HospitalInspections.org

Based on observation and/or review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 29, 2012 the following observations were made:

1) At approximately 1:20 PM, it was observed that there were eleven ceiling tiles missing, located in Room 127 of the 62 Building.
2) At approximately 1:23 PM, it was observed that there were twelve ceiling tiles missing, located in the Northwest Electrical Closet of the 62 Building.
3) At approximately 1:35 PM, it was observed that there was a ceiling tile missing, located in the 1st Floor Staff Lounge of the 62 Building.
4) At approximately 2:13 PM, it was observed that there was a ceiling tile missing, located in Room 250 of the 62 Building.

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 February 28, 2012 the following observations were made:

1) At approximately 1:35 PM, it was observed that there was an unsealed large diameter conduit on the south wall, located in the Communication Room on the 3rd Floor of the 75 Building.
2) At approximately 2:10 PM, it was observed that there were two unsealed holes in the wallboard, located under the Reception Desk on 2-South of the 75 Building.
3) At approximately 2:15 PM, it was observed that the corridor wall was not smoke tight, located by Exam Room #4 in the 1st Floor Cardiology Department in the 75 Building.

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 February 28, 2012 the following observations were made:

1) At approximately 8:30 AM, it was observed that the cross corridor smoke barrier door (east door) did not close to a positive latch, located by Room 3015.
2) At approximately 9:10 AM, it was observed that the door to the corridor was propped in the open position with a coat rack, located in the Doctor's Lounge - Room 3078, in the Surgery Department.
3) At approximately 9:15 AM, it was observed that the door did not close to a positive latch, located in Room 3068.
4) At approximately 10:35 AM, it was observed that the door did not close to a positive latch, located in Room 2064 A.
5) At approximately 12:38 PM, it was observed that the door did not close to a positive latch (due to tape applied to door jamb), located in the Changing Room by Room 1075 C.

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 February 29, 2012 the following observations were made:

1) At approximately 8:53 AM, it was observed that the door to the corridor did not close to a positive latch, located in Room 503 of the 28 Building.
2) At approximately 8:54 AM, it was observed that there was a dead-bolt lockset installed on the door to the corridor, located in Room 505 of the 28 Building.
3) At approximately 9:05 AM, it was observed that there was a dead-bolt lockset installed on the door to the corridor, located in Room 405 of the 28 Building.
4) At approximately 10:11 AM, it was observed that the door to the corridor did not close to a positive latch, located in the Basement Service Closet of the 28 Building.
5) At approximately 10:16 AM, it was observed that the door to the corridor did not close to a positive latch, located from the 28 Sub Basement corridor to the main corridor of the 28 Building.
6) At approximately 10:20 AM, it was observed that the door to the corridor did not close to a positive latch, located in the Lady's Locker Room to the main corridor on the Basement level of the 28 Building.
7) At approximately 10:33 AM, it was observed that the door to the corridor did not close to a positive latch, located in the Men's Locker Room to the main corridor on the Basement level of the 28 Building.
8) At approximately 12:15 PM, it was observed that there were two dead-bolt locksets installed on the doors into the Laboratory Department on the Ground Floor of the 62 Building.
9) At approximately 1:11 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 113 of the 62 Building.
10) At approximately 1:16 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 125 of the 62 Building.
11) At approximately 1:50 PM, it was observed that the door to the corridor did not close to a positive latch, located in the Clean Utility Room on the 2nd Floor of the 62 Building.
12) At approximately 2:12 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 245 of the 62 Building.
13) At approximately 2:13 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 247 of the 62 Building.
14) At approximately 2:15 PM, it was observed that the door to the corridor was missing, located in Room 252 of the 62 Building.
15) At approximately 2:16 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 255 of the 62 Building.
16) At approximately 2:17 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 256 of the 62 Building.

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 February 29, 2012 the following observation was made:

1) At approximately 10:14 AM, it was observed that the door did not close to a positive latch, located to the stairwell to the 28 Sub Basement.

Based on observation the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 29, 2012 the following observation was made:

1) At approximately 10:15 AM, it was observed that the exit was not clearly labeled as such, located in the corridor from the 28 Sub Basement of the 28 Building.

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 February 27, 2012 the following observations were made:

1) At approximately 11:40 AM, it was observed that there were three unsealed penetrations in the smoke barrier wall above the ceiling, located across from Room 8011.
2) At approximately 11:45 AM, it was observed that there were two unsealed EMT penetrations in the 1 hour wall above the ceiling, located in a hazard room - Room 8018.
3) At approximately 11:50 AM, it was observed that there were two unsealed EMT and Romex Wire penetrations above the ceiling in the smoke barrier wall, located in Room 8030.
4) At approximately 1:35 PM, it was observed that there was an unsealed conduit in a rated fire wall, located by the cross corridor smoke barrier by Room 7042.

On February 28, 2012 the following observations were made:

5) At approximately 8:10 AM, it was observed that there was an incomplete seal on a conduit penetration in a rated fire wall (east wall), located in the Main Electrical Closet, in the Kitchen.
6) At approximately 8:25 AM, it was observed that there was an unsealed wire penetration, an unsealed conduit penetration and a void in the cable tray, located at the cross corridor smoke barrier at the south corridor, on the 3rd Floor.
7) At approximately 9:07 AM, it was observed that there was an incomplete seal on a conduit penetration, located at the cross corridor smoke barrier by Room 3081.
8) At approximately 9:18 AM, it was observed that there were two incomplete seals on large diameter conduits, the wallboard seams need to be sealed by the door. Also, three walls are not smoke tight at the decking, located in Room 3058 A.
9) At approximately 9:25 AM, it was observed that there was an unsealed PVC pipe penetration and the wallboard seam was unsealed (lower left side), located at the cross corridor smoke barrier by the South Elevator, on the 3rd Floor by Clean Surgery.
10) At approximately 12:02 PM, it was observed that there was an unsealed conduit penetration in the fire rated wall, located between Elevators 1 and 2 on the 1st Floor.
11) At approximately 12:03 PM, it was observed that there was an unsealed water line pipe penetration above the door, located in Room 1001.
12) At approximately 12: 36 PM, it was observed that there were three incomplete seals on conduit penetrations on the east wall, located in the Communication Room on the 1st Floor.
13) At approximately 1:01 PM, it was observed that there were four unsealed penetrations (1-copper pipe, 3 conduit penetrations) on the corridor wall and one unsealed conduit, located in the Basement Switch Gear Room.

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 February 29, 2012 the following observations were made:

1) At approximately 9:31 AM, it was observed that there was a hole in the wallboard behind the door, located in the 2-North Stairwell on the 2nd Floor of the 28 Building.
2) At approximately 10:45 AM, it was observed that there incomplete seals on a wire penetration and a conduit penetration, located at the cross corridor smoke barrier from the 62 Building to the 28 Building at the Basement level.
3) At approximately 12:52 PM, it was observed that there was a large hole in the block wall separation above the ceiling at the door to the Computerized Tomography Department, located on the Ground Floor of the 62 Building.
4) At approximately 1:10 PM. it was observed that the door coordinator was missing from the cross corridor smoke barrier doors, located near Room 113 on the 1st Floor of the 62 Building.

