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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 potentially affect all patients, staff and visitors in the event of a fire not being properly contained away from this portion of the facility.

Findings include:
1. On 1/6/11 at approximately 12:03pm, the 90-minute separation doors from the 1968 Building failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation it was determined that the facility failed to maintain 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 potentially affect all patients, staff and visitors in the event of a structural failure during a fire.

Findings include:
1. On 1/5/11 at approximately 1:27pm, a portion of the steel structure located above the ceiling at the RCN Building connection was observed to be missing the required fireproofing material to maintain the required rating. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide corridor doors that would close, latch and resist the passage of smoke in accordance with the LSC section 19.3.6.3. . This deficient practice could potentially affect patients, staff and visitors in the affected areas by not confining smoke and fire away from the corridor.

Findings include:
1. On 1/6/11 at approximately 9:16am, Room 588 was observed to have a towel hanging over the door that prevented the door from latching. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/6/11 at approximately 9:28am, Room 567 was observed to have a towel hanging over the door that prevented the door from latching. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide corridor doors that would close, latch and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect patients, staff and visitors in the affected areas by not confining smoke and fire away from the corridor.

Findings include:
1. On 1/5/11 at approximately 11:07am, the suite separation doors in the Operating Room failed to latch when closed. This condition was noted with the Facilities Director and Maintenance Director present.

2. On 1/5/11 at approximately 2:09pm, the Nursing Student Conference Room door failed to latch when closed. This condition was noted with the Facilities Director and Maintenance Director present.

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 potentially affect patients, staff and visitors that utilize the identified stair by not properly containing fire and smoke away from the exit.

Findings include:
1. On 1/6/11 at approximately 10:13am, the door and frame to the 3rd Floor West Stairwell were observed to have holes from hardware that had been removed. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/6/11 at approximately 11:08am, the entrance door to Billing/Admitting failed to self-close and latch. This door is in the required 1-hour atrium separation. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide for doors hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect patients, staff and visitors in the affected smoke compartment in the event of a fire not being properly contained within a hazardous area.

Findings include:
1. On 1/5/11 at approximately 10:57am, the OR Storage Room door was observed to be equipped with a hold-open device tied to the building fire alarm system. No smoke detection for activation of the door release was installed in the area. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide for doors hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect staff in the affected area by not properly containing a fire to the hazardous area.

Findings include:
1. On 1/6/11 at approximately 8:56am, the door to File Room 690 was observed to be equipped with a hold-open device tied to the building fire alarm system. No smoke detection was provided to activate the door release. This condition was noted with the Facilities Director and Maintenance Director present.

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 19.2.2.2.6. This deficient practice could potentially affect patients, staff and visitors on the affected floor in the event of smoke not being properly contained to the compartment of origin.

Findings include:
1. On 1/6/11 at approximately 10:44am, the smoke barrier door in the 2nd Floor Birthing Center failed to close to a maximum gap of 1/8 of an inch. This condition was noted with the Facilities Director and Maintenance Director present.

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 19.2.2.2.6. This deficient practice could potentially affect patients, staff and visitors on the affected floor in the event that smoke is not properly contained to the compartment of origin.

Findings include:
1. On 1/5/11 at approximately 11:41am, the door to Room 701 which is located in the smoke barrier failed to self-close properly. This condition was noted with the Facilities Director and Maintenance Director present.

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 potentially affect patients, staff and visitors in the affected areas in the event of a fire not being properly contained to the hazardous area.

Findings include:
1. On 1/5/11 at approximately 10:28am, the ED Soiled Linen Room door failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/5/11 at approximately 10:33am, the ED West Hall Storage Room door failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.
3. On 1/5/11 at approximately 10:52am, the Ground Floor Storage Room 101 door was observed to not be equipped with a coordinator for the door leafs. This condition was noted with the Facilities Director and Maintenance Director present.

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 potentially affect patients, staff and visitors in the affected areas by failing to confine a fire within the hazardous area.

Findings include:
1. On 1/5/11 at approximately 11:09am, the door to the OR Storeroom failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/5/11 at approximately 1:31pm, a cable tray was observed above the ceiling at the 3rd Floor Communications Storage Room. The open space around the cables was not protected with an approved intumescent penetration firestopping system. This condition was noted with the Facilities Director and Maintenance Director present.
3. On 1/5/11 at approximately 2:02pm, the 2nd Floor Elevator Tower Storage Room door failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.
4. On 1/5/11 at approximately 2:04pm, the 2nd Floor Specialty Bed Storage Room door failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.
5. On 1/5/11 at approximately 2:26pm, the PACU Soiled Utility Room door failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.

