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The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one or two hours hour as required by the LSC.

On 11/24/14 at 9:30 AM and times throughout the day, the surveyor and the Director of Environmental Services observed that the rated fire walls entering the units and the through floor penetrations in the telecom closets for Building 7 facility had voids and penetrations that were not sealed using a UL approved system for fire stopping one (1) and two (2) hour enclosures i.e. caulked only one side, Non rated backing materials, caulk shrinking and sagging away from voids i.e. cable trays, cable chases, sleeves.

The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 as required by the LSC.

On 11/24/14 at 9:30 AM and times throughout the day, the surveyor and the Director of Environmental Services observed that smoke barrier walls above the suspended ceiling assembly for the corridor smoke doors and adjacent smoke barriers walls throughout buildings 1, 2, & 9 had voids and penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required.

The facility did not ensure that hazardous areas were separated by smoke resisting partitions and self-closing doors as required by section # 19.3.2.1 of the " Life Safety Code "

1. On 11/24/14 at 09:30 AM the surveyor while accompanied by the Vice President of Facilities and the Clinical Engineering Director observed that the double- doors to the Equipment Storage Room located on the 3rd floor of Building 7 (3-7 South) did not self-close, as required by section # 19.3.2.1 of the " Life Safety Code ";i.e. one of the leafs was never provided with a self-closing device;

2. On 11/24/14 at 09:40 AM the surveyor while accompanied by the Vice President of Facilities and the Clinical Engineering Director observed that the double- doors to the Central Storage Room located on the 3rd floor of Building 7 (3-7 ) did not self-close, as required by section # 19.3.2.1 of the " Life Safety Code ";i.e. a coordinator & self-closing device is required;

3. On 11/24/14 at 1:40 PM the surveyor while accompanied by the Vice President of Facilities and the Clinical Engineering Director observed that the door to the Housekeeping Closet located on the 1st floor of Building 7 (1-7 ) did not self-close, as required by section # 19.3.2.1 of the " Life Safety Code ";i.e. the arm to the hydraulic closer has been removed;

The facility did not ensure that hazardous areas were separated by smoke resisting partitions and self-closing doors as required by section # 19.3.2.1 of the " Life Safety Code "

1. On 11/25/14 at 09:30 AM the surveyor while accompanied by the Director of Engineering and the Maintenance Supervisor observed that the double- doors to the Storage Room located within the SurgiCare ASC suite on the 3rd floor did not self-close, as required by section # 19.3.2.1 of the " Life Safety Code ";i.e. doors are provided with magnetic hold-open devices that are not interconnected to the fire alarm;

2. On 11/25/14 at 09:40 AM the surveyor while accompanied by the Director of Engineering and the Maintenance Supervisor observed that the door to the Anesthesia Workroom located within the SurgiCare ASC suite on the 3rd floor did not self-close, as required by section # 19.3.2.1 of the " Life Safety Code ";i.e. the self-closing device has been removed;

The facility did not ensure that emergency lighting of at least 1½-hour duration is provided, as required by " Life Safety Code " section # ' s 7.9 & 19.2.9.1

On 11/25/14 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Supervisor to indicate that the battery backup emergency lights were inspected monthly and tested annually within the Hyperbaric Unit, as required by section # 7.9 of the referenced "Life Safety Code "; i.e. lights installed during hyperbaric chamber project and not included in testing/maintenance program

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically, as required by section # 19.7.6 of the referenced " Life Safety Code " .

On 11/25/14 at 09:40 AM the surveyor while accompanied by the Director of Engineering and the Maintenance Supervisor observed that the closely-spaced, sprinkler components that are obvious to the public located just outside the SurgiCare ASC suite on the 3rd floor were not maintained or removed, as required by section # 4.6.12.2 of the " Life Safety Code" ; i.e. Maintenance Supervisor believed one of each of the pairs of sprinkler heads has been disconnected-the head remains while not connected when the glazing was removed from corridor wall.

The facility did not ensure that soiled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended, as required by section # 19.7.5.5 the referenced "Life Safety Code" .

On 11/25/14 at 09:20 AM the surveyor while accompanied by the Director of Engineering and the Maintenance Supervisor observed that the 44 (forty-four) gallon, trash can located at the PACU area within the SurgiCare ASC suite on the 3rd floor was not stored in a room protected as a hazardous area when not attended, as required by section # 19.7.5.5 the referenced "Life Safety Code " .

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one or two hours hour as required by the LSC.

