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Based on observation it was determined that the facility failed to provide complete sprinkler coverage and does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could potentially affect the occupants of the facility located in 1 of 10 smoke zones located in the basement of the facility.

Findings include:

A. On February 4, 2011, at approximately 9:00 AM, while conducting a walk through with the Director of Plant Engineering and Director of Loss Prevention Services, it was observed that the fire protection on the structural steel in room, Sub5E, BB146A, in the basement had places where the protection had been removed.

This deficiency was confirmed at the time of discovery.

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect the occupants in: 1 of 3 smoke zones on the 6th floor and in 1 of 12 smoke zones on the ground floor if a fire should occur in one of the comm. closets.

Findings include:

A. On February 3, 2011, at approximately 2:30 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that there was a hole along the steel beam in the Comm. closet on sixth (6th) floor of "A" tower.

B. On February 3, 2011, at approximately 2:32 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that a 1/2 inch conduit penetrating the wall of the Comm. closet on the sixth (6th) floor of "A" tower was not properly sealed.

C. On February 8, 2011, at approximately 1:30 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the Comm. closet, CG278, on the ground floor of "C" tower was not separated from the corridor.

All deficiencies were confirmed at the time of discovery.

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 occupants in: 1 of 10 smoke zones in basement, 1 of 6 smoke zones on fourth floor and 1 of 3 smoke zones on sixth floor of the facility if a fire was allow to spread due to not having the proper separation on vertical openings.

Findings include:

A. On February 3, 2011, at approximately 2:47 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that in the North Stairwell of "A" Tower, a sprinkler pipe penetrating between the fifth (5th) and sixth (6th) floors was not properly sealed.

B. On February 3, 2011, at approximately 3:05 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that three (3) large conduits penetrating the Comm. vertical chase on the third (3rd) floor of "A" tower were not properly sealed.

C. On February 4, 2011, at approximately 8:25 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that a 1/2" conduit penetrating the Southwest Stairwell in the basement of "D" Tower was not properly sealed.

All deficiencies were confirmed at the time of discovery.

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 the occupants in: 1 of 3 smoke zones on the sixth (6th) floor, 1 of 12 smoke zones on second (2nd) floor, 1 of 7 smoke zones on first (1st) floor and 1 of 12 on ground floor of the facility if a fire/smoke was able to extend beyond the hazard area.

Findings include:

A. On February 4, 2011, at approximately 10:55 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the pipes penetrating the Mechanical room at the Penthouse of "D" tower was not properly sealed.

B. On February 4, 2011, at approximately 1:50 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that the penetrations over the door to storage room B1106 on the first (1st) floor of "B" tower was not properly sealed.

C. On February 4, 2011, at approximately 2:08 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that a conduit over the door to Mechanical room B1111 on the first (1st) floor of "B" tower was not properly sealed.

D. On February 4, 2011, at approximately 2:33 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that the hardware on door to OB storage room, BG162A, on the ground floor, was not working properly and causing door to not properly latch.

E. On February 8, 2011, at approximately 12:12 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed a opening around the escutcheon on the sprinkler head in Store room, C2121A, on the second (2nd) floor of "C" tower.

All deficiencies were confirmed at the time of discovery.

Based on observation and/or review of records the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6. This deficient practice could potentially affect the occupants of the second floor of the facility if the Simplex panel is not properly protected from fire.

Findings include:

A. On February 8, 2011, at approximately 12:15 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it of observed that the Simplex equipment located in the room at the West end of the elevators, C2109, did not have any smoke detection protecting it.

This deficiency was confirmed at the time of discovery.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect the occupants in 1 of 12 smoke zones on the ground floor, 1 of 7 smoke zones on the first (1st) floor and 1 of 7 smoke zones on the third (3rd) floor of the facility if the sprinkler system failed to operate as designed.

Findings include:

A. On February 3, 2011, at approximately 3:23 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that the Auxiliary drain for the sprinkler system in the EVS closet on the third floor of "A" tower, was not labeled.

B. On February 4, 2011, at approximately 10:00 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the Main Electrical Transformer room, located in the "C" basement, was not sprinklered

C. On February 4, 2011, at approximately 11:12 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the Auxiliary drain for the sprinkler system located in the EVS closet, D3105, on the third floor of "D" tower, was not labeled.

D. On February 8, 2011, at approximately 12:55 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the sprinkler heads located in patient room, C1644, located on the first floor of "C" tower, were improperly spaced to prevent cold soldering of the sprinkler heads.

