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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 1? inch sold-bonded core wood, capable of resisting the passage of smoke.

On 01/25/10 at 11:45 AM, the surveyor while accompanied by the Maintenance Foreman, observed that the double, entry doors to the Laboratory, from the X-ray corridor were damaged to the core and negated the doors ability to resist the passage of smoke, as required by the referenced LSC.

The facility did not ensure that stairways, elevator shafts, light and ventilation shafts, chutes and other vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour as required by the referenced LSC.

On 01/25/10 at 09:30 AM, the surveyor while accompanied by the Maintenance Foreman, observed that the door that separates the (freight) elevator shaft-outside the Morgue-Lower Level (Area 1A), from the corridor would not resist the passage of smoke: i.e. gaps in door, elevator car and components removed, resulting in an -unprotected vertical opening.

The facility did not ensure that emergency lighting is provided in accordance with LSC 7.9 & 19.2.9.1.

On 01/25/10 at 11:05 AM, the surveyor was not provided with documentation from the Director of Engineering that indicated that the battery-powered emergency light fixtures were being tested & inspected both monthly & annually as required by the referenced, LSC.

The facility did not ensure that a fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system has an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72.

On 01/25/10 at 09:15 AM, the surveyor while accompanied by the Maintenance Foreman, observed that a smoke detector, tied to the building ' s fire alarm was not installed/provided in the X-ray storage room-Lower Level (Area 1A); i.e. no smoke detection or sprinkler coverage.

The facility did not ensure that the required automatic sprinkler system was continuously maintained in reliable operating condition and was inspected and tested periodically as required by the referenced LSC.

1. On 01/25/10 at 09:30 AM, the surveyor was not provided with documentation from the Director of Engineering that indicated that 5th year, preventative maintenance/inspections had been conducted on either the wet-pipe or dry-pipe sprinkler systems; i.e. no pitch, internal obstruction investigation or internal valve inspection.

2. On 01/25/10 at 11:20 AM, the surveyor while accompanied by the Maintenance Foreman, observed that a section of ceiling tiles/pads had been removed in the Laboratory, negating the sprinkler system ' s ability to react when heat collects at the finished, ceiling level; i.e. egg-crate style grating material installed in grid to facilitate HVAC.

The facility did not ensure that the Type I Essential Electrical System powered by a generator with a transfer switch is being maintained in accordance with the LSC & NFPA 99.

1. On 01/25/10 at 09:25 AM, the surveyor was not provided with documentation from the Director of Engineering that indicated that the 2 (two), 600 KW emergency generators had preventative maintenance performed on them as required by the referenced LSC; i.e. major PM conducted 02/09/09-last pm 08/07 before that-no pm in 2008.

2. On 01/25/10 at 09:25 AM, the surveyor was not provided with documentation from the Director of Engineering that indicated that the 375 KW generator has had any preventative maintenance performed on it as required by the referenced LSC; i.e. gen set placed into service October 2008-no pm conducted yet.