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The facility did not ensure that corridors were separated from use areas by walls constructed to resist the passage of smoke, as required by the referenced LSC standard.

On 10/22/12 at 1:15 PM the surveyor, accompanied by the Director of Safety and Security, observed that the corridor wall within the Service Corridor in the basement area of the facility had holes in the wall surfaces, not meeting the referenced LSC standard.

The facility did not ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch sold-bonded core wood, capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke.

On 10/22/12 at 10:40 AM, the surveyor, accompanied by the Director of Engineering, observed that corridor door # W-250 to the Lounge area was damaged to the core, lacked integrity and was not capable of resisting the passage of smoke as required.

The facility did not ensure that doors in the fire separation walls, hazardous area enclosures, or smoke partitions were held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of the required manual alarm system and either a required smoke detection system and automatic sprinkler system as required by the referenced LSC.

On 10/23/12 at 10:00 AM, the surveyor, accompanied by the Director of Safety and Security, observed the two (2) entry doors to the Main Electrical Control Room and the entry door to the Emergency Generator Room were held in the open position by devices not designed and installed to automatically close the doors upon activation of the fire alarm system, not meeting the referenced LSC standard.

The facility did not ensure that hazardous areas were either separated by construction providing at least a one hour fire resistance rating or protected by an automatic extinguishing system, where the sprinkler option is used the areas shall be separated by smoke resisting partitions and self-closing doors as required by 19.3.2.1.

a. On 10/22/12 at 1:20 PM, the surveyor, accompanied by the Director of Safety and Security, observed that the Environmental Storage Closet was not constructed to be resistant to the passage of smoke from other spaces, not meeting the referenced LSC standard.

b. On 10/22/12 at 1:25 PM the surveyor, accompanied by the Director of Safety and Security, observed that the corridor doors to the Mop Room, Mechanical Room #4, and Laundry Room within the basement of the facility were not of 1 ¾ " construction and the doors failed to positively self-close and latch in order to maintain the required fire resistance rating at these fire rated assemblies into an opening to a hazardous area.

The facility did not ensure that nonflammable medical gas systems and equipment used for the administration of inhalation therapy and for resuscitative purposes was in compliance with NFPA 99- Heath Care Facilities.

On 10/23/12 at 1:40 PM the surveyor, accompanied by the Director of Safety and Security, observed that the corridor door to the medical gas cylinder storage room lacked a precautionary sign notifying occupants of the presence of stored medical gasses as required by section 8-3 of NFPA 99.

The facility did not ensure that piped in medical gas systems are in compliance with NFPA 99, 4.1, 4.1.1, NFPA 70.

On 10/23/12 at 1:20 PM, the surveyor was not provided with documentation by the Director, Engineering and Construction to indicate that deficiencies noted on the annual report for the Oxygen Medical Gas, Medical Air Compress and Vacuum System dated 08/28/12 and 08/30/12 by Airgas Medical Services had been corrected; i.e., valves for oxygen, air and vacuum were not tested in room W350 due to valves being obstructed.