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Based on observations, the facility did not maintain the smoke/fire resistive rating of wall and ceiling assemblies.

Findings included:

1. On 12/8/10 at 10:55 a.m., the surveyor observed a missing sheet rock measuring 15 inches by 7.5 inches, where the sprinkler entered the wall in the sprinkler stand pipe room off of the staff lounge (main hospital). The penetration was filled with wool insulation, which was exposed through the hole.

2. On 12/8/10 at 1:46 p.m., the ceiling tile was off the track exposing space above it in the lab. At the time of the observation, staff member E, stated the ceiling tile was off the track for about a week, as the contractor's were repairing a roof leak.

3. On 12/8/10 at 1:53 p.m., the ceiling tile was missing in CT room above the CT equipment. At the time of the observation, staff member F stated the ceiling tile was in this position for one week.

The findings were confirmed by staff member D, who accompanied the surveyor during the building tour.

Based on observation, the facility failed to ensure all corridor doors closed and latched properly to protect the exit corridor system in case of an emergency.

Findings included:

On 12/8/10 during the tour of the facility, the exit corridor doors to resident rooms 101 and 103 (at approximately 2:30 p.m.) could not latch positively. Both of the strike pins were stuck for both of the doors. The doors were exercised by the surveyor and staff member D several times. Staff member D fixed the stuck strike pin for room 103.

The findings were confirmed by staff member D, who accompanied the surveyor during the building tour.

Based on observations, the facility failed to maintain the smoke/fire resistive rating of smoke/fire barrier walls.

Findings included:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 18.3.7.3, 18.3.7.5, 18.1.6.3, 18.1.6.4 of NFPA 101, LSC (2000 edition).

1. The 2-hour rated fire barrier wall that separated the hospital from the main lobby (business occupancy) on the main floor had two unsealed penetrations around two conduits above the ceiling tiles at 2:58 p.m. on 12/8/10.

2. The 2-hour rated fire barrier wall above the clinic door (marked 1121) had an unsealed penetration around a conduit above the ceiling tiles at 3:05 p.m. on 12/8/10. This area separated the hospital from the clinic (business occupancy).

The findings were confirmed by staff member D, who accompanied the surveyor during the building tour.

Based on observation and staff interview, the facility failed to ensure that appropriate means of egress used to expedite rapid removal of the occupants to the public way.

Findings included:

On 12/8/10 at 2:16 p.m., the exit door next to room 106 (south/west acute wing) could not be opened due to ice accumulation on the exterior of the exit egress. This was due to melting of snow from the roof and dripping onto the exit discharge and freezing.

The findings were confirmed by staff member D, who accompanied the surveyor during the building tour.

Based on record review and staff interview, the facility failed to ensure that fire drills were held periodically where practical and with sufficient frequency to familiarize staff with the drill procedure.

Findings included:

Per record review and a discussion with staff member C during the course of the survey on 12/9/10, the facility could not provide the necessary documentation to show that the required fire drills were held annually (4.7.2 and 39.7.1). The office space designated for the physical therapy services was located in the main floor of the community center building.

Based on interview and record review, the facility was not able to provide a copy of fire alarm panel installation completion certificate at the time of the survey.

Findings included:

In accordance with NFPA 72 (1999 edition), section 1-6.1.2, before requesting final approval of the installation, if required by the authority having jurisdiction, the installing contractor shall furnish a written statement stating that the system has been installed in accordance with approved plans and tested in accordance with the manufacturer's specifications and the appropriate NFPA requirements.

And in accordance with section 1-6.2.1, a record of completion (Figure 1-6.2.1) shall be prepared for each system. Parts 1, 2, and 4 through 10 shall be completed after the system is installed and the installation wiring has been checked. Part 3 shall be completed after the operational acceptance tests have been completed. A preliminary copy of the record of completion shall be given to the system owner and, if requested, to other authorities having jurisdiction after completion of the installation wiring tests. A final copy shall be provided after completion of the operational acceptance tests.