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 XX occupants of the facility.

Findings include:

On February 27, 2012 the following observation was made:

1) At approximately 11:26 AM, it was observed that one door of the cross corridor smoke barrier doors did not open after testing, located by Room 9041. Note: the door was repaired a short time later.

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 February 28, 2012 the following observations were made:

1) At approximately 1:42 PM, it was observed that there were two unsealed holes in the wallboard on the corridor wall, located in the 75 Building Penthouse Mechanical Room.
2) At approximately 2:28 PM, it was observed that there was an unsealed conduit and an unsealed wire penetration, located in the Cardiac Cath Lab Mechanical Room on the 1st Floor of the 75 Building.
3) At approximately 2:42 PM, it was observed that there were nine unsealed conduits, located in the Cardiac Cath Storage Room of the 75 Building.

On February 29, 2012 the following observations were made:

4) At approximately 10:38 AM, it was observed that the doors to the exit corridor were propped in the open position, located in the Environmental Services Room in the Basement of the 28 Building.
5) At approximately 11:18 AM, it was observed that there was an incomplete seal on a pipe penetration above the door, located in the Generator Electrical Room on the Ground Floor of the 62 Building.
6) At approximately 1:25 PM, it was observed that the door did not close to a positive latch, located in the Janitor's Closet on the 1st Floor of the 62 Building.
7) At approximately 1:43 PM, it was observed that the door to the corridor was removed, located in the Laundry Room on the 2nd Floor of the 62 Building.
8) At approximately 2:03 PM, it was observed that the ceiling access hatch was open, located in the Janitor's Closet in the Psychiatric Ward on the 2nd Floor of the 62 Building.
9) At approximately 2:33 PM, it was observed that there was an unsealed conduit penetration, located in the Mechanical Room on the 3rd Floor of the 62 Building.

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 February 27, 2012 the following observations were made:

1) At approximately at 2:30 PM, it was observed that there was an unsealed beam penetration, located at the north end of the elevator shaft, in the North End Mechanical Room on the 5th Floor.
2) At approximately at 2:40 PM, it was observed that the door did not close to a positive latch, located at the Doctor's Dining Room Kitchen to the corridor on the 4th Floor.

On February 28, 2012 the following observations were made:

3) At approximately at 12:30 PM, it was observed that the door to the corridor was tided in the open position, located in the Linen Storage Room on the 1st Floor.
4) At approximately 12:40 PM, it was observed that the door did not close to a positive latch, located in the Pump Room.
5) At approximately 1:15 PM, it was observed that the door did not have a self closing mechanism device, located in the Basement Staff Lounge.
6) At approximately 1:16 PM, it was observed that the door did not have a self closing mechanism device, located in Room 0009 A in the Basement.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 28, 2012 the following observations were made:

1) At approximately 9:20 AM, it was observed that the emergency light fixture did not work when tested, located in OR Room #3.
2) At approximately 12:39 PM, it was observed that the emergency light fixture did not work when tested, located in corridor to the MRI docking area.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 29, 2012 the following observation was made:

1) At approximately 11:20 AM, it was observed that two emergency lighting fixtures did not work when tested, located in the PACS Room on the Ground Floor of the 62 Building.

Based on observation and/or review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 29, 2012 the following observation was made:

1) At approximately 1:36 PM, it was observed that there was an incomplete Fire Safety Plan for the staff and patient safety, located in the Emergency Procedure Book on the 1st Floor of the North Substance Abuse Ward.

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 all occupants of the facility. Findings include:

On February 29, 2012 the following observations were made:

1) At approximately 10:58 AM, it was observed that the room did not have a fire alarm strobe device installed, located in the Conference Room on the Ground Floor of the 62 Building.
2) At approximately 11:10 AM, it was observed that the room did not have a fire alarm strobe device installed, located in the large X-Ray Reading Room on the Ground Floor of the 62 Building.
3) At approximately 12:45 PM, it was observed that the room did not have a fire alarm strobe device installed, located in the X-Ray Waiting Room on the Ground Floor of the 62 Building.
4) At approximately 2:00 PM, it was observed that the smoke detector was installed within the required three foot spacing of an air vent, located in the Psychiatric Ward on the 2nd Floor of the 62 Building.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 28, 2012 the following observation was made:

1) At approximately 3:00 PM, it was observed during the review of the facility's documents that the facility did not have current documentation for the smoke detector sensitivity testing, for the 28, 62 and 75 Buildings.

On February 29, 2012 the following observations were made:

2) At approximately 10:00 AM, it was observed that the area used as a storage was not protected with smoke detectors, located in the Pharmacy Storage area on the 1st Floor of the 28 Building.
3) At approximately 11:05 AM, it was observed that the smoke detector was not properly mounted, located in the Old CAT Scan A/C Room on the Ground Floor of the 62 Building.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 28, 2012 the following observations were made:

1) At approximately 8:05 AM, it was observed that a smoke detector was not completely attached to it mounting base, located in the Main Kitchen.
2) At approximately 3:00 PM, it was observed during the review of the facility's documents that the facility did not have current documentation for the smoke detector sensitivity testing.

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 all occupants of the facility. Findings include:

On February 27, 2012 the following observations were made:

1) At approximately 10:49 AM, it was observed that there was a cloth rag attached to the fire sprinkler piping, located in the 11th Floor North Elevator Room.
2) At approximately 11:00 AM, it was observed that the fire sprinkler head was covered with dust, located in the 11th Floor South Elevator Room by Unit #5.
3) At approximately 12:06 PM, it was observed that the fire sprinkler head was missing an escutcheon plate, located by the 8 th Floor Men's Restroom.

On February 28, 2012 the following observations were made:

4) At approximately 8:40 AM, it was observed that the fire sprinkler head was missing an escutcheon plate, located by the Endo Classroom Corridor.
5) At approximately 8:42 AM, it was observed that the ceiling tile was out of place resulting in a space not protected by the fire sprinkler system, located in the Endo Room #1 in the Endo Department on the 3rd Floor.
6) At approximately 8:43 AM, it was observed that the ceiling tile was out of place resulting in a space not protected by the fire sprinkler system, located in the Endo Room #2 in the Endo Department on the 3rd Floor.
7) At approximately 8:44 AM, it was observed that the ceiling tile was out of place resulting in a space not protected by the fire sprinkler system, located in the Endo Room #3 in the Endo Department on the 3rd Floor.
8) At approximately 9:44 AM, it was observed that the fire sprinkler head was missing an escutcheon plate, located Medical Records Office Room 2006.
9) At approximately 9:55 AM, it was observed that the corridor to the restroom did not have proper fire sprinkler coverage, located in the Administration Offices.
10) At approximately 10:30 AM, it was observed that the fire sprinkler head was missing an escutcheon plate, located in the Locker Room/Restroom in the CSR Department.
11) At approximately 12:31 PM, it was observed that there were three ceiling tiles were out of place resulting in a space not protected by the fire sprinkler system, located in the Milk Cooler Room on the 1st Floor.
12) At approximately 12:45 PM, it was observed that the suction and supply gauges were missing at the fire pump, located in the Fire Pump Room.
13) At approximately 12:46 PM, it was observed that there was a storage of materials blocking access to the fire pump control valves, located in the Fire Pump Room.
14) At approximately 12:50 PM, it was observed that there were four ceiling tiles missing resulting in a space not protected by the fire sprinkler system, located in the Telecommunications Room in the Basement.

