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Based upon observation and staff interview it was determined that this facility failed to provide appropriate construction standards as required by the LSC, section 19.1.6 by failing to replace ceiling tiles in the EVS Storage room in 3North. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 11:29am, by observation and interview of the Engineering Services Manager, the facility failed to replace missing ceiling tiles in the EVS Storage room in 3North. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to ensure the proper operation of the doors on the housekeeping closet at Vascular Lab #2, cafeteria door on Ground North, Cardiac Rehab, trash chute door on 4Central, trash chute door in ED at room #260, door to dumbwaiter room, trash chute door 1st floor South Building 3rd floor, housekeeping closet South Building 3rd floor, west clean linen room 6South and east soiled utility room 5South in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 1:06pm, by observation and interview of the Engineering Services Manager, the door on the housekeeping closet at Vascular Lab #2 failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 2:16pm, by observation and interview of the Engineering Services Manager, the door on the Cafeteria on Ground North failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 2:45pm, by observation and interview of the Engineering Services Manager, the door on Cardiac Rehab failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:07am, by observation and interview of the Engineering Services Manager, the door on the trash chute on 4Central failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:50am, by observation and interview of the Engineering Services Manager, the door on the trash chute in ED at room #260 failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:15pm, by observation and interview of the Engineering Services Manager, the door on the dumbwaiter failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:20pm, by observation and interview of the Engineering Services Manager, the door on the trash chute in the south building on the 3rd floor failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:28pm, by observation and interview of the Engineering Services Manager, the door on the housekeeping closet in the south building on the 3rd floor failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:44am, by observation and interview of the Engineering Services Manager, the door on the west clean linen room on 6South failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 11:00am, by observation and interview of the Engineering Services Manager, the door on the east soiled utility room on 5South failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke barrier walls in 3North at elevator lobby, 3North at Central Perk, 3North east doors at the Doctor's Office, vascular lab #2, radiology room A, extended holding, X-Ray at room B, X-Ray Department east of waiting room, between C & D Buildings on 1North, 1North at treatment room #3, housekeeping closet 1North at breakroom, 7Central, waiting room 6Central, 4Central at room #469, 3Central at Pre-Op entrance, 3Central in Pre-Op at bed #8, 3Central in Pre-Op at bed #1, Emergency Department at room #17, smoke barrier wall at the Blood Bank, electrical closet 3South, smoke barrier wall 12th floor north hall, communication closet 12th floor north hall, smoke barrier wall 11South north hall, communication closet 11South north hall, smoke barrier wall 9South at visitor waiting room, communication closet 9South, smoke barrier wall 9South at room #918, communication closet 8South and smoke barrier wall 7South at room #701 in accordance with the LSC, section 19.3.7.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 11:20am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in 3North at the elevator lobby failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 11:32am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in 3North at the Central Perk failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 11:40am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in 3North east doors at the Doctor's Office failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:08pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall at vascular lab #2 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:14pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall at radiology room A failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:18pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall at extended holding failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:27pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in X-Ray at room B failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:36pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in X-Ray Department east of waiting room failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:40pm by observation and interview of the Engineering Services Manager, penetrations in the communication closet in the X-Ray Department failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:55pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 1North between the C & D Buildings failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:57pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in 1North at treatment room #3 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:59pm by observation and interview of the Engineering Services Manager, penetrations in 1North housekeeping closet at the break room failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 9:25am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 7Central failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 9:41am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 6Central at the waiting room failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:20am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 4Central at room #469 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:28am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 3Central at the Pre-Op entrance failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:35am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 3Central in Pre-Op at bed #8 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:43am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 3Central in Pre-Op at bed #1 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 11:08am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in the Emergency Department at room #17 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:10pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall at the Blood Bank failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:26pm by observation and interview of the Engineering Services Manager, penetrations in the electrical closet 3South failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 9:19am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 12th floor north hall failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 9:24am by observation and interview of the Engineering Services Manager, penetrations in the communication closet on the 12th floor north hall failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 9:36am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 11South north hall failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 9:38am by observation and interview of the Engineering Services Manager, penetrations in the communication closet on 11South north hall failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:00am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 9South at the visitor waiting room failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:03am by observation and interview of the Engineering Services Manager, penetrations in the communication closet on 9South failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:06am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 9South at room #918 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:09am by observation and interview of the Engineering Services Manager, penetrations in the communication closet on 8South failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:35am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 7South at room #701 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to ensure storage in areas with one hour fire rated construction and/or approved automatic fire extinguishing system in accordance with the LSC, section 8.4.1 and/or section 19.3.5.4 in the storage room/restroom in the Medical Library. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 11:25am by observation and interview of the Engineering Services Manager the facility failed to provide restroom in the Medical Library was being used as a storage room and did not have either one hour fire rated construction and/or an approved automatic fire extinguishing system. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to provide exit access readily accessible (free and unobstructed) at all times in the east stairwell between ED and Overflow and the corridor in 5South at the waiting room in accordance with the LSC, section 7.1. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/15/12 at approximately 10:55am, by observation and interview of the Engineering Services Manager the facility had storage in the east stairwell between ED and Overflow. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:55am, by observation and interview of the Engineering Services Manager the facility had storage (desk) in the corridor on 5South at the waiting room. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that staff be familiar with the facilities fire evacuation procedures by failing to participate during a fire alarm activation on 7South (failed to clear corridors) and Nutritional Services Staff passing through smoke barrier doors during fire alarm activation in accordance with the LSC, section 19.7.1.2. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/16/12 at approximately 12:50pm, by observation and interview of the Engineering Services Manager, staff on 7South failed to participate during a fire alarm activation in the facility by failing to clear corridors. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 12:50pm, by observation and interview of the Engineering Services Manager, nutritional staff on 7South passed through smoke barrier doors during a fire alarm activation in the facility. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to ensure that the sprinkler system was inspected and tested in accordance with the LSC, section 19.3.5 by failing to remove ceiling grid attached to sprinkler pipe in the PTCA Unit, wires attached to sprinkler pipe in the data room by OR #7 and wires attached to sprinkler pipe in the Center Stairs. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 1:17pm by observation and interview of the Engineering Services Manager the facility failed to remove ceiling grid that were attached to sprinkler pipe at the PTCA Unit. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:45pm by observation and interview of the Engineering Services Manager the facility failed to remove wires that were attached to sprinkler pipe in the data room by OR #7. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 9:26am by observation and interview of the Engineering Services Manager the facility failed to remove wires that were attached to sprinkler pipe in the Center Stairs. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to properly store oxygen cylinders in the storage room at room #919 and in patient bath at room #712 in accordance with NFPA 99. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/16/12 at approximately 10:07am by observation and interview of the Engineering Services Manager the facility failed to properly secure an oxygen cylinder in the storage room at room #919. This finding was verified with the Engineering Services Manger at the time of discovery.

