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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. This deficient practice could affect all occupants in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly fire separation.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:10 PM observed that building construction type and wall construction separation documents were not available for review to verify proper separation between any required areas in the facility, including proper separation between floors.

Based on observation it was determined that the facility does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could affect all occupants of the facility in the event of a fire which is allowed to more rapidly develop due to improper construction type and height.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:10 PM observed that building construction type documents were not available for review at the time of inspection to verify proper construction type and height.

Based on observation and review of records the facility failed to provide approved interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could affect all occupants within the smoke compartment in the event of a fire which is allowed to more rapidly develop due to improper interior finishes.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 04:30 PM observed that interior finish documents were not available for review.

Based on observation and review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could affect all occupants within the smoke compartment in the event of a fire which is allowed to more rapidly develop due to improper interior finishes.


Findings include:

On 07/07/10, the following observations were made:

- At approximately 04:30 PM observed that interior finish documents were not available for review at the time of inspection.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 18.3.6.3.6. This deficient practice could affect all occupants of the smoke compartment in the event of a fire in one of the rooms with improperly installed or maintained corridor doors.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 10:45 AM observed that Patient Room R211 does not close to a positive latch.

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 affect all occupants in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly fire separation.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:20 PM observed that construction type of stairways could not be verified at the time of inspection.

Based on observation and review of records the facility failed to provide smoke compartments in accordance with the LSC sections 19.3.7.1, 19.3.7.2. This deficient practice could affect all occupants of the facility in the event of a fire where a sufficient number of smoke compartments may not be available to provide refuge to protect them from the products of combustion.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:20 PM observed that locations of any smoke barriers could not be verified at the time of inspection.

Based on observation and review of records the facility failed to provide smoke compartments in accordance with the LSC section 19.3.7.1. This deficient practice could affect all occupants of the facility in the event of a fire where smoke compartment size and travel distance are too great which may result in ineffective protection from the products of combustion.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:20 PM observed that locations of any smoke barriers could not be verified at the time of inspection.

Based on observation and review of records 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 affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly located smoke barrier walls.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:20 PM observed that locations of any smoke barriers could not be verified at the time of inspection.

Based on observation and review of records the facility failed to provide smoke compartments in accordance with the LSC section 19.3.7.4. This deficient practice could affect all occupants of the facility in the event of a fire where adequate space is not provided to accomodate occupants to protect them from the products of combustion.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:20 PM observed that locations of any smoke barriers could not be verified at the time of inspection.

Based on observation and review of records the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly maintained doors.
Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:20 PM observed that location of smoke barrier walls could not be verified at the time of inspection, resulting in not being able to verify location of door openings in smoke barriers.

Based on observation and review of records the facility failed to provide smoke barriers in accordance with the LSC sections 19.3.7.5, 19.3.7.7. This deficient practice could affect all occupants in smoke compartments in the event of a fire where the exiting from the smoke compartment is delayed due to improperly sized doors.

Findings include:

- At approximately 03:20 PM observed that location of smoke barrier walls could not be verified at the time of inspection, resulting in not being able to verify location of door openings in smoke barriers.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could affect an undetermined number of occupants in the event of a fire within the hazardous area enclosure where the products of combustion are allowed to spread to the means of egress due to improperly installed or maintained hazardous room enclosures.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 10:40 AM observed that on the 2nd floor Clean Linen Room 2165 door does not auto close to a positive latch.
- At approximately 11:30 AM observed that on the 2nd floor above the ceiling at Storage Room 2152 there was a penetration to the right side of the duct work caused by drywall being improperly cut and not sealed.
- At approximately 11:30 AM observed that on the 2nd floor above the ceiling at Storage Room 2152 there was a penetration to the left side of the duct work caused by a fire alarm conduit that was not sealed with a fire rated material.
- At approximately 11:47 AM observed that on the 1st floor the Equipment Storage Room 1329 door was held in the open position with a bungee cord.
- At approximately 12:18 PM observed that on the 1st floor Soiled Utility Room 1323 door would not auto close to a positive latch.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit components in accordance with the LSC section 8.2.5.2, 19.3.11. This deficient practice could affect all occupants of the facility in the event of a fire where the products of combustion are allowed to transmit throughout the building due to improperly latching door.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:35 PM observed that on the 2nd floor the North Stairwell door did not close to a positive latch.

Based on observation the facility failed to provide approved means of egress in accordance with the LSC section 18.2.2.4. This deficient practice could affect all building occupants in the event of an emergency where the rapid evacuation of the facility is necessary, but is delayed due to improperly maintained means of egress.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 10:50 AM observed that the South Stairwell contained an exhaust duct, domestic water lines, and medical gas lines that were passing through the stairwell and do not serve the stairwell.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could affect all building occupants in the event of an emergency where the rapid evacuation of the facility is necessary, but is delayed due to improperly maintained means of egress.


Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:36 PM observed that the 2nd floor North Stairwell exterior exit does not provide a hard path to the public way.

Based on observation the facility failed to provide exit and directional signs in accordance with the LSC section 18.2.10.1. This deficient practice could affect all building occupants in the event of an emergency where the rapid evacuation of the facility is necessary, but is delayed due to improperly located/maintained marking of the means of egress.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 12:30 PM observed that there was an "Exit" sign leading occupants into the Ambulance Bay, a hazardous area.
- At approximately 12:43 PM observed that the monthly "Exit" sign maintenance records were not available for review at the time of inspection.

Based on observation and review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 18.7.1.1. This deficient practice could potentially affect all occupants of the facility in the event of a fire which requires containment of the fire and/or the rapid evacuation of the building, and the containment and/or evacuation is delayed due to an improper emergency plan.
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Findings include:

On 07/07/10, the following observations were made:

- At approximately 10:50 AM observed that the Fire Emergency Plan located at the Acute Care Nurses Station had not been revised for the new facility.

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. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 04:00 PM observed that fire drill records were not available for review at the time of inspection.

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 affect all building occupants in the event of a delay in occupant notification due to improperly maintained fire alarm system components.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:40 PM observed that in the Contractor's Room there was a fire alarm system strobe device not attached to wall and was hanging by its wiring.

Based on observation 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 affect all building occupants in the event of a delay in occupant notification due to improperly maintained smoke detectors.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 12:18 PM observed that in Soiled Utility Room 1323 there was a smoke detector that was covered with a dust cover.

Based on observation and review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 18.3.5. This deficient practice could affect all building occupants in the event of a delay in occupant notification due to improperly maintained fire sprinkler system components.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 10:30 AM observed that the 2nd floor Shell Space ceiling tile was not intact, resulting in the sprinkler heads being greater than 12 inches below the ceiling.
- At approximately 12:40 PM observed by review of records that the sprinkler system gauges and control valves inspection records were not available for review at the time of inspection.

Based on observation and review of records the facility failed to provide fire extinguishers in accordance with the LSC section 18.3.5.6. This deficient practice could affect all building occupants in the event of a fire which cannot be controlled due to improper maintenance of the portable fire extinguishers.

Finding include:

On 07/07/10, the following observations were made:

- At approximately 12:25 PM observed that monthly maintenance records for the Ambulance Bay portable fire extinguisher were not available for review at the time of inspection.
- At approximately 12:32 PM observed that monthly maintenance records for the Physical Therapy portable fire extinguisher was not available for review at the time of inspection.

Based on observation and review of records the facility failed to provide furnishing flammability documentation in accordance with provisions of the LSC section 10.3.1 and NFPA 13, Standards for the Installation of Sprinkler Systems. Newly introduced upholstered furniture within health care occupancies meets the criteria specified when tested in accordance with the methods cited in 10.3.2 (2) and 10.3.3. 19.7.5.1, NFPA 13

Newly introduced mattresses meet the criteria specified when tested in accordance with the method cited in 10.3.2 (3) , 10.3.4. 19.7.5.3

This deficient practice could affect all occupants within the facility in the event of a fire which is allowed to more rapidly develop due to improper flammable character of furnishings.


Findings include:

- At approximately 03:45 PM observed that the furnishing flammability documents were not available for review at the time of inspection.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could affect all occupants of the facility in the event of a fire where the improperly stored oxygen contributes to the rate of fire growth.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:22 PM observed that in ER Storage there were unsecured oxygen cylinders.

Based on observation and review of records the facility failed to provide smoke dampers in accordance with the LSC section 8.3.5. . This deficient practice could affect all occupants in adjacent smoke compartments in the event of a fire where the products of combustion are allowed to transmit throughout the affected smoke compartments due to improperly maintained duct penetrations.

Findings include:

- At approximately 03:20 PM observed that location of smoke barrier walls could not be verified at the time of inspection, resulting in not being able to verify necessity of duct penetration protection.

Based on observation the facility failed to maintain the electrical system in accordance with the LSC section 9.1.2. This deficient practice could affect all occupants of the facility in the event of a failure of the electrical equipment, or the exposure to hazardous electrical currents due to improper protection.

Findings include:

On 07/07/10, the following observations were made:

- At approximately 03:25 PM observed that in the Radiology Storage area there was exposed electrical wiring above the ceiling.