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 all occupants of the facility. Findings include:

On February 29, 2012 the following observations were made:

1) At approximately 9:32 AM, it was observed that there was a large amount of combustible items stored in the old Kitchen area which is not protected with a fire sprinkler system, located on the 2nd Floor of the 28 Building.
2) At approximately 10:04 AM, it was observed that there were three ceiling tiles missing resulting in a space not protected by the fire sprinkler system, located in the Old Kitchen on the 1st Floor of the 28 Building.
3) At approximately 10:25 AM, it was observed that there were three ceiling tiles missing resulting in a space not protected by the fire sprinkler system, located in the Pulmonary Function Testing Storage Room in the Basement of the 28 Building.
4) At approximately 10:30 AM, it was observed that there was a ceiling tile missing resulting in a space not protected by the fire sprinkler system, located in the X-Ray File Storage Room in the Basement of the 28 Building.
5) At approximately 10:31 AM, it was observed that there was a ceiling tile missing resulting in a space not protected by the fire sprinkler system, located in the Maintenance Office in the Basement of the 28 Building.
6) At approximately 10:50 AM, it was observed that there was a ceiling tile missing resulting in a space not protected by the fire sprinkler system, located in the Old CAT Scan Control Closet on the Ground Floor of the 62 Building.
7) At approximately 10:59 AM, it was observed that the fire sprinkler head was missing an escutcheon plate, located in the Ground Floor X-Ray File Room of the 62 Building.
8) At approximately 12:25 PM, it was observed that the fire sprinkler head was missing an escutcheon plate, located in the Ground Floor Chemistry Department of the 62 Building.
9) At approximately 12:30 PM, it was observed that there was incomplete coverage of the fire sprinkler system, located in the Blood Bank on the Ground Floor of the 62 Building.
10) At approximately 12:35 PM, it was observed that the fire sprinkler head was missing an escutcheon plate, located in the Employee Coat Closet of the Ground Floor Pathology Department of the 62 Building.
11) At approximately 12:40 PM, it was observed that the fire sprinkler head was missing an escutcheon plate, located in the Handicap Restroom of the 62 Building.
12) At approximately 12:47 PM, it was observed that there were three ceiling tiles missing resulting in a space not protected by the fire sprinkler system, located in the Break Room of the Laboratory on the Ground Floor of the 62 Building.
13) At approximately 12:50 PM, it was observed that there were two ceiling tiles missing resulting in a space not protected by the fire sprinkler system, located in the IT Room by the Elevator Lobby on the 2nd Floor of the 62 Building.

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:

1) At approximately 12:50 PM, it was observed that the left side coupling was difficult to turn, located at the fire department connection on the Ground Floor of the 62 Building.

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 February 27, 2012 the following observation was made:

1) At approximately 10:59 AM, it was observed that the fire extinguisher was positioned on the floor, located in the 11th Floor South Elevator Control 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 February 28, 2012 the following observation was made:

1) At approximately 2:45 PM, it was observed that there was a fire extinguisher that needed to be recharged, located in the ER Fire Alarm Closet on the 1st Floor of the 75 Building.

On February 29, 2012 the following observations were made:

2) At approximately 12:29 PM, it was observed that the access to the fire extinguisher was blocked by a refrigerator, located in the Blood Bank on the Ground Floor of the 62 Building.
3) At approximately 12:48 PM, it was observed that there was a fire extinguisher with an out dated inspection tag (February 2009), located in the IT Room on the Ground Floor of the 62 Building.
4) At approximately 1:43 PM, it was observed that there was a fire extinguisher with an out dated inspection tag (February 2003), located in the Old CSR Room on the 1st Floor of the 62 Building.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 28, 2012 the following observations were made:

1) At approximately at 8:00 AM, it was observed that the cook was unable to clearly identify the proper operation of the Fire Hood Suppression System, on the 4th Floor.
2) At approximately 8:03 AM, it was observed that an appliance was plugged into a duplex outlet outside the main hood, in the front cooking area, on the 4th Floor. Provide documentation that this outlet shuts down electrical power to the appliances once the fire hood suppression system is activated.
3) At approximately 8:05 AM, it was observed that there were two emergency gas shut offs that were not labeled as such, located in the Main Kitchen and Doctor's Dining Room Kitchen, on the 4th Floor.

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 February 28, 2012 the following observations were made:

1) At approximately 2:03 PM, it was observed that there was a portable electrical space heater, located in the 2-South Staff Break Room of the 75 Building.
2) At approximately 2:25 PM, it was observed that there was a portable electrical space heater, located in the 2-South Cardiac Cath Nurse's Station of the 75 Building.
3) At approximately 2:42 PM, it was observed that there were three portable electrical space heaters, located on the Ground Floor in the Security - Fire Alarm Panel Room, of the 75 Building.

On February 29, 2012 the following observations were made:

4) At approximately 8:50 AM, it was observed that there was a portable electrical space heater, located in Room 510 of the 28 Building.
5) At approximately 8:56 AM, it was observed that there was a portable electrical space heater, located in Room 506 of the 28 Building.
6) At approximately 8:57 AM, it was observed that there was a portable electrical space heater, located in Room 508 of the 28 Building.
7) At approximately 9:10 AM, it was observed that there was a portable electrical space heater, located in the storage room of the Community Programming Office 4th Floor of the 28 Building.
8) At approximately 9:22 AM, it was observed that there was a portable electrical space heater, located in the Library Office on the 3rd Floor of the 28 Building.
9) At approximately 10:50 AM, it was observed that there was a portable electrical space heater, located in the large X-Ray Reading Room on the Ground Floor of the 62 Building.
10) At approximately 1:05 PM, it was observed that there was a portable electrical space heater, located in the Room 109 of the 62 Building.
11) At approximately 1:18 PM, it was observed that there were three portable electrical space
heaters, located in the Room 123 of the 62 Building.
12) At approximately 1:21 PM, it was observed that there was a portable electrical space heater, located at the Northwest Nursing Station on the 1st Floor of the 62 Building.
13) At approximately 1:28 PM, it was observed that there was a portable electrical space heater, located in the Social Workers Office on the 1st Floor of the 62 Building.

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 February 28, 2012, the following observation was made:

1) At approximately 12:10 PM, it was observed that there was a portable electric space heater, located in Room 1050.

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 February 27, 2012 the following observations were made:

1) At approximately 11:35 AM, it was observed that there was a bed stored in the corridor, located by Room 8030.
2) At approximately 2:06 PM, it was observed that there was a bed stored in the corridor, located by Room 6030.

