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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 32 occupants of the facility.

Findings include:

On 8/26/15 at approximately 10:00 AM, the following observations were made:

· 10:14 AM - Observed the rated fire door to the corridor from Jnitors Closet # 16 failed to close to a positive latch.
· 10:50 AM - Observed in the Computer Servers Room, the ceiling was damaged and failed to provide seperation of the room to hidden space. Ceiling shall provide a complete barrier.

The above mentioned was observed and noted by the Facility Manager.

Based on observation, the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect 27 occupants of the facility.

Findings include:

On 8/26/15 at approximately 11:00 AM, the following observations were made:

· 11:40 AM - Observed during inspection the corridor off of the CD Unit, near the Maintenance Hall, was used as storage and the corridor off of the Kitchen was used as storage.
· 12:45 PM - Observed during active fire drill, staff failed to clear the corridors of all non-essential items.

These findings were also observed by the facility director.

Based on observation and/or review of records, the facility failed to provide an approved written emergency plan in accordance with the LSC section 18.7.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 8/26/15 at approximately 8:50 AM, the following observations were made:

10:05 AM - Observed during review of the facility's emergency plans, the Life Safety Drawing was outdated.

12:15 PM - Staff was unable to locate the emergency binder located at the Nurses' Desk.

The above mentioned were confirmed and discussed with the Facility Manager.

Based on observation and/or review of records, the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 8/26/15 at approximately 8:50 AM, the following observations were made:

· 10:05 AM - Observed during review of the facility's Emergency Plans, the Life Safety Drawing was outdated.
· 12:15 PM - Staff was unable to locate the Emergency Binder located at the Nurses' Desk.

The above mentioned were confirmed and discussed with the Facility Manager.

Based on observation and/or review of records, the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 8/26/15 at approximately 8:50 AM, the following observations were made:

· 8:50 AM - Observed upon entry, the evacuation plan located in the Front Lobby was outdated and failed to show the new constructed building and exiting plan.
· 10:05 AM - Observed during review of the facilities emergency plans, the Life Safety Drawing was outdated.
· 10:10 AM - During inspection, the Front Desk Emergency Folder was missing the Evacuation Procedure.
· 10:34 AM - During questioning, staff failed to locate emergency folder located at the Front Desk.
· 12:15 PM - Staff was unable to locate emergency binder located at the Nurses' Desk.

The above mentioned was confirmed and discussed with the Facility Manager.

Based on observation, the facility failed to provide fire alarm initiation in accordance with the LSC sections 19.3.4.2, 9.6.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 8/26/15 at approximately 11:00 AM, the following observations were made:

· 11:18 AM - During questioning of staff on fire procedures and allowing for demonstration, the staff was unable to quickly and efficiently locate and decifer the correct operation of the pull station located in the CD Unit. It was also observed that the Fire Alarm pull station was concealed from view by a liquid dispenser and confusing signage was placed on the wall in and around the pull station which blended the pull station into corridor decor. Pull stations are designed to be obvious on location and intent.

This finding was also observed by the Facility Manager.

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 12 occupants of the facility.

Findings include:

On 8/26/15 at approximately 10:00 AM, the following observations were made:

· 10:19 AM - Observed in the Administrators Conference Room, a low voltage data cable box unsecured to the wall and free hanging by the wire.
· 10:27 AM - Observed in the Front Office Room #11, the emergency eletrical circuit was not properly labeled for easy and quick isolation as required per code.

The above mentioned were noted by the Facility Manager.

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 32 occupants of the facility.

Findings include:

On 8/26/15 at approximately 10:00 AM, the following observations were made:

· 10:14 AM - Observed the rated fire door to the corridor from Jnitors Closet # 16 failed to close to a positive latch.
· 10:50 AM - Observed in the Computer Servers Room, the ceiling was damaged and failed to provide seperation of the room to hidden space. Ceiling shall provide a complete barrier.

The above mentioned was observed and noted by the Facility Manager.

Based on observation, the facility failed to provide exit access in accordance with the LSC section 19.2.3.3. This deficient practice could potentially affect 27 occupants of the facility.

Findings include:

On 8/26/15 at approximately 11:00 AM, the following observations were made:

· 11:40 AM - Observed during inspection the corridor off of the CD Unit, near the Maintenance Hall, was used as storage and the corridor off of the Kitchen was used as storage.
· 12:45 PM - Observed during active fire drill, staff failed to clear the corridors of all non-essential items.

These findings were also observed by the facility director.

Based on observation and/or review of records, the facility failed to provide an approved written emergency plan in accordance with the LSC section 18.7.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 8/26/15 at approximately 8:50 AM, the following observations were made:

10:05 AM - Observed during review of the facility's emergency plans, the Life Safety Drawing was outdated.

12:15 PM - Staff was unable to locate the emergency binder located at the Nurses' Desk.

The above mentioned were confirmed and discussed with the Facility Manager.

Based on observation and/or review of records, the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 8/26/15 at approximately 8:50 AM, the following observations were made:

· 10:05 AM - Observed during review of the facility's Emergency Plans, the Life Safety Drawing was outdated.
· 12:15 PM - Staff was unable to locate the Emergency Binder located at the Nurses' Desk.

The above mentioned were confirmed and discussed with the Facility Manager.

Based on observation and/or review of records, the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 8/26/15 at approximately 8:50 AM, the following observations were made:

· 8:50 AM - Observed upon entry, the evacuation plan located in the Front Lobby was outdated and failed to show the new constructed building and exiting plan.
· 10:05 AM - Observed during review of the facilities emergency plans, the Life Safety Drawing was outdated.
· 10:10 AM - During inspection, the Front Desk Emergency Folder was missing the Evacuation Procedure.
· 10:34 AM - During questioning, staff failed to locate emergency folder located at the Front Desk.
· 12:15 PM - Staff was unable to locate emergency binder located at the Nurses' Desk.

The above mentioned was confirmed and discussed with the Facility Manager.

Based on observation, the facility failed to provide fire alarm initiation in accordance with the LSC sections 19.3.4.2, 9.6.2.1. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 8/26/15 at approximately 11:00 AM, the following observations were made:

· 11:18 AM - During questioning of staff on fire procedures and allowing for demonstration, the staff was unable to quickly and efficiently locate and decifer the correct operation of the pull station located in the CD Unit. It was also observed that the Fire Alarm pull station was concealed from view by a liquid dispenser and confusing signage was placed on the wall in and around the pull station which blended the pull station into corridor decor. Pull stations are designed to be obvious on location and intent.

This finding was also observed by the Facility Manager.

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 12 occupants of the facility.

Findings include:

On 8/26/15 at approximately 10:00 AM, the following observations were made:

· 10:19 AM - Observed in the Administrators Conference Room, a low voltage data cable box unsecured to the wall and free hanging by the wire.
· 10:27 AM - Observed in the Front Office Room #11, the emergency eletrical circuit was not properly labeled for easy and quick isolation as required per code.

The above mentioned were noted by the Facility Manager.