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23515 HIGHWAY 190

MANDEVILLE, LA 70448

Alcohol Based Hand Rub Dispenser (ABHR)

Tag No.: K0325

Based on visual observation the facility failed to assure proper placement of alcohol based hand sanitizer dispensers. The content of the sanitizers has the probability to be flammable and incorrect placement could result in a fire emergency. The deficient practice has the potential to affect 14 of 20 residents.

Findings:

During the facility tour on 8/1/2018 between the hours of 11:45 am to 5:30 pm and on 8/2/2018 between the hours of 8:30 am to 2:00 pm it was observed the alcohol dispenser located in the nursing station nearest the fire alarm panel located directly above a electrical receptacle.

Interview with Plant and Operations Director revealed the facility was not aware of the dangers when placement of a hand sanitizer is not adhered to.

Corridors - Construction of Walls

Tag No.: K0362

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 13 of 20 residents.
1 of 1 smoke compartments were deficient.

Findings:

During the facility tour 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30am to 2:00pm it was observed all psychiatric Hospital sleeping rooms have transfer grills / louvers in the concrete corridor walls. Thus, allowing the corridor to freely transfer smoke and comprise the ½ hour required corridor wall fire rating.

NFPA 101: 19.3.6.2.2* states, "Corridor walls shall have a minimum 1/2-hour fire resistance rating".

Interview with Plant and Operations Director revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

Corridors - Construction of Walls

Tag No.: K0362

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 14 of 20 residents.
1 of 1 smoke compartments were deficient.

Findings:

During the facility tour 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30am to 2:00pm it was observed all psychiatric Hospital sleeping rooms have transfer grills / louvers in the concrete corridor walls. Thus, allowing the corridor to freely transfer smoke and comprise the ½ hour required corridor wall fire rating.

NFPA 101: 19.3.6.2.2* states, "Corridor walls shall have a minimum 1?2-hour fire resistance rating".

Interview with Plant and Operations Director revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

Corridors - Construction of Walls

Tag No.: K0362

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 18 of 20 residents.
1 of 1 smoke compartments were deficient.

Findings:

During the facility tour 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30am to 2:00pm it was observed all psychiatric Hospital sleeping rooms have transfer grills / louvers in the concrete corridor walls. Thus, allowing the corridor to freely transfer smoke and comprise the ½ hour required corridor wall fire rating.

NFPA 101: 19.3.6.2.2* states, "Corridor walls shall have a minimum 1?2-hour fire resistance rating".

Interview with Plant and Operations Director revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

Corridors - Construction of Walls

Tag No.: K0362

Based on visual observation this sprinklered facility failed to assure that the smoke compartmentation of the membrane between the egress corridor and rooms, adjacent to the egress corridor, were not compromised. Repairs to assure the protection of occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 19 of 20 residents.
1 of 1 smoke compartments were deficient.

Findings:

During the facility tour 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30 am to 2:00 pm it was observed all psychiatric Hospital sleeping rooms have transfer grills / louvers in the concrete corridor walls. Thus, allowing the corridor to freely transfer smoke and comprise the ½ hour required corridor wall fire rating.

NFPA 101: 19.3.6.2.2* states, "Corridor walls shall have a minimum 1/2-hour fire resistance rating".

Interview with Plant and Operations Director revealed the facility was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another.

Corridor - Openings

Tag No.: K0364

Based on visual observation this facility failed to assure that the smoke compartmentation of the membrane between the egress corridor walls and the sleeping room doors were not compromised. Repairs to assure the protection of the occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 13 of 20 residents. 1 of 1 smoke compartments were deficient.

Findings:

During the facility tour 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30am to 2:00pm it was observed all psychiatric Hospital sleeping rooms have transfer grills / louvers in the concrete corridor walls. Thus, allowing the corridor to freely transfer smoke and comprise the ½ hour required corridor wall fire rating.

NFPA 101:19.3.6.4.1 states, "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors."

