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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.

New 09/28/10

During the Recheck LSC survey, review of construction documents revealed that there was proper separation between floors except at the stairwell. The facility is making progress on completing a 2 hour separation between the 1st floor and the stairwell. The POC date submitted is 10/05/10.

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.

New 08/28/10

During the Recheck LSC survey, the interior finish documents were not available. The facility is making progress on procuring the required documentation. The POC date submitted is 10/20/10.

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.

New 09/28/10

During the Recheck LSC survey, the interior finish documents were not available. The facility is making progress on procuring the required documentation. The POC date submitted is 10/20/10.

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 18.3.7.5, 18.3.7.6, 18.3.7.8. 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 10:41 AM observed that on the 2nd floor the smoke barrier doors located near Patient Room 212 did not come to a complete close.
- At approximately 10:50 PM observed that on the 2nd floor the smoke barrier doors located near Patient Room 203 did not come to a complete close.
- At approximately 11:50 observed that the smoke barrier doors near Janitor Closet #1027 when closed had a gap of approximately 1/2 inch.

New 09/28/10

During the Recheck LSC survey, the gap of approximately 1/2 inch at the smoke barrier doors near Janitor Closet #1027 had not been reduced. The facility is making progress on acquiring parts necessary for this correction. The POC date submitted is 10/29/10.

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.

New 09/28/10

During the Recheck LSC survey, the 2nd floor Clean Linen Room 2165 door did not auto close to a positive latch. The facility is making progress on acquiring parts necessary to make this correction. The POC date submitted is 10/29/10.

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 affect all occupants of the facility 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 area separation.

Findings include:

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

- At approximately 03:15 PM observed there was a rolling door separating the Ambulance Bay/Storage Area from the ER Area. This door operation is not activated by smoke detection as required.
- At approximately 03:25 PM observed that the Janitor's Closet door would not close to a positive latch due to the latching mechanism being secured with tape.
- At approximately 03:27 PM observed that the Lab door was being held in the open position by a foot operated device.
- At approximately 03:28 PM observed that the Soiled Linen Room door does not auto close to a positive latch.
- At approximately 03:30 PM observed that the 2nd floor telephone room had 2 pipe chases in the floor that were filled with an insulation type material that was not fire rated.
- At approximately 3:30 PM observed that the 2nd floor telephone room had 4 conduit chases in the ceiling that were filled with an insulation type material that was not fire rated.
- At approximately 03:40 PM observed that the Contractor's Room door was not equipped with a self-closing device.

New 09/28/10

During the Recheck LSC survey, operation of the rolling door separating the Ambulance Bay/Storage Area from the ER Area door is not activated by smoke detection. The facility is making progress on acquiring the proper initiation device for this area. The POC date submitted is 11/15/10.

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.

New 09/28/10

During the Recheck LSC survey, the exhaust duct, domestic water lines, and medical gas lines that were passing through the South Stairwell had not been separated from the stairwell. The facility is making progress on separating the items not serving the stairwell from the stairwell. The POC date submitted is 12/20/10.