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Based on observation, the facility failed to provide corridor doors with no impediment to closing the door in accordance with NFPA 101, LSC, Section 19.3.6.3. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the products of combustion could not be readily contained due to a corridor door which is impeded from being readily closed.

Findings include:

On June 7, 2011 at approximately 10:36 a.m., the corridor door to the multi-purpose room was observed to have a privacy curtain placed in front of and against this automatic closing fire rated door. The door failed to close when released from its' magnetic hold open device. The curtain had to first be moved in order to allow the door to close. This finding was confirmed with the maintenance supervisor at the time of discovery.

Based on observation, it was determined that the facility failed to provide vertical openings between floors which are protected by construction having at least a one-hour fire resistance rating in accordance with NFPA 101, LSC, Section 19.3.1.1. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the fire is allowed to spread vertically between floors due to improperly protected floor penetrations.

Findings include:

On June 7, 2011 the following condition was observed:

At approximately 10:50 a.m. new telephone and other communications cables were observed to penetrate the floor-ceiling assembly between the basement and first floor in the telephone room on the basement level by the east elevator. There was no U.L. listed fire stop system in place. This finding was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to provide for laboratory spaces which are protected as a hazardous area in accordance with NFPA 101, LSC, Section 10.5.1 and NFPA 99. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire within the laboratory space which cannot be effectively contained to that space due to improper separation of the laboratory from the remainder of the facility.

Findings include:

On June 7, 2011 at approximately 11:30 a.m., a former "pass-through" window was observed to have been in-filled with metal studs and drywall. The drywall on the hazard side of the assembly was observed to be held to the studs by screws with an uneven spacing of approximately 2 feet or more. The facility was unable to provide any documentation that the assembly met any recognized fire rated designs. This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to maintain exits as readily accessible at all times in accordance with NFPA 101, LSC, Sections 7.1 and 19.2.1. This deficient practice could affect an undetermined number of residents staff and visitors in the event of a fire or other emergency requiring the evacuation of the facility and the occupants are directed to an unusable exit.

Findings include:

On June 7, 2011 the following conditions were observed:

a) At approximately 11:12 a.m., the exit discharge was from the emergency department exit (ambulance entrance) was observed to be inaccessible and unusable due to site excavation work for a construction project. The exit signs leading persons to this exit had not been re-arranged to lead persons to other available exits. This exit was electronically locked against egress and when unlocked by the facility maintenance director, it was noted that there was no path to a place of safety or to the public way. The discharge path leads into an excavated hole. This deficiency was confirmed with the facility maintenance director at the time of discovery.

b) At approximately 10:10 a.m., the staff lounge/bathroom in the basement level near the maintenance office was observed to be equipped with a corridor door which had a slide bolt lock installed on the inside of the door. This arrangement requires more than a single action to open the door. This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to maintain all required smoke detectors in accordance with NFPA 101, LSC, Section 9.6.1.3. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the automatic discovery of the fire is delayed due to improperly installed system smoke detectors.

Findings include:

On June 7, 2011 at approximately 11:04 a.m. a smoke detector near the clinic nurses station was observed to be mounted within 3 feet of a supply air diffuser. This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to properly maintain the facility automatic sprinkler and stand-pipe system in accordance with NFPA 101, LSC, Sections 19.7.6 and 9.7.5 and NFPA 25. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the suppression of the fire is delayed due to the improperly maintained sprinkler and stand-pipe system.

Findings include:

On June 7, 2011 at approximately 10:19 a.m., the following conditions were observed:

a) The stand-pipe hose connection cabinet located near the boiler room on the basement level was observed to be obstructed from access by housekeeping carts placed in front of the cabinet.

b) The hose within the stand-pipe hose cabinet in "a" above was not labeled as having been subjected to service testing.

This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to properly maintain portable fire extinguishers in accordance with NFPA 101, LSC, Sections 19.3.5.6 and 9.7.4.1 and NFPA 10. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the fire cannot be immediately controlled by a portable fire extinguisher due to the improper maintenance of the portable fire extinguisher.