Interview with Plant and Operations Director revealed the facility was not aware a transfer grill in the corridor wall transferring corridor air freely to the psychiatric sleeping rooms is prohibited.

Corridor - Openings

Tag No.: K0364

Based on visual observation this facility failed to assure that the smoke compartmentation of the membrane between the egress corridor walls and the sleeping room doors were not compromised. Repairs to assure the protection of the occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 14 of 20 residents. 1 of 1 smoke compartments were deficient.

Findings:

During the facility tour 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30am to 2:00pm it was observed all psychiatric Hospital sleeping rooms have transfer grills / louvers in the concrete corridor walls. Thus, allowing the corridor to freely transfer smoke and comprise the ½ hour required corridor wall fire rating.

NFPA 101:19.3.6.4.1 states, "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors."

Interview with Plant and Operations Directorrevealed the facility was not aware a transfer grill in the corridor wall transferring corridor air freely to the psychiatric sleeping rooms is prohibited.

Corridor - Openings

Tag No.: K0364

Based on visual observation this facility failed to assure that the smoke compartmentation of the membrane between the egress corridor walls and the sleeping room doors were not compromised. Repairs to assure the protection of the occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 18 of 20 residents. 1 of 1 smoke compartments were deficient.

Findings:

During the facility tour 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30am to 2:00pm it was observed all psychiatric Hospital sleeping rooms have transfer grills / louvers in the concrete corridor walls. Thus, allowing the corridor to freely transfer smoke and comprise the ½ hour required corridor wall fire rating.

NFPA 101:19.3.6.4.1 states, "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors."

Interview with Plant and Operations Directorrevealed the facility was not aware a transfer grill in the corridor wall transferring corridor air freely to the psychiatric sleeping rooms is prohibited.

Corridor - Openings

Tag No.: K0364

Based on visual observation this facility failed to assure that the smoke compartmentation of the membrane between the egress corridor walls and the sleeping room doors were not compromised. Repairs to assure the protection of the occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 19 of 20 residents. 1 of 1 smoke compartments were deficient.

Findings:

During the facility tour 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30am to 2:00pm it was observed all psychiatric Hospital sleeping rooms have transfer grills / louvers in the concrete corridor walls. Thus, allowing the corridor to freely transfer smoke and comprise the ½ hour required corridor wall fire rating.

NFPA 101:19.3.6.4.1 states, "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors."

Interview with Plant and Operations Director revealed the facility was not aware a transfer grill in the corridor wall transferring corridor air freely to the psychiatric sleeping rooms is prohibited.

HVAC

Tag No.: K0521

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect 14 of 20 residents.
2 of 2 corridors are deficient in being used as a return air plenum.

Findings:

During the facility tour on 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30 am to 2:00 pm it was observed the corridor is being as a return air plenum to supply HVAC air to all psychiatric patient sleeping rooms and then exhausted to the corridor.

NFPA 90A: 4.3.12.1.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.2.1 through 4.3.12.1.2.4.

NFPA 90A: 4.3.12.1.2 An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

NFPA 90A: 4.3.12.1.2.1 An air transfer opening(s) shall be permitted in walls or doors from toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridor.

NFPA 90A: 4.3.12.1.2.2 Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Other Opening Protectives, air transfer caused by pressure differentials shall be permitted.

NFPA 90A: 4.3.12.1.2.3 Use of egress corridors shall be permitted as part of an engineered smoke-control system.

NFPA 90A: 4.3.12.1.2.4 Air transfer opening(s) shall be permitted in walls or in doors separating egress corridors from adjoining areas in detention and correctional occupancies with corridor separations of open construction (e.g., grating doors or grating partitions).

Interview with Plant and Operations Director revealed the facility was not aware the HVAC system was using the corridors as a return air plenum.

HVAC

Tag No.: K0521

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect 0 of 20 residents.
3 of 3 corridors are deficient in being used as a return air plenum.