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 potentially affect patients, staff and visitors in the affected areas in the event of a fire not being properly contained to the hazardous area.

Findings include:
1. On 1/6/11 at approximately 10:31am, the Birthing Education Storage Room door was observed to be equipped with a drop foot. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/6/11 at approximately 11:12am, the Lower Level Trash Storage Room had an inactive door leaf that did not latch when closed. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 18.2.1. This deficient practice could potentially affect staff by delaying egress due to reduced stairway width.

Findings include:
1. On 1/5/11 at approximately 10:20am, the 4th Floor Stairwell was observed to have items stored within the egress stair enclosure. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect patients, staff and visitors by delaying egress due to reduced corridor width.

Findings include:
1. On 1/5/11 at approximately 12:43pm, the documentation station door failed to self-close upon testing. This failure caused the corridor width to be reduced below the designed 8-foot width. This condition was noted with the Facilities Director and Maintenance Director present.

Based on review of records, the facility failed to test emergency lighting in accordance with the LSC section 19.2.9.1.
This deficient practice could potentially affect patients and staff in the operating rooms in the event of a power failure.

Findings include:
1. On 1/5/11 between 8:30am and 10:15am during records review, no documentation of the required 90-minute annual test of the battery-operated emergency lights serving the operating rooms was provided. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect patients, staff and visitors by allowing a fire to grow uncontrolled due to a lack of sprinkler coverage.

Findings include:
1. On 1/5/11 at approximately 1:52pm, the 3rd Floor CS Electrical Room was observed to have no sprinkler head protecting the room. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to ensure that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect patients, staff and visitors in the affected areas in the event of a fire not being properly controlled by the sprinkler system.

Findings include:
1. On 1/5/11 at approximately 11:49am, the 7th Floor North Clean Utility Room was observed to have storage that was within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/5/11 at approximately 12:39pm, the 6th Floor Elevator Tower Communications Room was observed to have a ceiling tile missing. No sprinkler protection is provided above the ceiling. This condition was noted with the Facilities Director and Maintenance Director present.
3. On 1/5/11 at approximately 12:55pm, the 5th Floor Elevator Tower Communications Room was observed to have a ceiling tile missing. No sprinkler protection is provided above the ceiling. This condition was noted with the Facilities Director and Maintenance Director present.
4. On 1/5/111 at approximately 1:45pm, the 3rd Floor Lab Storage Room was observed to have storage that was within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
5. On 1/5/11 at approximately 2:11pm, the 1st Floor Elevator Tower Storage Room was observed to have an IV pole hanging from the sprinkler pipe. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to ensure that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, and 9.7.5. This deficient practice could potentially affect patients, staff and visitors in the affected area by allowing a fire to be properly controlled by the sprinkler system.

Findings include:
1. On 1/6/11 at approximately 8:53am, the 6th Floor NW Records Storage Room had items stored within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/6/11 at approximately 9:25am, the sprinkler pipe above the ceiling in the CIAS Central Hallway was observed to have wired connected to it. This condition was noted with the Facilities Director and Maintenance Director present.
3. On 1/6/11 at approximately 9:42am, the sprinkler pipe above the ceiling in the 4th Floor East Corridor was observed to be supporting several bundles of cables. This condition was noted with the Facilities Director and Maintenance Director present.
4. On 1/6/11 at approximately 9:46am, the 4th Floor Cath Lab Supply Room had items stored within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
5. On 1/6/11 at approximately 10:02am, the 3rd Floor Electrical Room was observed to be missing a ceiling tile. No sprinklers were installed above the ceiling. This condition was noted with the Facilities Director and Maintenance Director present.
6. On 1/6/11 at approximately 10:10am, the 3rd Floor Outpatient Rehab Storage Room had items stored within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
7. On 1/6/11 at approximately 10:39am, the 2nd Floor East Storage Room had items stored within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
8. On 1/6/11 at approximately 10:49am, the 2nd Floor NICU Storage Room had items stored within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide ensure that the automatic sprinkler system is maintained in accordance with the LSC sections 18.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect staff in the event of a failure of the sprinkler system.

