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Based on observation it was determined that the facility did not maintain the required minimum 2-hour fire resistance rating of the separation wall to the adjacent non-conforming building in accordance with the LSC, sections 1.1.4.1, 19.1.1.4.2. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 8-4-10, between approximately 9:45am and
12:45pm, by observation and/or interview of the
maintenance director, it was discovered that
the door to the physical therapy room located in
the 2 hour fire wall is not rated for that assembly.
This finding was verified with the maintenance
director at the time of discovery.

On 8-4-10, between approximately 9:45am and
12:45pm, by observation and/or interview of the
maintenance director, it was discovered that the
cross corridor doors between this facility and the
main hospital, located in the 2 hour fire wall, are
not rated for that assembly. This finding was
verified with the maintenance director at the
time of discovery.

Based on observation it was determined that the facility failed to provide corridor walls that could provide at least 30 minute fire-resistance rating in accordance with the LSC section 19.3.6.1, 19.3.6.2.1. This deficient practice could potentially affect all occupants of the facility. Findings include:

On 8-4-10, between approximately 9:45am and
12:45pm, by observation and/or interview of the
maintenance director, it was discovered there are
penetrations that need to be filled with a material
toresist the passage of smoke, above the ceiling
tile in the corridor wall above the equipment
alcove. This finding was verified with the
maintenance director at the time of discovery.

Based upon observation and staff review, it was determined the facility failed to ensure storage in areas with one hour fire rated construction or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This deficient practice could potentially affect all occupants of the facility. Findings Include:

On 8-4-10, between approximately 9:45am and
12:45pm, by observation and/or interview of the
maintenance director, it was discovered there
are penetrations that need to be filled with a
material to resist the passage of smoke, above
the ceiling tile in the large storage room. This
finding was verified with the maintenance
director 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:

On 8-4-10, between approximately 9:45am
and 12:45pm, by observation and/or interview
of the maintenance director, it
was discovered during a test of the
facilities fire alarm system that the visual
devices located in the med/surgical room
corridors are not in synchronization. This
finding was verified with the maintenance
director at the time of discovery.