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Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms and 1 of 1 Radiology Suite electrical rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. This deficient practice could affect 3 patients in the changing rooms across from the Radiology Suite electrical room. The elevator equipment rooms were located in the basement and could affect any number of staff in the hospital.

Findings include:

a. Based on an observation and interview with the Safety Coordinator, Facilities Engineering Technician II # 1 and Facilities Engineering Technician II # 2 on 01/08/13 from 2:02 p.m. to 2:20 p.m., it was acknowledged both basement elevator equipment rooms lacked sprinkler coverage.
b. Based on observation and interview with the Safety Coordinator, Facilities Engineering Technician II # 1, Facilities Engineering Technician II # 2 and the Environmental Supervisor on 01/09/13 at 11:40 a.m., it was acknowledged the Radiology Suite electrical room lacked sprinkler coverage.

Based on observation and interview, the facility failed to ensure oxygen stored in 1 of 2 sprinklered oxygen storage locations was separated from any portion of a facility wherein residents are housed, examined, or treated by a separation of a fire barrier of 1 hour fire resistive construction and is vented to the outside. This deficient practice could affect 4 patients in the Cardiac Rehabilitation room at the hospital.

Findings include:

Based on observation with the Safety Coordinator, Facilities Engineering Technician II # 1, Facilities Engineering Technician II # 2 and the Chief Operating Office on 01/08/13 at 2:55 p.m., a large stationary liquid oxygen unit was stored in the Cardiac Rehabilitation room. It was not enclosed in a 1 hour construction with ventilation. The Safety Coordinator was unaware the liquid oxygen unit was stored in the Cardiac Rehabilitation room.

1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control panels, located in an area that was not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, National Fire Alarm Code, at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuous occupied to provide notification of a fire in that location. This deficient practice could affect any patient, staff or visitor in the Ligonier Rehabilitation Services facility.

Findings include:

Based on observation and interview on 01/08/130 at 2:00 p.m. with the Chief Operating Officer, it was acknowledged the fire alarm control panel located in the enclosed vestibule at the rear exit of the Ligonier Rehabilitation Services facility was not provided with automatic smoke detection.

2. Based on observation and interview, the facility failed to ensure emergency lighting was tested for 9 of 9 battery operated emergency lights. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Ligonier Rehabilitation Services facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 1:45 p.m. to 2:15 p.m. on 01/08/13, the Ligonier Rehabilitation Services facility has nine battery operated emergency lights. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II # 1, there was no written record of a 90 minute annual test regarding the battery operated emergency lights available for review.

3. Based on observation and interview, the facility failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 2 of 2 battery operated exit signs. LSC 38.2.10 requires means of egress shall have signs in accordance with Section 7.10. LSC 4.5.7 states whenever any device, equipment, system, condition, arrangement, level of protection or any other feature is required for compliance, such device, equipment, system, condition, arrangement, level of protection or other feature shall thereafter be maintained. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ½ hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Ligonier Rehabilitation Services facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 1:45 p.m. to 2:15 p.m., on 01/08/13, the Ligonier Rehabilitation Services facility has two exit signs with battery backup. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II # 1, there was no written record of a 90 minute annual test regarding the exit signs with battery backup available for review.

1. Based on observation and interview, the facility failed to ensure 1 of 1 portable fire extinguishers was given maintenance at periods not more than one year apart. NFPA 38.3.5 refers to 9.7.4.1. 9.4.7.1 states portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10, the Standard for Portable Fire Extinguishers. NFPA 10 in 4-4.1 requires extinguishers shall be subjected to maintenance not more than one year apart or when specifically indicated by a monthly inspection. NFPA 10, 4-2.2 defines maintenance as a "thorough check" of the extinguisher. It is intended to give maximum assurance the extinguisher will operate effectively and safely. This deficient practice could affect any patient, staff or visitor at the Satellite Rehab Therapy building.

Findings include:

Based on observation and interview with the Chief Operating Officer from 2:30 p.m. to 3:00 p.m. on 01/08/13, it was acknowledged the Satellite Rehab Therapy building had one portable fire extinguisher and it lacked an annual maintenance tag.