And in accordance with section 1-6.2.1.1, all fire alarm systems that are modified after the initial installation shall have the original record of completion revised to show all changes from the original information and shall include a revision date.

Patient admission to the new facility occurred on 11/17/10. Upon request, as of the survey of 12/8/10 and 12/9/10, the facility was not able to provide a record of completion for the fire alarm panel and systems.

Based on observation and record review, facility failed to maintain all components of the automatic sprinkler system in accordance with NFPA 25.

Findings included:

In accordance with NFPA 25, section 2-2.7* Hydraulic Nameplate, the hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

On 12/13/10, scanned emailed copy of the Contractor's Material and Test Certificate for Aboveground Piping dated 9/30/10 was reviewed by the surveyor. According to this document, on page two, the hydraulic data nameplate was provided at the time of the completion of the sprinkler installation. However, on 12/8/10 at 11:03 a.m., the hydraulic nameplate was missing at the location of the sprinkler riser.

Based on observation and interview, the facility did not maintain fire extinguishers as required per NFPA 10.

Findings included:

In accordance with section 4-3.1 of NFPA 10, portable fire extinguishers are required to be inspected monthly.

Also, in accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

1. On 12/9/10 at 9:25 a.m. all three of the portable fire extinguishers were found to be missing their monthly inspections for the entire year of 2010.

2. On 12/9/10 at 9:30 a.m., one portable fire extinguisher was observed sitting on the floor next to the the receptionist's chair.

The findings were confirmed by staff member C, who accompanied the surveyor during the building tour.

Based on observation and interview, the facility did not maintain fire extinguishers as required per NFPA 10.

Findings included:

In accordance with section 4-3.1 of NFPA 10, portable fire extinguishers are required to be inspected monthly.

On 12/8/10 at 4:35 p.m. all three of the portable fire extinguishers were found to be missing their monthly inspections for the entire year of 2010.

The findings were confirmed by staff member C, who accompanied the surveyor during the building tour.

Based on observation, the facility failed to maintain the exit corridors free of all obstructions and failed to prevent the exit corridors from being used for storage purposes.

In accordance with CMS interpretation Ref: S&C - 04-41 effective August 12, 2004, items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery item, and other similar items must be stored properly or removed from the corridor.

On 12/8/10 at 2:23 p.m., a plant and a bench were observed obstructing the 8 feet acute wing. The plant was repositioned by staff member D at the time of the survey.

Based on observations, the facility did not ensure that med gas cylinders were properly restrained against falling over or being knocked down.

The findings include:

Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per sections 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99, 1999 Edition.

Three "E" size cylinders of oxygen were freestanding in the general storage room near the door to the room as observed at 9:10 a.m. on 12/9/10. The forth cylinder of oxygen was observed free standing near the window by the bio-hazard bin in the general storage room.

The findings were confirmed by staff member C, who accompanied the surveyor during the building tour.

Based on observations, the facility failed to ensure that an medical gas cylinders were secured against falling over or being knocked down.

Findings included:

Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per sections 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99, 1999 edition.

In accordance with NFPA 99 (1999 edition), 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement)(b)(3); the walls, floors, and ceilings of locations for supply systems of more than 3000 ft 3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1- hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.

1. On 12/8/10 at 1:25 p.m., six "E" size cylinders (one carbon dioxide, 2 nitrous oxide, and 3 compressed air) of medical gas were observed to be freestanding in room 1098, central suction/compression room.

2. On 12/8/10 at 1:29 p.m., the 1-hour rated oxygen room door (1098) opening onto the suction/compression room was held open with a wooden wedge.

3. The following unsealed wall penetrations were observed in the oxygen storage room (1096) at 1:20 p.m. on 12/8/10:

a. an open ended conduit on the north wall, the main electrical room for the building was on the other side (sealed on this side)

b. an open ended conduit with green and white wires extending through on the south wall

The findings were confirmed by staff member D, who accompanied the surveyor during the building tour.

Based on record review and staff interview, the facility failed to ensure that the generator was inspected on a weekly basis and the inspections were documented.