On 2/16/12 at approximately 10:29am by observation and interview of the Engineering Services Manager the facility failed to properly secure an oxygen cylinder in the patient bath at room #712. This finding was verified with the Engineering Services Manger at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to ensure electrical wiring to be in accordance with NFPA 70, National Electrical Code, section 9.1.2 by having an open electrical junction box above the ceiling at the smoke barrier wall to Extended Holding, open electrical junction box in the loading dock in kitchen, open-wiring splices above the ceiling at room #767 in 7Central, open-wiring splices above the ceiling at the waiting room in 6Central, open electrical junction box in the east stairwell in 6Central and open electrical junction box at the Nurses Station west end of 6Central. This deficient practices could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 1:18pm by observation and interview of the Engineering Services Manager the facility failed to cover an open electrical junction box above the ceiling at the smoke barrier wall to the Extended Holding Area. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 2:30pm by observation and interview of the Engineering Services Manager the facility failed to cover an open electrical junction box in the loading dock of the kitchen. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 9:33am by observation and interview of the Engineering Services Manager the facility failed to cover open-wiring splices above the ceiling at room #767 in 7Central. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 9:41am by observation and interview of the Engineering Services Manager the facility failed to cover open-wiring splices above the ceiling at the waiting room on 6Central. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 9:52am by observation and interview of the Engineering Services Manager the facility failed to cover an open electrical junction box in the east stairwell in 6Central. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:01am by observation and interview of the Engineering Services Manager the facility failed to cover an open electrical junction box in the Nurses Station west end of 6Central. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview it was determined that this facility failed to provide appropriate construction standards as required by the LSC, section 19.1.6 by failing to replace ceiling tiles in the EVS Storage room in 3North. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 11:29am, by observation and interview of the Engineering Services Manager, the facility failed to replace missing ceiling tiles in the EVS Storage room in 3North. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to ensure the proper operation of the doors on the housekeeping closet at Vascular Lab #2, cafeteria door on Ground North, Cardiac Rehab, trash chute door on 4Central, trash chute door in ED at room #260, door to dumbwaiter room, trash chute door 1st floor South Building 3rd floor, housekeeping closet South Building 3rd floor, west clean linen room 6South and east soiled utility room 5South in accordance with the LSC, section 19.3.6.3.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 1:06pm, by observation and interview of the Engineering Services Manager, the door on the housekeeping closet at Vascular Lab #2 failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 2:16pm, by observation and interview of the Engineering Services Manager, the door on the Cafeteria on Ground North failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 2:45pm, by observation and interview of the Engineering Services Manager, the door on Cardiac Rehab failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:07am, by observation and interview of the Engineering Services Manager, the door on the trash chute on 4Central failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:50am, by observation and interview of the Engineering Services Manager, the door on the trash chute in ED at room #260 failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:15pm, by observation and interview of the Engineering Services Manager, the door on the dumbwaiter failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:20pm, by observation and interview of the Engineering Services Manager, the door on the trash chute in the south building on the 3rd floor failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:28pm, by observation and interview of the Engineering Services Manager, the door on the housekeeping closet in the south building on the 3rd floor failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:44am, by observation and interview of the Engineering Services Manager, the door on the west clean linen room on 6South failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 11:00am, by observation and interview of the Engineering Services Manager, the door on the east soiled utility room on 5South failed to close and latch properly when tested. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure the integrity of the smoke barrier walls in 3North at elevator lobby, 3North at Central Perk, 3North east doors at the Doctor's Office, vascular lab #2, radiology room A, extended holding, X-Ray at room B, X-Ray Department east of waiting room, between C & D Buildings on 1North, 1North at treatment room #3, housekeeping closet 1North at breakroom, 7Central, waiting room 6Central, 4Central at room #469, 3Central at Pre-Op entrance, 3Central in Pre-Op at bed #8, 3Central in Pre-Op at bed #1, Emergency Department at room #17, smoke barrier wall at the Blood Bank, electrical closet 3South, smoke barrier wall 12th floor north hall, communication closet 12th floor north hall, smoke barrier wall 11South north hall, communication closet 11South north hall, smoke barrier wall 9South at visitor waiting room, communication closet 9South, smoke barrier wall 9South at room #918, communication closet 8South and smoke barrier wall 7South at room #701 in accordance with the LSC, section 19.3.7.3. