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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 November 10, 2010 at approximately 1:10 PM, observed that the door to the "Seclusion Room" in the 1st floor patient wing has a significant gap at the top of the door and is not reasonably smoke tight.

This finding was observed and confirmed by the maintenance director at the time of the inspection.

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 November 10, 2010 at approximately 10:58 AM, observed that the basement fire door to the electrical room failed to close and latch. The door hardware was also missing.

- On November 10, 2010 at approximately 11:02 AM, observed trash stored in the stairwell of the basement boiler room.

- On November 10, 2010 at approximately 11:07 AM, observed combustible storage in the basement boiler room.

- On November 10, 2010 at approximately 11:08 AM, observed that the basement fire door separating the boiler boom and the maintenance room does not fully close and latch.

- On November 10, 2010 at approximately 11:10 AM, observed penetrations through the wall of the basement IT Server Room. Also, the fire rated door does not have a door self-closer installed.

- On November 10, 2010 at approximately 11:17 AM, observed that the rated door off the stairwell to the basement Transformer Room does not have a door self-closer installed.

- On November 10, 2010 at approximately 11:27 AM, observed that the self-closer on the door to the 1st floor administration wing copy room has been removed. (Note: This door is installed in a 2-hour separation wall).

- On November 10, 2010 at approximately 12:11 PM, observed combustibles stored in the 1st floor elevator room # 134.

- On November 10, 2010 at approximately 1:37 PM, observed that the self-closer on the door to the 1st floor pharmacy near room 150 has been removed.

- On November 10, 2010 at approximately 1:39 PM, observed that the self-closer on the door to the 1st floor outpatient pharmacy maintenance storage room has been removed.

- On November 10, 2010 at approximately 1:40 PM, observed unsealed penetrations through the two-hour fire wall in the pharmacy maintenance storage room.

These findings were observed and confirmed by the maintenance director at the time of the inspection.

Based on observation the facility failed to provide approved means of egress in accordance with the LSC section 19.2.2.3, 19.2.2.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

- On November 10, 2010 at approximately 11:00 AM, observed combustibles stored in the basement stairwell exiting to the south side of the building, located in the boiler room.

- On November 10, 2010 at approximately 11:16 AM, observed combustibles and oxygen stored in the stairwell off the main lobby. Also, clearance has been diminished by construction of a wall in the stairwell.

- On November 10, 2010 at approximately 11:55 AM, observed that the 2nd floor south stairwell door is not reasonably smoke tight. Also noted a penetration located on the latch side of the door near the magnet lock.

These findings were observed and confirmed by the maintenance director at the time of the inspection.

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 November 10, 2010 at approximately 11:42 AM while questioning staff on the fire procedures, it was noted that staff did not respond appropriately and as written in the Emergency Action Plan.

- On November 10, 2010 at approximately 2:09 PM while questioning staff on the fire procedures, observed that not all staff has keys to activate the fire alarm pull stations and access the fire extinguishers.

These findings were observed and confirmed by the security director at the time of the inspection.

Based on observation and/or review of records the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 11-10-10 the following observations were made:

- On November 10, 2010 at approximately 9:05 AM by review of the fire drill logs, it was observed the facility is not conducting the required number of drills (once per shift, per quarter).

This finding was observed and confirmed by the security director at the time of the inspection.

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 November 10, 2010 at approximately 9:05 AM by review of the facilities fire alarm inspection records, it was noted that a duct detector has not be tested due to limited accessibility. The report from IQ Life Safety dated March 13, 2008 and prior reports confirmed that this has been previously noted and has not been addressed by the facility.

This finding was observed and confirmed by the maintenance director at the time of the inspection.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all occupants of the facility. Findings include:

- On November 10, 2010 at approximately 9:00 AM by review of the facilities sprinkler log, it was observed the facility is not conducting quarterly water flow and main drain tests as required by NFPA 25.

- On November 20, 1020 at approximately 11:22 AM, observed that the gauges on the 1st floor sprinkler riser are out of compliance. The gauges were dated 2003. Also, noted that the fire alarm tamper switches have been modified and an alarm junction box with exposed wires.

- On November 10, 2010 at approximately 11:43 AM, observed that the inspector's test valve pipe located in room 310 does not have a restrictor to simulate sprinkler head.

- On November 10, 2010 at approximately 1:46 PM, observed a sprinkler escutcheon ring not properly secured in the outpatient pharmacy.

These findings were observed and confirmed by the maintenance director at the time of the inspection.

Based on observation the facility failed to provide smoking regulations in accordance with the LSC section 19.7.4. This deficient practice could potentially affect all occupants of the facility. Findings include:

- On November 10, 2010 at approximately 9:10 AM, observed staff smoking directly outside the pharmacy door to the hospital in a non-designated location.

- On November 10, 2010 at approximately 10:59 AM, observed evidence of smoking in non-designated areas. Cigarette butts were found on the ground near the electrical transformers to the building.

The maintenance director was informed of these observations at the time of the inspection.

Based on observation and/or review of records the facility failed to provide flame resistant curtains in accordance with the LSC section 10.3.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

- On November 10, 2010 at approximately 9:10 AM upon review of records, it was noted that the facility was unable to locate flame spread documentation for the cubicle curtains and drapes.

- On November 10, 2010 at approximately 11:59 AM, observed non-compliant curtains in the 2nd floor linen closet 226. Also, no flame spread documentation was available for these curtains.

These findings were observed and confirmed by the maintenance director at the time of the inspection.

The facility failed to protect fire/smoke wall duct penetrations in accordance with LSC 101:8.3.5. This deficient practice could potentially affect all occupants of the facility. Findings include:

- On November 10, 2010 at approximately 9:10 AM by review of the facilities logs, observed that the fire dampers throughout the hospital have not been properly logged or tested nor the fusible links replaced as required.

This finding was observed and confirmed by the maintenance director at the time of the inspection.

Based on observation and/or review of records the facility failed to provide Annual Fire Door Drop testing records per the requirement of NFPA 80 Chp 5.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

- On November 10, 2010 at approximately 9:05 AM during review of the facilities logs, observed that two fire shutters are past due for inspection as required in NFPA 80 Chap 5.2. (Note: The last test date indicated was 6-30-09.)

This finding was observed and confirmed by the maintenance director at the time of the inspection.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect all occupants of the facility. Findings include:

- On November 10, 2010 at approximately 11:00 AM, observed that the emergency generator does not have a remote annunciator panel at a constantly attended location as required in NFPA 110.

This finding was observed and confirmed by the maintenance director at the time of the inspection.

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 November 10, 2010 at approximately 10:56 AM, observed the high voltage box to the generator was unlocked and the cabinet was unsecured. Also, the maintenance director stated he kept his generator logs inside the cabinet exposing him to unprotected high voltage wiring.

- On November 10, 2010 at approximately 12:11 PM, observed in the 1st floor elevator room # 134, a high voltage panel cover was removed and exposed wiring.

These findings were observed and confirmed by the maintenance director at the time of the inspection.

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 November 10, 2010 at approximately 9:05 AM during review of the Emergency Action Plan, it was noted that the facility does not have a procedure in-place in the event the fire alarm or sprinkler systems are offline for 4-hours or more.

This finding was observed and confirmed by the maintenance director at the time of the inspection.