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Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with LSC Section 19.3.6.3. This deficient practice could potentially affect 16 patients and 8 staff in the affected smoke compartment if smoke and fire were allowed to be transferred into the corridor. Findings include:

1. On 10/12/16 at 10:31 AM, the corridor door to #4116 Nurses Room failed to positively latch when tested.

In an interview on 10/12/16 at 10:31 AM, DIR#1 confirmed that the corridor door to #4116 Nurses Room failed to positively latch and that the door was scheduled to be replaced.

2. On 10/12/16 at 10:31 AM, the corridor door to #4116 Nurses Room was observed to have four (4) open through holes approximately 1/4" in size above the door handle.

In an interview on 10/12/16 at 10:31 AM, DIR#1 confirmed that the corridor door to #4116 Nurses Room had four (4) open through holes approximately 1/4" in size above the door handle and that the door was scheduled to be replaced.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with LSC Sections 19.3.7.3 and 19.3.7.5. This deficient practice could potentially affect 35 patients and 16 staff on the 5th Floor; 0 patients and 12 staff on the 4th Floor; 24 patients and 10 staff on the 3rd Floor; and 10 patients and 24 staff on the 2nd Floor if the smoke barriers allowed smoke and fire to transfer from one smoke compartment to another. Findings include:

1. On 10/12/16 at 10:45 AM, an open penetration was observed in the smoke barrier wall separating 5 Main and 5 East.

In an interview on 10/12/16 at 10:45 AM, FACMAN#2 confirmed an open penetration in the smoke barrier wall separating 5 Main and 5 East.
2. On 10/12/16 at 10:50 AM, an open penetration was observed in Environmental Services Room 5EA 070.

In an interview on 10/12/16 at 10:50 AM, FACMAN#2 confirmed an open penetration in Environmental Services Room 5EA 070.

3. On 10/12/16 at 11:16 AM, an open penetration was observed in 4 West Wire Room.

In an interview on 10/12/16 at 11:16 AM, FACMAN#2 confirmed an open penetration in 4 West Wire Room.

4. On 10/12/16 at 11:19 AM, an open penetration was observed in 4 West North Mechanical Room.

In an interview on 10/12/16 at 11:19 AM, FACMAN#2 confirmed an open penetration in 4 West North Mechanical Room.

5. On 10/12/16 at 11:21 AM, an open penetration was observed in 4 West South Mechanical Room.

In an interview on 10/12/16 at 11:21 AM, FACMAN#2 confirmed an open penetration in 4 West South Mechanical Room.

6. On 10/12/16 at 11:33 AM, an open penetration was observed in Wire Room 3NE 020.

In an interview on 10/12/16 at 11:33 AM, FACMAN#2 confirmed an open penetration in Wire Room 3NE 020.

7. On 10/12/16 at 12:56 PM, an open penetration was observed in the 2nd Floor Wire Room outside of OR.

In an interview on 10/12/16 at 12:56 PM, FACMAN#2 confirmed an open penetration in the 2nd Floor Wire Room outside of OR.

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 0 patients and 6 staff in the Basement if smoke and fire were allowed to transfer into the corridors. Findings include:

1. On 10/12/16 at 12:54 PM, the self-closing unit to the door to the Basement AV Storage Room was not attached to the door.

In an interview on 10/12/16 at 12:54 PM, SD#1 confirmed that the self-closing unit to the door to the Basement AV Storage Room was not attached to the door.

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 12 patients and 6 staff on the 4th Floor in a non-sleeping patient care area and 24 patients and 10 staff on the 3rd Floor if smoke and fire were allowed to transfer into the corridors. Findings include:

1. On 10/12/16 at 10:59 AM, it was observed that Room 409 was being used as a Storage Room and did not have a self-closing unit on the door.

In an interview on 10/12/16 at 10:59 AM, FACMAN#2 confirmed that Room 409 was being used as a Storage Room and did not have a self-closing unit on the door.

2. On 10/12/16 at 11:31 AM, it was observed that a self-closing unit was needed on the door to Environmental Services Room 3NA 030.