On February 28, 2012 the following observations were made:

3) At approximately 9:13 AM, it was observed that the exit corridor was blocked by X-ray equipment, located by Room 3070, in the Surgery Department.
4) At approximately 12:40 PM, it was observed that there were signs and a floor buffer pad stored in the stairwell, located in Stairwell #1 at the Basement Level.

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 February 28, 2012 the following observation was made:

1) At approximately 2:35 PM, it was observed that there was one patient cart, one wheel chair along with wheelchair parts and a dust mop stored in the stairwell, located on the Ground Floor in the North 75 Stairwell in the 75 Building.

On February 29, 2012 the following observations were made:

2) At approximately 8:35 AM, it was observed that there were items stored in the exit corridor, located in the North Exit Corridor on the 6th Floor of the 28 Building.
3) At approximately 9:10 AM, it was observed that there were items stored in the exit corridor, located in the North Exit Corridor on the 4th Floor of the 28 Building.

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 February 28, 2012 the following observation was made:

1) At approximately 12:00 PM, it was observed that there was a large helium tank that was not secured, located in Room 1001.

Based on observation and/or review of records the facility failed to submit plans for the renovation project taking place in the 7-north wing. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 29, 2012 the following observation was made:

1) At approximately 8:20 AM, observed that there was an unapproved project in progress with walls under demolition, ceilings removed and unsealed holes in the corridor walls, located on the North Wing of the 7th Floor in the 28 Building. Note: plans have not been submitted to the Bureau of Fire Services for review as of this date.

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 February 27, 2012 the following observations were made:

1) At approximately 10:48 AM it was observed that there was an electrical junction box missing a cover plate, located in the 11th Floor North Elevator Room, by Elevator #1.
2) At approximately 1:30 PM it was observed that there was an electrical extension cord in use, located in Room 7044.
3) At approximately 1:40 PM it was observed that there was an electrical outlet within three feet of the sink, which was not equipped with a GFCI outlet, located in the Pantry (Room 7013).

On February 28, 2012 the following observations were made:

4) At approximately 8:14 AM, it was observed that the wiring on the dishwasher steamer was separated from the electrical junction box, located in the Main Kitchen.
5) At approximately 8:17 AM, it was observed that there was an electrical extension cord in use, located under the fire hood suppression system, in the Main Kitchen.
6) At approximately 10:14 AM, it was observed that there was a damaged electrical power strip in use, located in the Pharmacy Department on the 2nd Floor. Note: the damaged device was removed at time of inspection.
7) At approximately 12:47 PM, it was observed that there was an electrical extension cord in use, located in the Fire Pump Room in the Basement.
8) At approximately 1:17 PM, it was observed that there was a quad outlet box missing a cover plate, located in Room 0009 A.

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 February 28, 2012 the following observations were made:

1) At approximately 1:32 PM, it was observed that there was an electrical extension cord in use, located in the Trauma Coordinator's Office on the 3rd Floor of the 75 Building.
2) At approximately 1:35 PM, it was observed that the flexible conduit was not attached to the junction box of the circulating pump, located at AHU #1 in the 75 Building Mechanical Room.
3) At approximately 1:42 PM, it was observed that there were 110 volt wires that did not terminate in an electrical junction box, located on the corridor wall in the 75 Building Penthouse Mechanical Room.
4) At approximately 1:45 PM, it was observed that there was an electrical junction box missing a cover plate, located in the 75 Building Chiller Room.
5) At approximately 1:46 PM, it was observed that there was an electrical conduit was detached for the junction box of the hot water circulating pump by AHU #3, located in the 75 Building Mechanical Room.
6) At approximately 2:04 PM, it was observed that there was an electrical extension cord in use, located in the 2 - South Staff Break Room of the 75 Building.
7) At approximately 2:21 PM, it was observed that there were two electrical power strips interconnected, located in the Cardiologist's Office on the 1st Floor of the 75 Building.
8) At approximately 2:40 PM, it was observed that there were three electrical extension cords in use, located in Pam's Office on the Ground Floor of the 75 Building.

On February 29, 2012 the following observations were made:

9) At approximately 8:33 AM it was observed that there were two electrical power strips interconnected, located in the Medical Education Office on the 6th Floor of the 28 Building.
10) At approximately 8:57 AM, it was observed that there was an electrical extension cord in use, located in Room 508 of the 28 Building.
11) At approximately 9:15 AM, it was observed that there was an electrical extension cord in use, located in the Department of Education Office on the 4th Floor of the 28 Building.
12) At approximately 9:40 AM, it was observed that there was an electrical extension cord in use, located by the rear exit in the Clinical Engineering Department on the 2nd Floor of the 28 Building.
13) At approximately 10:23 AM, it was observed that there was an electrical extension cord in use, located in the Basement Office by the Respiratory Therapy Department of the 28 Building.
14) At approximately 10:25 AM, it was observed that there was an electrical extension cord in use, located in the Basement Respiratory Therapy Department Storage Room of the 28 Building.
15) At approximately 10:32 AM, it was observed that there was an electrical extension cord in use, located in the Basement Men's Locker Room of the 28 Building.
16) At approximately 10:55 AM, it was observed that there was an electrical extension cord in use, located in the X-Ray Control Room on the Ground Floor of the 62 Building.
17) At approximately 10:58 AM, it was observed that the electrical outlet was missing a cover plate, located in the Conference Room on the Ground Floor of the 62 Building.
18) At approximately 12:42 PM, it was observed that there was an electrical junction box missing a cover plate, located in the Mechanical Room on the Ground Floor of the 62 Building.
19) At approximately 12:43 PM, it was observed that there was an electrical junction box missing a cover plate, located on the east wall of the Mechanical Room on the Ground Floor of the 62 Building.
20) At approximately 12:56 PM, it was observed that there were two electrical junction boxes missing cover plates, located in the old employee entrance corridor across from the ER Department door on the Ground Floor of the 62 Building.
21) At approximately 1:05 PM, it was observed that there was an electrical extension cord in use, located in Patty's Office on the 1st Floor of the 62 Building.
22) At approximately 1:19 PM, it was observed that there was an electrical extension cord in use, located in Room 123 of the 62 Building.
23) At approximately 2:08 PM, it was observed that there was an electrical outlet not protected with a GFIC, located in the Clean Storage Room on the 2nd Floor of the 62 Building.
24) At approximately 2:32 PM, it was observed that there was an electrical junction box missing a cover plate, located in the Mechanical Room on the 3rd Floor of the 62 Building.

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 February 27, 2012 the following observation was made:

1) At approximately 11:55 AM, it was observed during the review of the facility documents the facility failed to provide a document for notifying 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 February 29, 2012 the following observation was made:

1) At approximately 2:50 PM, it was observed during the review of the facility documents the facility failed to provide a document for notifying 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 February 27, 2012 the following observation was made:

1) At approximately 11:56 AM, it was observed during the review of the facility documents that the facility failed to provide a document for notifying 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 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 February 29, 2012 the following observation was made:

1) At approximately 2:50 PM, it was observed during the review of the facility documents that the facility failed to provide a document for notifying 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 and/or review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 29, 2012 the following observations were made:

1) At approximately 1:20 PM, it was observed that there were eleven ceiling tiles missing, located in Room 127 of the 62 Building.
2) At approximately 1:23 PM, it was observed that there were twelve ceiling tiles missing, located in the Northwest Electrical Closet of the 62 Building.
3) At approximately 1:35 PM, it was observed that there was a ceiling tile missing, located in the 1st Floor Staff Lounge of the 62 Building.
4) At approximately 2:13 PM, it was observed that there was a ceiling tile missing, located in Room 250 of the 62 Building.

