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Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. Findings include:

1. On 4/26/12 at approximately 9:30 AM, the door to the gift shop storage room did not self close and positively latch due the closing device being disabled. This observation was verified by the maintenance director.

2. On 4/26/12 at approximately 10:30 AM, the door to the kitchen dry storage room did not self close and positively latch due the closing device being disabled. This observation was verified by the maintenance director.

Based on observation and/or review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1. Findings include:

1. On 4/26/12 at approximately 9:00 AM during review of the facility's emergency plan, it was observed that the emergency evacuation plan did not specify directions for evacuation of the affected smoke compartment. This observation was verified by the Director of Human Resources and Environment of Care.

2. On 4/26/12 at approximately 8:30 AM during review of the facility's emergency plan and fire drill records, it was observed that the facility failed to document the transmission of the fire alarm signal to the central monitoring station. This observation was verified by the Director of Human Resources and Environment of Care.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. Findings include:

1. On 01/01/01 at approximately 9:45 AM, the sprinkler head in the Chapel hall housekeeping closet was observed to be hanging down from the ceiling approximately 2 to 3 inches. Further investigation revealed that the sprinkler piping was loose indicating that the pipe hanger had become loose or had broken. This observation was verified by the maintenance director.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. Findings include:

1. On 4/26/12 at approximately 8:15 AM during review of the facility's generator maintenance records and by interview with the maintenance director, it was observed that the facility failed to conduct weekly visual inspection of the emergency power generator. This observation was verified by the maintenance director.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. Findings include:

1. On 4/26/12 at approximately 8:10 AM, it was observed that the facility's sprinkler system fire watch policy did not contain directions for notifying the AHJ of an outage of greater than 4 hours in a 24 hour period. This observation was verified by the Director of Human Services and Environment of Care.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. Findings include:

1. On 4/26/12 at approximately 8:10 AM, it was observed that the facility's fire alarm system fire watch policy did not contain directions for notifying the AHJ of an outage of greater than 4 hours in a 24 hour period. This observation was verified by the Director of Human Services and Environment of Care.

Based on observation the facility failed to provide for the protection of hazardous areas in accordance with the LSC section 19.3.2.1. Findings include:

1. On 4/26/12 at approximately 9:30 AM, the door to the gift shop storage room did not self close and positively latch due the closing device being disabled. This observation was verified by the maintenance director.

2. On 4/26/12 at approximately 10:30 AM, the door to the kitchen dry storage room did not self close and positively latch due the closing device being disabled. This observation was verified by the maintenance director.

Based on observation and/or review of records the facility failed to provide an approved written emergency plan in accordance with the LSC section 19.7.1.1. Findings include:

1. On 4/26/12 at approximately 9:00 AM during review of the facility's emergency plan, it was observed that the emergency evacuation plan did not specify directions for evacuation of the affected smoke compartment. This observation was verified by the Director of Human Resources and Environment of Care.

2. On 4/26/12 at approximately 8:30 AM during review of the facility's emergency plan and fire drill records, it was observed that the facility failed to document the transmission of the fire alarm signal to the central monitoring station. This observation was verified by the Director of Human Resources and Environment of Care.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. Findings include:

1. On 01/01/01 at approximately 9:45 AM, the sprinkler head in the Chapel hall housekeeping closet was observed to be hanging down from the ceiling approximately 2 to 3 inches. Further investigation revealed that the sprinkler piping was loose indicating that the pipe hanger had become loose or had broken. This observation was verified by the maintenance director.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. Findings include:

1. On 4/26/12 at approximately 8:15 AM during review of the facility's generator maintenance records and by interview with the maintenance director, it was observed that the facility failed to conduct weekly visual inspection of the emergency power generator. This observation was verified by the maintenance director.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. Findings include:

1. On 4/26/12 at approximately 8:10 AM, it was observed that the facility's sprinkler system fire watch policy did not contain directions for notifying the AHJ of an outage of greater than 4 hours in a 24 hour period. This observation was verified by the Director of Human Services and Environment of Care.

Based on observation and/or review of records the facility failed to provide an emergency plan in accordance with the LSC section 9.7.6.1. Findings include:

1. On 4/26/12 at approximately 8:10 AM, it was observed that the facility's fire alarm system fire watch policy did not contain directions for notifying the AHJ of an outage of greater than 4 hours in a 24 hour period. This observation was verified by the Director of Human Services and Environment of Care.