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 11:20am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in 3North at the elevator lobby failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 11:32am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in 3North at the Central Perk failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 11:40am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in 3North east doors at the Doctor's Office failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:08pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall at vascular lab #2 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:14pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall at radiology room A failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:18pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall at extended holding failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:27pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in X-Ray at room B failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:36pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in X-Ray Department east of waiting room failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:40pm by observation and interview of the Engineering Services Manager, penetrations in the communication closet in the X-Ray Department failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:55pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 1North between the C & D Buildings failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:57pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in 1North at treatment room #3 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 1:59pm by observation and interview of the Engineering Services Manager, penetrations in 1North housekeeping closet at the break room failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 9:25am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 7Central failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 9:41am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 6Central at the waiting room failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:20am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 4Central at room #469 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:28am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 3Central at the Pre-Op entrance failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:35am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 3Central in Pre-Op at bed #8 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:43am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 3Central in Pre-Op at bed #1 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 11:08am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall in the Emergency Department at room #17 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:10pm by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall at the Blood Bank failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:26pm by observation and interview of the Engineering Services Manager, penetrations in the electrical closet 3South failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 9:19am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 12th floor north hall failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 9:24am by observation and interview of the Engineering Services Manager, penetrations in the communication closet on the 12th floor north hall failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 9:36am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 11South north hall failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 9:38am by observation and interview of the Engineering Services Manager, penetrations in the communication closet on 11South north hall failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:00am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 9South at the visitor waiting room failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:03am by observation and interview of the Engineering Services Manager, penetrations in the communication closet on 9South failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:06am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 9South at room #918 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:09am by observation and interview of the Engineering Services Manager, penetrations in the communication closet on 8South failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:35am by observation and interview of the Engineering Services Manager, penetrations of the smoke barrier wall on 7South at room #701 failed to be properly sealed. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to ensure storage in areas with one hour fire rated construction and/or approved automatic fire extinguishing system in accordance with the LSC, section 8.4.1 and/or section 19.3.5.4 in the storage room/restroom in the Medical Library. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 11:25am by observation and interview of the Engineering Services Manager the facility failed to provide restroom in the Medical Library was being used as a storage room and did not have either one hour fire rated construction and/or an approved automatic fire extinguishing system. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to provide exit access readily accessible (free and unobstructed) at all times in the east stairwell between ED and Overflow and the corridor in 5South at the waiting room in accordance with the LSC, section 7.1. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/15/12 at approximately 10:55am, by observation and interview of the Engineering Services Manager the facility had storage in the east stairwell between ED and Overflow. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 10:55am, by observation and interview of the Engineering Services Manager the facility had storage (desk) in the corridor on 5South at the waiting room. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to ensure that staff be familiar with the facilities fire evacuation procedures by failing to participate during a fire alarm activation on 7South (failed to clear corridors) and Nutritional Services Staff passing through smoke barrier doors during fire alarm activation in accordance with the LSC, section 19.7.1.2. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/16/12 at approximately 12:50pm, by observation and interview of the Engineering Services Manager, staff on 7South failed to participate during a fire alarm activation in the facility by failing to clear corridors. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 12:50pm, by observation and interview of the Engineering Services Manager, nutritional staff on 7South passed through smoke barrier doors during a fire alarm activation in the facility. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to ensure that the sprinkler system was inspected and tested in accordance with the LSC, section 19.3.5 by failing to remove ceiling grid attached to sprinkler pipe in the PTCA Unit, wires attached to sprinkler pipe in the data room by OR #7 and wires attached to sprinkler pipe in the Center Stairs. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 1:17pm by observation and interview of the Engineering Services Manager the facility failed to remove ceiling grid that were attached to sprinkler pipe at the PTCA Unit. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 1:45pm by observation and interview of the Engineering Services Manager the facility failed to remove wires that were attached to sprinkler pipe in the data room by OR #7. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/16/12 at approximately 9:26am by observation and interview of the Engineering Services Manager the facility failed to remove wires that were attached to sprinkler pipe in the Center Stairs. This finding was verified with the Engineering Services Manager at the time of discovery.