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 February 28, 2012 the following observations were made:

1) At approximately 1:35 PM, it was observed that there was an unsealed large diameter conduit on the south wall, located in the Communication Room on the 3rd Floor of the 75 Building.
2) At approximately 2:10 PM, it was observed that there were two unsealed holes in the wallboard, located under the Reception Desk on 2-South of the 75 Building.
3) At approximately 2:15 PM, it was observed that the corridor wall was not smoke tight, located by Exam Room #4 in the 1st Floor Cardiology Department in the 75 Building.

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 February 28, 2012 the following observations were made:

1) At approximately 8:30 AM, it was observed that the cross corridor smoke barrier door (east door) did not close to a positive latch, located by Room 3015.
2) At approximately 9:10 AM, it was observed that the door to the corridor was propped in the open position with a coat rack, located in the Doctor's Lounge - Room 3078, in the Surgery Department.
3) At approximately 9:15 AM, it was observed that the door did not close to a positive latch, located in Room 3068.
4) At approximately 10:35 AM, it was observed that the door did not close to a positive latch, located in Room 2064 A.
5) At approximately 12:38 PM, it was observed that the door did not close to a positive latch (due to tape applied to door jamb), located in the Changing Room by Room 1075 C.

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 February 29, 2012 the following observations were made:

1) At approximately 8:53 AM, it was observed that the door to the corridor did not close to a positive latch, located in Room 503 of the 28 Building.
2) At approximately 8:54 AM, it was observed that there was a dead-bolt lockset installed on the door to the corridor, located in Room 505 of the 28 Building.
3) At approximately 9:05 AM, it was observed that there was a dead-bolt lockset installed on the door to the corridor, located in Room 405 of the 28 Building.
4) At approximately 10:11 AM, it was observed that the door to the corridor did not close to a positive latch, located in the Basement Service Closet of the 28 Building.
5) At approximately 10:16 AM, it was observed that the door to the corridor did not close to a positive latch, located from the 28 Sub Basement corridor to the main corridor of the 28 Building.
6) At approximately 10:20 AM, it was observed that the door to the corridor did not close to a positive latch, located in the Lady's Locker Room to the main corridor on the Basement level of the 28 Building.
7) At approximately 10:33 AM, it was observed that the door to the corridor did not close to a positive latch, located in the Men's Locker Room to the main corridor on the Basement level of the 28 Building.
8) At approximately 12:15 PM, it was observed that there were two dead-bolt locksets installed on the doors into the Laboratory Department on the Ground Floor of the 62 Building.
9) At approximately 1:11 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 113 of the 62 Building.
10) At approximately 1:16 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 125 of the 62 Building.
11) At approximately 1:50 PM, it was observed that the door to the corridor did not close to a positive latch, located in the Clean Utility Room on the 2nd Floor of the 62 Building.
12) At approximately 2:12 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 245 of the 62 Building.
13) At approximately 2:13 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 247 of the 62 Building.
14) At approximately 2:15 PM, it was observed that the door to the corridor was missing, located in Room 252 of the 62 Building.
15) At approximately 2:16 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 255 of the 62 Building.
16) At approximately 2:17 PM, it was observed that the door to the corridor did not close to a positive latch, located in Room 256 of the 62 Building.

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 February 29, 2012 the following observation was made:

1) At approximately 10:14 AM, it was observed that the door did not close to a positive latch, located to the stairwell to the 28 Sub Basement.

Based on observation the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 29, 2012 the following observation was made:

1) At approximately 10:15 AM, it was observed that the exit was not clearly labeled as such, located in the corridor from the 28 Sub Basement of the 28 Building.

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 February 27, 2012 the following observations were made:

1) At approximately 11:40 AM, it was observed that there were three unsealed penetrations in the smoke barrier wall above the ceiling, located across from Room 8011.
2) At approximately 11:45 AM, it was observed that there were two unsealed EMT penetrations in the 1 hour wall above the ceiling, located in a hazard room - Room 8018.
3) At approximately 11:50 AM, it was observed that there were two unsealed EMT and Romex Wire penetrations above the ceiling in the smoke barrier wall, located in Room 8030.
4) At approximately 1:35 PM, it was observed that there was an unsealed conduit in a rated fire wall, located by the cross corridor smoke barrier by Room 7042.

On February 28, 2012 the following observations were made:

5) At approximately 8:10 AM, it was observed that there was an incomplete seal on a conduit penetration in a rated fire wall (east wall), located in the Main Electrical Closet, in the Kitchen.
6) At approximately 8:25 AM, it was observed that there was an unsealed wire penetration, an unsealed conduit penetration and a void in the cable tray, located at the cross corridor smoke barrier at the south corridor, on the 3rd Floor.
7) At approximately 9:07 AM, it was observed that there was an incomplete seal on a conduit penetration, located at the cross corridor smoke barrier by Room 3081.
8) At approximately 9:18 AM, it was observed that there were two incomplete seals on large diameter conduits, the wallboard seams need to be sealed by the door. Also, three walls are not smoke tight at the decking, located in Room 3058 A.
9) At approximately 9:25 AM, it was observed that there was an unsealed PVC pipe penetration and the wallboard seam was unsealed (lower left side), located at the cross corridor smoke barrier by the South Elevator, on the 3rd Floor by Clean Surgery.
10) At approximately 12:02 PM, it was observed that there was an unsealed conduit penetration in the fire rated wall, located between Elevators 1 and 2 on the 1st Floor.
11) At approximately 12:03 PM, it was observed that there was an unsealed water line pipe penetration above the door, located in Room 1001.
12) At approximately 12: 36 PM, it was observed that there were three incomplete seals on conduit penetrations on the east wall, located in the Communication Room on the 1st Floor.
13) At approximately 1:01 PM, it was observed that there were four unsealed penetrations (1-copper pipe, 3 conduit penetrations) on the corridor wall and one unsealed conduit, located in the Basement Switch Gear Room.

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 February 29, 2012 the following observations were made:

1) At approximately 9:31 AM, it was observed that there was a hole in the wallboard behind the door, located in the 2-North Stairwell on the 2nd Floor of the 28 Building.
2) At approximately 10:45 AM, it was observed that there incomplete seals on a wire penetration and a conduit penetration, located at the cross corridor smoke barrier from the 62 Building to the 28 Building at the Basement level.
3) At approximately 12:52 PM, it was observed that there was a large hole in the block wall separation above the ceiling at the door to the Computerized Tomography Department, located on the Ground Floor of the 62 Building.
4) At approximately 1:10 PM. it was observed that the door coordinator was missing from the cross corridor smoke barrier doors, located near Room 113 on the 1st Floor of the 62 Building.

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 XX occupants of the facility.

