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Based on record review, observation and interview, the facility failed to ensure the interior finish for room walls in smoke compartments of 2 of 5 stories had a flame spread rating (FSR) of Class A or B. This deficient practice affects visitors, staff and 12 or more patients on the fourth and ground floors.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 1:20 p.m., three coffered ceiling areas measuring 12 by 12 by 3 feet in the ground floor cafeteria were covered with a wood grain material. The flame spread rating records reviewed on 12/07/11 at 11:40 a.m. with the Plant Operations Director, did not include this ceiling finish. The Plant Operations Director said he had no flame spread rating for the finish.

Based on observation with the Plant Operations Director on 12/06/11 at 2:40 p.m., the fourth floor office off the lobby had one wall covered in brown paneling. The flame spread rating records reviewed on 12/07/11 at 11:40 a.m. with the Plant Operations Director, did not include this wall finish. The Plant Operations Director said he had no flame spread rating for the finish.

Based on observation and interview, the facility failed to ensure there were no impediments to closing doors protecting corridor openings on 2 of 4 floors. This deficient practice affects staff, visitors and 5 patients observed in the affected third floor smoke compartment.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 between 11:30 a.m. and 4:30 p.m. doors protecting corridor openings to the Chaplains office, and offices located in rooms 426, 427 and 428 were prevented from closing by wedges. The door to room 318 in Respiratory Therapy was prevented from closing by a chair. The Plant Operations Director said at the time of observation, the practice was against facility policy and he removed the wedges.

1. Based on observation and interview, the facility failed to ensure doors to hazardous areas on 1 of 5 floors, such as storage rooms and kitchens larger than 50 square feet were only held open by a device which would allow them to close upon activation of the fire alarm system. Sprinklered hazardous areas are required to be equipped with self closing doors or with doors that close automatically upon activation of the fire alarm system. This deficient practice affects visitors, staff, and any patients visiting the cafeteria and vending areas on the ground floor.

Findings include:

a. Based on observation with the Plant Operations Director on 12/06/11 at 1:15 p.m., on 12/07/11 at 10:50 a.m. and 12/07/11 at 1:20 p.m. the self closing door to the 20 by 40 foot Materials Management supply storage room on the ground floor was held open by a rubber wedge. The Plant Operations Director informed staff at the time of observation on 12/06/11 the practice was not permitted and removed the wedge. He said it was an ongoing problem when the door was observed wedged open again on 12/07/11.
b. Based on observation with the Plant Operations Director on 12/06/11 at 1:15 p.m. and 12/07/11 at 12:10 p.m., the kitchen dish room doorway opened into a vending area where the corridor door stood wide open. The door to the dish room, provided with a self closer was prevented from self closing by a bubble gum machine placed in front of the door. The Plant Operations Director said at the time of observations the door was held open in this manner every day.


2. Based on observation the facility failed to ensure doors in smoke barriers on 2 of 5 floors were arranged to self close. This deficient practice could affect visitors, staff, and 14 or more patients.

Findings include:

a. Based on observation during a tour of the fourth floor on 12/06/11 at 3:35 p.m. with the Plant Operations Director, the door to the Nursing Department Scheduling office was located in a smoke barrier wall. The self closing door was held open by a wooden wedge. The Plant Operations Director said at the time of observation, wedges were not permitted.
b. Based on observation during a tour of the first floor on 12/07/11 at 10:50 a.m. with the Plant Operations Director, the door to the Hazardous Materials Office was located in a smoke barrier wall. The self closing door was held open by a rubber wedge. The Plant Operations Director said at the time of observation, wedges were not permitted.
c. Based on observation during a tour of the first floor on 12/07/11 at 11:25 a.m. with the Plant Operations Director, the door between the radiology reception area and file room was located in a smoke barrier wall. The self closing door was held open by a cart. The Plant Operations Director said at the time of observation, the cart held the door open all the time.

1. Based on observation and interview, the facility failed to maintain smoke barrier walls to provide a fire rating of one half hour. LSC 8.3.2 requires smoke barriers shall be continuous from a floor to a floor or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. This deficient practice affects visitors, staff and 5 or more patients on the third floor.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 3:15 p.m., a twenty by four foot section of drywall was missing above the laid in ceiling in the smoke barrier wall separating the administration wing from the patient waiting area and elevator lobby on the third floor. The Plant Operations Director said at the time of observation he was unaware the wall was incomplete.

2. Based on observation and interview, the facility failed to ensure openings through smoke barriers on 2 of 5 floors were protected with approved materials to maintain the smoke resistance of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient could affect visitors, staff and 12 or more patients on the third and fourth floors.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 between 11:30 a.m. and 4:30 p.m. and on 12/07/11 between 9:30 a.m. and 3:30 p.m.:
a. Conduit penetrating the west smoke barrier on the fourth floor
above the smoke barrier doors was unsealed leaving a one inch gap;
b. Two penetrations of the north smoke barrier between the third floor ICU and the lobby were unsealed leaving one inch gaps;
c. Ceiling smoke barriers were not in place above built in refrigeration units on the third and fourth floors in the center
core units where eighteen, eighteen inch by six inch louvers at the top of the refrigeration units would allow the passage of smoke into the space above the ceilings.
The Plant Operations Director agreed at the time of observations, penetrations should have been sealed.

