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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.

3/4/11 The facility has secured a contractor and obtained the required installation permits. The date of compliance indicated on the original plan of correction of 4/1/11 is expected to be met.

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.

3/4/11 The facility has secured a contractor and obtained the required installation permits. The date of compliance indicated on the original plan of correction of 4/1/11 is expected to be met.

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.

3/4/11 The facility has started the testing of the emergency lights and the date of compliance indicated on the original plan of correction of 4/1/11 is expected to be met.

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.

3/4/11 The facility has secured a contractor and obtained the required installation permits. The date of compliance indicated on the original plan of correction of 4/1/11 is expected to be met.

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.

3/4/11 The facility has secured a contractor to assist in-house staff with obtaining access to the dampers. The date of compliance indicated on the original plan of correction of 5/1/11 is expected to be met.

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.

3/4/11 The facility has secured a contractor to assist in-house staff with obtaining access to the dampers. The date of compliance indicated on the original plan of correction of 5/1/11 is expected to be met.