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Based on observation and interview, 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 effect 5 staff members and 3 patients of the facility to be injured in the event of a fire that started in the hazardous room area.

Findings include:

1. On 12/14/16 at 9:54 AM, it was observed that the 3rd floor former office room is being used as an equipment storage room and the room is not rated for storage. This observation was verified by interview of the Operations Director at the time of discovery.

Based on observation and interview, the facility failed to provide room corridors doors that positive latch when closed in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 3 residents and 1 staff member of the facility to be injured in the event of a fire that started in the room area.

Findings include:

1. On 12/14/16 at 1:34 PM, it was observed that the OB labor delivery soiled utility room door when closed did not positively latch when tested. This observation was verified by interview of the Operations Director at the time of discovery.

Based on observation and interview, the facility failed to provide fire rated decorations in accordance with the LSC section 19.7.5.6. This deficient practice could potentially effect 1 resident and 12-15 staff members of the facility to be injured in the event of a fire that started in this room area.

Findings include:

1. On 12/14/16 at 10:44 AM, it was observed the use of non-fire rated holiday decorations hanging from the ceiling in the staff training room. This observation was verified by interview of the Operations Director at the time of discovery.

Based on observation and interview, the facility failed to maintain basic electrical systems in accordance with the LSC section 9.1.2 and NFPA 70. This deficient practice could potentially effect 3 residents and 5 staff members of the facility to be injured in the event of a fire that started in the 3rd floor janitors closet and 14 residents and 5 staff members of the facility to be injured in the event of a fire that started in the 2nd floor Information Technology (IT) closet.

Findings include:

1. On 12/14/16 at 10:00 AM, it was observed in the 3rd floor janitors closet a ceiling electrical junction box was lacking a cover plate. This observation was verified by interview of the Operations Director at the time of discovery.

2. On 12/14/16 at 10:13 AM, it was observed in the 2nd floor IT closet an electrical junction box above the door was lacking a cover plate. This observation was verified by interview of the Operations Director at the time of discovery.

Based on observation and interview, the facility failed to provide electrical power strips or hard wiring in accordance with the LSC section 9.1.2, NFPA 70, and NFPA 99. This deficient practice could potentially effect 3 staff members of the facility to be injured in the event of a fire that started in the respiratory care office.

Findings include:

1. On 12/14/16 at 11:17 AM, it was observed in the respiratory care business office the use of an extension cord beneath the desk area. This observation was verified by interview of the Operations Director at the time of discovery.

Based on observation and interview, the facility failed to maintain proper storage of oxygen bottles in accordance with NFPA 99. This deficient practice could potentially effect 1 resident and 12 staff members of the facility to be injured in the event of a fire that started in the radiology supply room.

Findings include:

1. On 12/14/16 at 10:37 AM, it was observed in the radiology storage room the storage of 3 bottles of oxygen that had combustible storage within 5 feet of the bottles. This observation was verified by interview of the Operations Director at the time of discovery.