Based on observation and interview, the facility failed to provide an automatic closer for the door providing access to 1 of 8 hazardous areas such as a combustible materials storage room larger than 50 square feet. Sprinklered hazardous areas are required to be equipped with self closing doors or with doors that close automatically upon activation of the fire alarm system. This deficient practice could affect visitors, staff and 5 or more patients observed on the third floor.

Findings include:

a. Based on observation with the Plant Operations Director on 12/06/11 at 4:11 p.m., the door to the 154 square foot storage room 318 on the third floor was not equipped with a self closer. The Plant Operations Director said at the time of observation, someone had removed the device.
b. Based on observation with the Plant Operations Director on 12/06/11 at 3:05 p.m., the door to the 63 square foot storage room near stairway #3 on the third floor was not equipped with a self closer. The Plant Operations Director said at the time of observation, he had not known the closer was needed.

Based on record review and interview, the facility failed to provide a complete written plan for the evacuation of 14 of 14 patients in the event of an emergency. This deficient practice could affect all occupants in the event of an emergency when the required information should be immediately available.

Findings include:

Based on a record review with the Plant Operations Director on 12/06/11 at 1:30 p.m., the policy and procedure for the evacuation of occupants in the event of an emergency was part of Hospital Regulation 40-2. Pages 10 and 11 of the regulation included an Emergency Call List which was updated June 2011 listed staff and physicians to be contacted in the event of an emergency requiring evacuation. Based on interview with the Plant Operations Director, listed as the Safety Officer at the time of record review, the list was not current and two of eleven doctors, three of 28 nursing staff and 9 of 11 hospital administrative staff were no longer on staff and many had been gone as long as two years. In addition pager and other contact numbers were incorrect. He said his efforts to have the lists made current had not been successful.

Based on record review and interview, the facility failed to provide a complete written plan for the evacuation of 14 of 14 patients in the event of an emergency. This deficient practice could affect all occupants in the event of an emergency when the required information should be immediately available.

Findings include:

Based on a record review with the Plant Operations Director on 12/06/11 at 1:30 p.m., the policy and procedure for the evacuation of occupants in the event of an emergency was part of Hospital Regulation 40-2. Pages 10 and 11 of the regulation included an Emergency Call List which was updated June 2011 listed staff and physicians to be contacted in the event of an emergency requiring evacuation. Based on interview with the Plant Operations Director, listed as the Safety Officer at the time of record review, the list was not current and two of eleven doctors, three of twenty eight nursing staff and nine of eleven hospital administrative staff were no longer on staff and many had been gone as long as two years. In addition pager and other contact numbers were incorrect. He said his efforts to have the lists made current had not been successful.

1. Based on observation and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. NFPA 72, 1-5.2.5.2 requires the fire alarm circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Plant Operations Director on 12/07/11 at 2:15 p.m., the fire alarm system circuit breaker located in the emergency power breaker box lacked the required identification. An "FA" in black marker was written alongside one circuit in the panel. The Plant Operations Director said at the time of observation, he was not aware of the requirement for identifying the circuit. In addition, the breaker panel was located on a wall in the emergency department access corridor. The panel was unsecured to prevent tampering.

2. Based on observation and interview, the facility failed to ensure 2 of 3 fire alarm panels in areas not continuously occupied, were provided with automatic smoke detection to ensure notification of a fire at the location before it could be incapacitated by fire. LSC 9.6.2.10. requires smoke alarms shall be in accordance with NFPA 72, National Fire Alarm Code. NFPA 72, 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 continuously occupied to provide notification of a fire in that location. This deficient practice affects all occupants.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 4:40 p.m. and 12/07/11 at 11:45 a.m., an adjunct fire alarm control panel (FACP) was located in the surgical entry foyer which was not continuously occupied. The main FACP was located in the Plant Operations Director's office which the Director of Plant Operations confirmed at the time of observation, was not continuously occupied. The areas were not electrically supervised by a smoke detector.

3. Based on observation and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. NFPA 72, 7-1.1.1 requires fire alarm systems shall be inspected, tested and maintained. NFPA 72, 7-5.2.2 requires a permanent record of all inspections, testing and maintenance shall be provided. This deficient practice affects staff, visitors and 5 or more patients on the second floor.

Findings include:

Based on the Serviceman's Recommendation and Summary Report following the annual Fire Alarm Test and Inspection with the Plant Operations Director on 12/06/11 at 12:50 p.m., The report noted "there are six heat detectors in the boiler room that are damaged and need replaced". The Plant Operations Director said at the time of record review the heat detectors "still worked" and had not been replaced.