Findings include:

On June 7, 2011 at approximately 11:09 a.m. the portable fire extinguisher cabinet located in the E.R. waiting room corridor was observed to be obstructed from access by chairs which had been placed in front of it. This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to properly protect the cooking facilities in accordance with NFPA 101, LSC, Sections 19.3.2.6 and 9.2.3 and NFPA 96. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire on the kitchen range where the fire cannot be rapidly controlled due to improper protection of the kitchen range from fire.

Findings include:

On June 7, 2011 at approximately 10:46 a.m. the kitchen range was observed to be positioned too far to the right under the kitchen hood. This placement caused hood suppression system nozzles to be aimed at the floor to the left of the range rather than at the cook top.

Based on observation, it was determined that the facility failed to provide loosely hanging fabrics which are in accordance with NFPA 101, LSC, Section 19.7.5.3 and NFPA 701. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire involving improperly installed loosely hanging fabrics.

Findings include:

On June 7, 2011 at approximately 11:30 a.m. a fabric wall hanging was observed to be hung on the wall outside of the lab draw room. The fabric was not labeled as being compliant with NFPA 701 or inherently flame retardant and the facility was unable to provide documentation that indicated that the fabric complied with NFPA 701. This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to provide electrical wiring and equipment which is in accordance with NFPA 101, LSC, Section 9.1.2 and NFPA 70 (National Electrical Code). This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire caused by overloaded electrical cords or a shock hazard created by unprotected electrical equipment.

Findings include:

On June 7, 2011 the following conditions were observed:

a) at approximately 10:30 a.m. multiple open spaces were observed in electrical panels "EQ" and "LS" in the main electrical room where circuit breakers had been removed.

b) at approximately 10:38 a.m., a multiple outlet power strip (RPT) was observed to be in use in the multi-purpose room. This RPT was observed to have no integrated circuit breaker and was observed to have multiple food service steam trays and soup kettles plugged into it. The RPT was plugged into a temporary movable office partition. The facility could not provide documentation that this arrangement did not present an electrical overload hazard.

Based on observation, the facility failed to provide corridor doors with no impediment to closing the door in accordance with NFPA 101, LSC, Section 19.3.6.3. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the products of combustion could not be readily contained due to a corridor door which is impeded from being readily closed.

Findings include:

On June 7, 2011 at approximately 10:36 a.m., the corridor door to the multi-purpose room was observed to have a privacy curtain placed in front of and against this automatic closing fire rated door. The door failed to close when released from its' magnetic hold open device. The curtain had to first be moved in order to allow the door to close. This finding was confirmed with the maintenance supervisor at the time of discovery.

Based on observation, it was determined that the facility failed to provide vertical openings between floors which are protected by construction having at least a one-hour fire resistance rating in accordance with NFPA 101, LSC, Section 19.3.1.1. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the fire is allowed to spread vertically between floors due to improperly protected floor penetrations.

Findings include:

On June 7, 2011 the following condition was observed:

At approximately 10:50 a.m. new telephone and other communications cables were observed to penetrate the floor-ceiling assembly between the basement and first floor in the telephone room on the basement level by the east elevator. There was no U.L. listed fire stop system in place. This finding was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to provide for laboratory spaces which are protected as a hazardous area in accordance with NFPA 101, LSC, Section 10.5.1 and NFPA 99. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire within the laboratory space which cannot be effectively contained to that space due to improper separation of the laboratory from the remainder of the facility.

Findings include:

On June 7, 2011 at approximately 11:30 a.m., a former "pass-through" window was observed to have been in-filled with metal studs and drywall. The drywall on the hazard side of the assembly was observed to be held to the studs by screws with an uneven spacing of approximately 2 feet or more. The facility was unable to provide any documentation that the assembly met any recognized fire rated designs. This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to maintain exits as readily accessible at all times in accordance with NFPA 101, LSC, Sections 7.1 and 19.2.1. This deficient practice could affect an undetermined number of residents staff and visitors in the event of a fire or other emergency requiring the evacuation of the facility and the occupants are directed to an unusable exit.