Findings include:

On February 27, 2012 the following observation was made:

1) At approximately 11:26 AM, it was observed that one door of the cross corridor smoke barrier doors did not open after testing, located by Room 9041. Note: the door was repaired a short time later.

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 February 28, 2012 the following observations were made:

1) At approximately 1:42 PM, it was observed that there were two unsealed holes in the wallboard on the corridor wall, located in the 75 Building Penthouse Mechanical Room.
2) At approximately 2:28 PM, it was observed that there was an unsealed conduit and an unsealed wire penetration, located in the Cardiac Cath Lab Mechanical Room on the 1st Floor of the 75 Building.
3) At approximately 2:42 PM, it was observed that there were nine unsealed conduits, located in the Cardiac Cath Storage Room of the 75 Building.

On February 29, 2012 the following observations were made:

4) At approximately 10:38 AM, it was observed that the doors to the exit corridor were propped in the open position, located in the Environmental Services Room in the Basement of the 28 Building.
5) At approximately 11:18 AM, it was observed that there was an incomplete seal on a pipe penetration above the door, located in the Generator Electrical Room on the Ground Floor of the 62 Building.
6) At approximately 1:25 PM, it was observed that the door did not close to a positive latch, located in the Janitor's Closet on the 1st Floor of the 62 Building.
7) At approximately 1:43 PM, it was observed that the door to the corridor was removed, located in the Laundry Room on the 2nd Floor of the 62 Building.
8) At approximately 2:03 PM, it was observed that the ceiling access hatch was open, located in the Janitor's Closet in the Psychiatric Ward on the 2nd Floor of the 62 Building.
9) At approximately 2:33 PM, it was observed that there was an unsealed conduit penetration, located in the Mechanical Room on the 3rd Floor of the 62 Building.

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 February 27, 2012 the following observations were made:

1) At approximately at 2:30 PM, it was observed that there was an unsealed beam penetration, located at the north end of the elevator shaft, in the North End Mechanical Room on the 5th Floor.
2) At approximately at 2:40 PM, it was observed that the door did not close to a positive latch, located at the Doctor's Dining Room Kitchen to the corridor on the 4th Floor.

On February 28, 2012 the following observations were made:

3) At approximately at 12:30 PM, it was observed that the door to the corridor was tided in the open position, located in the Linen Storage Room on the 1st Floor.
4) At approximately 12:40 PM, it was observed that the door did not close to a positive latch, located in the Pump Room.
5) At approximately 1:15 PM, it was observed that the door did not have a self closing mechanism device, located in the Basement Staff Lounge.
6) At approximately 1:16 PM, it was observed that the door did not have a self closing mechanism device, located in Room 0009 A in the Basement.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 28, 2012 the following observations were made:

1) At approximately 9:20 AM, it was observed that the emergency light fixture did not work when tested, located in OR Room #3.
2) At approximately 12:39 PM, it was observed that the emergency light fixture did not work when tested, located in corridor to the MRI docking area.

Based on observation the facility failed to provide emergency lighting in accordance with the LSC section 19.2.9.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 29, 2012 the following observation was made:

1) At approximately 11:20 AM, it was observed that two emergency lighting fixtures did not work when tested, located in the PACS Room on the Ground Floor of the 62 Building.

Based on observation and/or review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 29, 2012 the following observation was made:

1) At approximately 1:36 PM, it was observed that there was an incomplete Fire Safety Plan for the staff and patient safety, located in the Emergency Procedure Book on the 1st Floor of the North Substance Abuse Ward.

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 all occupants of the facility. Findings include:

On February 29, 2012 the following observations were made:

1) At approximately 10:58 AM, it was observed that the room did not have a fire alarm strobe device installed, located in the Conference Room on the Ground Floor of the 62 Building.
2) At approximately 11:10 AM, it was observed that the room did not have a fire alarm strobe device installed, located in the large X-Ray Reading Room on the Ground Floor of the 62 Building.
3) At approximately 12:45 PM, it was observed that the room did not have a fire alarm strobe device installed, located in the X-Ray Waiting Room on the Ground Floor of the 62 Building.
4) At approximately 2:00 PM, it was observed that the smoke detector was installed within the required three foot spacing of an air vent, located in the Psychiatric Ward on the 2nd Floor of the 62 Building.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 28, 2012 the following observation was made:

1) At approximately 3:00 PM, it was observed during the review of the facility's documents that the facility did not have current documentation for the smoke detector sensitivity testing, for the 28, 62 and 75 Buildings.

On February 29, 2012 the following observations were made:

2) At approximately 10:00 AM, it was observed that the area used as a storage was not protected with smoke detectors, located in the Pharmacy Storage area on the 1st Floor of the 28 Building.
3) At approximately 11:05 AM, it was observed that the smoke detector was not properly mounted, located in the Old CAT Scan A/C Room on the Ground Floor of the 62 Building.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 28, 2012 the following observations were made:

1) At approximately 8:05 AM, it was observed that a smoke detector was not completely attached to it mounting base, located in the Main Kitchen.
2) At approximately 3:00 PM, it was observed during the review of the facility's documents that the facility did not have current documentation for the smoke detector sensitivity testing.

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 all occupants of the facility. Findings include:

On February 27, 2012 the following observations were made:

1) At approximately 10:49 AM, it was observed that there was a cloth rag attached to the fire sprinkler piping, located in the 11th Floor North Elevator Room.
2) At approximately 11:00 AM, it was observed that the fire sprinkler head was covered with dust, located in the 11th Floor South Elevator Room by Unit #5.
3) At approximately 12:06 PM, it was observed that the fire sprinkler head was missing an escutcheon plate, located by the 8 th Floor Men's Restroom.

On February 28, 2012 the following observations were made:

4) At approximately 8:40 AM, it was observed that the fire sprinkler head was missing an escutcheon plate, located by the Endo Classroom Corridor.
5) At approximately 8:42 AM, it was observed that the ceiling tile was out of place resulting in a space not protected by the fire sprinkler system, located in the Endo Room #1 in the Endo Department on the 3rd Floor.
6) At approximately 8:43 AM, it was observed that the ceiling tile was out of place resulting in a space not protected by the fire sprinkler system, located in the Endo Room #2 in the Endo Department on the 3rd Floor.
7) At approximately 8:44 AM, it was observed that the ceiling tile was out of place resulting in a space not protected by the fire sprinkler system, located in the Endo Room #3 in the Endo Department on the 3rd Floor.
8) At approximately 9:44 AM, it was observed that the fire sprinkler head was missing an escutcheon plate, located Medical Records Office Room 2006.
9) At approximately 9:55 AM, it was observed that the corridor to the restroom did not have proper fire sprinkler coverage, located in the Administration Offices.
10) At approximately 10:30 AM, it was observed that the fire sprinkler head was missing an escutcheon plate, located in the Locker Room/Restroom in the CSR Department.
11) At approximately 12:31 PM, it was observed that there were three ceiling tiles were out of place resulting in a space not protected by the fire sprinkler system, located in the Milk Cooler Room on the 1st Floor.
12) At approximately 12:45 PM, it was observed that the suction and supply gauges were missing at the fire pump, located in the Fire Pump Room.
13) At approximately 12:46 PM, it was observed that there was a storage of materials blocking access to the fire pump control valves, located in the Fire Pump Room.
14) At approximately 12:50 PM, it was observed that there were four ceiling tiles missing resulting in a space not protected by the fire sprinkler system, located in the Telecommunications Room in the Basement.