1. Based on observation and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. NFPA 72, 1-5.2.5.2 requires the fire alarm circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Plant Operations Director on 12/07/11 at 2:15 p.m., the fire alarm system circuit breaker located in the emergency power breaker box lacked the required identification. An "FA" in black marker was written alongside one circuit in the panel. The Plant Operations Director said at the time of observation, he was not aware of the requirement for identifying the circuit. In addition, the breaker panel was located on a wall in the emergency department access corridor. The panel was unsecured to prevent tampering.

2. Based on observation and interview, the facility failed to ensure 2 of 3 fire alarm panels in areas not continuously occupied, were provided with automatic smoke detection to ensure notification of a fire at the location before it could be incapacitated by fire. LSC 9.6.2.10. requires smoke alarms shall be in accordance with NFPA 72, National Fire Alarm Code. NFPA 72, 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 continuously occupied to provide notification of a fire in that location. This deficient practice affects all occupants.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 4:40 p.m. and 12/07/11 at 11:45 a.m., an adjunct fire alarm control panel (FACP) was located in the surgical entry foyer which was not continuously occupied. The main FACP was located in the Plant Operations Director's office which the Plant Operations Director confirmed at the time of observation, was not continuously occupied. The areas were not electrically supervised by a smoke detector.

3. Based on observation and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. NFPA 72, 7-1.1.1 requires fire alarm systems shall be inspected, tested and maintained. NFPA 72, 7-5.2.2 requires a permanent record of all inspections, testing and maintenance shall be provided. This deficient practice affects staff, visitors and 5 or more patients on the second floor.

Findings include:

Based on the Serviceman's Recommendation and Summary Report following the annual Fire Alarm Test and Inspection with the Plant Operations Director on 12/06/11 at 12:50 p.m., the report noted "there are six heat detectors in the boiler room that are damaged and need replaced". The Plant Operations Director said at the time of record review the heat detectors "still worked" and had not been replaced.

Based on observation and interview, the facility failed to ensure smoke detectors connected to the fire alarm system in 3 of 12 smoke detectors in the surgery department, were properly separated from an air supply. LSC 9.6 refers to NFPA 72. NFPA 72, 2-3.5.1 requires spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect visitors, staff, and 4 or more patients in surgery.

Findings include:

Based on observation with the Plant Operations Director on 12/07/11 between 11:45 p.m. and 12:15 p.m., three smoke detectors were located 12 inches from air supply vents in the sterile side of the surgery suite. The Plant Operations Director confirmed the distance measurements and agreed at the time of observations, the air flow could impede the function of the smoke detectors.

Based on record review and interview, the facility failed to ensure 100% of the smoke detectors were maintained in accordance with NFPA 72. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 7-1.1.1 requires fire alarm systems shall be inspected, tested and maintained. NFPA 72, 7-5.2.2 requires a permanent record of all inspections, testing and maintenance shall be provided. This deficient practice affects staff, visitors and 5 or more patients on the second floor.

Findings include:

Based on the Serviceman's Recommendation and Summary Report following the annual Fire Alarm Test and Inspection with the Plant Operations Director on 12/06/11 at 12:50 p.m., The report noted the failure of the duct detector "attached to the 2nd floor mech room north AHU by the roof access" to shut down the unit upon alarm. The Plant Operations Director confirmed at the time of record review the duct detector malfunction had not yet been repaired.

1. Based on record review and interview, the facility failed to perform weekly sprinkler system fire pump tests. NFPA 25, 5-3.2.1 requires a weekly test of electric motor driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes. This deficient practice could affect all staff, visitors and patients.

Findings include:

Based on review of sprinkler system Reports of inspection by the sprinkler contractor on 12/06/11 at 12:45 p.m. with the Plant Operations Director, a fire pump test was done on 09/30/11. However, there was no record of a weekly fire pump test performed in facility preventive maintenance logs. The Plant Operations Director confirmed at the time of record review, no weekly testing was done.

3.1-19(b)



2. Based on observation and interview, the facility failed to ensure 1 of 2 Whisper Hearing Room sprinkler heads was free of obstructions to spray patterns. NFPA 25, 2-2.1.2 requires unacceptable obstructions to spray patterns shall be corrected. Further NFPA 13, Installation of Sprinkler Systems, in 4-5.6 requires the the clearance between sprinkler deflectors and the top of storage should be 18 inches or more. This deficient practice would affect staff and 1 patient in the testing room.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 4:05 p.m., the Whisper Hearing Room had a seven by eight by eight foot booth six inches below a sprinkler head protecting the room. There was no way sprinkler spray could affect a fire started at the side of the testing booth which was used for storing empty cardboard cartons. The Plant Operations Director agreed the booth was less than the minimum distance allowed between a sprinkler head and obstruction.

3.1-19(b)

Based on record review and interview, the facility failed to perform weekly sprinkler system fire pump tests. NFPA 25, 5-3.2.1 requires a weekly test of electric motor driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes. This deficient practice could affect all staff, visitors and patients.

Findings include:

Based on review of sprinkler system Reports of inspection by the sprinkler contractor on 12/06/11 at 12:45 p.m. with the Plant Operations Director, a fire pump test was done on 09/30/11, however, there was no record of a weekly fire pump test performed in facility preventive maintenance logs. The Plant Operations Director confirmed at the time of record review, no weekly testing was done.