Findings:

During the facility tour on 8/1/2018 between the hours of 11:45 am to 5:30 pm and on 8/2/2018 between the hours of 8:30 am to 2:00 pm it was observed the corridor is being as a return air plenum to supply HVAC air to all psychiatric patient sleeping rooms and then exhausted to the corridor.

NFPA 90A: 4.3.12.1.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.2.1 through 4.3.12.1.2.4.

NFPA 90A: 4.3.12.1.2 An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

NFPA 90A: 4.3.12.1.2.1 An air transfer opening(s) shall be permitted in walls or doors from toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridor.

NFPA 90A: 4.3.12.1.2.2 Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Other Opening Protectives, air transfer caused by pressure differentials shall be permitted.

NFPA 90A: 4.3.12.1.2.3 Use of egress corridors shall be permitted as part of an engineered smoke-control system.

NFPA 90A: 4.3.12.1.2.4 Air transfer opening(s) shall be permitted in walls or in doors separating egress corridors from adjoining areas in detention and correctional occupancies with corridor separations of open construction (e.g., grating doors or grating partitions).

Interview with Plant and Operations Directorrevealed the facility was not aware the HVAC system was using the corridors as a return air plenum.

HVAC

Tag No.: K0521

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect 13 of 20 residents.
1 of 1 corridors are deficient in being used as a return air plenum.

Findings:

During the facility tour on 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30 am to 2:00 pm it was observed the corridor is being as a return air plenum to supply HVAC air to all psychiatric patient sleeping rooms and then exhausted to the corridor.

NFPA 90A: 4.3.12.1.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.2.1 through 4.3.12.1.2.4.

NFPA 90A: 4.3.12.1.2 An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

NFPA 90A: 4.3.12.1.2.1 An air transfer opening(s) shall be permitted in walls or doors from toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridor.

NFPA 90A: 4.3.12.1.2.2 Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Other Opening Protectives, air transfer caused by pressure differentials shall be permitted.

NFPA 90A: 4.3.12.1.2.3 Use of egress corridors shall be permitted as part of an engineered smoke-control system.

NFPA 90A: 4.3.12.1.2.4 Air transfer opening(s) shall be permitted in walls or in doors separating egress corridors from adjoining areas in detention and correctional occupancies with corridor separations of open construction (e.g., grating doors or grating partitions).

Interview with Plant and Operations Director revealed the facility was not aware the HVAC system was using the corridors as a return air plenum.

HVAC

Tag No.: K0521

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect 14 of 20 residents.
3 of 3 corridors are deficient in being used as a return air plenum.

Findings:

During the facility tour on 8/1/2018 between the hours of 11:45 am to 5:30 pm and on 8/2/2018 between the hours of 8:30 am to 2:00 pm it was observed the corridor is being as a return air plenum to supply HVAC air to all psychiatric patient sleeping rooms and then exhausted to the corridor.

NFPA 90A: 4.3.12.1.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.2.1 through 4.3.12.1.2.4.

NFPA 90A: 4.3.12.1.2 An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

NFPA 90A: 4.3.12.1.2.1 An air transfer opening(s) shall be permitted in walls or doors from toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridor.

NFPA 90A: 4.3.12.1.2.2 Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Other Opening Protectives, air transfer caused by pressure differentials shall be permitted.

NFPA 90A: 4.3.12.1.2.3 Use of egress corridors shall be permitted as part of an engineered smoke-control system.

NFPA 90A: 4.3.12.1.2.4 Air transfer opening(s) shall be permitted in walls or in doors separating egress corridors from adjoining areas in detention and correctional occupancies with corridor separations of open construction (e.g., grating doors or grating partitions).

Interview with Plant and Operations Directorrevealed the facility was not aware the HVAC system was using the corridors as a return air plenum.

HVAC

Tag No.: K0521

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect 18 of 20 residents.
1 of 1 corridors are deficient in being used as a return air plenum.

Findings:

During the facility tour on 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30 am to 2:00 pm it was observed the corridor is being as a return air plenum to supply HVAC air to all psychiatric patient sleeping rooms and then exhausted to the corridor.