2. Based on observation and interview, the facility failed to ensure 2 of 2 battery powered emergency lights were tested and would function. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Satellite Rehab Therapy facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 2:30 p.m. to 3:00 p.m., on 01/08/13, the Satellite Rehab Therapy building has two battery operated emergency lights which failed to illuminate when tested. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II # 1, there was no written record of a 30 second monthly test or a 90 minute annual test regarding the battery operated emergency lights available for review.

3. Based on observation and interview, the facility failed to ensure 4 of 4 exit signs connected to, or provided with, a battery operated emergency back up power source were tested and would function. LSC 38.2.10 requires means of egress shall have signs in accordance with Section 7.10. LSC 4.5.7 states whenever any device, equipment, system, condition, arrangement, level of protection or any other feature is required for compliance, such device, equipment, system, condition, arrangement, level of protection or other feature shall thereafter be maintained. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ½ hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Satellite Rehab Therapy facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 2:30 p.m. to 3:00 p.m. on 01/08/13, the Satellite Rehab Therapy building has two exit signs with battery backup. Two of the exit signs were not illuminated under normal power and all four failed to illuminate when the battery was tested. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II # 1, there was no written record of a 30 second monthly test or a 90 minute annual test regarding the exit signs with battery backup available for review.

1. Based on observation and interview, the facility failed to ensure emergency lighting was tested in accordance with LSC 7.9 for 5 of 5 battery operated emergency lights. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Satellite Imaging Center including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 11:45 a.m. to 12:30 p.m., on 01/08/13, the Satellite Imaging Center has five battery operated emergency lights. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II # 1, there was no written record of a 90 minute annual test regarding the battery operated emergency lights available for review.

2. Based on observation and interview, the facility failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 2 of 2 battery operated exit signs. LSC 4.5.7 states whenever any device, equipment, system, condition, arrangement, level of protection or any other feature is required for compliance, such device, equipment, system, condition, arrangement, level of protection or other feature shall thereafter be maintained. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30-day intervals and an annual test to be conducted on every required battery-powered emergency lighting system for not less than 1 ½ -hr duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 11:45 a.m. to 12:30 p.m., on 01/08/13, the Satellite Imaging Center has two exit signs with battery backup. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II #1, there was no written record of a 90 minute annual test regarding the exit signs with battery backup available for review.

3. Based on observation and interview, the facility failed to ensure 1 of 1 portable fire extinguishers was given maintenance at periods not more than one year apart. NFPA 38.3.5 refers to 9.7.4.1. 9.4.7.1 states portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10. NFPA 10, the Standard for Portable Fire Extinguishers, in 4-4.1 requires extinguishers shall be subjected to maintenance not more than one year apart or when specifically indicated by a monthly inspection. 4-2.2 defines maintenance as a "thorough check" of the extinguisher. It is intended to give maximum assurance the extinguisher will operate effectively and safely. This deficient practice could affect any patient, staff or visitor.

Findings include:

Based on observation and interview with the Chief Operating Officer from 11:45 a.m. to 12:30 p.m., on 01/08/13, it was acknowledged that the Satellite Imaging Center had one portable fire extinguisher manufactured in 2006 and lacked an annual maintenance tag.

4. Based on observation, the facility failed to ensure extension cords were not used as a substitute for fixed wiring. LSC 38.5.1 refers to LSC 9.1. LSC 9.1.1 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect any staff or patient.

Findings include:

Based on observation and interview with the Chief Operating Officer from 11:45 a.m. to 12:30 p.m., on 01/08/13, it was acknowledged a microwave oven was plugged into an extension cord in the employee break room and not directly into a wall outlet.

Based on record review and interview, the facility failed to provide complete documentation for testing 1 of 1 emergency generators providing power to the emergency lighting systems. NFPA 99, Section 3-4.1.1.8 states the generator set shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. This deficient practice affects all occupants of the hospital.

Findings include:

Based on review of the generator log titled "Emergency Generator Log" with Facilities Engineering Technician II # 1 on 01/08/13 at 12:34 p.m., the emergency generator was tested monthly under load for at least 30 minutes, however, the monthly load test record did not include the time for the transfer of power from the main source to the generator. This was acknowledged by Facilities Engineering Technician II # 1 at the time of record review.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms and 1 of 1 Radiology Suite electrical rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. This deficient practice could affect 3 patients in the changing rooms across from the Radiology Suite electrical room. The elevator equipment rooms were located in the basement and could affect any number of staff in the hospital.

