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Based on observation and interview, the facility failed to ensure 1 of 1 Nutrition Centers was separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception. LSC 19-3.6.1, Exception # 6, Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas may be open to the corridor and unlimited in area provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, and (b) Each space is protected by an automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. This deficient practice could affect 14 patients on the East Hall.

Findings include:

Based on an observation with the Facility Engineer Supervisor and the Material Management Coordinator on 03/25/14 at 10:50 a.m., the Nutrition Center in the East Hall lacked a corridor door and could not be viewed from the nurses' station. Furthermore, Exception # 6, requirement (a) of the LSC Section 19-3.6.1 was not met because the Nutrition Center was not protected by an electrically supervised automatic smoke detection system. This was acknowledged by the Facility Engineer Supervisor at the time of observation.

Based on observation and interview, the facility failed to ensure 2 of 15 East Hall patient room corridor doors and 1 of 1 electrical closet corridor doors closed and latched into the door frame. This deficient practice affects any of the 14 patients on the East Hall.

Findings includes:

Based on observation with the Facility Engineer Supervisor and the Material Management Coordinator on 03/25/14 from 10:36 a.m. to 11:13 a.m., patient rooms 503, 507 and the electrical closet, were designed with double corridor doors. One door was equipped with a manual latching device that would latch into the door frame and the remaining door was designed to latch into the stationary door. Each door could not latch automatically, and independent of the other door, into the door frame. This was acknowledged by the Facility Engineer Supervisor and the Material Management Coordinator at the time of observations.

Based on observation and interview, the facility failed to maintain 1 of 6 passenger elevator enclosures in accordance with NFPA 101, Section 8.2.5.2. Section 8.2.5.2 requires openings through floors, such as hoistways for elevators and stairways shall be enclosed with two hour fire barriers walls when connecting 4 or more stories and requires penetrations to be protected in accordance with ASTM E 814, Methods for Fire Tests of Through-Penetration Fire Stops. This deficient practice could affect 1 of 3 smoke compartments.

Findings include:

Based on an observation with the Facility Engineer Supervisor and the Material Management Coordinator on 03/25/14 at 10:56 a.m., there was a six inch by six inch penetration sealed with expandable foam, with which was not a fire rated material for maintaining the fire resistance of a fire barrier in the elevator shaft wall of the data room. This was acknowledged by the Facility Engineer Supervisor and the Material Management Coordinator at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 4 stairwell exits was provided with an effective means of preventing travel beyond the level of exit discharge. LSC 19.2.1 requires compliance with LSC 7.7.1 and 7.7.3. LSC 7.7.3 states when stairs that continue more than one half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors or other effective means. This deficient practice could affect any patient evacuated through the center stairwell.

Findings include:

Based on observation with the Facility Engineer Supervisor and the Material Management Coordinator on 03/25/14 at 11:50 a.m., the center stairwell continues beyond the level of exit discharge into the lower level. There was no barrier to prevent patients from continuing past the level of exit into the lower level. Based on an interview with the Facility Engineer Supervisor at the time of observation, the facility has been made aware of this issue.

Based on observations, record review and interview; the facility failed to ensure 1 of 2 fire barrier door sets was provided with the appropriate fire protection rating for the location in which they are installed. LSC 7.2.4.3.4 requires openings in fire barriers comply with LSC 8.2.3.2.3.1 which requires 1 1/2 hour doors in a 2 hour fire barrier wall. This deficient practice could affect 2 of 3 smoke compartments.

Findings include:

Based on an observation with the Facility Engineer Supervisor and the Material Management Coordinator on 03/25/14 at 12:40 p.m., the East hall two hour fire barrier wall had twenty minute fire rated cross corridor doors. Based on record review and interview with the Facility Engineer Supervisor at the time of observation, this was a two hour fire barrier wall.

Based on observation and interview, the facility failed to ensure a continuously illuminated exit sign, where the exit or way to reach the exit was not apparent, was immediately visible from 1 of 4 stairwells. LSC 7.10.1.4 requires access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not apparent to the occupants. This deficient practice could affect 14 patients evacuated through the east stairwell from the East Hall.

Findings include:

Based on observation with the Facility Engineer Supervisor on 03/25/14 at 11:55 a.m., there was no illuminated exit sign on the first floor after exiting the east stairwell. This was acknowledged by the Facility Engineer Supervisor at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 3 water valves for the sprinkler system was electronically supervised. This deficient practice affects all occupants.

Findings include:

Based on observation with the Facility Engineer Supervisor on 03/25/14 at 12:20 p.m., the water shut off valves on the main water inlet line lacked electronic supervision. According to the Facility Engineer Supervisor at the time of observation, this was the main water inlet line for the sprinkler system and the valve was not electronically supervised.

1. Based on observation and interview, the facility failed to ensure 2 of 6 sprinkler gauges were tested every five years. NFPA 25, Section 2-3.2 states gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice could affect all occupants.

Findings include:

Based on an observation with the Facility Engineer Supervisor and the Material Management coordinator on 03/25/14 at 11:40 a.m., the sprinkler gauges of the sprinkler riser on the second and third floor of the west stairwell had a date of 2008. Based on an interview with Facility Engineer Supervisor at the time of observation, he was unable to verify if the sprinkler gauges had been calibrated.

2. Based on observation and interview, the facility failed to ensure the spray pattern for 1 of 2 data room sprinkler heads was unobstructed. LSC 9.7.5 requires all automatic sprinkler systems be inspected, tested and maintained in accordance with NFPA 25, Standard for the inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, Section 2-2.1.2 states unacceptable obstructions to spray patterns shall be corrected. This deficient practice could affect 1 of 3 smoke compartments.

Findings include:

Based on observation with the Facility Engineer Supervisor and the Material Management Coordinator on 03/25/14 at 12:20 p.m., the spray pattern of the back sprinkler head in the data room was obstructed by an equipment rack located three inches from the sprinkler head. This was acknowledged by the Facility Engineer Supervisor at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 1 flexible cords was not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA 70, National Electrical Code, 1999 Edition, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice was not in a patient care area but could affect facility staff.

Findings include:

Based on observation with the Facility Engineer Supervisor and the Material Management Coordinator on 03/25/14 at 11:07 a.m., a small refrigerator was plugged into an extension cord power strip. The Material Management Coordinator acknowledged and removed the power strip at the time of observation.