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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 all occupants of the facility. Findings include:

On January 11, 2012 at approximately 10:55 AM, the following observations were made:

1) Observed that there was an incomplete seal on a wire penetration, located by the back door in the Adolescent Hospital.

2) Observed that there was an unsealed conduit penetration, located in the Main Hallway on the Dining Room wall by the old bell.

3) Observed that there was an unsealed conduit penetration, located in the Main Hallway by the Gym door.

4) Observed that there was an unsealed conduit in the corridor (right side of door), located in the south hall by Stairwell #1. (New RTC)

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 12, 2012 at approximately 9:53 AM, the following observation was made:

1) Observed that the door to the exit corridor did not have a self closing mechanism installed, located in the Fiscal Office.

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 all occupants of the facility. Findings include:

On January 11, 2012 at approximately 11:00 AM, the following observations were made:

1) Observed that there was an unsealed conduit in the fire rated wall, located at the Main Hospital Stairwell.

2) Observed that there were two unsealed pipe penetrations (both sides), located in Stairwell #4. (New RTC)

3) Observed that there were two unsealed conduits, one unsealed wire penetration and one incomplete seal on a conduit penetration, located at Stairwell #4. (New RTC)

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 11, 2012 at approximately 10:04 AM, the following observations were made:

1) Observed that there was an unsealed 3/4" conduit penetration and one unsealed conduit, located at the cross corridor smoke barrier by Interview Room #1.

2) Observed that there was an unsealed conduit, one unsealed conduit penetration and one unsealed wire penetration (above the office door), located at the cross corridor smoke barrier by Interview Room #3.

3) Observed that there was an incomplete seal on a conduit penetration, located at the cross corridor smoke barrier (FD #3).

4) Observed that there were two unsealed wire penetrations (right side), and one unsealed conduit penetration, located in the cross corridor smoke barrier by the "A Unit" entry door.

5) Observed that there was an unsealed conduit penetration, the rated fire wall was not smoke tight at the deck and there were voids in the mortar joints between the block, located in the Main Hallway across from the Break Room.

6) Observed that there was an unsealed conduit in the fire rated wall, located in the CFO Office.

7) Observed that there was an unsealed 1" conduit (left side, B side of corridor), located at the cross corridor smoke barrier between "B" and "C" Units.

8) Observed that the fire rated walls were not smoke tight to the decking, located at the cross corridor smoke barrier (FD #5).

9) Observed that there was one unsealed conduit penetration, an incomplete seal on a wire penetration and the two hour rated fire wall was not sealed at the deck, located at the cross corridor smoke barrier (FD#4).

10) Observed that there was an unsealed conduit (lower right side), located at the cross corridor smoke barrier by Stairwell #3. (New RTC)

11) Observed that there was a large void in the smoke barrier (above the air duct) and an incomplete seal on a conduit, located in the north wing cross corridor smoke barrier, by Room 316. (New RTC)

12) Observed that the was an unsealed hole in the block, located at the north wing cross corridor smoke barrier by Room 517. (New RTC)

13) Observed that there was a large void in the block wall (just above the ceiling), located in the cross corridor smoke barrier by Stairwell #3. (New RTC)

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 all occupants of the facility. Findings include:

On January 11, 2012 at approximately 10:35 AM, the following observations were made:

1) Observed that there were two unsealed holes in the block fire rated wall, located in the Fiscal Electrical Room.

2) Observed that there was an unsealed conduit penetration, located on the west fire rated wall in the Fiscal Storage Room.

3) Observed that there were two unsealed copper pipe penetrations in the fire rated wall, located in the Main Corridor by the electrical room.

4) Observed that there were two large diameter sprinkler pipes unsealed penetrations in the fire rated wall, located by the ambulance foyer.

5) Observed that there was a large gap between the block and the air duct in the fire rated wall, located off the Scan Room in the Day/Dining Room.

6) Observed that there was an unsealed wire penetration, one unsealed flexible conduit penetration and an incomplete seal on a 3/4" water line, located in the fire rated wall by the 2nd door to the Day Room.