On 11/24/14 at 9:30 AM and times throughout the day, the surveyor and the Director of Environmental Services observed that the rated fire walls entering the units and the through floor penetrations in the telecom closets for Building 7 facility had voids and penetrations that were not sealed using a UL approved system for fire stopping one (1) and two (2) hour enclosures i.e. caulked only one side, Non rated backing materials, caulk shrinking and sagging away from voids i.e. cable trays, cable chases, sleeves.

The facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3 as required by the LSC.

On 11/24/14 at 9:30 AM and times throughout the day, the surveyor and the Director of Environmental Services observed that smoke barrier walls above the suspended ceiling assembly for the corridor smoke doors and adjacent smoke barriers walls throughout buildings 1, 2, & 9 had voids and penetrations used for the passage of wires, conduit, etc. that were not sealed with materials having at least a half hour fire resistance rating as required.

The facility did not ensure that hazardous areas were separated by smoke resisting partitions and self-closing doors as required by section # 19.3.2.1 of the " Life Safety Code "

1. On 11/24/14 at 09:30 AM the surveyor while accompanied by the Vice President of Facilities and the Clinical Engineering Director observed that the double- doors to the Equipment Storage Room located on the 3rd floor of Building 7 (3-7 South) did not self-close, as required by section # 19.3.2.1 of the " Life Safety Code ";i.e. one of the leafs was never provided with a self-closing device;

2. On 11/24/14 at 09:40 AM the surveyor while accompanied by the Vice President of Facilities and the Clinical Engineering Director observed that the double- doors to the Central Storage Room located on the 3rd floor of Building 7 (3-7 ) did not self-close, as required by section # 19.3.2.1 of the " Life Safety Code ";i.e. a coordinator & self-closing device is required;

3. On 11/24/14 at 1:40 PM the surveyor while accompanied by the Vice President of Facilities and the Clinical Engineering Director observed that the door to the Housekeeping Closet located on the 1st floor of Building 7 (1-7 ) did not self-close, as required by section # 19.3.2.1 of the " Life Safety Code ";i.e. the arm to the hydraulic closer has been removed;

The facility did not ensure that hazardous areas were separated by smoke resisting partitions and self-closing doors as required by section # 19.3.2.1 of the " Life Safety Code "

1. On 11/25/14 at 09:30 AM the surveyor while accompanied by the Director of Engineering and the Maintenance Supervisor observed that the double- doors to the Storage Room located within the SurgiCare ASC suite on the 3rd floor did not self-close, as required by section # 19.3.2.1 of the " Life Safety Code ";i.e. doors are provided with magnetic hold-open devices that are not interconnected to the fire alarm;

2. On 11/25/14 at 09:40 AM the surveyor while accompanied by the Director of Engineering and the Maintenance Supervisor observed that the door to the Anesthesia Workroom located within the SurgiCare ASC suite on the 3rd floor did not self-close, as required by section # 19.3.2.1 of the " Life Safety Code ";i.e. the self-closing device has been removed;

The facility did not ensure that emergency lighting of at least 1½-hour duration is provided, as required by " Life Safety Code " section # ' s 7.9 & 19.2.9.1

On 11/25/14 at 1:00 PM, the surveyor was not provided with documentation from the Maintenance Supervisor to indicate that the battery backup emergency lights were inspected monthly and tested annually within the Hyperbaric Unit, as required by section # 7.9 of the referenced "Life Safety Code "; i.e. lights installed during hyperbaric chamber project and not included in testing/maintenance program

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically, as required by section # 19.7.6 of the referenced " Life Safety Code " .

On 11/25/14 at 09:40 AM the surveyor while accompanied by the Director of Engineering and the Maintenance Supervisor observed that the closely-spaced, sprinkler components that are obvious to the public located just outside the SurgiCare ASC suite on the 3rd floor were not maintained or removed, as required by section # 4.6.12.2 of the " Life Safety Code" ; i.e. Maintenance Supervisor believed one of each of the pairs of sprinkler heads has been disconnected-the head remains while not connected when the glazing was removed from corridor wall.

The facility did not ensure that soiled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity and that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended, as required by section # 19.7.5.5 the referenced "Life Safety Code" .

On 11/25/14 at 09:20 AM the surveyor while accompanied by the Director of Engineering and the Maintenance Supervisor observed that the 44 (forty-four) gallon, trash can located at the PACU area within the SurgiCare ASC suite on the 3rd floor was not stored in a room protected as a hazardous area when not attended, as required by section # 19.7.5.5 the referenced "Life Safety Code " .