Based upon observation and staff interview, it was determined that the facility failed to properly store oxygen cylinders in the storage room at room #919 and in patient bath at room #712 in accordance with NFPA 99. This deficient practice could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/16/12 at approximately 10:07am by observation and interview of the Engineering Services Manager the facility failed to properly secure an oxygen cylinder in the storage room at room #919. This finding was verified with the Engineering Services Manger at the time of discovery.

On 2/16/12 at approximately 10:29am by observation and interview of the Engineering Services Manager the facility failed to properly secure an oxygen cylinder in the patient bath at room #712. This finding was verified with the Engineering Services Manger at the time of discovery.

Based upon observation and staff interview it was determined that the facility failed to ensure electrical wiring to be in accordance with NFPA 70, National Electrical Code, section 9.1.2 by having an open electrical junction box above the ceiling at the smoke barrier wall to Extended Holding, open electrical junction box in the loading dock in kitchen, open-wiring splices above the ceiling at room #767 in 7Central, open-wiring splices above the ceiling at the waiting room in 6Central, open electrical junction box in the east stairwell in 6Central and open electrical junction box at the Nurses Station west end of 6Central. This deficient practices could affect an isolated number of occupants including residents, staff and visitors.

Findings Include:

On 2/14/12 at approximately 1:18pm by observation and interview of the Engineering Services Manager the facility failed to cover an open electrical junction box above the ceiling at the smoke barrier wall to the Extended Holding Area. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/14/12 at approximately 2:30pm by observation and interview of the Engineering Services Manager the facility failed to cover an open electrical junction box in the loading dock of the kitchen. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 9:33am by observation and interview of the Engineering Services Manager the facility failed to cover open-wiring splices above the ceiling at room #767 in 7Central. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 9:41am by observation and interview of the Engineering Services Manager the facility failed to cover open-wiring splices above the ceiling at the waiting room on 6Central. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 9:52am by observation and interview of the Engineering Services Manager the facility failed to cover an open electrical junction box in the east stairwell in 6Central. This finding was verified with the Engineering Services Manager at the time of discovery.

On 2/15/12 at approximately 10:01am by observation and interview of the Engineering Services Manager the facility failed to cover an open electrical junction box in the Nurses Station west end of 6Central. This finding was verified with the Engineering Services Manager at the time of discovery.