E. On February 8, 2011, at approximately 1:50 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the sprinkler heads located in Radiology store room, CG169, on the ground floor, were improperly spaced to prevent cold soldering of the sprinkler heads.

F. On February 8, 2011, at approximately 1:51 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the Radiology store room, CG169, on the ground floor, had a mixture of standard response sprinkler heads and quick response sprinklers heads located within the same space.

All the deficiencies were confirmed at the time of discovery.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect the occupants in 1 of 10 smoke zones in the basement, 1 of 12 smoke zones on ground floor, 1 of 7 smoke zones on first (1st) floor, 1 of 12 smoke zones on second (2nd) floor, 1 of 7 smoke zones on third (3rd) floor and 1 of 6 smoke zones on the fourth (4th) floor of the facility if the sprinkler system failed to operate as designed due to lack of maintenance.

Findings include:

A. On February 3, 2011, at approximately 3:25 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that the sprinkler heads in Consultation room, AG121, in the ER department on ground floor, had debris and lint build-up on the sprinkler heads.

B. On February 3, 2011, at approximately 3:28 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that the sprinkler heads in room AG106 and other areas of the Emergency Department on the ground floor had debris and lint build-up on the sprinkler heads.

C. On February 4, 2011, at approximately 9:04 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the escutcheon on the sprinkler head located in the Women's Locker room in the "B" basement was missing and the head needs to be lowered in the ceiling to allow the escutcheon to stay in place.

D. On February 4, 2011, at approximately 9:37 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that old abandoned speciality fire suppression equipment was still located in the X-ray Film Storage of Ambulatory Care Facility basement.

E. On February 4, 2011, at approximately 11:05 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed lint and debris build-up on sprinkler head located in the Pantry on the fourth (4th) floor of the "D" tower.

F. On February 4, 2011, at approximately 11:20 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed lint and debris build-up on sprinkler head located in room D3123 on the third (3rd) floor of "D" tower.

G. On February 4, 2011, at approximately 12:55 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on sprinkler heads located in Conference Room by Nurse's Station on the third (3rd) floor of "B" tower.

H. On February 4, 2011, at approximately 1:05 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on sprinkler head located in Pantry, B3123, on the third (3rd) floor of "B" tower.

I. On February 4, 2011, at approximately 1:08 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that wires were hanging on the sprinkler piping by the doors at the smoke/fire wall, CCB3105, on the third (3rd) floor of "B" tower.

J. On February 4, 2011, at approximately 1:18 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that wires were hanging on sprinkler piping at the smoke/fire wall, CCB3161, on the third (3rd) floor of "B" tower at B south.

K. On February 4, 2011, at approximately 1:40 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on sprinkler head located in the Respiratory Therapy room of ICU, B2250, on the second (2nd) floor of "B" tower.

L. On February 4, 2011, at approximately 2:27 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on the sprinkler head in the Pantry of OB on the ground floor of "B" tower.

M. On February 4, 2011, at approximately 2:43 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on the sprinkler head in Triage and Emergency Care room, BG120, of OB on the ground floor of "B" tower.

N. On February 4, 2011, at approximately 2:50 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on the sprinkler head in the Lactation Consultants office, BG183, of OB on the ground floor of "B" tower.

O. On February 8, 2011, at approximately 11:59 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed lint and debris build-up on sprinkler head in room B3112 on the third (3rd) floor of "C" tower.

All deficiencies were confirmed at the time of discovery.

Based on observation and/or review of records the facility failed to provide portable fire extinguishers in accordance with the LSC sections 19.3.5.6, 9.7.4.1, and NFPA 10. This deficient practice could potentially affect the occupants in 1 of 12 smoke zones on the ground floor, 1 of 7 smoke zones on the first (1st) floor and 1 of 12 smoke zones on the second (2nd) floor if the improper extinguisher is installed.


Findings include:

A. On February 8, 2011, at approximately 12:23 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that a CO2 (type BC) extinguisher was placed in the corridor outside EEG Neurology Staff Physicians room on the second (2nd) floor of "C" tower where ordinary combustibles (type A) are located.

B. On February 8, 2011, at approximately 12:28 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that a CO2 (type BC) extinguisher was placed in the old EP lab across from EEG testing 2 on the second (2nd) floor of "C" tower, where ordinary combustibles (type A) are located.

C. On February 8, 2011, at approximately 1:10 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that a CO2 (type BC) extinguisher was placed in the OT Kitchen, C1173, on the first (1st) floor of "C" tower, where ordinary combustibles (type A) are located.

