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Based on interview 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 residents, visitors, and staff members in all smoke compartments of the facility.

Interior finish materials fire rating for this facility are unknown could be highly flammable, thus in the case of a fire having the potential to cause harm/injuries to all occupants.

Findings include:

On 05-04-16, at approximately 10:45 AM, during tour of the facility with the Maintenance person (Staff W), it was discovered he did not have knowledge of the facility's interior finish fire rating or have access to documents pertaining to the facility's interior finish fire rating.

In an interview with the Maintenance person (Staff W), on 05-04-16, at approximately 10:47 AM, he stated he had no knowledge of where documents pertaining to the facility's interior finish fire rating were stored.

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 affect all occupants of the facility to be injured in the event of a fire that started in the hazardous area.

Findings include:

On 04-03-16, at 1:57 PM, it was observed in the OB (Obstetrical Unit) break room the storage of combustible plastic storage tubs were filled with combustible storage and this room is not rated for storage.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

Based on observation and interview, the facility failed to provide exit and directional signs in accordance with LSC Sections 19.2.10.1 and 7.10.5.1 This deficient practice could potentially affect all occupants of the facility during low lighting conditions as to the location of an exit.

Findings include:

On 04-03-16, at approximately 10:40 AM, it was discovered on the 1st floor southeastern fire escape exit corridor that an exit sign was not illuminated.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

Based upon review observation and interview the facility failed to provide and maintain fire extinguishers in accordance with LSC Sections 19.3.5.6 and 9.7.4.1 and NFPA 10. This deficient practice could potentially affect all occupants of the facility from accessing a fire extinguisher in the event of a fire.

Findings Include:

1) On 04-03-16, at approximately 1:21 PM, it was discovered in the main storage room, in the 3 separate caged in storage areas, a lack of access to a portable fire extinguisher.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

2) On 04-03-16, at approximately 1:32 PM, it was discovered in the kitchen area, access to a wall mounted extinguisher was obstructed with the portable eye washing device thus limiting unobstructed access to the fire extinguisher.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

Based on observation and interview, the facility failed to provide protection of medical gasses in accordance with LSC Section 19.3.2.4 and NFPA 99 Section 4-3.1.1.2. This deficient practice could potentially affect all occupants of the facility due to the practice of improper storing of oxygen bottles.

Findings Include:

1) On 04-03-16, at approximately 10:15 AM, it was discovered in the 3rd floor medication room, the storage of one e-tank of oxygen is stored closer than 5 feet of any combustibles in the same room.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

2) On 04-03-16, at approximately 10:41 AM, it was discovered in the nurse's station small storage room behind the desk area, the storage of 3 e-tank bottles of oxygen.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

Based on observation and interview, the facility failed to provide the electrical system in accordance with LSC Sections 19.5.1, 19.9.1, and 9.1.2. and NFPA 70, This deficient practice could potentially affect all occupants of the facility if an electrical short was to take place in a panel and start a fire.

Findings Include:

1) On 04-03-16, at approximately 10:30 AM, the storage of a combustible trash container beneath the electrical panel was discovered in the 1st floor report room.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

2) On 04-03-16, at approximately 10:46 AM, the storage of a trash basket directly beneath an electrical panel was discovered in the CCU (Critical Care Unit) mechanical room.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

3) On 04-03-16, at approximately 1:17 PM, it was discovered in electrical room G158, an electrical junction box was missing its cover plate.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

Based on interview 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 residents, visitors, and staff members in all smoke compartments of the facility.

Interior finish materials fire rating for this facility are unknown could be highly flammable, thus in the case of a fire having the potential to cause harm/injuries to all occupants.

Findings include:

On 05-04-16, at approximately 10:45 AM, during tour of the facility with the Maintenance person (Staff W), it was discovered he did not have knowledge of the facility's interior finish fire rating or have access to documents pertaining to the facility's interior finish fire rating.

In an interview with the Maintenance person (Staff W), on 05-04-16, at approximately 10:47 AM, he stated he had no knowledge of where documents pertaining to the facility's interior finish fire rating were stored.

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 affect all occupants of the facility to be injured in the event of a fire that started in the hazardous area.

Findings include:

On 04-03-16, at 1:57 PM, it was observed in the OB (Obstetrical Unit) break room the storage of combustible plastic storage tubs were filled with combustible storage and this room is not rated for storage.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

Based on observation and interview, the facility failed to provide exit and directional signs in accordance with LSC Sections 19.2.10.1 and 7.10.5.1 This deficient practice could potentially affect all occupants of the facility during low lighting conditions as to the location of an exit.

Findings include:

On 04-03-16, at approximately 10:40 AM, it was discovered on the 1st floor southeastern fire escape exit corridor that an exit sign was not illuminated.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

Based upon review observation and interview the facility failed to provide and maintain fire extinguishers in accordance with LSC Sections 19.3.5.6 and 9.7.4.1 and NFPA 10. This deficient practice could potentially affect all occupants of the facility from accessing a fire extinguisher in the event of a fire.

Findings Include:

1) On 04-03-16, at approximately 1:21 PM, it was discovered in the main storage room, in the 3 separate caged in storage areas, a lack of access to a portable fire extinguisher.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

2) On 04-03-16, at approximately 1:32 PM, it was discovered in the kitchen area, access to a wall mounted extinguisher was obstructed with the portable eye washing device thus limiting unobstructed access to the fire extinguisher.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

Based on observation and interview, the facility failed to provide protection of medical gasses in accordance with LSC Section 19.3.2.4 and NFPA 99 Section 4-3.1.1.2. This deficient practice could potentially affect all occupants of the facility due to the practice of improper storing of oxygen bottles.

Findings Include:

1) On 04-03-16, at approximately 10:15 AM, it was discovered in the 3rd floor medication room, the storage of one e-tank of oxygen is stored closer than 5 feet of any combustibles in the same room.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

2) On 04-03-16, at approximately 10:41 AM, it was discovered in the nurse's station small storage room behind the desk area, the storage of 3 e-tank bottles of oxygen.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

Based on observation and interview, the facility failed to provide the electrical system in accordance with LSC Sections 19.5.1, 19.9.1, and 9.1.2. and NFPA 70, This deficient practice could potentially affect all occupants of the facility if an electrical short was to take place in a panel and start a fire.

Findings Include:

1) On 04-03-16, at approximately 10:30 AM, the storage of a combustible trash container beneath the electrical panel was discovered in the 1st floor report room.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

2) On 04-03-16, at approximately 10:46 AM, the storage of a trash basket directly beneath an electrical panel was discovered in the CCU (Critical Care Unit) mechanical room.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.

3) On 04-03-16, at approximately 1:17 PM, it was discovered in electrical room G158, an electrical junction box was missing its cover plate.

This observation was verified by interview of the Maintenance person (Staff W) at the time of discovery.