Findings included:

The monthly generator testing logs were reviewed on the morning of 12/9/10 at the facility. There were no documented logs for the required weekly generator visual inspections. Staff A, maintenance director, verified this information during the exit conference on the same morning.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70 and interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings included:

In accordance with 240-4 of the NFPA 70 (1999 edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 edition) and previous interpretations from CMS (transmittal notice dated 3-30-99) extension cords or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing surge strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings.

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle and not connected in series or "daisy chained".

1. A staff refrigerator was plugged into a surge protector in the general storage room at 9:15 a.m. on 12/9/10.

2. Two coffee makers were plugged in to an extension cord without overcurrent protection in the general storage room at 9:20 a.m. on 12/9/10.

3. Second extension cord without overcurrent protection was found near the desk of the receptionist at 9:30 a.m. on 12/9/10, it was plugged into a surge protector.

Note: The refrigerator were plugged directly into wall receptacle after the surveyor notified staff member C, the director rehabilitation services. Also, staff member C confiscated the extension cords after she was notified by the surveyor.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, NFPA 99 or CMS interpretations.

Findings included:

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle and not connected in series or "daisy chained".

1. On 12/8/10 12:48 p.m., a refrigerator was plugged into a surge protector in the central supply. Maintenance staff corrected this issue during the course of the survey.

2. The unused electrical receptacle located on the south wall of the exit corridor next to room 1063, restroom had a missing plate cover at 1:53 p.m. on 12/8/10.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70 and interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings included:

In accordance with Article 110-22 of NFPA 70, circuits at electrical panels are to be identified.

The boiler room was observed on 12/8/10 at 4:34 p.m. Breakers 6, 8, 15 and 17 in the electrical panel were in on position. However, they were marked as spares in the breaker directory.

Based on observations, the facility did not maintain the smoke/fire resistive rating of wall and ceiling assemblies.

Findings included:

1. On 12/8/10 at 10:55 a.m., the surveyor observed a missing sheet rock measuring 15 inches by 7.5 inches, where the sprinkler entered the wall in the sprinkler stand pipe room off of the staff lounge (main hospital). The penetration was filled with wool insulation, which was exposed through the hole.

2. On 12/8/10 at 1:46 p.m., the ceiling tile was off the track exposing space above it in the lab. At the time of the observation, staff member E, stated the ceiling tile was off the track for about a week, as the contractor's were repairing a roof leak.

3. On 12/8/10 at 1:53 p.m., the ceiling tile was missing in CT room above the CT equipment. At the time of the observation, staff member F stated the ceiling tile was in this position for one week.

The findings were confirmed by staff member D, who accompanied the surveyor during the building tour.

Based on observation, the facility failed to ensure all corridor doors closed and latched properly to protect the exit corridor system in case of an emergency.

Findings included:

On 12/8/10 during the tour of the facility, the exit corridor doors to resident rooms 101 and 103 (at approximately 2:30 p.m.) could not latch positively. Both of the strike pins were stuck for both of the doors. The doors were exercised by the surveyor and staff member D several times. Staff member D fixed the stuck strike pin for room 103.

The findings were confirmed by staff member D, who accompanied the surveyor during the building tour.

Based on observations, the facility failed to maintain the smoke/fire resistive rating of smoke/fire barrier walls.

Findings included:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 18.3.7.3, 18.3.7.5, 18.1.6.3, 18.1.6.4 of NFPA 101, LSC (2000 edition).

1. The 2-hour rated fire barrier wall that separated the hospital from the main lobby (business occupancy) on the main floor had two unsealed penetrations around two conduits above the ceiling tiles at 2:58 p.m. on 12/8/10.

2. The 2-hour rated fire barrier wall above the clinic door (marked 1121) had an unsealed penetration around a conduit above the ceiling tiles at 3:05 p.m. on 12/8/10. This area separated the hospital from the clinic (business occupancy).