In an interview on 10/12/16 at 10:59 AM, FACMAN#2 confirmed that a self-closing unit was needed on the door to Environmental Services Room 3NA 030.

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 30 patients and 12 staff in the affected smoke compartments if smoke and fire were allowed to transfer into the corridors. Findings include:

1. On 10/12/16 at 9:54 AM, the door to Med Storage Room #602 failed to completely self-close and positively latch when tested.

In an interview on 10/12/16 at 9:54 AM, DIR#1 confirmed that the door to Med Storage Room #602 failed to completely self-close and positively latch when tested.

2. On 10/12/16 at 10:10 AM, the door to Storage Room #6045 failed to completely self-close and positively latch when tested.

In an interview on 10/12/16 at 10:10 AM, DIR#1 confirmed that the door to Storage Room #6045 failed to completely self-close and positively latch when tested.

3. On 10/12/16 at 10:18 AM, the door to the 5th Floor OR Storage Room failed to completely self-close and positively latch when tested.

In an interview on 10/12/16 at 10:18 AM, DIR#1 confirmed that the door to the 5th Floor OR Storage Room failed to completely self-close and positively latch when tested.

Based on observation and interview, the facility failed to provide the required one-hour fire resistance rating (buildings less than four stories), or the required two-hour fire resistance rating (buildings four stories or more) for the exit component in accordance with LSC Sections 19.2.1, 7.1.3.2.1 and 8.2.5.4. This deficient practice could potentially affect 30 patients and 12 staff in the affected smoke compartment if smoke and fire were allowed to transfer from the stairway into the smoke compartment. Findings include:

1. On 10/12/16 at 10:31 AM, the 4th Floor West Stairway Door Frame was observed to have a one (1) inch hole on the latching side.

In an interview on 10/12/16 at 10:31 AM, DIR#1 confirmed that the 4th Floor West Stairway Door Frame had a one (1) inch hole on the latching side.

Based on observation and interview, the facility failed to maintain, inspect and test smoke detection devices in accordance with LSC Section 9.6.1.3 and NFPA 72 Section 7.3.2.1. This deficient practice could potentially affect 30 patients and 12 staff in the affected smoke compartment if a fire was to go undetected. Findings include:

1. On 10/12/16 at 10:50 AM, the Doctors Sleep Room #3022 was not equipped with a required smoke detector.

In an interview on 10/12/16 at 10:50 AM, DIR#1 confirmed that the Doctors Sleep Room #3022 was not equipped with a required smoke detector.

Based on observation and interview, the facility failed to ensure that the automatic sprinkler system is maintained and tested 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 2 patients and 6 staff on the 3rd Floor and 0 patients and 12 staff in the Basement if the automatic sprinkler system failed to operate as designed during a fire. Findings include:

1. On 10/12/16 at 11:28 AM, it was observed that the ceiling tile above the light had a hole in it in Utility Room 3020.

In an interview on 10/12/16 at 11:28 AM, SD#1 confirmed that the ceiling tile above the light had a hole in it in Utility Room 3020.

2. On 10/12/16 at 12:21 PM, it was observed that Room BNA 107 had numerous ceiling tile penetrations.

In an interview on 10/12/16 at 12:21 PM, SD#1 confirmed that Room BNA 107 had numerous ceiling tile penetrations.

3. On 10/12/16 at 12:23 PM, it was observed that Room BMA 072, Server Room had numerous ceiling tile penetrations.

In an interview on 10/12/16 at 12:21 PM, SD#1 confirmed that Room BMA 072, Server Room had numerous ceiling tile penetrations.

4. On 10/12/16 at 12:54 PM, it was observed that the Basement AV Storage Room had storage within 18 inches of the bottom of the sprinkler heads.

In an interview on 10/12/16 at 12:54 PM, SD#1 confirmed that the Basement AV Storage Room had storage within 18 inches of the bottom of the sprinkler heads.

5. On 10/12/16 at 12:54 PM, it was observed that the Basement AV Storage Room had a ceiling tile that was out of place.

In an interview on 10/12/16 at 12:54 PM, SD#1 confirmed that the Basement AV Storage Room had a ceiling tile that was out of place.