Based on observation and interview, the facility failed to ensure 45 of 45 hanging curtains were rendered flame resistant on the third and fourth floors. LSC 19.7.5.1 requires draperies, curtains, including cubicle curtains, and other loosely hanging fabrics to be in accordance with 10.3.1. LSC 10.3.1 requires draperies, curtains, and other similar loosely hanging furnishings and decorations to have flame resistance as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. This deficient practice affects all occupants. This deficient practice could affect all patients on the third and fourth floors.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 between 3:00 p.m. and 4:05 p.m., window curtains in patient rooms on the third and fourth floors lacked evidence indicating flame resistance as demonstrated by testing in accordance with NFPA 701. The Plant Operations Director said at the time of observations, there was no documentation or other evidence to provide fire resistance information for the material.

1. Based on record review and interview, the facility failed to ensure 1 of 1 generators serving as the alternate source of power was maintained and capable of operating at full capacity. NFPA 101, 4.6.12 requires equipment required for compliance with the provisions of the Code shall be continuously maintained. This deficient practice affects all occupants.

Findings include:

Based on review of the Load Bank Test Report with the Plant Operations Director on 12/06/11 at 12:15 p.m., the generator was load bank tested by the generator contractor on 07/07/11. Their record noted the test was aborted at 55 percent load because the "unit overheats at above 55% load". The contractor reported the louvers were stuck which would allow cooling. He removed the rods for the louvers and forced them open but the overheating problem persisted. He noted it was possible the fuel was getting hot due to a smaller day tank and no cooler. The Plant Operations Director said at the time of record review the problem had not yet been corrected.

2. Based on record review and interview, the facility failed to ensure monthly generator load test records for 1 of 1 emergency generators included complete information for testing using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on review of the facility Emergency Generator Logs with the Plant Operations Director on 12/07/11 at 12:00 p.m., the record failed to include the percent load carried during each test, the readings for each of the three phases during the test or information regarding the minimum loading and exhaust temperatures during the tests. The Plant Operations Director said at the time of record review this information was not recorded and he did not know the percent load on the generator during testing.

3. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a 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 with the Plant Operations Director on 12/07/11 at 3:20 p.m. no emergency shut off was evident for the emergency generator. The Plant Operations Director said at the time of observation the emergency generator was larger than 100 horsepower and there was no emergency stop of any kind.

1. Based on record review and interview, the facility failed to ensure 1 of 1 generators serving as the alternate source of power was maintained and capable of operating at full capacity. NFPA 101, 4.6.12 requires equipment required for compliance with the provisions of the Code shall be continuously maintained. This deficient practice affects all occupants.

Findings include:

Based on review of the Load Bank Test Report with the Plant Operations Director on 12/06/11 at 12:15 p.m., the generator was load bank tested by the generator contractor on 07/07/11. There record noted the test was aborted at 55 percent load because the "unit overheats at above 55% load". The contractor reported the louvers were stuck which would allow cooling. He removed the rods for the louvers and forced them open but the overheating problem persisted. He noted it was possible the fuel was getting hot due to a smaller day tank and no cooler. The Plant Operations Director said at the time of record review the problem had not yet been corrected.

2. Based on record review and interview, the facility failed to ensure monthly generator load test records for 1 of 1 emergency generators included complete information for testing using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on review of the facility Emergency Generator Logs with the Plant Operations Director on 12/07/11 at 12:00 p.m., the record failed to include the percent load carried during each test, the readings for each of the three phases during the test or information regarding the minimum loading and exhaust temperatures during the tests. The Plant Operations Director said at the time of record review this information was not recorded and he did not know the percent load on the generator during testing.

3. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a 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 with the Plant Operations Director on 12/07/11 at 3:20 p.m. no emergency shut off was evident for the emergency generator. The Plant Operations Director said at the time of observation the emergency generator was larger than 100 horsepower and there was no emergency stop of any kind.

1. Based on observation and interview, the facility failed to ensure electrical junction boxes above the laid in ceiling were maintained in a safe operating condition on 1 of 4 floors. LSC 19.5.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, 1999 Edition, Article 370-28(c) requires all junction boxes shall be provided with covers compatible with the box. This deficient practice could visitors, staff and 12 patients on the fourth floor.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 2:50 p.m., a junction box in the space above the laid in ceiling near stairway #2 on the fourth floor had no cover. The Plant Operations Director agreed at the time of observation, the cover should have been on the box.

2. Based on observation and interview, the facility failed to ensure 1 of 1 flexible cords were not used as a substitute for fixed wiring. NFPA 70 (National Electrical Code), 1999 Edition, 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 residents, staff, and visitors in the central smoke compartment where the nurses station and dining room with 10 residents were located.

Findings include:

Based on observation with the Plant Operations Director on 12/07/11 at 11:30 a.m., a power strip extension cord was used to supply power to a microwave, two refrigerators, a coffee pot and toaster. In the radiology break room. The Plant Operations Director said at the time of observation, the power strips were not approved for this use.

