with the Maintenance Supervisor, the following observation was made:

1. Observed the PIV outside the administration entrance not equipped with approved tamper switch supervised through the building fire alarm system.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to maintain the automatic sprinkler system in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5.

Findings include:

On 02/01/12 at approximately 11:20 AM during inspection of the sprinkler system with the Maintenance Supervisor, the following observation was made:

1. Observed blue cables attached to the sprinkler lines above the ceiling of the Lab.

This deficiency was confirmed with the Maintenance Supervisor.

Based on observation the facility failed to provide smoke dampers in accordance with the LSC section 8.3.5.

Findings include:

On 02/01/12 at approximately 1:00 PM during an inspection of smoke barriers with the Maintenance Supervisor, the following observations were made:

1. Observed duct penetrations of smoke barrier walls; with openings on both sides of the smoke barrier walls, not protected at the following locations:

A. Above the cross-corridor smoke barrier doors near the pharmacy.

B. Above the cross-corridor smoke barrier doors near the entrance to the OB.

C. Above the cross-corridor smoke barrier doors next to room # 240.

These deficiencies were confirmed with the Maintenance Supervisor.