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Based on observation and interview the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all staff who normally work in this corridor area and to be injured in the event of a fire due to an unclosed corridor door. Findings include:

1. On 7/20/16 at approximately 1:16 PM, it was discovered the corridor door to the air handler room was damaged and coming apart in pieces at its lower part.

In an interview on 7/20/16 at approximately 1:17PM, the Safety Supervisor indicated she was not aware of this damaged door.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 4 staff members and when fully occupied 15 patients who may reside in patient rooms, to be injured in the event of a fire due to smoke passing between smoke compartments. Findings include:

1. On 7/20/16 at approximately 12:54 PM, the ceiling area in the janitor closet across from the mammogram room has a ceiling pipe penetration in the smoke barrier ceiling of the closet.

In an interview on 7/20/16 at 12:55 PM, the Safety Supervisor stated that she was unaware of the penetration not being properly sealed.

Based on observation and interview, the facility failed to store oxygen tanks and supporting equipment in accordance with NFPA 99 section 4-3.1.1.2, 8-3.1.11.1 & sections 19.3.2.4. This deficient practice could potentially affect 4 staff members and when fully occupied 15 patients who may reside in patient rooms, to be injured in the event of a fire due to the improper storage of oxygen tanks.

Findings include:

1. On 7/20/16 at approximately 12:13 PM, in was discovered the in the oxygen tank storage room, the storage of 6 tanks of oxygen being stored closer than 5 feet of combustibles.

In an interview on 7/20/16 at 1214 PM, the Safety Supervisor stated that she was unaware of this improper storage with combustibles..

Based on observation and interview the facility failed to provide the proper storage of combustibles in the vicinity of electrical panels. NFPA 70. 9-1.2, & 99-19.1.1. This deficient practice could potentially affect all staff who normally work in this corridor area and to be injured in the event of a fire due to this improper storage. Findings include:

1. On 7/20/16 at approximately 1:16 PM, it was discovered there are cardboard boxes being stored directly beneath electrical panels in the air handler room.

In an interview on 7/20/16 at approximately 1:17 PM, the Safety Supervisor indicated she was not aware of this improper storage issue..

2. On 7/20/16 at approximately 1:17 PM, it was discovered there are cardboard boxes being stored directly in front of the large electrical panels in the vacuum room.

In an interview on 7/20/16 at approximately 1:18 PM, the Safety Supervisor indicated she was not aware of this improper storage issue.

Based on observation and interview the facility failed to provide corridor doors that would close and resist the passage of smoke and/or able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect all staff who normally work in this corridor area and to be injured in the event of a fire due to an unclosed corridor door. Findings include:

1. On 7/20/16 at approximately 1:16 PM, it was discovered the corridor door to the air handler room was damaged and coming apart in pieces at its lower part.

In an interview on 7/20/16 at approximately 1:17PM, the Safety Supervisor indicated she was not aware of this damaged door.

Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect 4 staff members and when fully occupied 15 patients who may reside in patient rooms, to be injured in the event of a fire due to smoke passing between smoke compartments. Findings include:

1. On 7/20/16 at approximately 12:54 PM, the ceiling area in the janitor closet across from the mammogram room has a ceiling pipe penetration in the smoke barrier ceiling of the closet.

In an interview on 7/20/16 at 12:55 PM, the Safety Supervisor stated that she was unaware of the penetration not being properly sealed.

Based on observation and interview, the facility failed to store oxygen tanks and supporting equipment in accordance with NFPA 99 section 4-3.1.1.2, 8-3.1.11.1 & sections 19.3.2.4. This deficient practice could potentially affect 4 staff members and when fully occupied 15 patients who may reside in patient rooms, to be injured in the event of a fire due to the improper storage of oxygen tanks.

Findings include:

1. On 7/20/16 at approximately 12:13 PM, in was discovered the in the oxygen tank storage room, the storage of 6 tanks of oxygen being stored closer than 5 feet of combustibles.

In an interview on 7/20/16 at 1214 PM, the Safety Supervisor stated that she was unaware of this improper storage with combustibles..

Based on observation and interview the facility failed to provide the proper storage of combustibles in the vicinity of electrical panels. NFPA 70. 9-1.2, & 99-19.1.1. This deficient practice could potentially affect all staff who normally work in this corridor area and to be injured in the event of a fire due to this improper storage. Findings include:

1. On 7/20/16 at approximately 1:16 PM, it was discovered there are cardboard boxes being stored directly beneath electrical panels in the air handler room.

In an interview on 7/20/16 at approximately 1:17 PM, the Safety Supervisor indicated she was not aware of this improper storage issue..

2. On 7/20/16 at approximately 1:17 PM, it was discovered there are cardboard boxes being stored directly in front of the large electrical panels in the vacuum room.

In an interview on 7/20/16 at approximately 1:18 PM, the Safety Supervisor indicated she was not aware of this improper storage issue.