Based on observation and interview, the facility failed to ensure that the automatic sprinkler system is maintained and tested 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 15 patients and 8 staff on the 6th Floor if the automatic sprinkler system failed to operate as designed during a fire. Findings include:

1. On 10/12/16 at 10:30 AM, it was observed that the sprinkler head in the 6 North Break Room was missing its escutcheon ring.

In an interview on 10/12/16 at 10:30 AM, FACMAN#2 confirmed that the sprinkler head in the 6 North Break Room was missing its escutcheon ring.

Based upon observation and interview, the facility failed to provide and maintain fire extinguishers in accordance with LSC Sections 19.3.5.6 and 9.7.4.1 and NFPA 10. This deficient practice could potentially affect 0 patients and 6 staff in the Kitchen if the fire extinguisher failed to operate as designed during a fire. Findings include:

1. On 10/12/16 at 11:55 AM, it was observed that the 2.5 gallon K class fire extinguisher was damaged around its base.

In an interview on 10/12/16 at 11:55 AM, SD#1 confirmed that the 2.5 gallon K class fire extinguisher was damaged around its base.

Based on review of records and interview, the facility failed to protect cooking facilities in accordance with LSC Section 19.3.2.6 and NFPA 96. This deficient practice could potentially affect 0 patients and 6 staff in the Kitchen if the hood suppression system failed to operate as designed during a fire. Findings include:

1. On 10/12/16 at 1:19 PM during the review of records it was observed that the semi-annual inspection and maintenance of the hood suppression system was performed late. Review of records showed that the inspection and maintenance was performed on 9/14/15 and 5/6/16.

In an interview on 10/12/16 at 1:19 PM, FACMAN#1 confirmed that the semi-annual inspection and maintenance of the hood suppression system was performed late on the dates noted above.

Based on observation and interview, the facility failed to provide unobstructed egress in accordance with LSC Section 7.1.10. This deficient practice could potentially affect 24 patients and 10 staff on the 3rd Floor if the means of egress was blocked during an emergency. Findings include:

1. On 10/12/16 at 11:35 AM, the charting unit at Room 367 did not close properly when tested.

In an interview on 10/12/16 at 11:35 AM, FACMAN#2 confirmed that the charting unit at Room 367 did not close properly when tested.




25492

On 10/12/16 at 12:55 PM, the lower level corridor near BMA 260 was observed to have storage of wooden pallets and computer equipment on both sides of an exit door.

In an interview on 10/12/16 at 12:55 PM, DIR#1 confirmed that the lower level corridor near BMA 260 had storage of wooden pallets and computer equipment on both sides of an exit door.

Based on observation and interview, the facility failed to provide unobstructed egress in accordance with LSC Section 7.1.10. This deficient practice could potentially affect 20 patients and 12 staff in a non-sleeping patient care area if the means of egress was blocked during an emergency. Findings include:

1. On 10/12/16 at 11:52 AM, the 1st Floor Transportation Corridor #1074 was observed to have storage of hospital beds, cribs, wheelchairs and miscellaneous construction equipment.

In an interview and review of the facility's Life Safety blueprints on 10/12/16 at 12:20 PM, FACMAN#1 confirmed that the 1st Floor Transportation Corridor #1074 was not a storage area and should not contain storage of any type.

Based on observation and interview, the facility failed to provide protection of medical gasses in accordance with LSC Section 19.3.2.4 and NFPA 99 Section 4-3.1.1.2. This deficient practice could potentially affect 0 patients and 1 staff of the facility if a fire were to worsen due to the improper storage of medical gasses. Findings include:

1. On 10/12/16 at 12:40 PM, it was observed that Oxygen Storage Room BMA-051 had combustibles stored within five (5) feet of the oxygen tanks.

In an interview on 10/12/16 at 12:40 PM, SD#1 confirmed that Oxygen Storage Room BMA-051 had combustibles stored within five (5) feet of the oxygen tanks.

