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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 80 occupants in adjacent smoke compartments by allowing heat and smoke to pass from and affected smoke compartment to and adjacent non affected smoke compartment. Findings include:

1. On 1/28/15 at 10:25 AM, an unapproved 10" X 10" "board on board" patch was observed in the 3 west smoke barrier wall above the doors.

In an interview on 1/28/15 at 10:25 AM, AFM#1 acknowledged the improper patch of the smoke barrier wall.

2. On 1/28/15 at 10:40 AM, an unapproved 3" X 3" and a 6" X 8" "board on board" patch was observed in the NICU south hall smoke barrier wall above the doors.

In an interview on 1/28/15 at 10:40 AM, AFM#1 acknowledged the improper patches in the smoke barrier wall.

3. On 1/28/15 at 10:50 AM, two unprotected conduit penetrations were observed in the NICU south hall smoke barrier wall above the doors.

In an interview on 1/28/15 at 10:50 AM, AFM#1 acknowledged the unprotected conduit penetrations in the smoke barrier wall.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect 20 occupants of the facility by allowing heat and smoke to escape the hazardous area during a fire. Findings include:

1. On 1/28/15 at 1:30 PM, multiple "board on board" drywall patches were observed in the 1 hour rated wall in the large 2 south electrical room.

In an interview on 1/28/15 at 1:30 PM, AFM#1 acknowledged the unapproved patching of the fire rated wall.

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 40 occupants of in each smoke compartment by allowing heat and smoke to pass into the exit corridor. Findings include:

1. On 1/28/15 at 10:00 AM the door to the 5 west soiled linen room failed to positively latch when closed.

In an interview on 1/28 at 10:00 AM, AFM#1 acknowledged that the door failed to latch when closed.

2. On 1/28/15 at 10:20 AM the door to the 4 west soiled linen room failed to positively latch when closed.

In an interview on 1/28 at 10:20 AM, AFM#1 acknowledged that the door failed to latch when closed.

3. On 1/28/15 at 11:00 AM the door to the NICU soiled linen room failed to positively latch when closed.

In an interview on 1/28 at 11:00 AM, AFM#1 acknowledged that the door failed to latch when closed.

4. On 1/28/15 at 11:30 AM the door to the CCU soiled linen room failed to positively latch when closed.

In an interview on 1/28 at 11:30 AM, AFM#1 acknowledged that the door failed to latch when closed.

Based on review of records and interview the facility failed to provide fire drills in accordance with the LSC section 18.7.1.2. This deficient practice could potentially affect all 250 patients of the facility along with all of the staff and any visitors present at the time of a potential incident if staff failed to respond correctly during a fire emergency. Findings include:

1. On 01/28/15 at 11:10 AM, during review of the 2014 Fire Drill Records it was observed that the third shift fire drill times needed to be varied. Observed third shift drill times were 11:13 PM; 11:33 PM; 2:33 AM; and 11:51 PM.

In an interview on 01/28/15 at 11:11 AM, FM#1 verified that the third shift fire drills were conducted at the times stated above.

Based on review of records and interview the facility failed to provide fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all 16 patients of the facility along with all of the staff and any visitors present at the time of a potential incident if staff failed to respond correctly during a fire emergency. Findings include:

1. On 01/28/15 at 1:20 PM, during review of the 2014 Fire Drill Records it was observed the first and third shift fire drill times needed to be varied. Observed first shift drill times were 10:52 AM; 10:17 AM; 1:08 PM; and 11:20 AM. Observed third shift drill times were 10:33 PM; 10:41 PM; 10:33 PM; and 10:34 PM.

In an interview on 01/28/15 at 1:21 PM, FM#1 verified the first and third shift fire drills were conducted at the times stated above.

Based on review of records and interview the facility failed to provide fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all 250 patients of the facility along with all of the staff and any visitors present at the time of a potential incident if staff failed to respond correctly during a fire emergency. Findings include:

1. On 01/28/15 at 11:10 AM, during review of the 2014 Fire Drill Records it was observed that the third shift fire drill times needed to be varied. Observed third shift drill times were 11:13 PM; 11:33 PM; 2:33 AM; and 11:51 PM.

In an interview on 01/28/15 at 11:11 AM, FM#1 verified that the third shift fire drills were conducted at the times stated above.