NFPA 90A: 4.3.12.1.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.2.1 through 4.3.12.1.2.4.

NFPA 90A: 4.3.12.1.2 An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

NFPA 90A: 4.3.12.1.2.1 An air transfer opening(s) shall be permitted in walls or doors from toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridor.

NFPA 90A: 4.3.12.1.2.2 Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Other Opening Protectives, air transfer caused by pressure differentials shall be permitted.

NFPA 90A: 4.3.12.1.2.3 Use of egress corridors shall be permitted as part of an engineered smoke-control system.

NFPA 90A: 4.3.12.1.2.4 Air transfer opening(s) shall be permitted in walls or in doors separating egress corridors from adjoining areas in detention and correctional occupancies with corridor separations of open construction (e.g., grating doors or grating partitions).

Interview with Plant and Operations Director revealed the facility was not aware the HVAC system was using the corridors as a return air plenum.

HVAC

Tag No.: K0521

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect 19 of 20 residents.
2 of 2 corridors are deficient in being used as a return air plenum.

Findings:

During the facility tour on 7/31/2018 between the hours of 9:00 am to 2:00 pm and on 8/3/2018 between the hours of 8:30 am to 2:00 pm it was observed the corridor is being as a return air plenum to supply HVAC air to all psychiatric patient sleeping rooms and then exhausted to the corridor.

NFPA 90A: 4.3.12.1.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.2.1 through 4.3.12.1.2.4.

NFPA 90A: 4.3.12.1.2 An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

NFPA 90A: 4.3.12.1.2.1 An air transfer opening(s) shall be permitted in walls or doors from toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridor.

NFPA 90A: 4.3.12.1.2.2 Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Other Opening Protectives, air transfer caused by pressure differentials shall be permitted.

NFPA 90A: 4.3.12.1.2.3 Use of egress corridors shall be permitted as part of an engineered smoke-control system.

NFPA 90A: 4.3.12.1.2.4 Air transfer opening(s) shall be permitted in walls or in doors separating egress corridors from adjoining areas in detention and correctional occupancies with corridor separations of open construction (e.g., grating doors or grating partitions).

Interview with Plant and Operations Director revealed the facility was not aware the HVAC system was using the corridors as a return air plenum.

HVAC

Tag No.: K0521

Based on visual observation the facility failed to assure that the heating, ventilation and air conditioning system was installed in accordance with NFPA 90A. The system could re-circulate smoke originating from one part of the building into other parts of the building otherwise unaffected. The deficient practice had the potential to affect 4 of 20 residents.
3 of 3 corridors are deficient in being used as a return air plenum.

Findings:

During the facility tour on 8/1/2018 between the hours of 11:45 am to 5:30 pm and on 8/2/2018 between the hours of 8:30 am to 2:00 pm it was observed the corridor is being as a return air plenum to supply HVAC air to all psychiatric patient sleeping rooms and then exhausted to the corridor.

NFPA 90A: 4.3.12.1.1 Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.2.1 through 4.3.12.1.2.4.

NFPA 90A: 4.3.12.1.2 An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

NFPA 90A: 4.3.12.1.2.1 An air transfer opening(s) shall be permitted in walls or doors from toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridor.

NFPA 90A: 4.3.12.1.2.2 Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Other Opening Protectives, air transfer caused by pressure differentials shall be permitted.

NFPA 90A: 4.3.12.1.2.3 Use of egress corridors shall be permitted as part of an engineered smoke-control system.

NFPA 90A: 4.3.12.1.2.4 Air transfer opening(s) shall be permitted in walls or in doors separating egress corridors from adjoining areas in detention and correctional occupancies with corridor separations of open construction (e.g., grating doors or grating partitions).

Interview with Plant and Operations Director revealed the facility was not aware the HVAC system was using the corridors as a return air plenum.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 0 of 20 residents.