Based on observation and interview, the facility failed to provide the electrical system in accordance with LSC Sections 19.5.1 and 9.1.2. This deficient practice could potentially affect 8 patients and 8 staff of the facility if the electrical system was to cause a fire. Findings include:

1. On 10/12/16 at 11:04 AM it was observed that an electrical junction box above the 4th Floor east/west cross corridor rated doors was missing its cover plate.

In an interview on 10/12/16 at 11:04 AM, SD#1 confirmed that an electrical junction box above the 4th Floor east/west cross corridor rated doors was missing its cover plate.

2. On 10/12/16 at 12:12 PM it was observed that the cover plate to an electrical junction box was not permanently attached in Air Handler Room #12, BNE 110.

In an interview on 10/12/16 at 12:12 PM, SD#1 confirmed that the cover plate to an electrical junction box was not permanently attached in Air Handler Room #12, BNE 110.

Based on observation and interview, the facility failed to provide protection from the potential hazards of flammable liquids contained in alcohol based hand cleaners in accordance with CFR Sections 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, and 485.623. This deficient practice could potentially affect 34 patients and 18 staff of the facility if the alcohol based hand cleaners were located too close to an ignition source. Findings include:

1. On 10/12/16 at 11:01 AM in Room 4021, it was observed that an alcohol based hand cleaner dispenser was closer than one (1) inch to a 2 gang light switch.

In an interview on 10/12/16 at 11:01 AM, SD#1 confirmed that an alcohol based hand cleaner dispenser was closer than one (1) inch to a 2 gang light switch in Room 4021.

2. On 10/12/16 at 11:18 AM in Room 4002, it was observed that an alcohol based hand cleaner dispenser was closer than one (1) inch to a 2 gang light switch.

In an interview on 10/12/16 at 11:18 AM, SD#1 confirmed that an alcohol based hand cleaner dispenser was closer than one (1) inch to a 2 gang light switch in Room 4002.

3. On 10/12/16 at 11:24 AM in Room 4012, it was observed that an alcohol based hand cleaner dispenser was closer than one (1) inch to a 3 gang light switch.

In an interview on 10/12/16 at 11:24 AM, SD#1 confirmed that an alcohol based hand cleaner dispenser was closer than one (1) inch to a 3 gang light switch in Room 4012.

4. On 10/12/16 at 11:31 AM in Room 3015, it was observed that an alcohol based hand cleaner dispenser was closer than one (1) inch (directly above) to a 3 gang light switch.

In an interview on 10/12/16 at 11:31 AM, SD#1 confirmed that an alcohol based hand cleaner dispenser was closer than one (1) inch (directly above) to a 3 gang light switch in Room 3015.

5. On 10/12/16 at 11:32 AM in Room 3012, it was observed that an alcohol based hand cleaner dispenser was closer than one (1) inch (directly above) to a 3 gang light switch.

In an interview on 10/12/16 at 11:32 AM, SD#1 confirmed that an alcohol based hand cleaner dispenser was closer than one (1) inch (directly above) to a 3 gang light switch in Room 3012.

6. On 10/12/16 at 12:40 PM in Room BMA-036, it was observed that an alcohol based hand cleaner dispenser was closer than one (1) inch to a light switch.

In an interview on 10/12/16 at 12:40 PM, SD#1 confirmed that an alcohol based hand cleaner dispenser was closer than one (1) inch to a light switch in Room BMA-036.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with LSC Section 19.3.6.3. This deficient practice could potentially affect 16 patients and 8 staff in the affected smoke compartment if smoke and fire were allowed to be transferred into the corridor. Findings include:

1. On 10/12/16 at 10:31 AM, the corridor door to #4116 Nurses Room failed to positively latch when tested.

In an interview on 10/12/16 at 10:31 AM, DIR#1 confirmed that the corridor door to #4116 Nurses Room failed to positively latch and that the door was scheduled to be replaced.

2. On 10/12/16 at 10:31 AM, the corridor door to #4116 Nurses Room was observed to have four (4) open through holes approximately 1/4" in size above the door handle.