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 all occupants of the facility. Findings include:

On February 29, 2012 the following observations were made:

1) At approximately 9:32 AM, it was observed that there was a large amount of combustible items stored in the old Kitchen area which is not protected with a fire sprinkler system, located on the 2nd Floor of the 28 Building.
2) At approximately 10:04 AM, it was observed that there were three ceiling tiles missing resulting in a space not protected by the fire sprinkler system, located in the Old Kitchen on the 1st Floor of the 28 Building.
3) At approximately 10:25 AM, it was observed that there were three ceiling tiles missing resulting in a space not protected by the fire sprinkler system, located in the Pulmonary Function Testing Storage Room in the Basement of the 28 Building.
4) At approximately 10:30 AM, it was observed that there was a ceiling tile missing resulting in a space not protected by the fire sprinkler system, located in the X-Ray File Storage Room in the Basement of the 28 Building.
5) At approximately 10:31 AM, it was observed that there was a ceiling tile missing resulting in a space not protected by the fire sprinkler system, located in the Maintenance Office in the Basement of the 28 Building.
6) At approximately 10:50 AM, it was observed that there was a ceiling tile missing resulting in a space not protected by the fire sprinkler system, located in the Old CAT Scan Control Closet on the Ground Floor of the 62 Building.
7) At approximately 10:59 AM, it was observed that the fire sprinkler head was missing an escutcheon plate, located in the Ground Floor X-Ray File Room of the 62 Building.
8) At approximately 12:25 PM, it was observed that the fire sprinkler head was missing an escutcheon plate, located in the Ground Floor Chemistry Department of the 62 Building.
9) At approximately 12:30 PM, it was observed that there was incomplete coverage of the fire sprinkler system, located in the Blood Bank on the Ground Floor of the 62 Building.
10) At approximately 12:35 PM, it was observed that the fire sprinkler head was missing an escutcheon plate, located in the Employee Coat Closet of the Ground Floor Pathology Department of the 62 Building.
11) At approximately 12:40 PM, it was observed that the fire sprinkler head was missing an escutcheon plate, located in the Handicap Restroom of the 62 Building.
12) At approximately 12:47 PM, it was observed that there were three ceiling tiles missing resulting in a space not protected by the fire sprinkler system, located in the Break Room of the Laboratory on the Ground Floor of the 62 Building.
13) At approximately 12:50 PM, it was observed that there were two ceiling tiles missing resulting in a space not protected by the fire sprinkler system, located in the IT Room by the Elevator Lobby on the 2nd Floor of the 62 Building.

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:

1) At approximately 12:50 PM, it was observed that the left side coupling was difficult to turn, located at the fire department connection on the Ground Floor of the 62 Building.

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 February 27, 2012 the following observation was made:

1) At approximately 10:59 AM, it was observed that the fire extinguisher was positioned on the floor, located in the 11th Floor South Elevator Control 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 February 28, 2012 the following observation was made:

1) At approximately 2:45 PM, it was observed that there was a fire extinguisher that needed to be recharged, located in the ER Fire Alarm Closet on the 1st Floor of the 75 Building.

On February 29, 2012 the following observations were made:

2) At approximately 12:29 PM, it was observed that the access to the fire extinguisher was blocked by a refrigerator, located in the Blood Bank on the Ground Floor of the 62 Building.
3) At approximately 12:48 PM, it was observed that there was a fire extinguisher with an out dated inspection tag (February 2009), located in the IT Room on the Ground Floor of the 62 Building.
4) At approximately 1:43 PM, it was observed that there was a fire extinguisher with an out dated inspection tag (February 2003), located in the Old CSR Room on the 1st Floor of the 62 Building.

Based on observation and/or review of records the facility failed to provide cooking facilities in accordance with the LSC section 19.3.2.6. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 28, 2012 the following observations were made:

1) At approximately at 8:00 AM, it was observed that the cook was unable to clearly identify the proper operation of the Fire Hood Suppression System, on the 4th Floor.
2) At approximately 8:03 AM, it was observed that an appliance was plugged into a duplex outlet outside the main hood, in the front cooking area, on the 4th Floor. Provide documentation that this outlet shuts down electrical power to the appliances once the fire hood suppression system is activated.
3) At approximately 8:05 AM, it was observed that there were two emergency gas shut offs that were not labeled as such, located in the Main Kitchen and Doctor's Dining Room Kitchen, on the 4th Floor.

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 February 28, 2012 the following observations were made:

1) At approximately 2:03 PM, it was observed that there was a portable electrical space heater, located in the 2-South Staff Break Room of the 75 Building.
2) At approximately 2:25 PM, it was observed that there was a portable electrical space heater, located in the 2-South Cardiac Cath Nurse's Station of the 75 Building.
3) At approximately 2:42 PM, it was observed that there were three portable electrical space heaters, located on the Ground Floor in the Security - Fire Alarm Panel Room, of the 75 Building.

On February 29, 2012 the following observations were made:

4) At approximately 8:50 AM, it was observed that there was a portable electrical space heater, located in Room 510 of the 28 Building.
5) At approximately 8:56 AM, it was observed that there was a portable electrical space heater, located in Room 506 of the 28 Building.
6) At approximately 8:57 AM, it was observed that there was a portable electrical space heater, located in Room 508 of the 28 Building.
7) At approximately 9:10 AM, it was observed that there was a portable electrical space heater, located in the storage room of the Community Programming Office 4th Floor of the 28 Building.
8) At approximately 9:22 AM, it was observed that there was a portable electrical space heater, located in the Library Office on the 3rd Floor of the 28 Building.
9) At approximately 10:50 AM, it was observed that there was a portable electrical space heater, located in the large X-Ray Reading Room on the Ground Floor of the 62 Building.
10) At approximately 1:05 PM, it was observed that there was a portable electrical space heater, located in the Room 109 of the 62 Building.
11) At approximately 1:18 PM, it was observed that there were three portable electrical space
heaters, located in the Room 123 of the 62 Building.
12) At approximately 1:21 PM, it was observed that there was a portable electrical space heater, located at the Northwest Nursing Station on the 1st Floor of the 62 Building.
13) At approximately 1:28 PM, it was observed that there was a portable electrical space heater, located in the Social Workers Office on the 1st Floor of the 62 Building.

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 February 28, 2012, the following observation was made:

1) At approximately 12:10 PM, it was observed that there was a portable electric space heater, located in Room 1050.

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 February 27, 2012 the following observations were made:

1) At approximately 11:35 AM, it was observed that there was a bed stored in the corridor, located by Room 8030.
2) At approximately 2:06 PM, it was observed that there was a bed stored in the corridor, located by Room 6030.

