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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 22 occupants of the facility. Findings include:

- On December 6, 2011 at approximately 10:30 AM, observed that a vacant Operating Room in the vacant OR Wing is being used as a storage room. The door is propped open by medical equipment storage over flow. This deficiency is not in accordance with LSC 2000 Edition 19.3.2.1

- On December 6, 2011 at approximately 10:45 AM, observed that there is a 1/4 - inch wall through penetration around a pipe protruding through the fire wall next to the hood suppression cylinders in the facility Kitchen. This deficiency would not prevent the spread of smoke and heat from entering the Dining Room.

- On December 6, 2011 at approximately 10:55 AM, observed that there is a 1/4 - inch wall through penetration around a cable protruding through the fire wall located in the 1st Floor Main Housekeeping Storage Room. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

- On December 6, 2011 at approximately 11:45 AM, observed that there is a 1/4 - inch wall through penetration around a cable protruding through the fire wall located above the entrance door to the 1st Floor Main Storage Room. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor.

- On December 6, 2011 at approximately 12:10 PM, observed that there is a 1/2 - inch wall through penetration in the fire wall to the right of the entrance door to the Bio-Med Storage Room. This deficiency would not prevent the spread of smoke and heat from entering the adjacent smoke zone.

These findings were observed and confirmed by the maintenance staff 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 22 occupants of the facility. Findings include:

- On December 6, 2011 at approximately 10:50 AM, observed that there is a 1/4 - inch wall through penetration around a cable protruding through the 2-hour rated fire wall above the door to the 1st Floor North Stairway. This deficiency would not prevent the spread of smoke and heat from entering the exit access stairway and is not in accordance with LSC 2000 Edition 7.2. 19.2.2.3, 19.2.2.4

- On December 6, 2011 at approximately 11:30 AM, observed that there is a 1/4 - inch wall through penetration around a cable protruding through the 2-hour rated fire wall above the door to the 1st Floor South Stairway. This deficiency would not prevent the spread of smoke and heat from entering the exit access stairway and is not in accordance with LSC 2000 Edition 7.2. 19.2.2.3, 19.2.2.4

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

Based on observation the facility failed to provide approved exit access in accordance with the LSC section 19.2.1. This deficient practice could potentially affect the staff occupants of the facility. Findings include:

- On December 6, 2011 at approximately 10:15 AM, observed that the door handle to the door in the 1st Floor Men's Locker Room which leads into the vacant OR Rooms has been disabled and the door could not be opened from the Locker Room side of the door. The door is not identified as a No Exit. This deficiency is not in accordance with the LSC Code 2000 Edition 7.1, 19.2.1

- On December 6, 2011 at approximately 1:20 PM observed that the vacant 2nd Floor smoke barrier doors to the North and South Wings have a hasp and pad lock attached to the doors. The doors could not be opened from the direction of travel side of the smoke barrier doors. This deficiency creates a dead end corridor that exceeds the maximum allowable distance, and is not in accordance with LSC Code 2000 Edition 7.1, 19.2.1.

These findings were observed and confirmed by the maintenance staff 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 22 occupants of the facility. Findings include:

- On December 5, 2011 at approximately 1:15 PM, observed by review of the facility fire drill records that fire drills are not being conducted under varied emergency condition. This deficiency is not in accordance with LSC 2000 Edition 19.7.1.2

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 22 occupants of the facility. Findings include:

- On December 6, 2011 at approximately 10:00 AM, observed that the automatic sprinkler head located in the 1st Floor Soiled Linen Room by the elevators is obstructed by the light fixture. This deficiency would prevent the proper operation of the sprinkler head and is not in accordance with LSC 2000 Edition 19.7.6,4.6.12, NFPA 13, NFPA 25, 9.7.5

- On December 6, 2011 at approximately 12:45 PM, observed that the automatic sprinkler head located in the corridor by the 5th Floor elevators is missing an escutcheon plate. This deficiency is not in accordance with LSC 2000 Edition 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

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

Based on observation the facility failed to provide chutes that are not in accordance with the LSC sections 9.5, 9.7, 8.4. This deficient practice could potentially affect 22 occupants of the facility. Findings include:

- On December 6, 2011 at approximately 12:15 PM, observed that there is a hole in the door to the 5th Floor Laundry Chute. This deficiency would not prevent the spread of smoke and heat from entering the exit access corridor. This is not in accordance with LSC 2000 Edition 9.5

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

Based on observation the facility failed to provide protection of medical gasses in accordance with NFPA 99. This deficient practice could potentially affect 22 occupants of the facility. Findings include:

- On December 6, 2011 at approximately 10:40 AM, observed that E-Type Oxygen Cylinders are being stored to close to combustible materials in the 1st Floor Physical Therapy Room. This deficiency is not in accordance with NFPA 99 Standards for Health Care Facilities.

This finding was observed and confirmed by the maintenance staff 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 22 occupants of the facility. Findings include:

- On December 6, 2011 at approximately 1:45 PM, observed that there is an electrical junction box located in the rear wall in the 2nd Floor Mechanical Room that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2

- On December 6, 2011 at approximately 2:20 PM, observed that there is an electrical junction box located in the stairway from the Basement to the Boiler Room that is missing a cover plate. This deficiency is not in accordance with NFPA 70, National Electrical Code. 9.1.2

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