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Based on observation and interview the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 30 occupants of the facility by contributing to the spread of fire and smoke into the corridor exposing occupants to fire and the products of combustion rendering the corridor unusable for evacuation of the facility.

Findings include:

1. On 3-15-16 at about 10:20 AM during an inspection of corridor doors with the maintenance supervisor, the following observation was made: Observed the dead leaf for the corridor door to room C244 was not closed. This prevented the door from closing to positive latch.
2. On 3-16-16 at about 9:30 AM during an inspection of corridor doors with the maintenance supervisor, the following observation was made: Observed the dead leaf portion of patient room 1 of CDU-1 is damaged and won't positive latch. This prevents the main leaf from positive latching.
This deficiency was confirmed with the maintenance supervisor (Staff JJ).

Based on observation and interview the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect 24 occupants of the facility by contributing to delay in exiting in an emergency due to inadequately identified exits.

Findings include:

1. On 3-15-16 at approximately 10:50 AM during an inspection of exits with the maintenance supervisor, the following observation was made: Observed the exit sign located at the 3rd floor stairway 4 is turned the wrong way and cannot be seen from either direction down the corridor.
This deficiency was confirmed with the maintenance supervisor (Staff JJ).

Based on observation and interview 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 40 occupants of the facility contributing to the spread of fire and the products of combustion between smoke compartments exposing occupants to the products of combustion.

Findings include:

1. On 3-16-16 at about 11:45 AM during an inspection of smoke barrier walls with the maintenance staff, the following observation was made: Observed a cross corridor door near room Q161 does not close with operation of the fire alarm.
2. On 3-16-16 at about 11:45 AM during an inspection of smoke barrier walls with the maintenance staff the following observation was made: Observed the gap between the smoke barrier doors located near room Q161 is greater than 1/8 inch.
This deficiency was confirmed with the maintenance staff (Staff LL).



32266

Findings include:
1. On 3-16-16 at approximately 10:05 AM during an inspection of smoke barrier walls with the maintenance staff, the following observations were made: Observed a penetration above the Won-door for a ¾ inch fire alarm conduit which was not fire stopped.
2. On 3-16-16 at approximately 1:25 PM during an inspection of smoke barrier walls with the maintenance staff, the following observation was made: Observed the gap between the smoke barrier doors identified as Q195 was greater than 1/8" and did not provide the required smoke resistance.
These deficiencies were confirmed with the maintenance staff (Staff MM).

Based on observation and interview 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 by contributing to the spread of fire between a protected area and unprotected area exposing occupants to fire and the products of combustion.

Findings include:

1. On 3-15-16 at approximately 10:20 AM during an inspection of hazard rooms with the maintenance supervisor, the following observations were made: Soiled linen room M306 corridor door did not close to positive latch.
This deficiency was confirmed with the maintenance supervisor.

2. On 3-16-16 at approximately 11:35 AM during an inspection of hazard rooms with the maintenance supervisor, the following observation was made: Observed the door to storage room R059 is not a rated fire door and is not equipped with a self-closing device.
This deficiency was confirmed with the maintenance supervisor (Staff JJ).



32266

Findings include:

1. On 3-16-16 at approximately 12:45 PM during an inspection of hazard rooms with the maintenance staff, the following observation was made: In room Q153 observed a drain pipe above the ceiling tile over the sink is not fire stopped as required.

This was also observed by the maintenance staff (Staff MM).

Based on observation and interview the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect 50 occupants of the facility by contributing to a delay in exiting the facility increasing the occupants exposure to a hazardous condition.

Findings include:

1. On 3-16-16 between the hours of 12:30 PM and 2:30 PM during an inspection of exits with the maintenance staff, the following observations were made: Observed all Garden level exterior exit doors are not posted with the required delayed-egress signage.
This deficiency was confirmed with the maintenance staff (Staff LL).

Based on record review and interview the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures outlined in the facility emergency response policy which may lead to a delay in response to an emergency exposing occupants to a hazardous condition.

Findings include:
1. On 3-17-16 at about 10:15 AM during a review of records with the security supervisor, the following deficiency was discovered: Only 1 fire drill had been conducted on the night shift during the previous year. It was performed on 2-25-15, 1:40 AM.
This was confirmed by the maintenance supervisor (Staff JJ) and the security supervisor (Staff KK).



13546

Findings include:

1. On 3-15-16 between approximately 10: 00 AM and 11:30 AM random staff throughout the 3RD Floor were interviewed on the facilities Emergency Action Plan and their role and responsibility in the event of a fire. All were found to be deficient in one or more of the following areas:

- Facility code word for fire
- How and when to activate the fire alarm system, including calling 911
- Rescue, evacuation and relocation of patients
- Containment of fire
- Use of fire extinguishers

This deficiency was confirmed with the maintenance personal (Staff MM).

Based on observation and interview the facility failed to provide a sprinkler system in accordance with the LSC section 9.7.1.1. This deficient practice could potentially affect 10 occupants of the facility by failure of the sprinkler system to adequately suppress a fire due to an inadequate water supply available to the sprinkler system.