Findings include:

a. Based on an observation and interview with the Safety Coordinator, Facilities Engineering Technician II # 1 and Facilities Engineering Technician II # 2 on 01/08/13 from 2:02 p.m. to 2:20 p.m., it was acknowledged both basement elevator equipment rooms lacked sprinkler coverage.
b. Based on observation and interview with the Safety Coordinator, Facilities Engineering Technician II # 1, Facilities Engineering Technician II # 2 and the Environmental Supervisor on 01/09/13 at 11:40 a.m., it was acknowledged the Radiology Suite electrical room lacked sprinkler coverage.

Based on observation and interview, the facility failed to ensure oxygen stored in 1 of 2 sprinklered oxygen storage locations was separated from any portion of a facility wherein residents are housed, examined, or treated by a separation of a fire barrier of 1 hour fire resistive construction and is vented to the outside. This deficient practice could affect 4 patients in the Cardiac Rehabilitation room at the hospital.

Findings include:

Based on observation with the Safety Coordinator, Facilities Engineering Technician II # 1, Facilities Engineering Technician II # 2 and the Chief Operating Office on 01/08/13 at 2:55 p.m., a large stationary liquid oxygen unit was stored in the Cardiac Rehabilitation room. It was not enclosed in a 1 hour construction with ventilation. The Safety Coordinator was unaware the liquid oxygen unit was stored in the Cardiac Rehabilitation room.

1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control panels, located in an area that was not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, National Fire Alarm Code, at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuous occupied to provide notification of a fire in that location. This deficient practice could affect any patient, staff or visitor in the Ligonier Rehabilitation Services facility.

Findings include:

Based on observation and interview on 01/08/130 at 2:00 p.m. with the Chief Operating Officer, it was acknowledged the fire alarm control panel located in the enclosed vestibule at the rear exit of the Ligonier Rehabilitation Services facility was not provided with automatic smoke detection.

2. Based on observation and interview, the facility failed to ensure emergency lighting was tested for 9 of 9 battery operated emergency lights. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Ligonier Rehabilitation Services facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 1:45 p.m. to 2:15 p.m. on 01/08/13, the Ligonier Rehabilitation Services facility has nine battery operated emergency lights. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II # 1, there was no written record of a 90 minute annual test regarding the battery operated emergency lights available for review.

3. Based on observation and interview, the facility failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 2 of 2 battery operated exit signs. LSC 38.2.10 requires means of egress shall have signs in accordance with Section 7.10. LSC 4.5.7 states whenever any device, equipment, system, condition, arrangement, level of protection or any other feature is required for compliance, such device, equipment, system, condition, arrangement, level of protection or other feature shall thereafter be maintained. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ½ hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Ligonier Rehabilitation Services facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 1:45 p.m. to 2:15 p.m., on 01/08/13, the Ligonier Rehabilitation Services facility has two exit signs with battery backup. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II # 1, there was no written record of a 90 minute annual test regarding the exit signs with battery backup available for review.

1. Based on observation and interview, the facility failed to ensure 1 of 1 portable fire extinguishers was given maintenance at periods not more than one year apart. NFPA 38.3.5 refers to 9.7.4.1. 9.4.7.1 states portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10, the Standard for Portable Fire Extinguishers. NFPA 10 in 4-4.1 requires extinguishers shall be subjected to maintenance not more than one year apart or when specifically indicated by a monthly inspection. NFPA 10, 4-2.2 defines maintenance as a "thorough check" of the extinguisher. It is intended to give maximum assurance the extinguisher will operate effectively and safely. This deficient practice could affect any patient, staff or visitor at the Satellite Rehab Therapy building.

Findings include:

Based on observation and interview with the Chief Operating Officer from 2:30 p.m. to 3:00 p.m. on 01/08/13, it was acknowledged the Satellite Rehab Therapy building had one portable fire extinguisher and it lacked an annual maintenance tag.