In an interview on 10/12/16 at 10:31 AM, DIR#1 confirmed that the corridor door to #4116 Nurses Room had four (4) open through holes approximately 1/4" in size above the door handle and that the door was scheduled to be replaced.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with LSC Sections 19.3.7.3 and 19.3.7.5. This deficient practice could potentially affect 35 patients and 16 staff on the 5th Floor; 0 patients and 12 staff on the 4th Floor; 24 patients and 10 staff on the 3rd Floor; and 10 patients and 24 staff on the 2nd Floor if the smoke barriers allowed smoke and fire to transfer from one smoke compartment to another. Findings include:

1. On 10/12/16 at 10:45 AM, an open penetration was observed in the smoke barrier wall separating 5 Main and 5 East.

In an interview on 10/12/16 at 10:45 AM, FACMAN#2 confirmed an open penetration in the smoke barrier wall separating 5 Main and 5 East.
2. On 10/12/16 at 10:50 AM, an open penetration was observed in Environmental Services Room 5EA 070.

In an interview on 10/12/16 at 10:50 AM, FACMAN#2 confirmed an open penetration in Environmental Services Room 5EA 070.

3. On 10/12/16 at 11:16 AM, an open penetration was observed in 4 West Wire Room.

In an interview on 10/12/16 at 11:16 AM, FACMAN#2 confirmed an open penetration in 4 West Wire Room.

4. On 10/12/16 at 11:19 AM, an open penetration was observed in 4 West North Mechanical Room.

In an interview on 10/12/16 at 11:19 AM, FACMAN#2 confirmed an open penetration in 4 West North Mechanical Room.

5. On 10/12/16 at 11:21 AM, an open penetration was observed in 4 West South Mechanical Room.

In an interview on 10/12/16 at 11:21 AM, FACMAN#2 confirmed an open penetration in 4 West South Mechanical Room.

6. On 10/12/16 at 11:33 AM, an open penetration was observed in Wire Room 3NE 020.

In an interview on 10/12/16 at 11:33 AM, FACMAN#2 confirmed an open penetration in Wire Room 3NE 020.

7. On 10/12/16 at 12:56 PM, an open penetration was observed in the 2nd Floor Wire Room outside of OR.

In an interview on 10/12/16 at 12:56 PM, FACMAN#2 confirmed an open penetration in the 2nd Floor Wire Room outside of OR.

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 0 patients and 6 staff in the Basement if smoke and fire were allowed to transfer into the corridors. Findings include:

1. On 10/12/16 at 12:54 PM, the self-closing unit to the door to the Basement AV Storage Room was not attached to the door.

In an interview on 10/12/16 at 12:54 PM, SD#1 confirmed that the self-closing unit to the door to the Basement AV Storage Room was not attached to the door.

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 12 patients and 6 staff on the 4th Floor in a non-sleeping patient care area and 24 patients and 10 staff on the 3rd Floor if smoke and fire were allowed to transfer into the corridors. Findings include:

1. On 10/12/16 at 10:59 AM, it was observed that Room 409 was being used as a Storage Room and did not have a self-closing unit on the door.

In an interview on 10/12/16 at 10:59 AM, FACMAN#2 confirmed that Room 409 was being used as a Storage Room and did not have a self-closing unit on the door.

2. On 10/12/16 at 11:31 AM, it was observed that a self-closing unit was needed on the door to Environmental Services Room 3NA 030.

In an interview on 10/12/16 at 10:59 AM, FACMAN#2 confirmed that a self-closing unit was needed on the door to Environmental Services Room 3NA 030.

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 30 patients and 12 staff in the affected smoke compartments if smoke and fire were allowed to transfer into the corridors. Findings include:

1. On 10/12/16 at 9:54 AM, the door to Med Storage Room #602 failed to completely self-close and positively latch when tested.

In an interview on 10/12/16 at 9:54 AM, DIR#1 confirmed that the door to Med Storage Room #602 failed to completely self-close and positively latch when tested.

2. On 10/12/16 at 10:10 AM, the door to Storage Room #6045 failed to completely self-close and positively latch when tested.

In an interview on 10/12/16 at 10:10 AM, DIR#1 confirmed that the door to Storage Room #6045 failed to completely self-close and positively latch when tested.