Findings:

During the facility tour on 8/1/2018 between the hours of 11:45 am to 5:30 pm and on 8/2/2018 between the hours of 8:30 am to 2:00 pm it was observed that the generator weekly inspection logs had not been conducted from the previous year.

NFPA 110:8.3.7* states, "Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications".

NFPA 110:8.4.1* states, "EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly".

Interview with the Maintenance Director revealed the facility was not aware the weekly generator logs were not being conducted.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 13 of 20 residents.

Findings:

During the facility tour and record review on 7/31/2018 between the hours of 9:00am am to 2:00pm and on 8/3/2018 between the hours of 8:30 am to 2:00 pm. following items were observed:

(1) The generator was not provided with a remote manual stop and remote manual signage located outside the weatherproof enclosure.

NFPA 110:5.6.5.6 states, "All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

NFPA 110:5.6.5.6.1 states, "The remote manual stop station shall be labeled."

(2) The weekly emergency generator inspection logs were lacking from the previous year.

NFPA 110:8.3.7* states, "Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications".

NFPA 110:8.4.1* states, "EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly".

Interview with Plant and Operations Director revealed the facility was not aware that a remote manual stop for emergency generators and the weekly generator logs were required.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 13 of 20 residents.

Findings:

During the facility tour and record review on 7/31/2018 between the hours of 9:00am am to 2:00pm and on 8/3/2018 between the hours of 8:30 am to 2:00 pm. the following items were observed as deficient:

(1) The generator was not provided with a remote manual stop and remote manual signage located outside the weatherproof enclosure.

NFPA 110:5.6.5.6 states, "All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building".

NFPA 110:5.6.5.6.1 states, "The remote manual stop station shall be labeled".

(2) The weekly generator inspection logs lacking from the previous year of service.

NFPA 110:8.3.7* states, "Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications".

NFPA 110:8.4.1* states, "EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly".

Interview with Plant and Operations Director revealed the facility was not aware that a remote manual stop for emergency generators was required.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 13 of 20 residents.

Findings:

During the facility tour on 8/1/2018 between the hours of 11:45 am to 5:30 pm and on 8/2/2018 between the hours of 8:30 am to 2:00 pm it was observed that the generator weekly inspection logs had not been conducted from the previous year.

NFPA 110:8.3.7* states, "Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications".

NFPA 110:8.4.1* states, "EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly".

Interview with Plant and Operations Director revealed the facility was not aware the weekly generator logs were not being conducted.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 18 of 20 residents.

Findings:

During the facility tour and record review on 7/31/2018 between the hours of 9:00am am to 2:00pm and on 8/3/2018 between the hours of 8:30 am to 2:00 pm.the following items were observed as deficient:

(1) The generator was not provided with a remote manual stop and remote manual signage located outside the weatherproof enclosure.

NFPA 110:5.6.5.6 states, "All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building".

NFPA 110:5.6.5.6.1 states, "The remote manual stop station shall be labeled".

(2) The weekly generator inspection logs lacking from the previous year of service.

NFPA 110:8.3.7* states, "Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications".

NFPA 110:8.4.1* states, "EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly".

Interview with Plant and Operations Directorrevealed the facility was not aware that a remote manual stop for emergency generators was required.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 19 of 20 residents.

Findings:

During the facility tour and record review on 7/31/2018 between the hours of 9:00am am to 2:00pm and on 8/3/2018 between the hours of 8:30 am to 2:00 pm. following items were observed:

(1) The generator was not provided with a remote manual stop and remote manual signage located outside the weatherproof enclosure.

NFPA 110:5.6.5.6 states, "All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

NFPA 110:5.6.5.6.1 states, "The remote manual stop station shall be labeled."

(2) The weekly emergency generator inspection logs were lacking from the previous year.

NFPA 110:8.3.7* states, "Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications".

NFPA 110:8.4.1* states, "EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly".

Interview with Plant and Operations Director revealed the facility was not aware that a remote manual stop for emergency generators and the weekly generator logs were required