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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 in accordance with LSC Section 19.3.6.3. This deficient practice could potentially affect approximately 20 occupants in the smoke compartment if smoke was not contained to the room in the event of a fire.

Findings Include:
On 9/9/14 at approximately 12:01pm, the door to the Recreational Therapy Room was observed failing to latch when closed and provide the resistance of smoke passage as required by 19.3.6.3.1.

On 9/9/14 at approximately 12:01pm, Maintenance #2 in an interview stated he was unaware the door did not latch.

Based on review of records and interview, the facility failed to ensure fire drills were conducted in accordance with LSC Section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings Include:
On 9/9/14 between 10:20am and 11:20am during a review of records, the 1st shift drill times in the 1st and 2nd quarter were held between 10:45am and 11:00am; the 1st shift drill times in the 3rd and 4th quarter were held between 1:00pm and 1:20pm; and the 2nd shift drill times in the 2nd, 3rd and 4th quarter were held between 3:06pm and 3:27pm. These drills were not varied throughout the shift according to LSC Section 19.7.1.2.

On 9/15/14 at approximately 11:05am, Maintenance 2 stated during an interview on the phone that the times were accurate according to his records.

Based on observation and interview, the facility failed to ensure that the fire alarm system was maintained in accordance with LSC Section 9.6.1.4 and NFPA 72. This deficient practice could potentially affect all the staff, visitors and occupants of the facility in the event the notification of an alarm was delayed due to an alarm pull station being obstructed.

Findings Include:
On 9/9/14 at approximately 12:03pm, the fire alarm pull station in the cafeteria was observed being obstructed by a cart with signs on it which is a violation of Section 9.6.2.6.

On 9/9/14 at approximately 12:03pm, Maintenance #1 in an interview stated they are working on a different way to view the signs and the cart will not be needed there.

Based on observation and interview, the facility failed to ensure that the automatic sprinkler system is maintained in accordance with LSC Sections 19.7.6, 4.6.12, and 9.7.5 and NFPA 13 and 25. This deficient practice could potentially affect all occupants of the facility in the event failure of the sprinkler system to activate in a fire.

Findings Include:
1. On 9/9/14 at approximately 11:24am ceiling tiles were observed missing and out of place in the Boiler Room. The tiles form the ceiling of the space for the purposes of sprinkler coverage and no sprinklers were observed above the ceiling tiles within the required distance of the floor deck above. This condition allows heat to bypass the provided sprinkler heads and accumulate in an area where no sprinkler heads are provided within 1-12 inches of the roof deck as required by NFPA 13, Section 5-6.4.1.1.

On 9/9/14 at approximately 11:24am, Maintenance #1 in an interview stated he did not know why they were missing and out of place.

2. On 9/9/14 at approximately 11:40am the ceiling was observed to be open around the ladder to roof access in the Maintenance Room. The tiles form the ceiling of the space for the purposes of sprinkler coverage and no sprinklers were observed above the ceiling tiles within the required distance of the floor deck above. This condition allows heat to bypass the provided sprinkler heads and accumulate in an area where no sprinkler heads are provided within 1-12 inches of the roof deck as required by NFPA 13, Section 5-6.4.1.1.

On 9/9/14 at approximately 11:40am, Maintenance #1 and Maintenance #2 in an interview stated they did not realize that the space needed to be smoke tight.

3. On 9/9/14 at approximately 11:40am, a wire was observed to be attached by plastic tie straps to a Sprinkler Pipe Hanger above the ceiling in the Maintenance Room which is a violation of NFPA 25 Section 2-2.2

On 9/9/14 at approximately 11:40am, Maintenance #2 in an interview stated he was not aware that a wire had been attached to the hanger and removed it at this time.

Based upon observation and interview, the facility failed to 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 the staff, visitors and occupants of a smoke compartment in the event of a fire not being rapidly controlled due to the fire extinguisher not being visually mounted.

Findings Include:
On 9/9/14 at approximately 2:00 pm, the fire extinguisher at the Critical Care Nurses' Station was observed to be sitting on the floor under the desk which is in violation of NFPA 10 - 1.6.7

On 9/9/14 at approximately 2:00pm, Maintenance #2 in an interview stated he was unaware the fire extinguisher was not mounted.

Based on observation and interview, the facility failed to ensure the facility was free of combustible decorations in accordance with LSC Sections 19.7.5.2, 19.7.5.3, and 19.7.5.4. This deficient practice could potentially affect the occupants of the room in the event the combustibles increase the hazard of fire development or spread.

Findings Include:
On 9/9/14 at approximately 12:23pm, the Medical Imaging Manager's Room was observed to have an excessive amount of combustibles attached to the walls which violates 19.7.5.4.

On 9/9/14 at approximately 12:23pm, Maintenance #1 in an interview stated he was unaware the amount of combustibles would create a violation.

Based on observation and interview, the facility failed to provide the electrical system in accordance with LSC Sections 19.5.1 and 9.1.2. This deficient practice could potentially affect staff in the room in the event of an electrical overload of the wiring.

Findings Include:
On 9/9/14 at approximately 2:06pm, an extension cord was observed being used in the Med Room rather than permanent wiring as required by NFPA 70 Article 305-3.

On 9/9/14 at approximately 2:06pm Maintenance #1 and Maintenance #2 stated in an interview that they were unaware of the extension cord being used.