Based on review of records and interview the facility failed to maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all 16 patients of the facility along with all of the staff and any visitors present at the time of a potential incident in the event that the smoke detectors failed to operate as designed during a fire emergency. Findings include:

1. On 01/28/15 at 1:05 PM, during review of the facility's Fire Alarm records, the facility was unable to produce documentation for the sensitivity testing of the smoke detectors.

In an interview on 01/28/15 at 1:06 PM, FM#1 verified there was no documentation for the sensitivity testing of the smoke detectors.

Based on review of records and interview the facility failed to maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all 250 patients of the facility along with all of the staff and any visitors present at the time of a potential incident in the event that the smoke detectors failed to operate as designed during a fire emergency. Findings include:

1. On 01/28/15 at 10:40 AM, during review of the facility's Fire Alarm records, the facility was unable to produce documentation for the sensitivity testing of the smoke detectors.

In an interview on 01/28/15 at 10:41 AM, FM#1 stated the facility has a smart fire alarm panel constantly monitors the sensitivity of all of the smoke detectors. FM#1 was informed that documentation is required once every two years showing the sensitivity meets the requirement.

Based on review of records and interview the facility failed to maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all 250 patients of the facility along with all of the staff and any visitors present at the time of a potential incident in the event that the smoke detectors failed to operate as designed during a fire emergency. Findings include:

1. On 01/28/15 at 10:40 AM, during review of the facility's Fire Alarm records, the facility was unable to produce documentation for the sensitivity testing of the smoke detectors.

In an interview on 01/28/15 at 10:41 AM, FM#1 stated the facility has a smart fire alarm panel that constantly monitors the sensitivity of all of the smoke detectors. FM#1 was informed documentation is required once every two years showing the sensitivity meets the requirement.

Based on observation and interview the facility failed to provide the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all 16 patients of the facility along with all of the staff and any visitors present at the time of a potential incident to be injured if the automatic sprinkler system failed to operate as designed during a fire. Findings include:

1. On 01/29/15 at 10:37 AM, it was observed that the four (4) gauges on the wet sprinkler riser had not been replaced within the required five (5) years. Each gauge was marked 11-09.

In an interview on 01/29/15 at 10:38 AM, AFM#1 verified the gauges were beyond the 5 year replacement date.

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 80 occupants in adjacent smoke compartments by allowing heat and smoke to pass from and affected smoke compartment to and adjacent non affected smoke compartment. Findings include:

1. On 1/28/15 at 10:25 AM, an unapproved 10" X 10" "board on board" patch was observed in the 3 west smoke barrier wall above the doors.

In an interview on 1/28/15 at 10:25 AM, AFM#1 acknowledged the improper patch of the smoke barrier wall.

2. On 1/28/15 at 10:40 AM, an unapproved 3" X 3" and a 6" X 8" "board on board" patch was observed in the NICU south hall smoke barrier wall above the doors.

In an interview on 1/28/15 at 10:40 AM, AFM#1 acknowledged the improper patches in the smoke barrier wall.

3. On 1/28/15 at 10:50 AM, two unprotected conduit penetrations were observed in the NICU south hall smoke barrier wall above the doors.

In an interview on 1/28/15 at 10:50 AM, AFM#1 acknowledged the unprotected conduit penetrations in the smoke barrier wall.

Based on observation and interview, the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 18.3.2.1. This deficient practice could potentially affect 20 occupants of the facility by allowing heat and smoke to escape the hazardous area during a fire. Findings include:

1. On 1/28/15 at 1:30 PM, multiple "board on board" drywall patches were observed in the 1 hour rated wall in the large 2 south electrical room.

In an interview on 1/28/15 at 1:30 PM, AFM#1 acknowledged the unapproved patching of the fire rated wall.

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 40 occupants of in each smoke compartment by allowing heat and smoke to pass into the exit corridor. Findings include:

1. On 1/28/15 at 10:00 AM the door to the 5 west soiled linen room failed to positively latch when closed.

In an interview on 1/28 at 10:00 AM, AFM#1 acknowledged that the door failed to latch when closed.

2. On 1/28/15 at 10:20 AM the door to the 4 west soiled linen room failed to positively latch when closed.

In an interview on 1/28 at 10:20 AM, AFM#1 acknowledged that the door failed to latch when closed.

3. On 1/28/15 at 11:00 AM the door to the NICU soiled linen room failed to positively latch when closed.

In an interview on 1/28 at 11:00 AM, AFM#1 acknowledged that the door failed to latch when closed.

