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Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for 1 of 1 elevator machine rooms. NFPA 13, Section 5-1.1 states sprinklers shall be installed throughout the premises. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. This deficient practice could affect all patients, staff and/or visitors in the facility.

Findings include:

Based on observation and interview, the Director of Quality and the Maintenance Supervisor on 12/02/14 at 1:30 p.m., acknowledged the elevator equipment room in the new hospital addition lacked sprinkler coverage or alternative protection from an automatic extinguishing system.

1. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 1999 Edition, Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13, Section 5-6.3.4, " Minimum Distance between Sprinklers " , states sprinklers shall be spaced not less than 6 feet on center. In addition, LSC 19.1.1.4.5 requires minor renovations, alterations, modernizations, or repairs shall not reduce life safety below the level that previously existed. This deficient practice could affect patients, staff or visitors using the Radiology corridor.

Findings include:

Based on observation and interview on 12/02/14 at 1:00 p.m. with the Director of Quality and the Maintenance Supervisor, the nine foot by nine foot storage alcove in Radiology had a wall removed several years ago leaving two sprinklers with a distance of two feet between the sprinklers.



09412

2. Based on observation and interview, the facility failed to ensure 1 of 12 resident rooms was provided with an automatic sprinkler head to ensure sprinkler coverage in all portions of the building. This deficient practice could affect 14 residents as well as visitors or staff.

Findings include:

Based on observation on 12/02/14 at 10:50 a.m. with the Maintenance Supervisor, the bathroom in resident room 240 was not provided with sprinkler head protection. Based on interview concurrent with the observation with the Maintenance Supervisor it was acknowledged the aforementioned room was not equipped with sprinkler head protection in order to provide complete sprinkler coverage to all areas of the facility.

3. Based on observation and interview, the facility failed to ensure 2 of 9 steel armover sprinkler pipes observed were installed in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 1999 edition, Section 6-2.3.4 states the cumulative horizontal length of an unsupported armover to a sprinkler, sprinkler drop, or sprig-up shall not exceed 24 inches for steel pipe or 12 inches for copper tube. This deficient practice could affect all residents in the building if the sprinkler system required repair as well as staff or visitors.

Findings include:

Based on observations on 12/02/14 during the tour between 12:15 p.m. to 12:49 p.m. with the Maintenance Supervisor, the steel sprinkler pipe armovers observed in the Mechanical Penthouse next to air handler number one was measured to be 48 inches long. Furthermore, the entrance into the Mechanical Penthouse at the top of the stairs had an armover which measured thirty six inches long and both were unsupported.
Based on interview concurrent with the observations with the Maintenance Supervisor it was acknowledged the aforementioned steel sprinkler pipe armovers exceeded twenty four inches in length and were unsupported.

Based on observation and interview, the facility failed to ensure 2 of 2 exit stairs were provided with handrails on both sides. NFPA 101, 39.2.2.3.1 requires stairs to comply with Section 7.2.2. Section 7.2.2.4.2 states stairs shall have handrails on both sides. This deficient practice could affect any patient using the west and south exit of the medical center.

Findings include:

Based on observation on 01/09/15 at 10:15 a.m. with the Maintenance Director, the west and and south exits had two or more steps and were not provided with handrails on both sides of the steps. Based on interview at the time of observation, the Maintenance Director acknowledged the lack of handrails on the west and south exit steps.

Based on observation and interview; the facility failed to ensure 1 of 1 emergency generators was equipped with a working remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation of generator equipment on 12/02/14 at 2:45 p.m. with the Maintenance Supervisor, a remote shut off device was found inside the Boiler Power house, but, when tested during a generator exercise would not shut the generator down. The generator was installed after 2003 and over 100 horsepower and was required to have a working means to shut the generator off. Based on interview on 12/02/14 at 2:48 p.m. with the Maintenance Supervisor, it was acknowledged the facility was unaware the remote shut off for the generator was not working.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 1999 Standard for the Installation of Sprinkler Systems, to provide complete coverage for 1 of 1 elevator machine rooms. NFPA 13, Section 5-1.1 states sprinklers shall be installed throughout the premises. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. This deficient practice could affect all patients, staff and/or visitors in the facility.