On February 28, 2012 the following observations were made:

3) At approximately 9:13 AM, it was observed that the exit corridor was blocked by X-ray equipment, located by Room 3070, in the Surgery Department.
4) At approximately 12:40 PM, it was observed that there were signs and a floor buffer pad stored in the stairwell, located in Stairwell #1 at the Basement Level.

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 February 28, 2012 the following observation was made:

1) At approximately 2:35 PM, it was observed that there was one patient cart, one wheel chair along with wheelchair parts and a dust mop stored in the stairwell, located on the Ground Floor in the North 75 Stairwell in the 75 Building.

On February 29, 2012 the following observations were made:

2) At approximately 8:35 AM, it was observed that there were items stored in the exit corridor, located in the North Exit Corridor on the 6th Floor of the 28 Building.
3) At approximately 9:10 AM, it was observed that there were items stored in the exit corridor, located in the North Exit Corridor on the 4th Floor of the 28 Building.

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 February 28, 2012 the following observation was made:

1) At approximately 12:00 PM, it was observed that there was a large helium tank that was not secured, located in Room 1001.

Based on observation and/or review of records the facility failed to submit plans for the renovation project taking place in the 7-north wing. This deficient practice could potentially affect all occupants of the facility. Findings include:

On February 29, 2012 the following observation was made:

1) At approximately 8:20 AM, observed that there was an unapproved project in progress with walls under demolition, ceilings removed and unsealed holes in the corridor walls, located on the North Wing of the 7th Floor in the 28 Building. Note: plans have not been submitted to the Bureau of Fire Services for review as of this date.

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 February 27, 2012 the following observations were made:

1) At approximately 10:48 AM it was observed that there was an electrical junction box missing a cover plate, located in the 11th Floor North Elevator Room, by Elevator #1.
2) At approximately 1:30 PM it was observed that there was an electrical extension cord in use, located in Room 7044.
3) At approximately 1:40 PM it was observed that there was an electrical outlet within three feet of the sink, which was not equipped with a GFCI outlet, located in the Pantry (Room 7013).

On February 28, 2012 the following observations were made:

4) At approximately 8:14 AM, it was observed that the wiring on the dishwasher steamer was separated from the electrical junction box, located in the Main Kitchen.
5) At approximately 8:17 AM, it was observed that there was an electrical extension cord in use, located under the fire hood suppression system, in the Main Kitchen.
6) At approximately 10:14 AM, it was observed that there was a damaged electrical power strip in use, located in the Pharmacy Department on the 2nd Floor. Note: the damaged device was removed at time of inspection.
7) At approximately 12:47 PM, it was observed that there was an electrical extension cord in use, located in the Fire Pump Room in the Basement.
8) At approximately 1:17 PM, it was observed that there was a quad outlet box missing a cover plate, located in Room 0009 A.

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 February 28, 2012 the following observations were made:

1) At approximately 1:32 PM, it was observed that there was an electrical extension cord in use, located in the Trauma Coordinator's Office on the 3rd Floor of the 75 Building.
2) At approximately 1:35 PM, it was observed that the flexible conduit was not attached to the junction box of the circulating pump, located at AHU #1 in the 75 Building Mechanical Room.
3) At approximately 1:42 PM, it was observed that there were 110 volt wires that did not terminate in an electrical junction box, located on the corridor wall in the 75 Building Penthouse Mechanical Room.
4) At approximately 1:45 PM, it was observed that there was an electrical junction box missing a cover plate, located in the 75 Building Chiller Room.
5) At approximately 1:46 PM, it was observed that there was an electrical conduit was detached for the junction box of the hot water circulating pump by AHU #3, located in the 75 Building Mechanical Room.
6) At approximately 2:04 PM, it was observed that there was an electrical extension cord in use, located in the 2 - South Staff Break Room of the 75 Building.
7) At approximately 2:21 PM, it was observed that there were two electrical power strips interconnected, located in the Cardiologist's Office on the 1st Floor of the 75 Building.
8) At approximately 2:40 PM, it was observed that there were three electrical extension cords in use, located in Pam's Office on the Ground Floor of the 75 Building.

On February 29, 2012 the following observations were made:

9) At approximately 8:33 AM it was observed that there were two electrical power strips interconnected, located in the Medical Education Office on the 6th Floor of the 28 Building.
10) At approximately 8:57 AM, it was observed that there was an electrical extension cord in use, located in Room 508 of the 28 Building.
11) At approximately 9:15 AM, it was observed that there was an electrical extension cord in use, located in the Department of Education Office on the 4th Floor of the 28 Building.
12) At approximately 9:40 AM, it was observed that there was an electrical extension cord in use, located by the rear exit in the Clinical Engineering Department on the 2nd Floor of the 28 Building.
13) At approximately 10:23 AM, it was observed that there was an electrical extension cord in use, located in the Basement Office by the Respiratory Therapy Department of the 28 Building.
14) At approximately 10:25 AM, it was observed that there was an electrical extension cord in use, located in the Basement Respiratory Therapy Department Storage Room of the 28 Building.
15) At approximately 10:32 AM, it was observed that there was an electrical extension cord in use, located in the Basement Men's Locker Room of the 28 Building.
16) At approximately 10:55 AM, it was observed that there was an electrical extension cord in use, located in the X-Ray Control Room on the Ground Floor of the 62 Building.
17) At approximately 10:58 AM, it was observed that the electrical outlet was missing a cover plate, located in the Conference Room on the Ground Floor of the 62 Building.
18) At approximately 12:42 PM, it was observed that there was an electrical junction box missing a cover plate, located in the Mechanical Room on the Ground Floor of the 62 Building.
19) At approximately 12:43 PM, it was observed that there was an electrical junction box missing a cover plate, located on the east wall of the Mechanical Room on the Ground Floor of the 62 Building.
20) At approximately 12:56 PM, it was observed that there were two electrical junction boxes missing cover plates, located in the old employee entrance corridor across from the ER Department door on the Ground Floor of the 62 Building.
21) At approximately 1:05 PM, it was observed that there was an electrical extension cord in use, located in Patty's Office on the 1st Floor of the 62 Building.
22) At approximately 1:19 PM, it was observed that there was an electrical extension cord in use, located in Room 123 of the 62 Building.
23) At approximately 2:08 PM, it was observed that there was an electrical outlet not protected with a GFIC, located in the Clean Storage Room on the 2nd Floor of the 62 Building.
24) At approximately 2:32 PM, it was observed that there was an electrical junction box missing a cover plate, located in the Mechanical Room on the 3rd Floor of the 62 Building.

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 February 27, 2012 the following observation was made:

1) At approximately 11:55 AM, it was observed during the review of the facility documents the facility failed to provide a document for notifying 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 February 29, 2012 the following observation was made:

1) At approximately 2:50 PM, it was observed during the review of the facility documents the facility failed to provide a document for notifying 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 February 27, 2012 the following observation was made:

1) At approximately 11:56 AM, it was observed during the review of the facility documents that the facility failed to provide a document for notifying 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 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 February 29, 2012 the following observation was made:

1) At approximately 2:50 PM, it was observed during the review of the facility documents that the facility failed to provide a document for notifying 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.