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Based on observation and/or review of records the facility failed to provide minimum interior finish materials in accordance with the LSC sections 19.3.3.1, 19.3.3.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On August 22, 2010 at 11:34 a.m., observation revealed and was confirmed by the Assistant Facilities Director, holes and cracks in the ceiling tiles and fire caulk is tearing away from the ceiling tiles in the I.T. Room.

On August 22, 2010 at 12:23 p.m., observation revealed and was confirmed by the Assistant Facilities Director, gaps larger than 1/8" between the pipes, wires and the ceiling tiles inside the Emergency Closet.

Based on observation the facility failed to provide corridor doors that would close and resist the passage of smoke and/ or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all occupants of the facility.
Findings include:

On August 22, 2010 at 10:38 a.m., observation revealed and was confirmed by the Assistant Facilities Director, door to Medical Records from the corridor will only open approximately half to three quarters due to a file cabinet behind the door.

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. Findings include:

On August 22, 2010 at 11:45 a.m., observation revealed and was confirmed by the Assistant Facilities Director, a wood board was used to seal an old duct penetration from the 8th Floor to the 9th Floor Mechanical Room. Board is above the smoke barrier doors near Patient Room #843.

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 all occupants of the facility.
Findings include:

On August 22, 2010 at 10:30 a.m., observation revealed and was confirmed by the Assistant Facilities Director, a blue wire penetration, drywall patch not sealed, penetration above a one inch pipe and unknown white / pink material used to seal penetrations in the rated wall inside Medical Records.

On August 22, 2010 at 10:54 a.m., observation revealed and was confirmed by the Assistant Facilities Director, drywall patches in the two-hour wall inside Patient Room #837 were not sealed.

On August 22, 2010 at 12:09 p.m., observation revealed and was confirmed by the Assistant Facilities Director, penetrations in the rated wall between Patient Room #844 and Patient Room #843.

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:

On August 22, 2010 at 11:11 a.m., observation revealed and was confirmed by the Assistant Facilities Director, the Equipment Room doors and frames have no labels for any kind of rating. The room is used as a storage room.

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 all occupants of the facility. Findings include:

On August 22, 2010 at 10:45 a.m., observation revealed and was confirmed by the Assistant Facilities Director, the fire hose cabinet across from Medical Records had an annual inspection tag on the riser with a hand written message on the tag stating "Device leaks air. It has pressure but no water came out".

On August 22, 2010 at 12:30 p.m., observation revealed and was confirmed by the Assistant Facilities Director, the inspectors test valve was not labeled in the Housekeeping Closet.

Oxygen storage locations of 3000 cubic feet or less is permitted to be a storage area containing combustible materials, per 1999 NFPA 99, 8-3.1.11.2(c), if the tanks are a minimum of 20 feet from combustibles. A minimum separation of 5 feet is required where the storage area is NFPA 13 sprinklered (Fully Suppressed) This deficient practice could potentially affect all occupants of the facility. Findings Include:

On August 22, 2010 at 11:23 a.m., observation revealed and was confirmed by the Assistant Facilities Director, a rack of full oxygen cylinders were not labeled and there was a empty tag on a cylinder in the full tank rack inside Respiratory Equipment Room.

The facility failed to protect fire/smoke wall duct penetrations in accordance with LSC 101:8.3.5. Findings include: (NOTE 19.3.7.3, EXCEPTION NO. 2, which allows dampers to be omitted.) This deficient practice could potentially affect all occupants of the facility. Findings include:

On August 22, 2010 at 12:19 p.m., observation revealed and was confirmed by the Assistant Facilities Director, the duct penetrating the two-hour wall above the Exit Stair #5 door from the corridor was not properly protected.

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 all occupants of the facility. Findings include:

On August 22, 2010 at 10:58 a.m., observation revealed and was confirmed by the Assistant Facilities Director, an open junction box above the ceiling between the Equipment Room and the Shower Room.

On August 22, 2010 at 11:50 a.m., observation revealed and was confirmed by the Assistant Facilities Director, a missing circuit blank cover in the electrical panel #LP-4N between Patient Room #845 and Patient Room #846.