Findings include:

1. On 3-16-16 at approximately 11:15 AM during an inspection of the sprinkler system with the maintenance staff, the following observation was made: Observed paint overspray tape from the fire sprinkler in the Accessories store in the Lobby. Removed during the survey.
2. On 3-16-16 at approximately 11:15 AM during an inspection of the sprinkler system with the maintenance staff, the following observations were made: Observed 3 paint sprayed sprinklers in the Accessories store.
This deficiency was also confirmed with the maintenance supervisor (Staff JJ).

Based on observation and interview the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 50 occupants of the facility by contributing to the development and spread of fire, exposing occupants to fire and the products of combustion.

Findings include:

1. On 3-15-16 at approximately 2:15 PM during an inspection of oxygen storage with the maintenance supervisor, the following observations were made: Observed the door to the oxygen storage cabinet in room PP40 did not self-close to positive latch when the door was released.
2. On 3-16-16 at approximately 1:30 PM during an inspection of oxygen storage with the maintenance supervisor, the following observations were made: Observed the door to the oxygen storage cabinet located in room R052 did not self-close to positive latch when released.

This deficiency was confirmed with the maintenance staff (Staff LL).

Based on observation and interview the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 30 occupants of the facility by contributing to the overload of electrical circuits which increases the chance for the development of fire, exposing occupants to fire and the products of combustion.

Findings include:

1. On 3-15-16, at about 9:55 AM, observed the use of an unapproved 6-outlet strip type electrical extension being used at the NICU nurse station. Removed immediately by the maintenance supervisor.
2. On 3-15-16, at about 1:05 PM observed the use of strip type electrical outlet to power a pharmacy refrigerator at the PACUB nurse station. The strip plug had other devices plugged in and in use. There was also an open wall outlet not being used.
3. On 3-15-16, at about 1:15 PM observed the use of strip type electrical outlet to power a pharmacy refrigerator at the PACUC nurse station. The strip plug had others devices plugged in and in use. There was also an open wall outlet not being used.
4. On 3-15-16, at about 2:15 PM observed the use of strip type electrical outlet to power a pharmacy refrigerator across from ER 16. The strip plug had others devices plugged in and in use. There was also an open wall outlet not being used.
These deficiencies were confirmed at time of observation by the maintenance supervisor (Staff JJ).



32266

Findings include:

1. On 3-16-16, at approximately 1:45 PM during an above ceiling inspection of electrical system with the maintenance staff, the following observation was made: Observed a powered cord running through the ceiling tile to a portable heater in the loading dock corridor. The cord was removed immediately.

This deficiency was confirmed at time of observation by the maintenance supervisor (Staff MM).

Based on observation and interview the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 30 occupants of the facility by contributing to the spread of fire and smoke into the corridor exposing occupants to fire and the products of combustion rendering the corridor unusable for evacuation of the facility.

Findings include:

1. On 3-15-16 at about 10:20 AM during an inspection of corridor doors with the maintenance supervisor, the following observation was made: Observed the dead leaf for the corridor door to room C244 was not closed. This prevented the door from closing to positive latch.
2. On 3-16-16 at about 9:30 AM during an inspection of corridor doors with the maintenance supervisor, the following observation was made: Observed the dead leaf portion of patient room 1 of CDU-1 is damaged and won't positive latch. This prevents the main leaf from positive latching.
This deficiency was confirmed with the maintenance supervisor (Staff JJ).

Based on observation and interview the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect 24 occupants of the facility by contributing to delay in exiting in an emergency due to inadequately identified exits.

Findings include:

1. On 3-15-16 at approximately 10:50 AM during an inspection of exits with the maintenance supervisor, the following observation was made: Observed the exit sign located at the 3rd floor stairway 4 is turned the wrong way and cannot be seen from either direction down the corridor.
This deficiency was confirmed with the maintenance supervisor (Staff JJ).

Based on observation and interview 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 40 occupants of the facility contributing to the spread of fire and the products of combustion between smoke compartments exposing occupants to the products of combustion.

Findings include:

1. On 3-16-16 at about 11:45 AM during an inspection of smoke barrier walls with the maintenance staff, the following observation was made: Observed a cross corridor door near room Q161 does not close with operation of the fire alarm.
2. On 3-16-16 at about 11:45 AM during an inspection of smoke barrier walls with the maintenance staff the following observation was made: Observed the gap between the smoke barrier doors located near room Q161 is greater than 1/8 inch.
This deficiency was confirmed with the maintenance staff (Staff LL).



32266

Findings include:
1. On 3-16-16 at approximately 10:05 AM during an inspection of smoke barrier walls with the maintenance staff, the following observations were made: Observed a penetration above the Won-door for a ¾ inch fire alarm conduit which was not fire stopped.
2. On 3-16-16 at approximately 1:25 PM during an inspection of smoke barrier walls with the maintenance staff, the following observation was made: Observed the gap between the smoke barrier doors identified as Q195 was greater than 1/8" and did not provide the required smoke resistance.
These deficiencies were confirmed with the maintenance staff (Staff MM).

Based on observation and interview 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 by contributing to the spread of fire between a protected area and unprotected area exposing occupants to fire and the products of combustion.