7) Observed that there were incomplete seals on wire penetrations in the fire rated wall, located in the Coffee Break Room behind the Conference Room.


On January 12, 2012 at approximately 8:53 AM, the following observations were made:

1) Observed that there was an incomplete seal on a pipe penetration, located in the Infectious Waste Storage Room.

2) Observed that there were two incomplete seals on conduits, located along the north wall of Storage Room #1. (New RTC)

3) Observed that there was an unsealed hole in the concrete ceiling (above the boiler) and an unsealed pipe sleeve (south wall), located in the Boiler Room. (New RTC)

4) Observed that there was an incomplete seal on a water pipe penetration, located in the Janitor's Closet #1 across from Room #5. (New RTC)

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 all occupants of the facility. Findings include:

On January 12, 2012 at approximately 8:30 AM, the following observations were made:

1) Observed that the fire department connection coupling were difficult to spin, located outside the loading area.

2) Observed that there was a boxed artificial Christmas Tree stored on top of the walk-in cooler which was positioned within the required eighteen inch clearance of a fire sprinkler head, located in the Dietary Storage Room.

Based on observation and/or review of records the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 11, 2012 at approximately 2:25 PM, the following observation was made:

1) Observed that the fire extinguisher cabinet was damaged and was unable to be readily opened, located by Room 307.


On January 12, 2012 at approximately 9:10 AM, the following observations were made:

1) Observed a fire extinguisher that was missed on December 2011 monthly inspection, located in Storage Room #3.

2) Observed that the fire extinguisher cabinet was damaged and was unable to be readily opened, located by Room 502.

3) Observed that the fire extinguisher cabinet was damaged and was unable to be readily opened, located by South Wing Hallway.

4) Observed that the fire extinguisher cabinet was damaged and was unable to be readily opened, located by Classroom #4.

Based on observation the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 12, 2012 at approximately 10:10 AM, the following observation was made:

1) Observed that there was a portable space heater, located in the Medical Records Office.

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 all occupants of the facility. Findings include:

On January 12, 2012 at approximately 8:55 AM, the following observations were made:

1) Observed that there were fifty desk chairs stored in the corridor by the elevator in the basement. (New RTC)

2) Observed that there were snow sleds stored in the stairwell, located in Stairwell #2.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 12, 2012 at approximately 8:25 AM, the following observation was made:

1) Observed that there was an unsecured oxygen cylinder, located in the Oxygen Storage area.

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 all occupants of the facility. Findings include:

On January 11, 2012 at approximately 10:05 AM, the following observations were made:

1) Observed that the 110 volt wire connection was not enclosed in an electrical junction box, located at the cross corridor smoke barrier by Interview Room #1.

2) Observed that the 110 volt wire connection was not enclosed in an electrical junction box, located in the Fiscal Electrical Room.

3) Observed that the electrical junction box was missing a cover plate, located in the Main Hospital Stairwell.


On January 12, 2012 at approximately 10:00 AM, the following observations were made:

1) Observed that there were two electrical power strips interconnected, located in the Sr. A/R Clerk Office.

2) Observed that there were two electrical power strips interconnected, located in the Medical Records Office.

3) Observed that there were two electrical power strips interconnected, located in Office #6.

4) Observed that there was am electrical extension cord, located in Office #7.

5) Observed that there were two electrical extension cords, located in Risk Management Office.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 11, 2012 at approximately 1:20 PM, the following observation was made:

1) Observed during the review of the facility's emergency plan, the facility failed to provide a policy to notify the Bureau of Fire Services should an outage of the fire sprinkler system occur for more than four hours in a twenty four hour period.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 11, 2012 at approximately 1:20 PM, the following observation was made:

1) Observed during the review of the facility's emergency plan, the facility failed to provide a policy to notify the Bureau of Fire Services should an outage of the fire alarm system occur for more than four hours in a twenty four hour period.