D. On February 8, 2011, at approximately 2:07 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that a CO2 (type BC) extinguisher was placed in Radiology Recovery room, CG130, on the ground floor of "C" tower, where ordinary combustibles (type A) are located.

All deficiencies were confirmed at the time of discovery.

Based on observation the facility failed to provide chutes that are not in accordance with the LSC sections 9.5, 9.7, 8.4. This deficient practice could potentially affect the occupants in 1 of 6 smoke zones of the facility if the chute failed to operate as designed.

Findings include:

A. On February 4, 2011, at approximately 12:40 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that the door to the soiled linen chute in room B4128 on the fourth (4th) floor of "B" tower was not closing and latching properly.

This deficiency was confirmed at the time of discovery.

Based on observation the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10. This deficient practice could potentially affect the occupants in 1 of 12 smoke zones of the facility if egress becomes blocked.

Findings include:

A. On February 8, 2011, at approximately 1:40 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that recycling bundles of cardboard were partially blocking the exit from the EVS store room on the ground floor of "C" tower.

This deficiency was confirmed at the time of discovery.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect the occupants in 1 of 7 smoke zones on the first (1st) floor and 1 of 7 smoke zones on the third (3rd) floor of the facility if a fire occurred from improper electrical installation.

Findings include:

A. On February 3, 2011, at approximately 3:20 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that an electrical box located in the Electrical room on the third (3rd) floor of "A" tower, had an extra knockout removed causing a hole in the electrical box.

B. On February 4, 2011, at approximately 2:00 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that the multiple electrical boxes were missing covers located over the catwalk off the Mechanical room located on the first (1st) floor of "B" tower.

C. On February 8, 2011, at approximately 1:12 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that an electrical box was missing a cover located in the Comm. Closet, C1233, located on the first (1st) floor of "C" tower.

All deficiencies were confirmed at the time of discovery.

Based on observation it was determined that the facility failed to provide complete sprinkler coverage and does not meet the construction type in accordance with the LSC, sections 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1, 4.6.6, 4.6.7, 4.6.9, 4.6.10. This deficient practice could potentially affect the occupants of the facility located in 1 of 10 smoke zones located in the basement of the facility.

Findings include:

A. On February 4, 2011, at approximately 9:00 AM, while conducting a walk through with the Director of Plant Engineering and Director of Loss Prevention Services, it was observed that the fire protection on the structural steel in room, Sub5E, BB146A, in the basement had places where the protection had been removed.

This deficiency was confirmed at the time of discovery.

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect the occupants in: 1 of 3 smoke zones on the 6th floor and in 1 of 12 smoke zones on the ground floor if a fire should occur in one of the comm. closets.

Findings include:

A. On February 3, 2011, at approximately 2:30 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that there was a hole along the steel beam in the Comm. closet on sixth (6th) floor of "A" tower.

B. On February 3, 2011, at approximately 2:32 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that a 1/2 inch conduit penetrating the wall of the Comm. closet on the sixth (6th) floor of "A" tower was not properly sealed.

C. On February 8, 2011, at approximately 1:30 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the Comm. closet, CG278, on the ground floor of "C" tower was not separated from the corridor.

All deficiencies were confirmed at the time of discovery.

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 occupants in: 1 of 10 smoke zones in basement, 1 of 6 smoke zones on fourth floor and 1 of 3 smoke zones on sixth floor of the facility if a fire was allow to spread due to not having the proper separation on vertical openings.

Findings include:

A. On February 3, 2011, at approximately 2:47 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that in the North Stairwell of "A" Tower, a sprinkler pipe penetrating between the fifth (5th) and sixth (6th) floors was not properly sealed.

B. On February 3, 2011, at approximately 3:05 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that three (3) large conduits penetrating the Comm. vertical chase on the third (3rd) floor of "A" tower were not properly sealed.

C. On February 4, 2011, at approximately 8:25 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that a 1/2" conduit penetrating the Southwest Stairwell in the basement of "D" Tower was not properly sealed.

All deficiencies were confirmed at the time of discovery.

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 the occupants in: 1 of 3 smoke zones on the sixth (6th) floor, 1 of 12 smoke zones on second (2nd) floor, 1 of 7 smoke zones on first (1st) floor and 1 of 12 on ground floor of the facility if a fire/smoke was able to extend beyond the hazard area.