Based on record review, observation and interview, the facility failed to ensure the interior finish for room walls in smoke compartments of 2 of 5 stories had a flame spread rating (FSR) of Class A or B. This deficient practice affects visitors, staff and 12 or more patients on the fourth and ground floors.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 1:20 p.m., three coffered ceiling areas measuring 12 by 12 by 3 feet in the ground floor cafeteria were covered with a wood grain material. The flame spread rating records reviewed on 12/07/11 at 11:40 a.m. with the Plant Operations Director, did not include this ceiling finish. The Plant Operations Director said he had no flame spread rating for the finish.

Based on observation with the Plant Operations Director on 12/06/11 at 2:40 p.m., the fourth floor office off the lobby had one wall covered in brown paneling. The flame spread rating records reviewed on 12/07/11 at 11:40 a.m. with the Plant Operations Director, did not include this wall finish. The Plant Operations Director said he had no flame spread rating for the finish.

Based on observation and interview, the facility failed to ensure there were no impediments to closing doors protecting corridor openings on 2 of 4 floors. This deficient practice affects staff, visitors and 5 patients observed in the affected third floor smoke compartment.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 between 11:30 a.m. and 4:30 p.m. doors protecting corridor openings to the Chaplains office, and offices located in rooms 426, 427 and 428 were prevented from closing by wedges. The door to room 318 in Respiratory Therapy was prevented from closing by a chair. The Plant Operations Director said at the time of observation, the practice was against facility policy and he removed the wedges.

1. Based on observation and interview, the facility failed to ensure doors to hazardous areas on 1 of 5 floors, such as storage rooms and kitchens larger than 50 square feet were only held open by a device which would allow them to close upon activation of the fire alarm system. Sprinklered hazardous areas are required to be equipped with self closing doors or with doors that close automatically upon activation of the fire alarm system. This deficient practice affects visitors, staff, and any patients visiting the cafeteria and vending areas on the ground floor.

Findings include:

a. Based on observation with the Plant Operations Director on 12/06/11 at 1:15 p.m., on 12/07/11 at 10:50 a.m. and 12/07/11 at 1:20 p.m. the self closing door to the 20 by 40 foot Materials Management supply storage room on the ground floor was held open by a rubber wedge. The Plant Operations Director informed staff at the time of observation on 12/06/11 the practice was not permitted and removed the wedge. He said it was an ongoing problem when the door was observed wedged open again on 12/07/11.
b. Based on observation with the Plant Operations Director on 12/06/11 at 1:15 p.m. and 12/07/11 at 12:10 p.m., the kitchen dish room doorway opened into a vending area where the corridor door stood wide open. The door to the dish room, provided with a self closer was prevented from self closing by a bubble gum machine placed in front of the door. The Plant Operations Director said at the time of observations the door was held open in this manner every day.


2. Based on observation the facility failed to ensure doors in smoke barriers on 2 of 5 floors were arranged to self close. This deficient practice could affect visitors, staff, and 14 or more patients.

Findings include:

a. Based on observation during a tour of the fourth floor on 12/06/11 at 3:35 p.m. with the Plant Operations Director, the door to the Nursing Department Scheduling office was located in a smoke barrier wall. The self closing door was held open by a wooden wedge. The Plant Operations Director said at the time of observation, wedges were not permitted.
b. Based on observation during a tour of the first floor on 12/07/11 at 10:50 a.m. with the Plant Operations Director, the door to the Hazardous Materials Office was located in a smoke barrier wall. The self closing door was held open by a rubber wedge. The Plant Operations Director said at the time of observation, wedges were not permitted.
c. Based on observation during a tour of the first floor on 12/07/11 at 11:25 a.m. with the Plant Operations Director, the door between the radiology reception area and file room was located in a smoke barrier wall. The self closing door was held open by a cart. The Plant Operations Director said at the time of observation, the cart held the door open all the time.

1. Based on observation and interview, the facility failed to maintain smoke barrier walls to provide a fire rating of one half hour. LSC 8.3.2 requires smoke barriers shall be continuous from a floor to a floor or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. This deficient practice affects visitors, staff and 5 or more patients on the third floor.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 3:15 p.m., a twenty by four foot section of drywall was missing above the laid in ceiling in the smoke barrier wall separating the administration wing from the patient waiting area and elevator lobby on the third floor. The Plant Operations Director said at the time of observation he was unaware the wall was incomplete.

2. Based on observation and interview, the facility failed to ensure openings through smoke barriers on 2 of 5 floors were protected with approved materials to maintain the smoke resistance of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient could affect visitors, staff and 12 or more patients on the third and fourth floors.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 between 11:30 a.m. and 4:30 p.m. and on 12/07/11 between 9:30 a.m. and 3:30 p.m.:
a. Conduit penetrating the west smoke barrier on the fourth floor
above the smoke barrier doors was unsealed leaving a one inch gap;
b. Two penetrations of the north smoke barrier between the third floor ICU and the lobby were unsealed leaving one inch gaps;
c. Ceiling smoke barriers were not in place above built in refrigeration units on the third and fourth floors in the center
core units where eighteen, eighteen inch by six inch louvers at the top of the refrigeration units would allow the passage of smoke into the space above the ceilings.
The Plant Operations Director agreed at the time of observations, penetrations should have been sealed.

