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Based on document review and staff interview, the facility did not meet the requirements for conducting emergency disaster drills.

The findings include:
While on tour of the facility April 19, 2010 accompanied by the Maintenance Director, it was noted during document review that there was no documentation available during the survey to indicate that the emergency disaster plan and fire plan had been submitted and had been approved by the local authority having jurisdiction for 2009 and 2010, or that internal and external disaster fire drills had been conducted for 2009 In accordance with L.S.C 18.7.1.1, 19.7.1.1

Based on document review and staff interview, the facility did not meet the requirements for conducting fire drills.

The findings include:
While on tour of the facility April 27, 2010 accompanied by the Maintenance Director, it was noted during review of the facilities fire drill logs that there was no documentation available during the time of survey to indicate that fire drills had been conducted for the 3rd shift 4th quarter of 2009. In accordance with L.S.C 18.7.1.2, 19.7.1.2

Based on staff interview, testing and direct observation the facilities fire alarm system components had not been maintained in proper working condition.

The Findings Include:
While on tour of the facility April 27, 2010, accompanied by the Maintenance Director it was observed that the facilities fire alarm system it was discovered to be in trouble mode condition and is required to be maintained in proper operational condition. In accordance with NFPA 72.

Based on staff interview,observation and testing the facilities backflow for sprinkler system has not been properly maintained.

The findings include:
While on tour of the facility April 27, 2010 accompanied by a director of Maintenance, it was observed that the backflow for sprinkler system was not equipped with water flow and tamper switches, and is requried to be electrically connected to the building fire alarm system, which would prevent tamper of the system. In accordance with LSC 9.7.2.1 NFPA 72

Based on staff interview, document review and direct observation, the facilities Sprinkler system components had not been maintained in proper working condition.

1.The Findings Include:
While on tour of the facility April 27, 2010, accompanied by the Maintenance Director it was discovered during document review that there was no documentation available during the time of survey to indicate that the faciales sprinkler system had received a quarterly inspection for the 4th quarter of 2009 in addition it was discovered during document review that it was noted during a review of the facilities quarterly sprinkler system inspection report dated March 30, 2010 revealed as noted in the comments section, indicated that located in Bldg. C, control valve tamper above ceiling by Bldg. B, elevator was not operational and that located in Bldg. C, that the riser control valve was leaking and bolts were heavily corroded in addition facility sprinkler system pipes had not received a 5 year internal inspection, it was also observed that there were missing covers from sprinkler heads located on the 2nd floor inside residential treatment rooms and throughout the building. The quarterly sprinkler system inspection report shall be reviewed and all comments addressed and corrected. In accordance with NFPA 25, 13

Based on observation, the facilities private fire hydrants system was not properly maintained according to NFPA 101 Life Safety Code 2000 edition requirements.

2. The findings include:
While on tour of the facility April 27, 2010, accompanied by the Maintenance Director, it was determined that facility has one on property fire hydrant and had not received yearly functional test. In accordance with NFPA 25; 7.3.2, 7.3.1

Based on direct observation and staff interview, the facility did not meet the requirements for portable fire extinguishers in accordance with NFPA 10.

The findings include:
While on tour of the facility April 27,2010 accompanied by the Maintenance Director, it was observed that the fire extinguisher located in the 1st. floor elevator/mechanical room gauge indicated that it was in the over-charge zone requiring re-service. In accordance NFPA 10

Based on staff interview and, observation, air conditioning and ventilation had not been installed and maintained to all manufacturers specifications.


The findings include:
On tour of the facility, while accompanied by the Maintenance Director, on April 27, 2010 it was observed that the exhaust fans located on the 2nd floor soiled hold, janitors, and bathrooms were not in proper working condition as required. This condition could be hazardous to patients and staff with noxious ordors entering the hallway. According to AIA Guidelines 2001, 59A,

In accordance with NFPA Life Safety code.NFPA 90A. LSC 18.5.2, 9.2

Based on staff interview, document review and direct observation the facilities cooking systems had not been maintained.

The Findings Include:
While on tour of the facility April 27, 2010, with Maintenance Director, that it was noted during document review that there was no documentation available at the time of survey to indicate that the facilities hood system had been cleaned at regular intervals as required by a certified technician. In accordance with the L.S.C. 9.2.3.18.3.2.6, 19.3.2.6, NFPA 96

Based on staff interview, document review and direct observation the documentation the facilities generator had not been maintained.

The Findings Include:
While on tour of the facility April 27, 2010 accompanied by the Maintenance Director it was noted that there was no documentation available at the time of survey to indicate that a monthly load test had been constantly conducted for facilities generator as required. It was determined through document review that the generator had not been placed under load condition for 30mins for the months of February, June, October and November 2009 as required, in addition it was observed that there was no emergency lighting unit provided for the facilities generator as required. In accordance with NFPA 110; 8.4.2; NFPA 99.