4. On 1/28/15 at 11:30 AM the door to the CCU soiled linen room failed to positively latch when closed.

In an interview on 1/28 at 11:30 AM, AFM#1 acknowledged that the door failed to latch when closed.

Based on review of records and interview the facility failed to provide fire drills in accordance with the LSC section 18.7.1.2. This deficient practice could potentially affect all 250 patients of the facility along with all of the staff and any visitors present at the time of a potential incident if staff failed to respond correctly during a fire emergency. Findings include:

1. On 01/28/15 at 11:10 AM, during review of the 2014 Fire Drill Records it was observed that the third shift fire drill times needed to be varied. Observed third shift drill times were 11:13 PM; 11:33 PM; 2:33 AM; and 11:51 PM.

In an interview on 01/28/15 at 11:11 AM, FM#1 verified that the third shift fire drills were conducted at the times stated above.

Based on review of records and interview the facility failed to provide fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all 16 patients of the facility along with all of the staff and any visitors present at the time of a potential incident if staff failed to respond correctly during a fire emergency. Findings include:

1. On 01/28/15 at 1:20 PM, during review of the 2014 Fire Drill Records it was observed the first and third shift fire drill times needed to be varied. Observed first shift drill times were 10:52 AM; 10:17 AM; 1:08 PM; and 11:20 AM. Observed third shift drill times were 10:33 PM; 10:41 PM; 10:33 PM; and 10:34 PM.

In an interview on 01/28/15 at 1:21 PM, FM#1 verified the first and third shift fire drills were conducted at the times stated above.

Based on review of records and interview the facility failed to provide fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all 250 patients of the facility along with all of the staff and any visitors present at the time of a potential incident if staff failed to respond correctly during a fire emergency. Findings include:

1. On 01/28/15 at 11:10 AM, during review of the 2014 Fire Drill Records it was observed that the third shift fire drill times needed to be varied. Observed third shift drill times were 11:13 PM; 11:33 PM; 2:33 AM; and 11:51 PM.

In an interview on 01/28/15 at 11:11 AM, FM#1 verified that the third shift fire drills were conducted at the times stated above.

Based on review of records and interview the facility failed to maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all 16 patients of the facility along with all of the staff and any visitors present at the time of a potential incident in the event that the smoke detectors failed to operate as designed during a fire emergency. Findings include:

1. On 01/28/15 at 1:05 PM, during review of the facility's Fire Alarm records, the facility was unable to produce documentation for the sensitivity testing of the smoke detectors.

In an interview on 01/28/15 at 1:06 PM, FM#1 verified there was no documentation for the sensitivity testing of the smoke detectors.

Based on review of records and interview the facility failed to maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all 250 patients of the facility along with all of the staff and any visitors present at the time of a potential incident in the event that the smoke detectors failed to operate as designed during a fire emergency. Findings include:

1. On 01/28/15 at 10:40 AM, during review of the facility's Fire Alarm records, the facility was unable to produce documentation for the sensitivity testing of the smoke detectors.

In an interview on 01/28/15 at 10:41 AM, FM#1 stated the facility has a smart fire alarm panel constantly monitors the sensitivity of all of the smoke detectors. FM#1 was informed that documentation is required once every two years showing the sensitivity meets the requirement.

Based on review of records and interview the facility failed to maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all 250 patients of the facility along with all of the staff and any visitors present at the time of a potential incident in the event that the smoke detectors failed to operate as designed during a fire emergency. Findings include:

1. On 01/28/15 at 10:40 AM, during review of the facility's Fire Alarm records, the facility was unable to produce documentation for the sensitivity testing of the smoke detectors.

In an interview on 01/28/15 at 10:41 AM, FM#1 stated the facility has a smart fire alarm panel that constantly monitors the sensitivity of all of the smoke detectors. FM#1 was informed documentation is required once every two years showing the sensitivity meets the requirement.

Based on observation and interview the facility failed to provide the automatic sprinkler system is maintained in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all 16 patients of the facility along with all of the staff and any visitors present at the time of a potential incident to be injured if the automatic sprinkler system failed to operate as designed during a fire. Findings include:

1. On 01/29/15 at 10:37 AM, it was observed that the four (4) gauges on the wet sprinkler riser had not been replaced within the required five (5) years. Each gauge was marked 11-09.

In an interview on 01/29/15 at 10:38 AM, AFM#1 verified the gauges were beyond the 5 year replacement date.