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 all occupants of the facility. Findings include:

On January 11, 2012 at approximately 10:55 AM, the following observations were made:

1) Observed that there was an incomplete seal on a wire penetration, located by the back door in the Adolescent Hospital.

2) Observed that there was an unsealed conduit penetration, located in the Main Hallway on the Dining Room wall by the old bell.

3) Observed that there was an unsealed conduit penetration, located in the Main Hallway by the Gym door.

4) Observed that there was an unsealed conduit in the corridor (right side of door), located in the south hall by Stairwell #1. (New RTC)

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 12, 2012 at approximately 9:53 AM, the following observation was made:

1) Observed that the door to the exit corridor did not have a self closing mechanism installed, located in the Fiscal Office.

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 all occupants of the facility. Findings include:

On January 11, 2012 at approximately 11:00 AM, the following observations were made:

1) Observed that there was an unsealed conduit in the fire rated wall, located at the Main Hospital Stairwell.

2) Observed that there were two unsealed pipe penetrations (both sides), located in Stairwell #4. (New RTC)

3) Observed that there were two unsealed conduits, one unsealed wire penetration and one incomplete seal on a conduit penetration, located at Stairwell #4. (New RTC)

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 11, 2012 at approximately 10:04 AM, the following observations were made:

1) Observed that there was an unsealed 3/4" conduit penetration and one unsealed conduit, located at the cross corridor smoke barrier by Interview Room #1.

2) Observed that there was an unsealed conduit, one unsealed conduit penetration and one unsealed wire penetration (above the office door), located at the cross corridor smoke barrier by Interview Room #3.

3) Observed that there was an incomplete seal on a conduit penetration, located at the cross corridor smoke barrier (FD #3).

4) Observed that there were two unsealed wire penetrations (right side), and one unsealed conduit penetration, located in the cross corridor smoke barrier by the "A Unit" entry door.

5) Observed that there was an unsealed conduit penetration, the rated fire wall was not smoke tight at the deck and there were voids in the mortar joints between the block, located in the Main Hallway across from the Break Room.

6) Observed that there was an unsealed conduit in the fire rated wall, located in the CFO Office.

7) Observed that there was an unsealed 1" conduit (left side, B side of corridor), located at the cross corridor smoke barrier between "B" and "C" Units.

8) Observed that the fire rated walls were not smoke tight to the decking, located at the cross corridor smoke barrier (FD #5).

9) Observed that there was one unsealed conduit penetration, an incomplete seal on a wire penetration and the two hour rated fire wall was not sealed at the deck, located at the cross corridor smoke barrier (FD#4).

10) Observed that there was an unsealed conduit (lower right side), located at the cross corridor smoke barrier by Stairwell #3. (New RTC)

11) Observed that there was a large void in the smoke barrier (above the air duct) and an incomplete seal on a conduit, located in the north wing cross corridor smoke barrier, by Room 316. (New RTC)

12) Observed that the was an unsealed hole in the block, located at the north wing cross corridor smoke barrier by Room 517. (New RTC)

13) Observed that there was a large void in the block wall (just above the ceiling), located in the cross corridor smoke barrier by Stairwell #3. (New RTC)

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 all occupants of the facility. Findings include:

On January 11, 2012 at approximately 10:35 AM, the following observations were made:

1) Observed that there were two unsealed holes in the block fire rated wall, located in the Fiscal Electrical Room.

2) Observed that there was an unsealed conduit penetration, located on the west fire rated wall in the Fiscal Storage Room.

3) Observed that there were two unsealed copper pipe penetrations in the fire rated wall, located in the Main Corridor by the electrical room.

4) Observed that there were two large diameter sprinkler pipes unsealed penetrations in the fire rated wall, located by the ambulance foyer.

5) Observed that there was a large gap between the block and the air duct in the fire rated wall, located off the Scan Room in the Day/Dining Room.

6) Observed that there was an unsealed wire penetration, one unsealed flexible conduit penetration and an incomplete seal on a 3/4" water line, located in the fire rated wall by the 2nd door to the Day Room.