Findings include:

1. On 3-15-16 at approximately 10:20 AM during an inspection of hazard rooms with the maintenance supervisor, the following observations were made: Soiled linen room M306 corridor door did not close to positive latch.
This deficiency was confirmed with the maintenance supervisor.

2. On 3-16-16 at approximately 11:35 AM during an inspection of hazard rooms with the maintenance supervisor, the following observation was made: Observed the door to storage room R059 is not a rated fire door and is not equipped with a self-closing device.
This deficiency was confirmed with the maintenance supervisor (Staff JJ).



32266

Findings include:

1. On 3-16-16 at approximately 12:45 PM during an inspection of hazard rooms with the maintenance staff, the following observation was made: In room Q153 observed a drain pipe above the ceiling tile over the sink is not fire stopped as required.

This was also observed by the maintenance staff (Staff MM).

Based on observation and interview the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect 50 occupants of the facility by contributing to a delay in exiting the facility increasing the occupants exposure to a hazardous condition.

Findings include:

1. On 3-16-16 between the hours of 12:30 PM and 2:30 PM during an inspection of exits with the maintenance staff, the following observations were made: Observed all Garden level exterior exit doors are not posted with the required delayed-egress signage.
This deficiency was confirmed with the maintenance staff (Staff LL).

Based on record review and interview the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures outlined in the facility emergency response policy which may lead to a delay in response to an emergency exposing occupants to a hazardous condition.

Findings include:
1. On 3-17-16 at about 10:15 AM during a review of records with the security supervisor, the following deficiency was discovered: Only 1 fire drill had been conducted on the night shift during the previous year. It was performed on 2-25-15, 1:40 AM.
This was confirmed by the maintenance supervisor (Staff JJ) and the security supervisor (Staff KK).



13546

Findings include:

1. On 3-15-16 between approximately 10: 00 AM and 11:30 AM random staff throughout the 3RD Floor were interviewed on the facilities Emergency Action Plan and their role and responsibility in the event of a fire. All were found to be deficient in one or more of the following areas:

- Facility code word for fire
- How and when to activate the fire alarm system, including calling 911
- Rescue, evacuation and relocation of patients
- Containment of fire
- Use of fire extinguishers

This deficiency was confirmed with the maintenance personal (Staff MM).

Based on observation and interview the facility failed to provide a sprinkler system in accordance with the LSC section 9.7.1.1. This deficient practice could potentially affect 10 occupants of the facility by failure of the sprinkler system to adequately suppress a fire due to an inadequate water supply available to the sprinkler system.

Findings include:

1. On 3-16-16 at approximately 11:15 AM during an inspection of the sprinkler system with the maintenance staff, the following observation was made: Observed paint overspray tape from the fire sprinkler in the Accessories store in the Lobby. Removed during the survey.
2. On 3-16-16 at approximately 11:15 AM during an inspection of the sprinkler system with the maintenance staff, the following observations were made: Observed 3 paint sprayed sprinklers in the Accessories store.
This deficiency was also confirmed with the maintenance supervisor (Staff JJ).

Based on observation and interview the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 50 occupants of the facility by contributing to the development and spread of fire, exposing occupants to fire and the products of combustion.

Findings include:

1. On 3-15-16 at approximately 2:15 PM during an inspection of oxygen storage with the maintenance supervisor, the following observations were made: Observed the door to the oxygen storage cabinet in room PP40 did not self-close to positive latch when the door was released.
2. On 3-16-16 at approximately 1:30 PM during an inspection of oxygen storage with the maintenance supervisor, the following observations were made: Observed the door to the oxygen storage cabinet located in room R052 did not self-close to positive latch when released.

This deficiency was confirmed with the maintenance staff (Staff LL).

Based on observation and interview the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect 30 occupants of the facility by contributing to the overload of electrical circuits which increases the chance for the development of fire, exposing occupants to fire and the products of combustion.

Findings include:

1. On 3-15-16, at about 9:55 AM, observed the use of an unapproved 6-outlet strip type electrical extension being used at the NICU nurse station. Removed immediately by the maintenance supervisor.
2. On 3-15-16, at about 1:05 PM observed the use of strip type electrical outlet to power a pharmacy refrigerator at the PACUB nurse station. The strip plug had other devices plugged in and in use. There was also an open wall outlet not being used.
3. On 3-15-16, at about 1:15 PM observed the use of strip type electrical outlet to power a pharmacy refrigerator at the PACUC nurse station. The strip plug had others devices plugged in and in use. There was also an open wall outlet not being used.
4. On 3-15-16, at about 2:15 PM observed the use of strip type electrical outlet to power a pharmacy refrigerator across from ER 16. The strip plug had others devices plugged in and in use. There was also an open wall outlet not being used.
These deficiencies were confirmed at time of observation by the maintenance supervisor (Staff JJ).



32266

Findings include:

1. On 3-16-16, at approximately 1:45 PM during an above ceiling inspection of electrical system with the maintenance staff, the following observation was made: Observed a powered cord running through the ceiling tile to a portable heater in the loading dock corridor. The cord was removed immediately.

This deficiency was confirmed at time of observation by the maintenance supervisor (Staff MM).