Findings include:
1. On 1/5/11 at approximately 10:44am, the sprinkler piping in the Ground Floor Shell Space was observed to have wires attached to the pipe and hangers. This condition was noted with the Facilities Director and Maintenance Director present.

Based on review of records the facility failed to maintain building services in accordance with the LSC sections 19.5.2.1, 9.2, and 19.6.2.2. This deficient practice could potentially affect all patients, staff and visitor in the event of a fire not being properly contained to the compartment of origin.

Findings include:
1. On 1/5/11 between 8:30am and 10:15am during records review, a portion of the fire dampers for the building as identified in Attachment 1 had not received the required 4-year testing. This condition was noted with the Facilities Director and Maintenance Director present.

Based on review of records the facility failed to maintain building services in accordance with the LSC sections 9.2, 18.5.2.1, and 18.5.2.2. This deficient practice could potentially affect all patients, staff and visitor in the event of a fire not being properly contained to the compartment of origin.

Findings include:
1. On 1/5/11 between 8:30am and 10:15am during records review, a portion of the fire dampers for the building as identified in Attachment 1 had not received the required 4-year testing. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect staff in the affected area in the event of a cylinder falling over.

Findings include:
1. On 1/6/11 at approximately 9:45am, the 4th Floor Cath Lab Soiled Utility Room had a oxygen cylinder that was not secured in the upright position. This condition was noted with the Facilities Director and Maintenance Supervisor present.

Based on review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all patients, staff and visitors in the event of a power failure.

Findings include:
1. On 1/5/11 between 8:30am and 10:15am during records review, the facility failed to provide documentation of the monthly load test for the generator for October 2010. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to maintain the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect patients, staff and visitors in the affected areas in the event of an electrical failure.

Findings include:
1. On 1/5/11 at approximately 12:53pm, the electrical junction boxes above the ceiling in the 6th Floor East Corridor were observed to be missing the cover plates. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/5/11 at approximately 1:06pm, an electrical junction box in the 4th Floor Electrical Room was observed to be missing the cover plate. This condition was noted with the Facilities Director and Maintenance Director present.

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 potentially affect all patients, staff and visitors in the event of a fire not being properly contained away from this portion of the facility.

Findings include:
1. On 1/6/11 at approximately 12:03pm, the 90-minute separation doors from the 1968 Building failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation it was determined that the facility failed to maintain 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 potentially affect all patients, staff and visitors in the event of a structural failure during a fire.

Findings include:
1. On 1/5/11 at approximately 1:27pm, a portion of the steel structure located above the ceiling at the RCN Building connection was observed to be missing the required fireproofing material to maintain the required rating. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide corridor doors that would close, latch and resist the passage of smoke in accordance with the LSC section 19.3.6.3. . This deficient practice could potentially affect patients, staff and visitors in the affected areas by not confining smoke and fire away from the corridor.

Findings include:
1. On 1/6/11 at approximately 9:16am, Room 588 was observed to have a towel hanging over the door that prevented the door from latching. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/6/11 at approximately 9:28am, Room 567 was observed to have a towel hanging over the door that prevented the door from latching. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide corridor doors that would close, latch and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect patients, staff and visitors in the affected areas by not confining smoke and fire away from the corridor.

Findings include:
1. On 1/5/11 at approximately 11:07am, the suite separation doors in the Operating Room failed to latch when closed. This condition was noted with the Facilities Director and Maintenance Director present.

2. On 1/5/11 at approximately 2:09pm, the Nursing Student Conference Room door failed to latch when closed. This condition was noted with the Facilities Director and Maintenance Director present.

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 potentially affect patients, staff and visitors that utilize the identified stair by not properly containing fire and smoke away from the exit.

Findings include:
1. On 1/6/11 at approximately 10:13am, the door and frame to the 3rd Floor West Stairwell were observed to have holes from hardware that had been removed. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/6/11 at approximately 11:08am, the entrance door to Billing/Admitting failed to self-close and latch. This door is in the required 1-hour atrium separation. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide for doors hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect patients, staff and visitors in the affected smoke compartment in the event of a fire not being properly contained within a hazardous area.

Findings include:
1. On 1/5/11 at approximately 10:57am, the OR Storage Room door was observed to be equipped with a hold-open device tied to the building fire alarm system. No smoke detection for activation of the door release was installed in the area. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide for doors hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect staff in the affected area by not properly containing a fire to the hazardous area.

