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Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with LSC Section 19.3.2.1. This deficient practice could potentially affect 5 occupants of the facility by allowing vertical passage of smoke or fire through fire rated construction to the occupied space above.

Findings Include:

#1 In an observation on 1/5/16 at 1:07 PM, an open conduit penetration at the ceiling in Mechanical Room #2 had not been sealed with an approved fire stopping system in accordance with NFPA 101, Section 8.2.3.2.4.2.

- In an interview on 1/5/16 at 1:07 PM, Facilities Director #2 confirmed an open conduit penetration at the ceiling in Mechanical Room #2 had not been sealed with an approved fire stopping system.

Based on review of records and interview, the facility failed to ensure fire drills were conducted in accordance with LSC Section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings Include:

#1 During review of records on 1/5/16 at 10:50 am, the Fire Drill Record documenting the drill conducted during the first quarter, third shift was performed after 6:00 am without fire alarm activation in accordance with NFPA 19.7.1.2.

-In an interview during review of records on 1/5/16 at 10:50 am, Facilities Director #2 confirmed a fire drill conducted during the first quarter, third shift was performed after 6:00 am without fire alarm activation.

#2 During review of records on 1/5/15 at 11:00 am, the Fire Dill Record documenting all second shift fire drills conducted during 2015 were found to vary by only a 1 hr 15 min time span during the day, and did not meet the unexpected time and varying conditions in accordance with NFPA 101, Section 19.7.1.2.

-In an interview during review of records on 1/5/15 at 11:00 am, Facilities Director #2 confirmed all second shift fire drills conducted during 2015 were found to vary by only a 1 hr 15 min time span during the shift, and did not meet the unexpected time and varying conditions.

Based on observation and interview, the facility failed to ensure that the automatic sprinkler system is maintained in accordance with LSC Sections 19.7.6, 4.6.12, and 9.7.5 and NFPA 13 and 25. This deficient practice could potentially affect all occupants of the facility if the automatic sprinkler system failed to operate in the event of a fire due to a lack of maintenance.

Findings Include:

#1 In an observation on 1/5/16 at 1:19 PM, communication wires subjecting an external load on a sprinkler pipe at the ceiling in the Basement Copier Hallway in violation of NFPA 25, Section 2.2.2.

- In an interview on 1/5/16 at 1:19 PM, Facilities Director #2 confirmed communication wires subjecting an external load on a sprinkler pipe at the ceiling in the Basement Copier Hallway.

#2 In an observation on 1/5/16 at 1:21 PM, a sprinkler head obstructed by duct work at the ceiling in Basement Copier Hallway in violation of NFPA 13, Section 5.5.5.3.

- In an interview on 1/5/16 at 1:21 PM, Facilities Director #2 confirmed a sprinkler head obstructed by duct work at the ceiling in Basement Copier Hallway.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with LSC Section 19.3.2.1. This deficient practice could potentially affect 5 occupants of the facility by allowing vertical passage of smoke or fire through fire rated construction to the occupied space above.

Findings Include:

#1 In an observation on 1/5/16 at 1:07 PM, an open conduit penetration at the ceiling in Mechanical Room #2 had not been sealed with an approved fire stopping system in accordance with NFPA 101, Section 8.2.3.2.4.2.

- In an interview on 1/5/16 at 1:07 PM, Facilities Director #2 confirmed an open conduit penetration at the ceiling in Mechanical Room #2 had not been sealed with an approved fire stopping system.

Based on review of records and interview, the facility failed to ensure fire drills were conducted in accordance with LSC Section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings Include:

#1 During review of records on 1/5/16 at 10:50 am, the Fire Drill Record documenting the drill conducted during the first quarter, third shift was performed after 6:00 am without fire alarm activation in accordance with NFPA 19.7.1.2.

-In an interview during review of records on 1/5/16 at 10:50 am, Facilities Director #2 confirmed a fire drill conducted during the first quarter, third shift was performed after 6:00 am without fire alarm activation.

#2 During review of records on 1/5/15 at 11:00 am, the Fire Dill Record documenting all second shift fire drills conducted during 2015 were found to vary by only a 1 hr 15 min time span during the day, and did not meet the unexpected time and varying conditions in accordance with NFPA 101, Section 19.7.1.2.

-In an interview during review of records on 1/5/15 at 11:00 am, Facilities Director #2 confirmed all second shift fire drills conducted during 2015 were found to vary by only a 1 hr 15 min time span during the shift, and did not meet the unexpected time and varying conditions.

Based on observation and interview, the facility failed to ensure that the automatic sprinkler system is maintained in accordance with LSC Sections 19.7.6, 4.6.12, and 9.7.5 and NFPA 13 and 25. This deficient practice could potentially affect all occupants of the facility if the automatic sprinkler system failed to operate in the event of a fire due to a lack of maintenance.

Findings Include:

#1 In an observation on 1/5/16 at 1:19 PM, communication wires subjecting an external load on a sprinkler pipe at the ceiling in the Basement Copier Hallway in violation of NFPA 25, Section 2.2.2.

- In an interview on 1/5/16 at 1:19 PM, Facilities Director #2 confirmed communication wires subjecting an external load on a sprinkler pipe at the ceiling in the Basement Copier Hallway.

#2 In an observation on 1/5/16 at 1:21 PM, a sprinkler head obstructed by duct work at the ceiling in Basement Copier Hallway in violation of NFPA 13, Section 5.5.5.3.

- In an interview on 1/5/16 at 1:21 PM, Facilities Director #2 confirmed a sprinkler head obstructed by duct work at the ceiling in Basement Copier Hallway.