Based on observation and interview, the facility failed to provide an automatic closer for the door providing access to 1 of 8 hazardous areas such as a combustible materials storage room larger than 50 square feet. Sprinklered hazardous areas are required to be equipped with self closing doors or with doors that close automatically upon activation of the fire alarm system. This deficient practice could affect visitors, staff and 5 or more patients observed on the third floor.

Findings include:

a. Based on observation with the Plant Operations Director on 12/06/11 at 4:11 p.m., the door to the 154 square foot storage room 318 on the third floor was not equipped with a self closer. The Plant Operations Director said at the time of observation, someone had removed the device.
b. Based on observation with the Plant Operations Director on 12/06/11 at 3:05 p.m., the door to the 63 square foot storage room near stairway #3 on the third floor was not equipped with a self closer. The Plant Operations Director said at the time of observation, he had not known the closer was needed.

Based on record review and interview, the facility failed to provide a complete written plan for the evacuation of 14 of 14 patients in the event of an emergency. This deficient practice could affect all occupants in the event of an emergency when the required information should be immediately available.

Findings include:

Based on a record review with the Plant Operations Director on 12/06/11 at 1:30 p.m., the policy and procedure for the evacuation of occupants in the event of an emergency was part of Hospital Regulation 40-2. Pages 10 and 11 of the regulation included an Emergency Call List which was updated June 2011 listed staff and physicians to be contacted in the event of an emergency requiring evacuation. Based on interview with the Plant Operations Director, listed as the Safety Officer at the time of record review, the list was not current and two of eleven doctors, three of 28 nursing staff and 9 of 11 hospital administrative staff were no longer on staff and many had been gone as long as two years. In addition pager and other contact numbers were incorrect. He said his efforts to have the lists made current had not been successful.

Based on record review and interview, the facility failed to provide a complete written plan for the evacuation of 14 of 14 patients in the event of an emergency. This deficient practice could affect all occupants in the event of an emergency when the required information should be immediately available.

Findings include:

Based on a record review with the Plant Operations Director on 12/06/11 at 1:30 p.m., the policy and procedure for the evacuation of occupants in the event of an emergency was part of Hospital Regulation 40-2. Pages 10 and 11 of the regulation included an Emergency Call List which was updated June 2011 listed staff and physicians to be contacted in the event of an emergency requiring evacuation. Based on interview with the Plant Operations Director, listed as the Safety Officer at the time of record review, the list was not current and two of eleven doctors, three of twenty eight nursing staff and nine of eleven hospital administrative staff were no longer on staff and many had been gone as long as two years. In addition pager and other contact numbers were incorrect. He said his efforts to have the lists made current had not been successful.

1. Based on observation and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. NFPA 72, 1-5.2.5.2 requires the fire alarm circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Plant Operations Director on 12/07/11 at 2:15 p.m., the fire alarm system circuit breaker located in the emergency power breaker box lacked the required identification. An "FA" in black marker was written alongside one circuit in the panel. The Plant Operations Director said at the time of observation, he was not aware of the requirement for identifying the circuit. In addition, the breaker panel was located on a wall in the emergency department access corridor. The panel was unsecured to prevent tampering.

2. Based on observation and interview, the facility failed to ensure 2 of 3 fire alarm panels in areas not continuously occupied, were provided with automatic smoke detection to ensure notification of a fire at the location before it could be incapacitated by fire. LSC 9.6.2.10. requires smoke alarms shall be in accordance with NFPA 72, National Fire Alarm Code. NFPA 72, 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 continuously occupied to provide notification of a fire in that location. This deficient practice affects all occupants.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 4:40 p.m. and 12/07/11 at 11:45 a.m., an adjunct fire alarm control panel (FACP) was located in the surgical entry foyer which was not continuously occupied. The main FACP was located in the Plant Operations Director's office which the Director of Plant Operations confirmed at the time of observation, was not continuously occupied. The areas were not electrically supervised by a smoke detector.

3. Based on observation and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. NFPA 72, 7-1.1.1 requires fire alarm systems shall be inspected, tested and maintained. NFPA 72, 7-5.2.2 requires a permanent record of all inspections, testing and maintenance shall be provided. This deficient practice affects staff, visitors and 5 or more patients on the second floor.

Findings include:

Based on the Serviceman's Recommendation and Summary Report following the annual Fire Alarm Test and Inspection with the Plant Operations Director on 12/06/11 at 12:50 p.m., The report noted "there are six heat detectors in the boiler room that are damaged and need replaced". The Plant Operations Director said at the time of record review the heat detectors "still worked" and had not been replaced.

1. Based on observation and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. NFPA 72, 1-5.2.5.2 requires the fire alarm circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Plant Operations Director on 12/07/11 at 2:15 p.m., the fire alarm system circuit breaker located in the emergency power breaker box lacked the required identification. An "FA" in black marker was written alongside one circuit in the panel. The Plant Operations Director said at the time of observation, he was not aware of the requirement for identifying the circuit. In addition, the breaker panel was located on a wall in the emergency department access corridor. The panel was unsecured to prevent tampering.