Findings include:
1. On 1/6/11 at approximately 8:56am, the door to File Room 690 was observed to be equipped with a hold-open device tied to the building fire alarm system. No smoke detection was provided to activate the door release. This condition was noted with the Facilities Director and Maintenance Director present.

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 19.2.2.2.6. This deficient practice could potentially affect patients, staff and visitors on the affected floor in the event of smoke not being properly contained to the compartment of origin.

Findings include:
1. On 1/6/11 at approximately 10:44am, the smoke barrier door in the 2nd Floor Birthing Center failed to close to a maximum gap of 1/8 of an inch. This condition was noted with the Facilities Director and Maintenance Director present.

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 19.2.2.2.6. This deficient practice could potentially affect patients, staff and visitors on the affected floor in the event that smoke is not properly contained to the compartment of origin.

Findings include:
1. On 1/5/11 at approximately 11:41am, the door to Room 701 which is located in the smoke barrier failed to self-close properly. This condition was noted with the Facilities Director and Maintenance Director present.

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 potentially affect patients, staff and visitors in the affected areas in the event of a fire not being properly contained to the hazardous area.

Findings include:
1. On 1/5/11 at approximately 10:28am, the ED Soiled Linen Room door failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/5/11 at approximately 10:33am, the ED West Hall Storage Room door failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.
3. On 1/5/11 at approximately 10:52am, the Ground Floor Storage Room 101 door was observed to not be equipped with a coordinator for the door leafs. This condition was noted with the Facilities Director and Maintenance Director present.

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 potentially affect patients, staff and visitors in the affected areas by failing to confine a fire within the hazardous area.

Findings include:
1. On 1/5/11 at approximately 11:09am, the door to the OR Storeroom failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/5/11 at approximately 1:31pm, a cable tray was observed above the ceiling at the 3rd Floor Communications Storage Room. The open space around the cables was not protected with an approved intumescent penetration firestopping system. This condition was noted with the Facilities Director and Maintenance Director present.
3. On 1/5/11 at approximately 2:02pm, the 2nd Floor Elevator Tower Storage Room door failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.
4. On 1/5/11 at approximately 2:04pm, the 2nd Floor Specialty Bed Storage Room door failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.
5. On 1/5/11 at approximately 2:26pm, the PACU Soiled Utility Room door failed to self-close and latch. This condition was noted with the Facilities Director and Maintenance Director present.

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 potentially affect patients, staff and visitors in the affected areas in the event of a fire not being properly contained to the hazardous area.

Findings include:
1. On 1/6/11 at approximately 10:31am, the Birthing Education Storage Room door was observed to be equipped with a drop foot. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/6/11 at approximately 11:12am, the Lower Level Trash Storage Room had an inactive door leaf that did not latch when closed. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 18.2.1. This deficient practice could potentially affect staff by delaying egress due to reduced stairway width.

Findings include:
1. On 1/5/11 at approximately 10:20am, the 4th Floor Stairwell was observed to have items stored within the egress stair enclosure. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect patients, staff and visitors by delaying egress due to reduced corridor width.

Findings include:
1. On 1/5/11 at approximately 12:43pm, the documentation station door failed to self-close upon testing. This failure caused the corridor width to be reduced below the designed 8-foot width. This condition was noted with the Facilities Director and Maintenance Director present.

Based on review of records, the facility failed to test emergency lighting in accordance with the LSC section 19.2.9.1.
This deficient practice could potentially affect patients and staff in the operating rooms in the event of a power failure.

Findings include:
1. On 1/5/11 between 8:30am and 10:15am during records review, no documentation of the required 90-minute annual test of the battery-operated emergency lights serving the operating rooms was provided. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect patients, staff and visitors by allowing a fire to grow uncontrolled due to a lack of sprinkler coverage.

Findings include:
1. On 1/5/11 at approximately 1:52pm, the 3rd Floor CS Electrical Room was observed to have no sprinkler head protecting the room. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to ensure that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect patients, staff and visitors in the affected areas in the event of a fire not being properly controlled by the sprinkler system.

