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Based on observation the facility failed to provide 1-hour fire resistive separation for the vertical openings in accordance with the LSC section 19.3.1.1. This deficient practice could potentially affect all occupants of the facility if fire was allowed to spread through a pipe chase.

Findings include:

A. On May 27, 2010, at approximately 12:55 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the top of the pipe chase in the penthouse had been opened up for new piping and never resealed.

This was confirmed by the Maintenance Supervisor at the time of discovery.

Based on observation the facility failed to provide for doors hold open devices in accordance with the LSC section 19.2.2.2.6. This deficient practice could potentially affect 20 occupants of the facility if the door failed to function properly.

Findings include:

A. On May 27, 2010, at approximately 3:45 PM, while conducting a walk through with the Maintenance Supervisor after a test of the fire alarm system, it was observed that the fire separation door to Facility Services on the 1st floor had hardware that did not properly latch when closed.

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 30 occupants of the facility if fire and smoke was able to spread beyond the hazard area.

Findings include:

A. On May 27, 2010, at approximately 12:45 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that several penetrations over the door to the penthouse was not properly sealed.

B. On May 27, 2010, at approximately 1:20 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the door to the Soiled Utility in the OR suite did not close and latch properly.

C. On May 27, 2010, at approximately 1:35 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the door to the Soiled Utility located in the Med/Surg on the 2nd floor did not close and latch properly.

D. On May 27, 2010, at approximately 1:45 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that a communication conduit and the wall over the fire separation doors to Med/Surg was not properly sealed.

E. On May 27, 2010, at approximately 1:55 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that a conduit in the Soiled Utility of the Sleep Lab was not properly sealed.

F. On May 27, 2010, at approximately 2:08 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that conduits in the Mechanical room in the Basement were not properly sealed.

G. On May 27, 2010, at approximately 2:25 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the sprinkler line penetrating the wall by the door of the 1st Floor Mechanical room was not properly sealed.

H. On May 27, 2010, at approximately 2:26 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that there was a hole in the drywall of the 1st Floor Mechanical room.

I. On May 27, 2010, at approximately 2:43 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that conduits and a hole in the wall of the PT emergency transfer room in the basement was not properly sealed.

J. On May 27, 2010, at approximately 2:44 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the door the the Elevator Equipment room in the PT area of the basement did not close and latch properly.

All these deficiencies were confirmed by the Maintenance Supervisor at the time of their discovery.

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 May 27, 2010, at approximately 12:35 PM, while reviewing records and conducting staff interviews it was determined that the Fire Safety Plan contained references to fire extinguishers [and their use] that are not used in the facility

This failure to update the Fire Safety Plan was confirmed by the Maintenance Supervisor at the time of discovery.

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 if staff are not properly trained in approved emergency procedures.

Findings include:

A. On May 27, 2010, at approximately 11:30 PM, while reviewing records and conducting staff interviews, it was determined that all the fire drills being conducted were taking place within the last 3 days of the month and not being done at varied times.


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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 10 occupants of the facility when using the stairwell..

Findings include:

A. On May 27, 2010, at approximately 3:40 PM, while conducting a fire drill and testing of the fire alarm system, it was observed that the horn/strobe located in the stairwell between the hospital and Educational building on the 1st floor did not sound.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all occupants of the facility if smoke detection does not perform as designed.

Findings include:

A. On May 27, 2010, at approximately 11:45 AM, while reviewing records and conducting staff interviews, it was determined that there was no records in the past 2 years, for sensitivity testing of the smoke detection located within the facility.

B. On May 27, 2010, at approximately 2:30 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the smoke detector located in the waiting area for Cardio Rehab was loose on the ceiling.

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 5 occupants of the facility if the sprinklers failed to operate as designed due to lack of maintenance.

Findings include:

A. On May 27, 2010, at approximately 1:50 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the sprinkler heads located in the Soiled Utility of the Sleep Lab on the 2nd floor were dirty and needed to be cleaned of lint and debris.

B. On May 27, 2010, at approximately 2:05 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the storage in the Sprinkler Riser room in the basement was too high.

C. On May 27, 2010, at approximately 2:50 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the ceiling tiles were missing in the MRI equipment room effecting the response of the sprinkler heads.

D. On May 27, 2010, at approximately 2:52 PM, while conducing a walk through with the Maintenance Supervisor, it was observed that the escutcheon on the sprinkler head for the Janitor's Closet in X-ray was missing.

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 15 occupants of the facility if a fire occurred because of an open electrical connection.

Findings include:

A. On May 27, 2010, at approximately 2:20 PM, while conducting a walk through with the Maintenance Supervisor, it was observed that the electrical box located on the ceiling of the 1st floor Mechanical room was open without a cover.

B. On May 27, 2010, at approximately 2:35 PM. while conducting a walk through with the Maintenance Supervisor, it was observed that the electrical box located on the ceiling of the Physical Therapy treatment room was open without a cover.