Findings include:

A. On February 4, 2011, at approximately 10:55 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the pipes penetrating the Mechanical room at the Penthouse of "D" tower was not properly sealed.

B. On February 4, 2011, at approximately 1:50 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that the penetrations over the door to storage room B1106 on the first (1st) floor of "B" tower was not properly sealed.

C. On February 4, 2011, at approximately 2:08 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that a conduit over the door to Mechanical room B1111 on the first (1st) floor of "B" tower was not properly sealed.

D. On February 4, 2011, at approximately 2:33 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that the hardware on door to OB storage room, BG162A, on the ground floor, was not working properly and causing door to not properly latch.

E. On February 8, 2011, at approximately 12:12 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed a opening around the escutcheon on the sprinkler head in Store room, C2121A, on the second (2nd) floor of "C" tower.

All deficiencies were confirmed at the time of discovery.

Based on observation and/or review of records the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6. This deficient practice could potentially affect the occupants of the second floor of the facility if the Simplex panel is not properly protected from fire.

Findings include:

A. On February 8, 2011, at approximately 12:15 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it of observed that the Simplex equipment located in the room at the West end of the elevators, C2109, did not have any smoke detection protecting it.

This deficiency was confirmed at the time of discovery.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect the occupants in 1 of 12 smoke zones on the ground floor, 1 of 7 smoke zones on the first (1st) floor and 1 of 7 smoke zones on the third (3rd) floor of the facility if the sprinkler system failed to operate as designed.

Findings include:

A. On February 3, 2011, at approximately 3:23 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that the Auxiliary drain for the sprinkler system in the EVS closet on the third floor of "A" tower, was not labeled.

B. On February 4, 2011, at approximately 10:00 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the Main Electrical Transformer room, located in the "C" basement, was not sprinklered

C. On February 4, 2011, at approximately 11:12 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the Auxiliary drain for the sprinkler system located in the EVS closet, D3105, on the third floor of "D" tower, was not labeled.

D. On February 8, 2011, at approximately 12:55 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the sprinkler heads located in patient room, C1644, located on the first floor of "C" tower, were improperly spaced to prevent cold soldering of the sprinkler heads.

E. On February 8, 2011, at approximately 1:50 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the sprinkler heads located in Radiology store room, CG169, on the ground floor, were improperly spaced to prevent cold soldering of the sprinkler heads.

F. On February 8, 2011, at approximately 1:51 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the Radiology store room, CG169, on the ground floor, had a mixture of standard response sprinkler heads and quick response sprinklers heads located within the same space.

All the deficiencies were confirmed at the time of discovery.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect the occupants in 1 of 10 smoke zones in the basement, 1 of 12 smoke zones on ground floor, 1 of 7 smoke zones on first (1st) floor, 1 of 12 smoke zones on second (2nd) floor, 1 of 7 smoke zones on third (3rd) floor and 1 of 6 smoke zones on the fourth (4th) floor of the facility if the sprinkler system failed to operate as designed due to lack of maintenance.

Findings include:

A. On February 3, 2011, at approximately 3:25 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that the sprinkler heads in Consultation room, AG121, in the ER department on ground floor, had debris and lint build-up on the sprinkler heads.

B. On February 3, 2011, at approximately 3:28 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that the sprinkler heads in room AG106 and other areas of the Emergency Department on the ground floor had debris and lint build-up on the sprinkler heads.

C. On February 4, 2011, at approximately 9:04 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that the escutcheon on the sprinkler head located in the Women's Locker room in the "B" basement was missing and the head needs to be lowered in the ceiling to allow the escutcheon to stay in place.

D. On February 4, 2011, at approximately 9:37 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that old abandoned speciality fire suppression equipment was still located in the X-ray Film Storage of Ambulatory Care Facility basement.

E. On February 4, 2011, at approximately 11:05 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed lint and debris build-up on sprinkler head located in the Pantry on the fourth (4th) floor of the "D" tower.

F. On February 4, 2011, at approximately 11:20 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed lint and debris build-up on sprinkler head located in room D3123 on the third (3rd) floor of "D" tower.

G. On February 4, 2011, at approximately 12:55 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on sprinkler heads located in Conference Room by Nurse's Station on the third (3rd) floor of "B" tower.

H. On February 4, 2011, at approximately 1:05 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on sprinkler head located in Pantry, B3123, on the third (3rd) floor of "B" tower.

I. On February 4, 2011, at approximately 1:08 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that wires were hanging on the sprinkler piping by the doors at the smoke/fire wall, CCB3105, on the third (3rd) floor of "B" tower.