2. Based on observation and interview, the facility failed to ensure 2 of 3 fire alarm panels in areas not continuously occupied, were provided with automatic smoke detection to ensure notification of a fire at the location before it could be incapacitated by fire. LSC 9.6.2.10. requires smoke alarms shall be in accordance with NFPA 72, National Fire Alarm Code. NFPA 72, 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 continuously occupied to provide notification of a fire in that location. This deficient practice affects all occupants.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 4:40 p.m. and 12/07/11 at 11:45 a.m., an adjunct fire alarm control panel (FACP) was located in the surgical entry foyer which was not continuously occupied. The main FACP was located in the Plant Operations Director's office which the Plant Operations Director confirmed at the time of observation, was not continuously occupied. The areas were not electrically supervised by a smoke detector.

3. Based on observation and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. NFPA 72, 7-1.1.1 requires fire alarm systems shall be inspected, tested and maintained. NFPA 72, 7-5.2.2 requires a permanent record of all inspections, testing and maintenance shall be provided. This deficient practice affects staff, visitors and 5 or more patients on the second floor.

Findings include:

Based on the Serviceman's Recommendation and Summary Report following the annual Fire Alarm Test and Inspection with the Plant Operations Director on 12/06/11 at 12:50 p.m., the report noted "there are six heat detectors in the boiler room that are damaged and need replaced". The Plant Operations Director said at the time of record review the heat detectors "still worked" and had not been replaced.

Based on observation and interview, the facility failed to ensure smoke detectors connected to the fire alarm system in 3 of 12 smoke detectors in the surgery department, were properly separated from an air supply. LSC 9.6 refers to NFPA 72. NFPA 72, 2-3.5.1 requires spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect visitors, staff, and 4 or more patients in surgery.

Findings include:

Based on observation with the Plant Operations Director on 12/07/11 between 11:45 p.m. and 12:15 p.m., three smoke detectors were located 12 inches from air supply vents in the sterile side of the surgery suite. The Plant Operations Director confirmed the distance measurements and agreed at the time of observations, the air flow could impede the function of the smoke detectors.

Based on record review and interview, the facility failed to ensure 100% of the smoke detectors were maintained in accordance with NFPA 72. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 7-1.1.1 requires fire alarm systems shall be inspected, tested and maintained. NFPA 72, 7-5.2.2 requires a permanent record of all inspections, testing and maintenance shall be provided. This deficient practice affects staff, visitors and 5 or more patients on the second floor.

Findings include:

Based on the Serviceman's Recommendation and Summary Report following the annual Fire Alarm Test and Inspection with the Plant Operations Director on 12/06/11 at 12:50 p.m., The report noted the failure of the duct detector "attached to the 2nd floor mech room north AHU by the roof access" to shut down the unit upon alarm. The Plant Operations Director confirmed at the time of record review the duct detector malfunction had not yet been repaired.

1. Based on record review and interview, the facility failed to perform weekly sprinkler system fire pump tests. NFPA 25, 5-3.2.1 requires a weekly test of electric motor driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes. This deficient practice could affect all staff, visitors and patients.

Findings include:

Based on review of sprinkler system Reports of inspection by the sprinkler contractor on 12/06/11 at 12:45 p.m. with the Plant Operations Director, a fire pump test was done on 09/30/11. However, there was no record of a weekly fire pump test performed in facility preventive maintenance logs. The Plant Operations Director confirmed at the time of record review, no weekly testing was done.

3.1-19(b)



2. Based on observation and interview, the facility failed to ensure 1 of 2 Whisper Hearing Room sprinkler heads was free of obstructions to spray patterns. NFPA 25, 2-2.1.2 requires unacceptable obstructions to spray patterns shall be corrected. Further NFPA 13, Installation of Sprinkler Systems, in 4-5.6 requires the the clearance between sprinkler deflectors and the top of storage should be 18 inches or more. This deficient practice would affect staff and 1 patient in the testing room.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 4:05 p.m., the Whisper Hearing Room had a seven by eight by eight foot booth six inches below a sprinkler head protecting the room. There was no way sprinkler spray could affect a fire started at the side of the testing booth which was used for storing empty cardboard cartons. The Plant Operations Director agreed the booth was less than the minimum distance allowed between a sprinkler head and obstruction.

3.1-19(b)

Based on record review and interview, the facility failed to perform weekly sprinkler system fire pump tests. NFPA 25, 5-3.2.1 requires a weekly test of electric motor driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes. This deficient practice could affect all staff, visitors and patients.

Findings include:

Based on review of sprinkler system Reports of inspection by the sprinkler contractor on 12/06/11 at 12:45 p.m. with the Plant Operations Director, a fire pump test was done on 09/30/11, however, there was no record of a weekly fire pump test performed in facility preventive maintenance logs. The Plant Operations Director confirmed at the time of record review, no weekly testing was done.

