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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 15 occupants of the facility if hazard room failed to prevent the spread of smoke and fire.

Findings include:

A. On June 27, 2013, at approximately 12:15 PM, while conducting a walk through with the Maintenance personnel, it was observed that the grill was missing from the ductwork in the Pharmacy storage in the basement leaving an opening between the ductwork and the ceiling.

B. On June 27, 2013, at approximately 12:25 PM, while conducting walk through with the Maintenance personnel, it was observed that the hardware on Clean Linen room in the basement was loose.

C. On June 27, 2013, at approximately 12:35 PM, while conducting a walk through with the Maintenance personnel, it was observed that there was an open conduit penetrating the Electrical room in the basement.

D. On June 27, 2013, at approximately 12:40 PM, while conducting a walk through with the Maintenance personnel, it was observed that the pipes penetrating the boiler room wall over the door left holes around them to the corridor that was not sealed.

These deficiencies were confirmed by the Maintenance personnel 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 10 occupants of the facility if the sprinkler system failed to function as designed.

Findings include:

A. On June 27, 2013, at approximately 12:17 PM, while conducting a walk through with the Maintenance personnel, it was observed that the sprinkler head in the Kitchen cleaning supplies room was misaligned in the ceiling causing the tile to be pulled up.

B. On June 27, 2013, at approximately 1:10 PM, while conducting a walk through with the Maintenance personnel, it was observed that the escutcheon was missing from the sprinkler head located in the Gift shop office.

These deficiencies were confirmed at the time of discovery by the Maintenance personnel.

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 15 occupants of the facility if hazard room failed to prevent the spread of smoke and fire.

Findings include:

A. On June 27, 2013, at approximately 12:15 PM, while conducting a walk through with the Maintenance personnel, it was observed that the grill was missing from the ductwork in the Pharmacy storage in the basement leaving an opening between the ductwork and the ceiling.

B. On June 27, 2013, at approximately 12:25 PM, while conducting walk through with the Maintenance personnel, it was observed that the hardware on Clean Linen room in the basement was loose.

C. On June 27, 2013, at approximately 12:35 PM, while conducting a walk through with the Maintenance personnel, it was observed that there was an open conduit penetrating the Electrical room in the basement.

D. On June 27, 2013, at approximately 12:40 PM, while conducting a walk through with the Maintenance personnel, it was observed that the pipes penetrating the boiler room wall over the door left holes around them to the corridor that was not sealed.

These deficiencies were confirmed by the Maintenance personnel 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 10 occupants of the facility if the sprinkler system failed to function as designed.

Findings include:

A. On June 27, 2013, at approximately 12:17 PM, while conducting a walk through with the Maintenance personnel, it was observed that the sprinkler head in the Kitchen cleaning supplies room was misaligned in the ceiling causing the tile to be pulled up.

B. On June 27, 2013, at approximately 1:10 PM, while conducting a walk through with the Maintenance personnel, it was observed that the escutcheon was missing from the sprinkler head located in the Gift shop office.

These deficiencies were confirmed at the time of discovery by the Maintenance personnel.