J. On February 4, 2011, at approximately 1:18 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that wires were hanging on sprinkler piping at the smoke/fire wall, CCB3161, on the third (3rd) floor of "B" tower at B south.

K. On February 4, 2011, at approximately 1:40 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on sprinkler head located in the Respiratory Therapy room of ICU, B2250, on the second (2nd) floor of "B" tower.

L. On February 4, 2011, at approximately 2:27 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on the sprinkler head in the Pantry of OB on the ground floor of "B" tower.

M. On February 4, 2011, at approximately 2:43 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on the sprinkler head in Triage and Emergency Care room, BG120, of OB on the ground floor of "B" tower.

N. On February 4, 2011, at approximately 2:50 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed lint and debris build-up on the sprinkler head in the Lactation Consultants office, BG183, of OB on the ground floor of "B" tower.

O. On February 8, 2011, at approximately 11:59 AM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed lint and debris build-up on sprinkler head in room B3112 on the third (3rd) floor of "C" tower.

All deficiencies were confirmed at the time of discovery.

Based on observation and/or review of records the facility failed to provide portable fire extinguishers in accordance with the LSC sections 19.3.5.6, 9.7.4.1, and NFPA 10. This deficient practice could potentially affect the occupants in 1 of 12 smoke zones on the ground floor, 1 of 7 smoke zones on the first (1st) floor and 1 of 12 smoke zones on the second (2nd) floor if the improper extinguisher is installed.


Findings include:

A. On February 8, 2011, at approximately 12:23 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that a CO2 (type BC) extinguisher was placed in the corridor outside EEG Neurology Staff Physicians room on the second (2nd) floor of "C" tower where ordinary combustibles (type A) are located.

B. On February 8, 2011, at approximately 12:28 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that a CO2 (type BC) extinguisher was placed in the old EP lab across from EEG testing 2 on the second (2nd) floor of "C" tower, where ordinary combustibles (type A) are located.

C. On February 8, 2011, at approximately 1:10 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that a CO2 (type BC) extinguisher was placed in the OT Kitchen, C1173, on the first (1st) floor of "C" tower, where ordinary combustibles (type A) are located.

D. On February 8, 2011, at approximately 2:07 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that a CO2 (type BC) extinguisher was placed in Radiology Recovery room, CG130, on the ground floor of "C" tower, where ordinary combustibles (type A) are located.

All deficiencies were confirmed at the time of discovery.

Based on observation the facility failed to provide chutes that are not in accordance with the LSC sections 9.5, 9.7, 8.4. This deficient practice could potentially affect the occupants in 1 of 6 smoke zones of the facility if the chute failed to operate as designed.

Findings include:

A. On February 4, 2011, at approximately 12:40 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that the door to the soiled linen chute in room B4128 on the fourth (4th) floor of "B" tower was not closing and latching properly.

This deficiency was confirmed at the time of discovery.

Based on observation the facility failed to provide unobstructed egress in accordance with the LSC section 7.1.10. This deficient practice could potentially affect the occupants in 1 of 12 smoke zones of the facility if egress becomes blocked.

Findings include:

A. On February 8, 2011, at approximately 1:40 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that recycling bundles of cardboard were partially blocking the exit from the EVS store room on the ground floor of "C" tower.

This deficiency was confirmed at the time of discovery.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect the occupants in 1 of 7 smoke zones on the first (1st) floor and 1 of 7 smoke zones on the third (3rd) floor of the facility if a fire occurred from improper electrical installation.

Findings include:

A. On February 3, 2011, at approximately 3:20 PM, while conducting a walk through with the Director of Plant Engineering and a Loss Prevention Technician, it was observed that an electrical box located in the Electrical room on the third (3rd) floor of "A" tower, had an extra knockout removed causing a hole in the electrical box.

B. On February 4, 2011, at approximately 2:00 PM, while conducting a walk through with the Manager of Facilities Maintenance and a Loss Prevention Technician, it was observed that the multiple electrical boxes were missing covers located over the catwalk off the Mechanical room located on the first (1st) floor of "B" tower.

C. On February 8, 2011, at approximately 1:12 PM, while conducting a walk through with the Directors of Plant Engineering and Loss Prevention Services, it was observed that an electrical box was missing a cover located in the Comm. Closet, C1233, located on the first (1st) floor of "C" tower.

All deficiencies were confirmed at the time of discovery.