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Based on observation and interview the facility failed to provide corridor doors that would close to a postive latch and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 0 patients and 3 staff of the facility to be injured by allowing heat and smoke to pass into the corridor during a fire. Findings include:

1. On 06/24/14 at 1:41 PM, it was observed that the West Entrance Door to the Kitchen failed to self-close and positively latch.

In an interview on 06/24/14 at 1:42 PM, FM#1 verified that the West Entrance Door to the Kitchen failed to self-close and positively latch.

2. On 06/24/14 at 2:35 PM, it was observed that the Surgery Hallway Door failed to self-close and positively latch.

In an interview on 06/24/14 at 2:36 PM, FM#1 verified that the Surgery Hallway Door failed to self-close and positively latch.

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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 0 patients and 3 staff of the facility to be injured if heat and smoke were allowed to pass from a room into the corridor during a fire. Findings include:

1. On 06/24/14 at 1:17 PM, a penetration was observed in the corridor wall in the Old Elevator Equipment Room. The penetration was caused by a conduit.

In an interview on 06/24/14 at 1:18 PM, FM#1 verified that there was a penetration in the Old Elevator Equipment Room.

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 0 patients and 3 staff of the facility to be injured if heat and smoke were allowed to pass from the hazardous room into the facility during a fire. Findings include:

1. On 06/24/14 at 1:38 PM, it was observed that the Kitchen Pantry Door failed to self-close and positively latch.

In an interview on 06/24/14 at 1:39 PM, FM#1 verified that the Kitchen Pantry Door failed to self-close and positively latch.

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Based on review of records and interview the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all 5 patients of the facility, all of the staff and any visitors present at the time of a potential incident to be injured if the staff failed to respond properly to a fire emergency. Findings include:

1. On 06/24/14 at 12:37 PM, during review of the facility's Fire Drill Records it was observed there was no fire drill conducted during the third shift of the second quarter of 2013-14; no fire drill conducted for the first shift of the third quarter of 2013; and no fire drill conducted for the third shift of the third quarter of 2013.

In an interview on 06/24/14 at 12:38 PM, FM#1 verified the above mentioned fire drills were not conducted.

2. On 06/24/14 at 12:39 PM, during review of the facility's Fire Drill Records it was observed that a coded announcement was used instead of the audible alarms for the fire drills conducted on 12/27/13 at 6:25 AM and on 12/31/13 at 7:35 PM.

In an interview on 06/24/14 at 12:40 PM, FM#1 verified a coded announcement had been used instead of audible alarms for the fire drills identified above.

Based on observation and interview the facility failed to provide corridor doors that would close to a postive latch and resist the passage of smoke in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 0 patients and 3 staff of the facility to be injured by allowing heat and smoke to pass into the corridor during a fire. Findings include:

1. On 06/24/14 at 1:41 PM, it was observed that the West Entrance Door to the Kitchen failed to self-close and positively latch.

In an interview on 06/24/14 at 1:42 PM, FM#1 verified that the West Entrance Door to the Kitchen failed to self-close and positively latch.

2. On 06/24/14 at 2:35 PM, it was observed that the Surgery Hallway Door failed to self-close and positively latch.

In an interview on 06/24/14 at 2:36 PM, FM#1 verified that the Surgery Hallway Door failed to self-close and positively latch.

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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 0 patients and 3 staff of the facility to be injured if heat and smoke were allowed to pass from a room into the corridor during a fire. Findings include:

1. On 06/24/14 at 1:17 PM, a penetration was observed in the corridor wall in the Old Elevator Equipment Room. The penetration was caused by a conduit.

In an interview on 06/24/14 at 1:18 PM, FM#1 verified that there was a penetration in the Old Elevator Equipment Room.

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 0 patients and 3 staff of the facility to be injured if heat and smoke were allowed to pass from the hazardous room into the facility during a fire. Findings include:

1. On 06/24/14 at 1:38 PM, it was observed that the Kitchen Pantry Door failed to self-close and positively latch.

In an interview on 06/24/14 at 1:39 PM, FM#1 verified that the Kitchen Pantry Door failed to self-close and positively latch.

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Based on review of records and interview the facility failed to provide written documentation regarding fire drills in accordance with the LSC section 19.7.1.2. This deficient practice could potentially affect all 5 patients of the facility, all of the staff and any visitors present at the time of a potential incident to be injured if the staff failed to respond properly to a fire emergency. Findings include:

1. On 06/24/14 at 12:37 PM, during review of the facility's Fire Drill Records it was observed there was no fire drill conducted during the third shift of the second quarter of 2013-14; no fire drill conducted for the first shift of the third quarter of 2013; and no fire drill conducted for the third shift of the third quarter of 2013.

In an interview on 06/24/14 at 12:38 PM, FM#1 verified the above mentioned fire drills were not conducted.

2. On 06/24/14 at 12:39 PM, during review of the facility's Fire Drill Records it was observed that a coded announcement was used instead of the audible alarms for the fire drills conducted on 12/27/13 at 6:25 AM and on 12/31/13 at 7:35 PM.

In an interview on 06/24/14 at 12:40 PM, FM#1 verified a coded announcement had been used instead of audible alarms for the fire drills identified above.