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Based on observation and interview the facility failed to provide egress doors in accordance with LSC section 19.2.2.2.6. This deficient practice could potentially affect 28 occupants of the facility in the event of an emergency which requires the rapid evacuation of the building, and the evacuation is delayed due to improper egress access.

Findings include:

On 10/31/17, the following observations were made:

At approximately 8:10 AM, while on tour with Facility Supervisor, observed that A Mod staff could not easily identify key to open secured egress door.

The Facility Supervisor confirmed the finding at the time of observation.

Based on observation and interview the facility failed to provide manual fire alarm pull stations in accordance with LSC section 9.6.2.7. This deficient practice could potentially affect 44 occupants of the facility in the event of a delay in occupant notification due to deficient access to fire alarm system activation components.

Findings include:

On 10/31/17, the following observations were made:

At approximately 8:15 AM while on tour with Facility Supervisor, observed that A Mod staff could not easily identify key to activate secured manual fire alarm pull station.

At approximately 10:30 AM while on tour with Facility Supervisor, observed that D Mod staff did not have key to activate secured manual fire alarm pull station.

The Facility Supervisor confirmed the findings at the time of observation.

Based on review of records and interview the facility did not follow their fire alarm system out of service policy in accordance with LSC section 9.6.1.6. This deficient practice could potentially affect 17 occupants of the facility if a fire watch does not provide the required coverage and protection of the facility.

Findings include:

On 10/31/17 at approximately 12:20 PM record review with the Facility Supervisor revealed the Authority Having Jurisdiction (AHJ) was not notified that 12 visual notification appliances on 3rd floor were not functional from 10/06/17 through 10/16/17 due to Class B NAC card failure.

The Facility Supervisor confirmed this finding during record review.

Based on observation and interview the facility did not provide sprinkler protection in accordance with LSC section 19.3.5.4. This deficient practice could potentially affect 17 occupants of the facility in the event of a fire where the early suppression of the fire does not occur due to deficient fire sprinkler system coverage.

Findings include:

On 10/31/17, the following observations were made:

At approximately 11:00 AM while on tour with Facility Supervisor, observed that in the corridor near Room S422 there was missing a ceiling tile, creating a space not provided with sprinkler protection.

At approximately 11:20 AM while on tour with Facility Supervisor, observed that at the entry doors at Patient Cafeteria there was missing ceiling tile, creating a space not provided with sprinkler protection.

The Facility Supervisor confirmed the finding at the time of observation.

Based on observation and interview the facility failed to provide fire extinguishers in accordance with LSC Section 19.3.5.12, NFPA 10 Section 6.1.3.10.1. This deficient practice could potentially affect 28 occupants of the facility in the event of a fire where the early suppression of the fire does not occur due to deficient access to portable fire extinguishers.

Findings include:

On 10/31/17, the following observation was made:

At approximately 8:12 AM while on tour with Facility Supervisor, observed that A Mod staff could not easily identify key to open portable fire extinguisher secured cabinet door.

The Facility Supervisor confirmed the finding at the time of observation.

Based on observation and interview the facility failed to provide electrical installation in accordance with NFPA 99 Section 6.3.2.1, NFPA 70 Section 300.11. This deficient practice could potentially affect 26 occupants of the facility in the event of failure of the wiring support system.

Findings include:

On 10/31/17, at approximately 10:00 AM while on tour with Facility Supervisor, observed that near Room S422 there were wiring/cables supported by the suspended ceiling grid.

The Facility Supervisor confirmed the finding at the time of observation.

Based on observation and interview the facility failed to provide a remote annunciator in accordance with NFPA 99 Section 6.4.1.1.17. This deficient practice could potentially affect all occupants of the facility in the event that the generators did not function as designed, affecting emergency lighting which would delay egress, and fire pump for fire sprinkler protection to control spread of fire.

Findings include:

On 10/31/17, at approximately 9:30 AM while on tour with Facility Supervisor, observed that there were not clear audible and visible signals of the remote annunciators at a constantly attended location for either of the 2 generator sets.

The Facility Supervisor confirmed the finding at the time of observation.

Based on observation and interview the facility failed to provide electrical installation in accordance NFPA 70 Section 400.8. This deficient practice could potentially affect 56 occupants of the facility in the event of a failure of the electrical equipment.

Findings include:

On 10/31/17, the following observations were made:

At approximately 9:00 AM while on tour with Facility Supervisor, observed that in the Activity Therapy Office there was a power strip attached to an extension cord being used in the place of permanent wiring.

At approximately 11:45 AM while on tour with Facility Supervisor, observed that in the Employee Dining Room there was a microwave oven attached to an extension cord being used in the place of permanent wiring.

The findings were confirmed by the Facility Supervisor at the time of observation.