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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 be able to provide a positive latch in accordance with the LSC section 19.3.6.3. This deficient practice could potentially affect 7 patients and 20 staff of the second floor along with any visitors present at the time of a potential incident to be injured if smoke and heat were allowed to pass from one smoke compartment to another during a fire. Findings include:

1. On 07/01/14 at 11:55 AM, it was observed that the cross corridor doors in the OB Corridor had more than an 1/8 inch gap and were warped so that they did not fully close when tested.

In an interview on 07/01/14 at 11:56 AM, MT#1 verified that the cross corridor doors in the OB Corridor had more than an 1/8 inch gap and were warped so that they did not fully close when tested.

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 7 patients and 20 staff of the second floor along with any visitors present at the time of a potential incident to be injured if smoke and heat were allowed to pass from a hazardous area into the corridor during a fire. Findings include:

1. On 07/01/14 at 11:38 AM, it was observed that Patient Room 202 was being used for storage and the door lacks a self-closer.

In an interview on 07/01/14 at 11:39 AM, MT#1 verified that Patient Room 202 was being used for storage and the door lacks a self-closer.

Based on review of records and interview, the facility failed to conduct fire drills in accordance with LSC section 19.7.1.2. This deficient practice could potentially affect all 20 patients of the facility, all of the staff and any visitors present at the time of a potential incident to be injured if staff failed to respond properly during a fire emergency. Findings include:

1. On 07/01/14 at 11:16 AM, during the review of the facility's Fire Drill Log, it was observed that the third shift fire drill times were not varied. Observed third shift drill times were 6:55 AM; 6:55 AM; 6:15 AM; and 5:33 AM.

In an interview on 07/01/14 at 11:17 AM, PO#1 verified that the third shift fire drills were conducted at the times stated above.

Based on observation 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 13 patients and 20 staff of the first floor along with any visitors present at the time of a potential incident to be injured if the smoke detectors failed to perform as designed during a fire emergency. Findings include:

1. On 07/01/14 at 1:00 PM, it was observed that a smoke detector was hanging by its wires in the Main Purchasing Storage Room.

In an interview on 07/01/14 at 1:01 PM, MT#1 verified that a smoke detector was hanging by its wires in the Main Purchasing Storage Room.

Based on observation and interview, the facility failed to provide that 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 7 patients and 20 staff of the second floor and 13 patients and 20 staff of the first floor, along with any visitors present at the time of a potential incident to be injured if the automatic sprinkler system failed to properly operate as designed during a fire emergency. Findings include:

1. On 07/01/14 at 12:00 PM, it was observed that there were penetrations of the OR Mechanical/Electrical Room ceiling by conduits, therefore not allowing the sprinkler system to operate as designed.

In an interview on 07/01/14 at 12:01 PM, MT#1 verified that there were penetrations of the OR Mechanical/Electrical Room ceiling by conduits.

2. On 07/01/14 at 1:00 PM, it was observed that there was a penetration of the Main Purchasing Storage Room ceiling by ductwork that was not tight to the ceiling grid, therefore not allowing the sprinkler system to operate as designed.

In an interview on 07/01/14 at 1:01 PM, MT#1 verified that there was a penetration of the Main Purchasing Storage Room ceiling by ductwork that was not tight to the ceiling grid.

3. On 07/01/14 at 1:35 PM, it was observed that there was a large penetration of the ceiling of the X-Ray back hallway made by wire bundles, therefore not allowing the sprinkler system to operate as designed.

In an interview on 07/01/14 at 1:36 PM, MT#1 verified that there was a large penetration of the ceiling of the X-Ray back hallway made by wire bundles.

Based on observation and interview, the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all 20 patients of the facility, all of the staff and any visitors present at the time of a potential incident to be injured if the electrical system malfunctioned and caused a fire. Findings include:

1. On 07/01/14 at 10:55 AM, it was observed that the 3rd Floor Conference Room had power strips (RPT's) that were interconnected.

In an interview on 07/01/14 at 10:56 AM, MT#1 verified that the 3rd Floor Conference Room had power strips (RPT's) that were interconnected.

2. On 07/01/14 at 11:00 AM, it was observed that the 3rd Floor IT Room had power strips (RPT's) that were interconnected.

In an interview on 07/01/14 at 11:01 AM, MT#1 verified that the 3rd Floor IT Room had power strips (RPT's) that were interconnected.

3. On 07/01/14 at 11:05 AM, it was observed that the 3rd Floor Business Office had power strips (RPT's) that were interconnected.

In an interview on 07/01/14 at 11:06 AM, MT#1 verified that the 3rd Floor Business Office had power strips (RPT's) that were interconnected.

4. On 07/01/14 at 11:11 AM, it was observed that there was combustible storage in direct contact with a power strip (RPT) in an enclosed space in Room 339, Third Floor.

In an interview on 07/01/14 at 11:12 AM, MT#1 verified that there was combustible storage in direct contact with a power strip (RPT) in an enclosed space in Room 339, Third Floor.

5. On 07/01/14 at 11:14 AM, it was observed that there was combustible storage beneath an electrical panel that was blocking access to the panel in the DLC Storage Room, Third Floor.

In an interview on 07/01/14 at 11:15 AM, MT#1 verified that there was combustible storage beneath an electrical panel that was blocking access to the panel in the DLC Storage Room, Third Floor.

6. On 07/01/14 at 12:00 PM, it was observed that there was combustible storage beneath the electrical panels that was blocking access to the panels in the OR Mechanical/Electrical Room, Second Floor.

In an interview on 07/01/14 at 12:01 PM, MT#1 verified that there was combustible storage beneath the electrical panels that was blocking access to the panels in the OR Mechanical/Electrical Room, Second Floor.

7. On 07/01/14 at 1:24 PM, it was observed that there was combustible storage beneath the electrical panels that was blocking access to the panels in the Northeast Mechanical Room, First Floor.

In an interview on 07/01/14 at 1:25 PM, MT#1 verified that there was combustible storage beneath the electrical panels that was blocking access to the panels in the Northeast Mechanical Room, First Floor.

8. On 07/01/14 at 1:56 PM, it was observed that the Laboratory on the First Floor had power strips (RPT's) that were interconnected.

In an interview on 07/01/14 at 1:57 PM, PO#1 verified that the Laboratory on the First Floor had power strips (RPT's) that were interconnected.

Based upon observation and interview, the facility failed to provide Alcohol Based Hand Rub (ABHR) dispensers in accordance with 42 CFR 403.744, 418.110, 460.72, 482.41, 483.70, 485.623. This deficient practice could potentially affect 13 patients and 20 staff of the First Floor, along with any visitors present at the time of a potential incident to be injured if the ABHR came into contact with an ignition source, creating a fire. Findings include:

1. On 07/01/14 at 1:14 PM, it was observed that there was an ABHR Dispenser mounted too close to a wall electrical outlet assembly in Cardio Rehab Room 128, First Floor.

In an interview on 07/01/14 at 1:15 PM, MT#1 verified that there was an ABHR Dispenser mounted too close to a wall electrical outlet assembly in Cardio Rehab Room 128, First Floor.