3. On 10/12/16 at 10:18 AM, the door to the 5th Floor OR Storage Room failed to completely self-close and positively latch when tested.

In an interview on 10/12/16 at 10:18 AM, DIR#1 confirmed that the door to the 5th Floor OR Storage Room failed to completely self-close and positively latch when tested.

Based on observation and interview, the facility failed to provide the required one-hour fire resistance rating (buildings less than four stories), or the required two-hour fire resistance rating (buildings four stories or more) for the exit component in accordance with LSC Sections 19.2.1, 7.1.3.2.1 and 8.2.5.4. This deficient practice could potentially affect 30 patients and 12 staff in the affected smoke compartment if smoke and fire were allowed to transfer from the stairway into the smoke compartment. Findings include:

1. On 10/12/16 at 10:31 AM, the 4th Floor West Stairway Door Frame was observed to have a one (1) inch hole on the latching side.

In an interview on 10/12/16 at 10:31 AM, DIR#1 confirmed that the 4th Floor West Stairway Door Frame had a one (1) inch hole on the latching side.

Based on observation and interview, the facility failed to maintain, inspect and test smoke detection devices in accordance with LSC Section 9.6.1.3 and NFPA 72 Section 7.3.2.1. This deficient practice could potentially affect 30 patients and 12 staff in the affected smoke compartment if a fire was to go undetected. Findings include:

1. On 10/12/16 at 10:50 AM, the Doctors Sleep Room #3022 was not equipped with a required smoke detector.

In an interview on 10/12/16 at 10:50 AM, DIR#1 confirmed that the Doctors Sleep Room #3022 was not equipped with a required smoke detector.

Based on observation and interview, the facility failed to ensure that the automatic sprinkler system is maintained and tested 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 2 patients and 6 staff on the 3rd Floor and 0 patients and 12 staff in the Basement if the automatic sprinkler system failed to operate as designed during a fire. Findings include:

1. On 10/12/16 at 11:28 AM, it was observed that the ceiling tile above the light had a hole in it in Utility Room 3020.

In an interview on 10/12/16 at 11:28 AM, SD#1 confirmed that the ceiling tile above the light had a hole in it in Utility Room 3020.

2. On 10/12/16 at 12:21 PM, it was observed that Room BNA 107 had numerous ceiling tile penetrations.

In an interview on 10/12/16 at 12:21 PM, SD#1 confirmed that Room BNA 107 had numerous ceiling tile penetrations.

3. On 10/12/16 at 12:23 PM, it was observed that Room BMA 072, Server Room had numerous ceiling tile penetrations.

In an interview on 10/12/16 at 12:21 PM, SD#1 confirmed that Room BMA 072, Server Room had numerous ceiling tile penetrations.

4. On 10/12/16 at 12:54 PM, it was observed that the Basement AV Storage Room had storage within 18 inches of the bottom of the sprinkler heads.

In an interview on 10/12/16 at 12:54 PM, SD#1 confirmed that the Basement AV Storage Room had storage within 18 inches of the bottom of the sprinkler heads.

5. On 10/12/16 at 12:54 PM, it was observed that the Basement AV Storage Room had a ceiling tile that was out of place.

In an interview on 10/12/16 at 12:54 PM, SD#1 confirmed that the Basement AV Storage Room had a ceiling tile that was out of place.

Based on observation and interview, the facility failed to ensure that the automatic sprinkler system is maintained and tested 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 15 patients and 8 staff on the 6th Floor if the automatic sprinkler system failed to operate as designed during a fire. Findings include:

1. On 10/12/16 at 10:30 AM, it was observed that the sprinkler head in the 6 North Break Room was missing its escutcheon ring.

In an interview on 10/12/16 at 10:30 AM, FACMAN#2 confirmed that the sprinkler head in the 6 North Break Room was missing its escutcheon ring.