Findings include:

Based on observation and interview, the Director of Quality and the Maintenance Supervisor on 12/02/14 at 1:30 p.m., acknowledged the elevator equipment room in the new hospital addition lacked sprinkler coverage or alternative protection from an automatic extinguishing system.

1. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13, 1999 Edition, Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13, Section 5-6.3.4, " Minimum Distance between Sprinklers " , states sprinklers shall be spaced not less than 6 feet on center. In addition, LSC 19.1.1.4.5 requires minor renovations, alterations, modernizations, or repairs shall not reduce life safety below the level that previously existed. This deficient practice could affect patients, staff or visitors using the Radiology corridor.

Findings include:

Based on observation and interview on 12/02/14 at 1:00 p.m. with the Director of Quality and the Maintenance Supervisor, the nine foot by nine foot storage alcove in Radiology had a wall removed several years ago leaving two sprinklers with a distance of two feet between the sprinklers.



09412

2. Based on observation and interview, the facility failed to ensure 1 of 12 resident rooms was provided with an automatic sprinkler head to ensure sprinkler coverage in all portions of the building. This deficient practice could affect 14 residents as well as visitors or staff.

Findings include:

Based on observation on 12/02/14 at 10:50 a.m. with the Maintenance Supervisor, the bathroom in resident room 240 was not provided with sprinkler head protection. Based on interview concurrent with the observation with the Maintenance Supervisor it was acknowledged the aforementioned room was not equipped with sprinkler head protection in order to provide complete sprinkler coverage to all areas of the facility.

3. Based on observation and interview, the facility failed to ensure 2 of 9 steel armover sprinkler pipes observed were installed in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 1999 edition, Section 6-2.3.4 states the cumulative horizontal length of an unsupported armover to a sprinkler, sprinkler drop, or sprig-up shall not exceed 24 inches for steel pipe or 12 inches for copper tube. This deficient practice could affect all residents in the building if the sprinkler system required repair as well as staff or visitors.

Findings include:

Based on observations on 12/02/14 during the tour between 12:15 p.m. to 12:49 p.m. with the Maintenance Supervisor, the steel sprinkler pipe armovers observed in the Mechanical Penthouse next to air handler number one was measured to be 48 inches long. Furthermore, the entrance into the Mechanical Penthouse at the top of the stairs had an armover which measured thirty six inches long and both were unsupported.
Based on interview concurrent with the observations with the Maintenance Supervisor it was acknowledged the aforementioned steel sprinkler pipe armovers exceeded twenty four inches in length and were unsupported.

Based on observation and interview, the facility failed to ensure 2 of 2 exit stairs were provided with handrails on both sides. NFPA 101, 39.2.2.3.1 requires stairs to comply with Section 7.2.2. Section 7.2.2.4.2 states stairs shall have handrails on both sides. This deficient practice could affect any patient using the west and south exit of the medical center.

Findings include:

Based on observation on 01/09/15 at 10:15 a.m. with the Maintenance Director, the west and and south exits had two or more steps and were not provided with handrails on both sides of the steps. Based on interview at the time of observation, the Maintenance Director acknowledged the lack of handrails on the west and south exit steps.

Based on observation and interview; the facility failed to ensure 1 of 1 emergency generators was equipped with a working remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation of generator equipment on 12/02/14 at 2:45 p.m. with the Maintenance Supervisor, a remote shut off device was found inside the Boiler Power house, but, when tested during a generator exercise would not shut the generator down. The generator was installed after 2003 and over 100 horsepower and was required to have a working means to shut the generator off. Based on interview on 12/02/14 at 2:48 p.m. with the Maintenance Supervisor, it was acknowledged the facility was unaware the remote shut off for the generator was not working.