2. Based on observation and interview, the facility failed to ensure 2 of 2 battery powered emergency lights were tested and would function. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Satellite Rehab Therapy facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 2:30 p.m. to 3:00 p.m., on 01/08/13, the Satellite Rehab Therapy building has two battery operated emergency lights which failed to illuminate when tested. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II # 1, there was no written record of a 30 second monthly test or a 90 minute annual test regarding the battery operated emergency lights available for review.

3. Based on observation and interview, the facility failed to ensure 4 of 4 exit signs connected to, or provided with, a battery operated emergency back up power source were tested and would function. LSC 38.2.10 requires means of egress shall have signs in accordance with Section 7.10. LSC 4.5.7 states whenever any device, equipment, system, condition, arrangement, level of protection or any other feature is required for compliance, such device, equipment, system, condition, arrangement, level of protection or other feature shall thereafter be maintained. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ½ hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Satellite Rehab Therapy facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 2:30 p.m. to 3:00 p.m. on 01/08/13, the Satellite Rehab Therapy building has two exit signs with battery backup. Two of the exit signs were not illuminated under normal power and all four failed to illuminate when the battery was tested. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II # 1, there was no written record of a 30 second monthly test or a 90 minute annual test regarding the exit signs with battery backup available for review.

1. Based on observation and interview, the facility failed to ensure emergency lighting was tested in accordance with LSC 7.9 for 5 of 5 battery operated emergency lights. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the Satellite Imaging Center including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 11:45 a.m. to 12:30 p.m., on 01/08/13, the Satellite Imaging Center has five battery operated emergency lights. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II # 1, there was no written record of a 90 minute annual test regarding the battery operated emergency lights available for review.

2. Based on observation and interview, the facility failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 2 of 2 battery operated exit signs. LSC 4.5.7 states whenever any device, equipment, system, condition, arrangement, level of protection or any other feature is required for compliance, such device, equipment, system, condition, arrangement, level of protection or other feature shall thereafter be maintained. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30-day intervals and an annual test to be conducted on every required battery-powered emergency lighting system for not less than 1 ½ -hr duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the facility including staff, visitors and patients if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on observation with the Chief Operating Officer from 11:45 a.m. to 12:30 p.m., on 01/08/13, the Satellite Imaging Center has two exit signs with battery backup. Based on interview at 4:30 p.m. on 01/08/13 with the Facility Engineering Technician II #1, there was no written record of a 90 minute annual test regarding the exit signs with battery backup available for review.

3. Based on observation and interview, the facility failed to ensure 1 of 1 portable fire extinguishers was given maintenance at periods not more than one year apart. NFPA 38.3.5 refers to 9.7.4.1. 9.4.7.1 states portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10. NFPA 10, the Standard for Portable Fire Extinguishers, in 4-4.1 requires extinguishers shall be subjected to maintenance not more than one year apart or when specifically indicated by a monthly inspection. 4-2.2 defines maintenance as a "thorough check" of the extinguisher. It is intended to give maximum assurance the extinguisher will operate effectively and safely. This deficient practice could affect any patient, staff or visitor.

Findings include:

Based on observation and interview with the Chief Operating Officer from 11:45 a.m. to 12:30 p.m., on 01/08/13, it was acknowledged that the Satellite Imaging Center had one portable fire extinguisher manufactured in 2006 and lacked an annual maintenance tag.

4. Based on observation, the facility failed to ensure extension cords were not used as a substitute for fixed wiring. LSC 38.5.1 refers to LSC 9.1. LSC 9.1.1 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect any staff or patient.

Findings include:

Based on observation and interview with the Chief Operating Officer from 11:45 a.m. to 12:30 p.m., on 01/08/13, it was acknowledged a microwave oven was plugged into an extension cord in the employee break room and not directly into a wall outlet.

Based on record review and interview, the facility failed to provide complete documentation for testing 1 of 1 emergency generators providing power to the emergency lighting systems. NFPA 99, Section 3-4.1.1.8 states the generator set shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. This deficient practice affects all occupants of the hospital.

Findings include:

Based on review of the generator log titled "Emergency Generator Log" with Facilities Engineering Technician II # 1 on 01/08/13 at 12:34 p.m., the emergency generator was tested monthly under load for at least 30 minutes, however, the monthly load test record did not include the time for the transfer of power from the main source to the generator. This was acknowledged by Facilities Engineering Technician II # 1 at the time of record review.