Based upon observation and interview, the facility failed to provide and maintain fire extinguishers in accordance with LSC Sections 19.3.5.6 and 9.7.4.1 and NFPA 10. This deficient practice could potentially affect 0 patients and 6 staff in the Kitchen if the fire extinguisher failed to operate as designed during a fire. Findings include:

1. On 10/12/16 at 11:55 AM, it was observed that the 2.5 gallon K class fire extinguisher was damaged around its base.

In an interview on 10/12/16 at 11:55 AM, SD#1 confirmed that the 2.5 gallon K class fire extinguisher was damaged around its base.

Based on review of records and interview, the facility failed to protect cooking facilities in accordance with LSC Section 19.3.2.6 and NFPA 96. This deficient practice could potentially affect 0 patients and 6 staff in the Kitchen if the hood suppression system failed to operate as designed during a fire. Findings include:

1. On 10/12/16 at 1:19 PM during the review of records it was observed that the semi-annual inspection and maintenance of the hood suppression system was performed late. Review of records showed that the inspection and maintenance was performed on 9/14/15 and 5/6/16.

In an interview on 10/12/16 at 1:19 PM, FACMAN#1 confirmed that the semi-annual inspection and maintenance of the hood suppression system was performed late on the dates noted above.

Based on observation and interview, the facility failed to provide unobstructed egress in accordance with LSC Section 7.1.10. This deficient practice could potentially affect 24 patients and 10 staff on the 3rd Floor if the means of egress was blocked during an emergency. Findings include:

1. On 10/12/16 at 11:35 AM, the charting unit at Room 367 did not close properly when tested.

In an interview on 10/12/16 at 11:35 AM, FACMAN#2 confirmed that the charting unit at Room 367 did not close properly when tested.




25492

On 10/12/16 at 12:55 PM, the lower level corridor near BMA 260 was observed to have storage of wooden pallets and computer equipment on both sides of an exit door.

In an interview on 10/12/16 at 12:55 PM, DIR#1 confirmed that the lower level corridor near BMA 260 had storage of wooden pallets and computer equipment on both sides of an exit door.

Based on observation and interview, the facility failed to provide unobstructed egress in accordance with LSC Section 7.1.10. This deficient practice could potentially affect 20 patients and 12 staff in a non-sleeping patient care area if the means of egress was blocked during an emergency. Findings include:

1. On 10/12/16 at 11:52 AM, the 1st Floor Transportation Corridor #1074 was observed to have storage of hospital beds, cribs, wheelchairs and miscellaneous construction equipment.

In an interview and review of the facility's Life Safety blueprints on 10/12/16 at 12:20 PM, FACMAN#1 confirmed that the 1st Floor Transportation Corridor #1074 was not a storage area and should not contain storage of any type.

Based on observation and interview, the facility failed to provide protection of medical gasses in accordance with LSC Section 19.3.2.4 and NFPA 99 Section 4-3.1.1.2. This deficient practice could potentially affect 0 patients and 1 staff of the facility if a fire were to worsen due to the improper storage of medical gasses. Findings include:

1. On 10/12/16 at 12:40 PM, it was observed that Oxygen Storage Room BMA-051 had combustibles stored within five (5) feet of the oxygen tanks.

In an interview on 10/12/16 at 12:40 PM, SD#1 confirmed that Oxygen Storage Room BMA-051 had combustibles stored within five (5) feet of the oxygen tanks.

Based on observation and interview, the facility failed to provide the electrical system in accordance with LSC Sections 19.5.1 and 9.1.2. This deficient practice could potentially affect 8 patients and 8 staff of the facility if the electrical system was to cause a fire. Findings include:

1. On 10/12/16 at 11:04 AM it was observed that an electrical junction box above the 4th Floor east/west cross corridor rated doors was missing its cover plate.

In an interview on 10/12/16 at 11:04 AM, SD#1 confirmed that an electrical junction box above the 4th Floor east/west cross corridor rated doors was missing its cover plate.

2. On 10/12/16 at 12:12 PM it was observed that the cover plate to an electrical junction box was not permanently attached in Air Handler Room #12, BNE 110.

In an interview on 10/12/16 at 12:12 PM, SD#1 confirmed that the cover plate to an electrical junction box was not permanently attached in Air Handler Room #12, BNE 110.