Based on observation and interview, the facility failed to ensure 45 of 45 hanging curtains were rendered flame resistant on the third and fourth floors. LSC 19.7.5.1 requires draperies, curtains, including cubicle curtains, and other loosely hanging fabrics to be in accordance with 10.3.1. LSC 10.3.1 requires draperies, curtains, and other similar loosely hanging furnishings and decorations to have flame resistance as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. This deficient practice affects all occupants. This deficient practice could affect all patients on the third and fourth floors.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 between 3:00 p.m. and 4:05 p.m., window curtains in patient rooms on the third and fourth floors lacked evidence indicating flame resistance as demonstrated by testing in accordance with NFPA 701. The Plant Operations Director said at the time of observations, there was no documentation or other evidence to provide fire resistance information for the material.

1. Based on record review and interview, the facility failed to ensure 1 of 1 generators serving as the alternate source of power was maintained and capable of operating at full capacity. NFPA 101, 4.6.12 requires equipment required for compliance with the provisions of the Code shall be continuously maintained. This deficient practice affects all occupants.

Findings include:

Based on review of the Load Bank Test Report with the Plant Operations Director on 12/06/11 at 12:15 p.m., the generator was load bank tested by the generator contractor on 07/07/11. Their record noted the test was aborted at 55 percent load because the "unit overheats at above 55% load". The contractor reported the louvers were stuck which would allow cooling. He removed the rods for the louvers and forced them open but the overheating problem persisted. He noted it was possible the fuel was getting hot due to a smaller day tank and no cooler. The Plant Operations Director said at the time of record review the problem had not yet been corrected.

2. Based on record review and interview, the facility failed to ensure monthly generator load test records for 1 of 1 emergency generators included complete information for testing using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on review of the facility Emergency Generator Logs with the Plant Operations Director on 12/07/11 at 12:00 p.m., the record failed to include the percent load carried during each test, the readings for each of the three phases during the test or information regarding the minimum loading and exhaust temperatures during the tests. The Plant Operations Director said at the time of record review this information was not recorded and he did not know the percent load on the generator during testing.

3. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a 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 with the Plant Operations Director on 12/07/11 at 3:20 p.m. no emergency shut off was evident for the emergency generator. The Plant Operations Director said at the time of observation the emergency generator was larger than 100 horsepower and there was no emergency stop of any kind.

1. Based on record review and interview, the facility failed to ensure 1 of 1 generators serving as the alternate source of power was maintained and capable of operating at full capacity. NFPA 101, 4.6.12 requires equipment required for compliance with the provisions of the Code shall be continuously maintained. This deficient practice affects all occupants.

Findings include:

Based on review of the Load Bank Test Report with the Plant Operations Director on 12/06/11 at 12:15 p.m., the generator was load bank tested by the generator contractor on 07/07/11. There record noted the test was aborted at 55 percent load because the "unit overheats at above 55% load". The contractor reported the louvers were stuck which would allow cooling. He removed the rods for the louvers and forced them open but the overheating problem persisted. He noted it was possible the fuel was getting hot due to a smaller day tank and no cooler. The Plant Operations Director said at the time of record review the problem had not yet been corrected.

2. Based on record review and interview, the facility failed to ensure monthly generator load test records for 1 of 1 emergency generators included complete information for testing using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on review of the facility Emergency Generator Logs with the Plant Operations Director on 12/07/11 at 12:00 p.m., the record failed to include the percent load carried during each test, the readings for each of the three phases during the test or information regarding the minimum loading and exhaust temperatures during the tests. The Plant Operations Director said at the time of record review this information was not recorded and he did not know the percent load on the generator during testing.

3. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a 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 with the Plant Operations Director on 12/07/11 at 3:20 p.m. no emergency shut off was evident for the emergency generator. The Plant Operations Director said at the time of observation the emergency generator was larger than 100 horsepower and there was no emergency stop of any kind.

1. Based on observation and interview, the facility failed to ensure electrical junction boxes above the laid in ceiling were maintained in a safe operating condition on 1 of 4 floors. LSC 19.5.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, 1999 Edition, Article 370-28(c) requires all junction boxes shall be provided with covers compatible with the box. This deficient practice could visitors, staff and 12 patients on the fourth floor.

Findings include:

Based on observation with the Plant Operations Director on 12/06/11 at 2:50 p.m., a junction box in the space above the laid in ceiling near stairway #2 on the fourth floor had no cover. The Plant Operations Director agreed at the time of observation, the cover should have been on the box.

2. Based on observation and interview, the facility failed to ensure 1 of 1 flexible cords were not used as a substitute for fixed wiring. NFPA 70 (National Electrical Code), 1999 Edition, 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 residents, staff, and visitors in the central smoke compartment where the nurses station and dining room with 10 residents were located.

Findings include:

Based on observation with the Plant Operations Director on 12/07/11 at 11:30 a.m., a power strip extension cord was used to supply power to a microwave, two refrigerators, a coffee pot and toaster. In the radiology break room. The Plant Operations Director said at the time of observation, the power strips were not approved for this use.