Findings include:

On June 7, 2011 the following conditions were observed:

a) At approximately 11:12 a.m., the exit discharge was from the emergency department exit (ambulance entrance) was observed to be inaccessible and unusable due to site excavation work for a construction project. The exit signs leading persons to this exit had not been re-arranged to lead persons to other available exits. This exit was electronically locked against egress and when unlocked by the facility maintenance director, it was noted that there was no path to a place of safety or to the public way. The discharge path leads into an excavated hole. This deficiency was confirmed with the facility maintenance director at the time of discovery.

b) At approximately 10:10 a.m., the staff lounge/bathroom in the basement level near the maintenance office was observed to be equipped with a corridor door which had a slide bolt lock installed on the inside of the door. This arrangement requires more than a single action to open the door. This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to maintain all required smoke detectors in accordance with NFPA 101, LSC, Section 9.6.1.3. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the automatic discovery of the fire is delayed due to improperly installed system smoke detectors.

Findings include:

On June 7, 2011 at approximately 11:04 a.m. a smoke detector near the clinic nurses station was observed to be mounted within 3 feet of a supply air diffuser. This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to properly maintain the facility automatic sprinkler and stand-pipe system in accordance with NFPA 101, LSC, Sections 19.7.6 and 9.7.5 and NFPA 25. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the suppression of the fire is delayed due to the improperly maintained sprinkler and stand-pipe system.

Findings include:

On June 7, 2011 at approximately 10:19 a.m., the following conditions were observed:

a) The stand-pipe hose connection cabinet located near the boiler room on the basement level was observed to be obstructed from access by housekeeping carts placed in front of the cabinet.

b) The hose within the stand-pipe hose cabinet in "a" above was not labeled as having been subjected to service testing.

This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to properly maintain portable fire extinguishers in accordance with NFPA 101, LSC, Sections 19.3.5.6 and 9.7.4.1 and NFPA 10. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire where the fire cannot be immediately controlled by a portable fire extinguisher due to the improper maintenance of the portable fire extinguisher.

Findings include:

On June 7, 2011 at approximately 11:09 a.m. the portable fire extinguisher cabinet located in the E.R. waiting room corridor was observed to be obstructed from access by chairs which had been placed in front of it. This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to properly protect the cooking facilities in accordance with NFPA 101, LSC, Sections 19.3.2.6 and 9.2.3 and NFPA 96. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire on the kitchen range where the fire cannot be rapidly controlled due to improper protection of the kitchen range from fire.

Findings include:

On June 7, 2011 at approximately 10:46 a.m. the kitchen range was observed to be positioned too far to the right under the kitchen hood. This placement caused hood suppression system nozzles to be aimed at the floor to the left of the range rather than at the cook top.

Based on observation, it was determined that the facility failed to provide loosely hanging fabrics which are in accordance with NFPA 101, LSC, Section 19.7.5.3 and NFPA 701. This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire involving improperly installed loosely hanging fabrics.

Findings include:

On June 7, 2011 at approximately 11:30 a.m. a fabric wall hanging was observed to be hung on the wall outside of the lab draw room. The fabric was not labeled as being compliant with NFPA 701 or inherently flame retardant and the facility was unable to provide documentation that indicated that the fabric complied with NFPA 701. This deficiency was confirmed with the facility maintenance director at the time of discovery.

Based on observation, it was determined that the facility failed to provide electrical wiring and equipment which is in accordance with NFPA 101, LSC, Section 9.1.2 and NFPA 70 (National Electrical Code). This deficient practice could affect an undetermined number of patients, staff and visitors in the event of a fire caused by overloaded electrical cords or a shock hazard created by unprotected electrical equipment.

Findings include:

On June 7, 2011 the following conditions were observed:

a) at approximately 10:30 a.m. multiple open spaces were observed in electrical panels "EQ" and "LS" in the main electrical room where circuit breakers had been removed.

b) at approximately 10:38 a.m., a multiple outlet power strip (RPT) was observed to be in use in the multi-purpose room. This RPT was observed to have no integrated circuit breaker and was observed to have multiple food service steam trays and soup kettles plugged into it. The RPT was plugged into a temporary movable office partition. The facility could not provide documentation that this arrangement did not present an electrical overload hazard.