Based on observation and interview, the facility failed to provide corridor doors that would close and resist the passage of smoke in accordance with LSC Section 19.3.6.3. This deficient practice could potentially affect approximately 20 occupants in the smoke compartment if smoke was not contained to the room in the event of a fire.

Findings Include:
On 9/9/14 at approximately 12:01pm, the door to the Recreational Therapy Room was observed failing to latch when closed and provide the resistance of smoke passage as required by 19.3.6.3.1.

On 9/9/14 at approximately 12:01pm, Maintenance #2 in an interview stated he was unaware the door did not latch.

Based on review of records and interview, the facility failed to ensure fire drills were conducted in accordance with LSC Section 19.7.1.2. This deficient practice could potentially affect all occupants of the facility if staff are not properly trained in approved emergency procedures.

Findings Include:
On 9/9/14 between 10:20am and 11:20am during a review of records, the 1st shift drill times in the 1st and 2nd quarter were held between 10:45am and 11:00am; the 1st shift drill times in the 3rd and 4th quarter were held between 1:00pm and 1:20pm; and the 2nd shift drill times in the 2nd, 3rd and 4th quarter were held between 3:06pm and 3:27pm. These drills were not varied throughout the shift according to LSC Section 19.7.1.2.

On 9/15/14 at approximately 11:05am, Maintenance 2 stated during an interview on the phone that the times were accurate according to his records.

Based on observation and interview, the facility failed to ensure that the fire alarm system was maintained in accordance with LSC Section 9.6.1.4 and NFPA 72. This deficient practice could potentially affect all the staff, visitors and occupants of the facility in the event the notification of an alarm was delayed due to an alarm pull station being obstructed.

Findings Include:
On 9/9/14 at approximately 12:03pm, the fire alarm pull station in the cafeteria was observed being obstructed by a cart with signs on it which is a violation of Section 9.6.2.6.

On 9/9/14 at approximately 12:03pm, Maintenance #1 in an interview stated they are working on a different way to view the signs and the cart will not be needed there.

Based on observation and interview, the facility failed to ensure that the automatic sprinkler system is maintained in accordance with LSC Sections 19.7.6, 4.6.12, and 9.7.5 and NFPA 13 and 25. This deficient practice could potentially affect all occupants of the facility in the event failure of the sprinkler system to activate in a fire.

Findings Include:
1. On 9/9/14 at approximately 11:24am ceiling tiles were observed missing and out of place in the Boiler Room. The tiles form the ceiling of the space for the purposes of sprinkler coverage and no sprinklers were observed above the ceiling tiles within the required distance of the floor deck above. This condition allows heat to bypass the provided sprinkler heads and accumulate in an area where no sprinkler heads are provided within 1-12 inches of the roof deck as required by NFPA 13, Section 5-6.4.1.1.

On 9/9/14 at approximately 11:24am, Maintenance #1 in an interview stated he did not know why they were missing and out of place.

2. On 9/9/14 at approximately 11:40am the ceiling was observed to be open around the ladder to roof access in the Maintenance Room. The tiles form the ceiling of the space for the purposes of sprinkler coverage and no sprinklers were observed above the ceiling tiles within the required distance of the floor deck above. This condition allows heat to bypass the provided sprinkler heads and accumulate in an area where no sprinkler heads are provided within 1-12 inches of the roof deck as required by NFPA 13, Section 5-6.4.1.1.

On 9/9/14 at approximately 11:40am, Maintenance #1 and Maintenance #2 in an interview stated they did not realize that the space needed to be smoke tight.

3. On 9/9/14 at approximately 11:40am, a wire was observed to be attached by plastic tie straps to a Sprinkler Pipe Hanger above the ceiling in the Maintenance Room which is a violation of NFPA 25 Section 2-2.2

On 9/9/14 at approximately 11:40am, Maintenance #2 in an interview stated he was not aware that a wire had been attached to the hanger and removed it at this time.

Based upon observation and interview, the facility failed to 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 the staff, visitors and occupants of a smoke compartment in the event of a fire not being rapidly controlled due to the fire extinguisher not being visually mounted.

Findings Include:
On 9/9/14 at approximately 2:00 pm, the fire extinguisher at the Critical Care Nurses' Station was observed to be sitting on the floor under the desk which is in violation of NFPA 10 - 1.6.7

On 9/9/14 at approximately 2:00pm, Maintenance #2 in an interview stated he was unaware the fire extinguisher was not mounted.

Based on observation and interview, the facility failed to ensure the facility was free of combustible decorations in accordance with LSC Sections 19.7.5.2, 19.7.5.3, and 19.7.5.4. This deficient practice could potentially affect the occupants of the room in the event the combustibles increase the hazard of fire development or spread.

Findings Include:
On 9/9/14 at approximately 12:23pm, the Medical Imaging Manager's Room was observed to have an excessive amount of combustibles attached to the walls which violates 19.7.5.4.

On 9/9/14 at approximately 12:23pm, Maintenance #1 in an interview stated he was unaware the amount of combustibles would create a violation.

Based on observation and interview, the facility failed to provide the electrical system in accordance with LSC Sections 19.5.1 and 9.1.2. This deficient practice could potentially affect staff in the room in the event of an electrical overload of the wiring.

Findings Include:
On 9/9/14 at approximately 2:06pm, an extension cord was observed being used in the Med Room rather than permanent wiring as required by NFPA 70 Article 305-3.

On 9/9/14 at approximately 2:06pm Maintenance #1 and Maintenance #2 stated in an interview that they were unaware of the extension cord being used.