Findings include:
1. On 1/5/11 at approximately 11:49am, the 7th Floor North Clean Utility Room was observed to have storage that was within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/5/11 at approximately 12:39pm, the 6th Floor Elevator Tower Communications Room was observed to have a ceiling tile missing. No sprinkler protection is provided above the ceiling. This condition was noted with the Facilities Director and Maintenance Director present.
3. On 1/5/11 at approximately 12:55pm, the 5th Floor Elevator Tower Communications Room was observed to have a ceiling tile missing. No sprinkler protection is provided above the ceiling. This condition was noted with the Facilities Director and Maintenance Director present.
4. On 1/5/111 at approximately 1:45pm, the 3rd Floor Lab Storage Room was observed to have storage that was within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
5. On 1/5/11 at approximately 2:11pm, the 1st Floor Elevator Tower Storage Room was observed to have an IV pole hanging from the sprinkler pipe. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to ensure that the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, and 9.7.5. This deficient practice could potentially affect patients, staff and visitors in the affected area by allowing a fire to be properly controlled by the sprinkler system.

Findings include:
1. On 1/6/11 at approximately 8:53am, the 6th Floor NW Records Storage Room had items stored within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/6/11 at approximately 9:25am, the sprinkler pipe above the ceiling in the CIAS Central Hallway was observed to have wired connected to it. This condition was noted with the Facilities Director and Maintenance Director present.
3. On 1/6/11 at approximately 9:42am, the sprinkler pipe above the ceiling in the 4th Floor East Corridor was observed to be supporting several bundles of cables. This condition was noted with the Facilities Director and Maintenance Director present.
4. On 1/6/11 at approximately 9:46am, the 4th Floor Cath Lab Supply Room had items stored within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
5. On 1/6/11 at approximately 10:02am, the 3rd Floor Electrical Room was observed to be missing a ceiling tile. No sprinklers were installed above the ceiling. This condition was noted with the Facilities Director and Maintenance Director present.
6. On 1/6/11 at approximately 10:10am, the 3rd Floor Outpatient Rehab Storage Room had items stored within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
7. On 1/6/11 at approximately 10:39am, the 2nd Floor East Storage Room had items stored within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.
8. On 1/6/11 at approximately 10:49am, the 2nd Floor NICU Storage Room had items stored within 18 inches of the sprinkler head and obstructing the sprinkler pattern development. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide ensure that the automatic sprinkler system is maintained in accordance with the LSC sections 18.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect staff in the event of a failure of the sprinkler system.

Findings include:
1. On 1/5/11 at approximately 10:44am, the sprinkler piping in the Ground Floor Shell Space was observed to have wires attached to the pipe and hangers. This condition was noted with the Facilities Director and Maintenance Director present.

Based on review of records the facility failed to maintain building services in accordance with the LSC sections 19.5.2.1, 9.2, and 19.6.2.2. This deficient practice could potentially affect all patients, staff and visitor in the event of a fire not being properly contained to the compartment of origin.

Findings include:
1. On 1/5/11 between 8:30am and 10:15am during records review, a portion of the fire dampers for the building as identified in Attachment 1 had not received the required 4-year testing. This condition was noted with the Facilities Director and Maintenance Director present.

Based on review of records the facility failed to maintain building services in accordance with the LSC sections 9.2, 18.5.2.1, and 18.5.2.2. This deficient practice could potentially affect all patients, staff and visitor in the event of a fire not being properly contained to the compartment of origin.

Findings include:
1. On 1/5/11 between 8:30am and 10:15am during records review, a portion of the fire dampers for the building as identified in Attachment 1 had not received the required 4-year testing. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect staff in the affected area in the event of a cylinder falling over.

Findings include:
1. On 1/6/11 at approximately 9:45am, the 4th Floor Cath Lab Soiled Utility Room had a oxygen cylinder that was not secured in the upright position. This condition was noted with the Facilities Director and Maintenance Supervisor present.

Based on review of records the facility failed to provide documentation that generators are maintained in accordance with NFPA 99. This deficient practice could potentially affect all patients, staff and visitors in the event of a power failure.

Findings include:
1. On 1/5/11 between 8:30am and 10:15am during records review, the facility failed to provide documentation of the monthly load test for the generator for October 2010. This condition was noted with the Facilities Director and Maintenance Director present.

Based on observation the facility failed to maintain the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect patients, staff and visitors in the affected areas in the event of an electrical failure.

Findings include:
1. On 1/5/11 at approximately 12:53pm, the electrical junction boxes above the ceiling in the 6th Floor East Corridor were observed to be missing the cover plates. This condition was noted with the Facilities Director and Maintenance Director present.
2. On 1/5/11 at approximately 1:06pm, an electrical junction box in the 4th Floor Electrical Room was observed to be missing the cover plate. This condition was noted with the Facilities Director and Maintenance Director present.