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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 12 occupants of the facility if the fire/smoke doors do not close completely.

Findings include:

- On April 17, 2012, at approximately 12:30 PM, while conducting a walk through with the Plant Operation Manager, it was observed that the smoke/fire doors located at the Sleep Center on 2nd Floor South did not close completely on the door coordinator. This was confirmed by the Plant Operation Manager at the time of discovery.

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 25 occupants of the facility if a hazardous area failed to protect the facility as constructed.

Findings include:

A. On April 17, 2012, at approximately 11:14 AM, while conducting a walk through with the Plant Operations Manager, it was observed that the facility had combustible storage in the Mechanical room Penthouse.

B. On April 17, 2012, at approximately 12:15 PM, while conducting a walk through with the Plant Operations Manager, it was observed that there was a gap around the electrical boxes in the Copy room on 2nd floor East.

C. On April 17, 2012, at approximately 12:18 PM, while conducting a walk through with the Plant Operations Manager, it was observed that combustible storage was in the Tub room on 2nd floor East without any separation or suppression.

D. On April 17, 2012, at approximately 1:25 PM, while conducting a walk through with the Plant Operations Manager, it was observed that the right leaf door to the X-ray Janitor Closet did not completely close and latch.

These deficiencies were confirmed at the time of discovery by the Plant Operations Manager.

Based on observation and/or review of records the facility failed to provide an approved fire alarm system in accordance with the LSC sections 19.3.4, 9.6. This deficient practice could potentially affect all occupants of the facility if the alarm location can not be communicated.

Findings include:

- On April 17, 2012, at approximately 3:22 PM, while conducting a function test of the fire alarm system with the Plant Operations Manager, it was observed that the intercom system did not function in all areas of the hospital announcing the fire alarm testing. This deficiency was confirmed by the Plant Operations Manager at the time of discovery.

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 15 occupants of the facility if a sprinkler failed to operate as designed.

Findings include:

A. On April 17, 2012, at approximately 11:32 AM, while conducting a walk through with the Plant Operation Manager, it was observed that the storage in the small closet was too close to the sprinkler head by the Nurse's Station, OB, 3rd floor, East.

B. On April 17, 2012, at approximately 11:25 AM, while conducting a walk through with the Plant Operation Manager, it was observed that lint and debris was on the sprinkler heads in the Transcription room, 3rd Floor, South.

C. On April 17, 2012, at approximately 1:10 PM, while conducting a walk through with the Plant Operation Manager, it was observed that lint and debris was on the sprinkler heads in the Registration rooms, Front Lobby, 1st Floor.

D. On April 17, 2012, at approximately 1:15 PM, while conducting a walk through with the Plant Operations Manager, it was observed that there was a gap around the sprinkler head located near the door of Radiology waiting, 1st Floor.

E. On April 17, 2012, at approximately 1:37 PM, while conducting a walk through with the Plant Operations Manager, it was observed that the facility had more spare sprinkler heads and wrenchs than would fit into the spare head box allowing for damage to the spare heads in the riser room, East basement.

These deficiencies were confirmed by the Plant Operation Manager at the time of disocovery.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies are in accordance with provisions of 10.3.1 and NFPA 13, Standards for the Installation of Sprinkler Systems. Newly introduced upholstered furniture within health care occupancies meets the criteria specified when tested in accordance with the methods cited in 10.3.2 (2) and 10.3.3. 19.7.5.1, NFPA 13

Newly introduced mattresses meet the criteria specified when tested in accordance with the method cited in 10.3.2 (3) , 10.3.4. 19.7.5.3

Findings include:

- On April 17, 2012, at approximately 12:40 PM, while conducting a walk through with the Plant Operation Manager, it was observed that new curtains were installed in the EEG testing room without any documentation of being fire retardant. This was confirmed by the Plant Operation Manager at the time of discovery.

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 from an open electrical box.

Findings include:

A. On April 17, 2012, at approximately 11:20 AM, while conducting a walk through with the Plant Operation Manager, it was observed that an open electrical box was located in the Autoclave room on the 3rd floor, South.

B. On April 17, 2012, at approximately 11:31 AM, while conducting a walk through with the Plant Operation Manager, it was observed an open electrical box above the ceiling in the Nursery of OB on 3rd floor, East.

These deficiencies were confirmed at the time of discovery by the Plant Operation Manager.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility if the fire watch does not provide the required coverage and protection of the facility.

Findings include:

- On April 17, 2012, at approximately 3:05 PM, while reviewing records and conducting staff interview, it was determined that the fire watch policy did not clearly state the policy was for loss of sprinkler protection or that it was for any outage of 4 hours or more in a 24 hour period. This was confirmed by the Plant Operation Manager at the time of discovery.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.6.1.8. This deficient practice could potentially affect all occupants of the facility if the fire watch does not provide the required coverage and protection of the facility.

Findings include:

- On April 17, 2012, at approximately 3:05 PM, while reviewing records and conducting staff interview, it was determined that the fire watch policy did not state the policy was for any outage of 4 hours or more in a 24 hour period. This was confirmed by the Plant Operation Manager at the time of discovery.