The findings were confirmed by staff member D, who accompanied the surveyor during the building tour.

Based on observation and staff interview, the facility failed to ensure that appropriate means of egress used to expedite rapid removal of the occupants to the public way.

Findings included:

On 12/8/10 at 2:16 p.m., the exit door next to room 106 (south/west acute wing) could not be opened due to ice accumulation on the exterior of the exit egress. This was due to melting of snow from the roof and dripping onto the exit discharge and freezing.

The findings were confirmed by staff member D, who accompanied the surveyor during the building tour.

Based on record review and staff interview, the facility failed to ensure that fire drills were held periodically where practical and with sufficient frequency to familiarize staff with the drill procedure.

Findings included:

Per record review and a discussion with staff member C during the course of the survey on 12/9/10, the facility could not provide the necessary documentation to show that the required fire drills were held annually (4.7.2 and 39.7.1). The office space designated for the physical therapy services was located in the main floor of the community center building.

Based on interview and record review, the facility was not able to provide a copy of fire alarm panel installation completion certificate at the time of the survey.

Findings included:

In accordance with NFPA 72 (1999 edition), section 1-6.1.2, before requesting final approval of the installation, if required by the authority having jurisdiction, the installing contractor shall furnish a written statement stating that the system has been installed in accordance with approved plans and tested in accordance with the manufacturer's specifications and the appropriate NFPA requirements.

And in accordance with section 1-6.2.1, a record of completion (Figure 1-6.2.1) shall be prepared for each system. Parts 1, 2, and 4 through 10 shall be completed after the system is installed and the installation wiring has been checked. Part 3 shall be completed after the operational acceptance tests have been completed. A preliminary copy of the record of completion shall be given to the system owner and, if requested, to other authorities having jurisdiction after completion of the installation wiring tests. A final copy shall be provided after completion of the operational acceptance tests.

And in accordance with section 1-6.2.1.1, all fire alarm systems that are modified after the initial installation shall have the original record of completion revised to show all changes from the original information and shall include a revision date.

Patient admission to the new facility occurred on 11/17/10. Upon request, as of the survey of 12/8/10 and 12/9/10, the facility was not able to provide a record of completion for the fire alarm panel and systems.

Based on observation and record review, facility failed to maintain all components of the automatic sprinkler system in accordance with NFPA 25.

Findings included:

In accordance with NFPA 25, section 2-2.7* Hydraulic Nameplate, the hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

On 12/13/10, scanned emailed copy of the Contractor's Material and Test Certificate for Aboveground Piping dated 9/30/10 was reviewed by the surveyor. According to this document, on page two, the hydraulic data nameplate was provided at the time of the completion of the sprinkler installation. However, on 12/8/10 at 11:03 a.m., the hydraulic nameplate was missing at the location of the sprinkler riser.

Based on observation and interview, the facility did not maintain fire extinguishers as required per NFPA 10.

Findings included:

In accordance with section 4-3.1 of NFPA 10, portable fire extinguishers are required to be inspected monthly.

Also, in accordance with 1-6.7 and 1-6.10 of NFPA 10, 1998 edition, portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

1. On 12/9/10 at 9:25 a.m. all three of the portable fire extinguishers were found to be missing their monthly inspections for the entire year of 2010.

2. On 12/9/10 at 9:30 a.m., one portable fire extinguisher was observed sitting on the floor next to the the receptionist's chair.

The findings were confirmed by staff member C, who accompanied the surveyor during the building tour.

Based on observation and interview, the facility did not maintain fire extinguishers as required per NFPA 10.

Findings included:

In accordance with section 4-3.1 of NFPA 10, portable fire extinguishers are required to be inspected monthly.

On 12/8/10 at 4:35 p.m. all three of the portable fire extinguishers were found to be missing their monthly inspections for the entire year of 2010.

The findings were confirmed by staff member C, who accompanied the surveyor during the building tour.

Based on observation, the facility failed to maintain the exit corridors free of all obstructions and failed to prevent the exit corridors from being used for storage purposes.

