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Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with the LSC section 19.3.6.3. . This deficient practice could potentially affect 35 occupants of the facility.

Findings include:

1. On 05/01/12 at 1:30 PM, observation revealed that the door to patient room 260/262 located on the 2nd floor had a gap between the face of the corridor door and the door stop exceeding the allowable 1/2-inch space.

2. On 05/01/12 at 1:39 PM, observation revealed that the door to patient room 217 located on the 2nd floor had a gap between the face of the corridor door and the door stop exceeding the allowable 1/2-inch space.

3. On 05/01/12 at 1:56 PM, observation revealed that the door to patient room LDRP 2 located on the 2nd floor did not shut and latch when tested.

These deficient practices were confirmed by the Director of Plant Operations at the time of discovery.

Based on observation the facility failed to provide signs in accordance with the LSC section 7.10.1.4. This deficient practice could potentially affect all occupants of the facility in the event of an emergency and the means of egress were not properly signed.

Findings include:

1. On 05/01/12 at 1:03 PM, observation revealed that there was not 2 visible marked means of egress from the corridor outside of patient room 231 on the 2nd floor.

2. On 05/01/12 at 1:37 PM, observation revealed that there was not 2 visible marked means of egress from the corridor outside of patient room 216 on the 2nd floor.

3. On 05/02/12 at 10:38 AM, observation revealed that there was not a visible marked means of egress from the Oncology area. There was a exit sign leading from the patient area of Oncology that led you into a waiting room, but no signs from the waiting room.

These deficient practices were confirmed by the Director of Plant Operations at the time of discovery.

Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 40 occupants of the facility.

Findings include:

On 05/02/12 at 11:51 AM, observation revealed the smoke barrier wall located on the 1st floor outside Room 122 Ultra Sound did not provide the minimum fire rating. The wall across the corridor consisted of a glass sidelight, glass top light and glass door. None of the glass was stamped showing it to be fire glazed to the minimum one half hour fire resistance rating.

This deficient practice was confirmed by the Director of Plant Operations at the time of discovery.

Based on observation the facility failed to provide for the smoke barrier doors to be self-closing or automatic closing in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 50 occupants of the facility.

Findings include:

1. On 05/01/12 at 11:36 AM, observation revealed the door to Treatment Room 2-333 on the 3rd floor was located in a smoke barrier wall per the prints provided. This door was not rated to meet the minimum requirement and was not provided with a self-closing or automatic closing device.

2. On 05/02/12 at 12:23 PM, observation revealed the door to the 1st floor Physicians Office Cashier was located in a smoke barrier wall per the prints provided. This door was not provided with a self-closing or automatic closing device.

3. On 05/02/12 at 12:26 PM, observation revealed the back door to the 1st floor Stereotatic was located in a smoke barrier wall per the prints provided. This door was not provided with a self-closing or automatic closing device.

These deficient practices were confirmed by the Director of Plant Operations at the time of discovery.

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:

1. On 05/02/12 at 10:53 AM, observation revealed the door to the storage room inside of the 1st floor Gift Shop was propped open using an unapproved door hold open.

2. On 05/02/12 at 11:45 AM, observation revealed the door to the flammable liquids storage room inside of the Laboratory did not close and latch when tested.

3. On 05/02/12 at 12:35 PM, observation revealed the door to the storage room inside of the 1st floor Medical Records Room 130 was propped open using an unapproved door hold open.

These deficient practices were confirmed by the Director of Plant Operations at the time of discovery.

Based on observation the facility failed to provide the required one-hour fire resistance rating for the exit component in accordance with the LSC section 8.2.5.2, 19.3.11. This deficient practice could potentially affect 25 occupants of the facility if the means of egress was not available during a fire emergency.

Findings include:

On 05/01/12 at 2:20 PM, observation revealed the door to the stairwell located in the 2nd floor Operating Room did not latch when tested.

This deficient practice was confirmed by the Director of Plant Operations at the time of discovery.

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:

1. On 05/01/12 at 1:06 PM, observation revealed the smoke detector located in the corridor outside of Equipment Storage Room 271 on the 2nd floor was within 3-feet of an air supply duct.

2. On 05/01/12 at 1:13 PM, observation revealed the smoke detector located in the corridor outside of Infant Delivery Scrub Area on the 2nd floor was within 3-feet of an air supply duct.

3. On 05/01/12 at 2:02 PM, observation revealed the smoke detector located in the corridor outside of Ambulatory Surgery Mechanical Room #2 on the 2nd floor was within 3-feet of an air supply duct.

These deficient practices were confirmed by the Director of Plant Operations at the time of discovery.

Based on observation and review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and 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:

1. On 05/01/12 at 10:03 AM, review of the document titled "Fire Safety Documents" in the "Sprinkler Systems" tab and interview of the Director of Plant Operations revealed that an interior inspection of their pressurized water storage tank had not been conducted during the previous 3 years. This inspection shall be completed not less than every 3 years.

2. On 05/02/12 at 10:15 AM, interview of the Director of Plant Operations revealed that a flow test of the standpipe system had not been completed during the previous 5 years. This inspection shall be completed not less than every 5 years.

3. On 05/02/12 at 10:21 AM, observation revealed that 2 of 3 sprinkler heads in the Medical Waste room located on the 1st floor had over spray paint on them.

These deficient practices were confirmed by the Director of Plant Operations at the time of discovery.

Portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 110, Standard for Portable Fire Extinguishers. 9.7.4.1

Findings include:

On 05/02/12 at 11:04 AM, observation revealed that only 2 extinguishers labeled as 1A were provided in the 1st floor Emergency Room. The minimum size of a fire extinguisher for a light hazard occupancy is 2A. Each unit of A shall cover a maximum of 3000 square feet. The Emergency Room area totals 6300 Square feet.

This deficient practice was confirmed by the Director of Plant Operations at the time of discovery.

Based on observation the facility failed to provide an essential electrical system in accordance with NFPA 99. This deficient practice could potentially affect all occupants of the facility.

Findings include:

1. On 05/02/12 at 12:02 PM, observation revealed that no emergency stop for the generator prime mover was provided for outside of the enclosed generator room for either of the provided generators.

2. On 05/02/12 at 12:09 PM, observation revealed that the 2-hour rated wall between the generator room and the fire suppression room was not sealed tight to the deck.

These deficient practices were confirmed by the Director of Plant Operations at the time of discovery.