7) Observed that there were incomplete seals on wire penetrations in the fire rated wall, located in the Coffee Break Room behind the Conference Room.


On January 12, 2012 at approximately 8:53 AM, the following observations were made:

1) Observed that there was an incomplete seal on a pipe penetration, located in the Infectious Waste Storage Room.

2) Observed that there were two incomplete seals on conduits, located along the north wall of Storage Room #1. (New RTC)

3) Observed that there was an unsealed hole in the concrete ceiling (above the boiler) and an unsealed pipe sleeve (south wall), located in the Boiler Room. (New RTC)

4) Observed that there was an incomplete seal on a water pipe penetration, located in the Janitor's Closet #1 across from Room #5. (New RTC)

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 all occupants of the facility. Findings include:

On January 12, 2012 at approximately 8:30 AM, the following observations were made:

1) Observed that the fire department connection coupling were difficult to spin, located outside the loading area.

2) Observed that there was a boxed artificial Christmas Tree stored on top of the walk-in cooler which was positioned within the required eighteen inch clearance of a fire sprinkler head, located in the Dietary Storage Room.

Based on observation and/or review of records the facility failed to provide fire extinguishers in accordance with the LSC section 19.3.5.6. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 11, 2012 at approximately 2:25 PM, the following observation was made:

1) Observed that the fire extinguisher cabinet was damaged and was unable to be readily opened, located by Room 307.


On January 12, 2012 at approximately 9:10 AM, the following observations were made:

1) Observed a fire extinguisher that was missed on December 2011 monthly inspection, located in Storage Room #3.

2) Observed that the fire extinguisher cabinet was damaged and was unable to be readily opened, located by Room 502.

3) Observed that the fire extinguisher cabinet was damaged and was unable to be readily opened, located by South Wing Hallway.

4) Observed that the fire extinguisher cabinet was damaged and was unable to be readily opened, located by Classroom #4.

Based on observation the facility failed to provide for the protection of occupants by allowing space heaters that are not in accordance with the LSC section 19.7.8. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 12, 2012 at approximately 10:10 AM, the following observation was made:

1) Observed that there was a portable space heater, located in the Medical Records Office.

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 all occupants of the facility. Findings include:

On January 12, 2012 at approximately 8:55 AM, the following observations were made:

1) Observed that there were fifty desk chairs stored in the corridor by the elevator in the basement. (New RTC)

2) Observed that there were snow sleds stored in the stairwell, located in Stairwell #2.

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 12, 2012 at approximately 8:25 AM, the following observation was made:

1) Observed that there was an unsecured oxygen cylinder, located in the Oxygen Storage area.

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 all occupants of the facility. Findings include:

On January 11, 2012 at approximately 10:05 AM, the following observations were made:

1) Observed that the 110 volt wire connection was not enclosed in an electrical junction box, located at the cross corridor smoke barrier by Interview Room #1.

2) Observed that the 110 volt wire connection was not enclosed in an electrical junction box, located in the Fiscal Electrical Room.

3) Observed that the electrical junction box was missing a cover plate, located in the Main Hospital Stairwell.


On January 12, 2012 at approximately 10:00 AM, the following observations were made:

1) Observed that there were two electrical power strips interconnected, located in the Sr. A/R Clerk Office.

2) Observed that there were two electrical power strips interconnected, located in the Medical Records Office.

3) Observed that there were two electrical power strips interconnected, located in Office #6.

4) Observed that there was am electrical extension cord, located in Office #7.

5) Observed that there were two electrical extension cords, located in Risk Management Office.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 11, 2012 at approximately 1:20 PM, the following observation was made:

1) Observed during the review of the facility's emergency plan, the facility failed to provide a policy to notify the Bureau of Fire Services should an outage of the fire sprinkler system occur for more than four hours in a twenty four hour period.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On January 11, 2012 at approximately 1:20 PM, the following observation was made:

1) Observed during the review of the facility's emergency plan, the facility failed to provide a policy to notify the Bureau of Fire Services should an outage of the fire alarm system occur for more than four hours in a twenty four hour period.