In accordance with CMS interpretation Ref: S&C - 04-41 effective August 12, 2004, items not in use in exit corridors (i.e. left unattended for more than 30 minutes), such as linen carts, medication carts, janitorial equipment, chairs, wheelchairs, delivery item, and other similar items must be stored properly or removed from the corridor.

On 12/8/10 at 2:23 p.m., a plant and a bench were observed obstructing the 8 feet acute wing. The plant was repositioned by staff member D at the time of the survey.

Based on observations, the facility did not ensure that med gas cylinders were properly restrained against falling over or being knocked down.

The findings include:

Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per sections 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99, 1999 Edition.

Three "E" size cylinders of oxygen were freestanding in the general storage room near the door to the room as observed at 9:10 a.m. on 12/9/10. The forth cylinder of oxygen was observed free standing near the window by the bio-hazard bin in the general storage room.

The findings were confirmed by staff member C, who accompanied the surveyor during the building tour.

Based on observations, the facility failed to ensure that an medical gas cylinders were secured against falling over or being knocked down.

Findings included:

Freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down per sections 8-3.1.11.2(h) and 4-3.5.2.1(b27) of NFPA 99, 1999 edition.

In accordance with NFPA 99 (1999 edition), 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement)(b)(3); the walls, floors, and ceilings of locations for supply systems of more than 3000 ft 3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1- hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.

1. On 12/8/10 at 1:25 p.m., six "E" size cylinders (one carbon dioxide, 2 nitrous oxide, and 3 compressed air) of medical gas were observed to be freestanding in room 1098, central suction/compression room.

2. On 12/8/10 at 1:29 p.m., the 1-hour rated oxygen room door (1098) opening onto the suction/compression room was held open with a wooden wedge.

3. The following unsealed wall penetrations were observed in the oxygen storage room (1096) at 1:20 p.m. on 12/8/10:

a. an open ended conduit on the north wall, the main electrical room for the building was on the other side (sealed on this side)

b. an open ended conduit with green and white wires extending through on the south wall

The findings were confirmed by staff member D, who accompanied the surveyor during the building tour.

Based on record review and staff interview, the facility failed to ensure that the generator was inspected on a weekly basis and the inspections were documented.

Findings included:

The monthly generator testing logs were reviewed on the morning of 12/9/10 at the facility. There were no documented logs for the required weekly generator visual inspections. Staff A, maintenance director, verified this information during the exit conference on the same morning.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70 and interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings included:

In accordance with 240-4 of the NFPA 70 (1999 edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 edition) and previous interpretations from CMS (transmittal notice dated 3-30-99) extension cords or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing surge strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings.

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle and not connected in series or "daisy chained".

1. A staff refrigerator was plugged into a surge protector in the general storage room at 9:15 a.m. on 12/9/10.

2. Two coffee makers were plugged in to an extension cord without overcurrent protection in the general storage room at 9:20 a.m. on 12/9/10.

3. Second extension cord without overcurrent protection was found near the desk of the receptionist at 9:30 a.m. on 12/9/10, it was plugged into a surge protector.

Note: The refrigerator were plugged directly into wall receptacle after the surveyor notified staff member C, the director rehabilitation services. Also, staff member C confiscated the extension cords after she was notified by the surveyor.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, NFPA 99 or CMS interpretations.

Findings included:

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle and not connected in series or "daisy chained".

1. On 12/8/10 12:48 p.m., a refrigerator was plugged into a surge protector in the central supply. Maintenance staff corrected this issue during the course of the survey.

2. The unused electrical receptacle located on the south wall of the exit corridor next to room 1063, restroom had a missing plate cover at 1:53 p.m. on 12/8/10.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70 and interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings included:

In accordance with Article 110-22 of NFPA 70, circuits at electrical panels are to be identified.

The boiler room was observed on 12/8/10 at 4:34 p.m. Breakers 6, 8, 15 and 17 in the electrical panel were in on position. However, they were marked as spares in the breaker directory.