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Based on observation and interview, the facility failed to ensure 1 of 1 open use areas was separated from the corridor, or met an Exception. LSC 19.3.6.1, Exception # 1, Spaces shall be permitted to be unlimited in area and open to the corridor, provided the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. This deficient practice could affect any patients in the corridor adjacent to the Front Reception office by the front entrance as well as visitors and staff.

Findings include:

Based on observation on 02/12/14 at 12:00 p.m. with the Maintenance Supervisor, the Reception office next to the front entrance had sliding glass windows separating the office from the corridor and was open to the corridor at the time of observation. Furthermore, there was an open space between the glass panes as they slide horizontally along its metal track. Exception # 1, requirement (b) and (c) of the Life Safety Code, Chapter 19.3.6.1 was not met as follows: the open area was not protected by an automatic smoke detection system or arranged to allow direct supervision by facility staff from a continuously staffed area such as a nurses' station and the corridors onto which the spaces open in the same smoke compartment were not protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4. Based on interview on 02/12/14 at 12:04 p.m. with the Maintenance Supervisor, it was acknowledged the Reception office which was open to the corridor without supervision from the nurse's station and was not protected by automatic smoke detection nor did the corridor have smoke detection protection in the same smoke compartment.

Based on observation and interview, the facility failed to ensure the lighting in 1 of 5 exit means of egress was arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness. LSC Section 7.8.1.4 requires illumination be arranged so the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area. This deficient practice could affect all patients on the second floor using the Business exit discharge to reach a public way as well as staff and visitors if the facility were required to evacuate and the single bulb outside failed leaving the area in darkness.

Findings include:

Based on observation on 02/12/14 at 1:45 p.m. with the Maintenance Supervisor, there was an exit light on generator back up located outside the Business exit on the west end of the building which only had a single bulb in the light fixture. Furthermore, the single light bulb fixture was the only light available to illuminate the fifty yards of travel down the sidewalk to a public way. Based on interview on 02/12/14 at 1:50 p.m. it was acknowledged by the Maintenance Supervisor, the outside light providing illumination for the exit discharge out of the west Business exit and the fifty yards of exit sidewalk was equipped with only a single bulb light fixture.

Based on record review and interview, the facility failed to conduct fire drills on all shifts for 2 of 4 quarters for 2013. This deficient practice affects all patients in the facility including staff and visitors.

Findings include:

Based on review of Monthly Fire Drill records on 02/12/14 at 3:15 p.m. with the Maintenance Supervisor, a fire drill report for the second and third shift of the third quarter of 2013 and the third shift of the fourth quarter of 2013 was not available for review. Based on interview on 02/12/14 at 3:17 p.m. with the Maintenance Supervisor, it was acknowledged the fire drills for the aforementioned shifts of the third and fourth quarter of 2013 had not been done.

1. Based on observation and interview, the facility failed to ensure sprinkler heads were spaced a minimum of 6 feet apart for 1 of 1 automatic sprinkler systems. NFPA 13, Section 5-6.3.4, "Minimum Distance between Sprinklers", states sprinklers shall be spaced not less than 6 feet on center. This deficient practice could affect any patient as well as staff or visitors.

Findings include:

Based on observation on 02/12/14 at 1:15 p.m. with the Maintenance Supervisor, the Maintenance office had three sprinkler heads which were each less than five feet apart.
Based on interview on 02/12/14 concurrent with the observation with the Maintenance Supervisor, it was acknowledged the aforementioned sprinkler heads observed were less than six feet apart.

2. Based on observation and interview, the facility failed to ensure 1 of 3 armover sprinkler pipes observed in the facility was installed in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 1999 edition, Section 6-2.3.4 states the cumulative horizontal length of an unsupported armover to a sprinkler, sprinkler drop, or sprig-up shall not exceed 24 inches for steel pipe or 12 inches for copper tube. This deficient practices could affect all patients as well as staff or visitors.

Findings include:

Based on observation on 02/12/14 at 1:36 p.m. with the Maintenance Supervisor, the Boiler/Riser room at the northwest portion of the building next to the electrical panel had an unsupported steel sprinkler pipe armover which was measured to be thirty one inches in length. Based on interview on 02/12/14 concurrent with the observation with the Maintenance Supervisor, it was acknowledged the aforementioned steel sprinkler pipe armover exceeded twenty four inches in length and was unsupported.

Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers and a sprinkler wrench in 1 of 1 riser rooms in accordance with NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 2-4.1.4 which requires a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. NFPA 25, 2-4.1.6 requires a special sprinkler wrench be provided and kept in the cabinet. This deficient practice could affect all patients throughout the facility as well as staff and visitors if the sprinkler system had to be shut down because a proper sprinkler head wasn't available as a replacement.

Findings include:

Based on observation on 02/12/14 at 1:55 p.m. with the Maintenance Supervisor, the riser room located on the northwest portion of the building on first floor had two glass pendant type sprinkler heads with red filaments located in the front lounge being utilized, however, there were no pendant type sprinkler heads with a red glass filament in the spare sprinkler cabinet located in the Boiler/Riser room on first floor. Furthermore, a sprinkler wrench was not available in the spare sprinkler cabinet. Based on interview on 02/12/14 at 1:56 p.m. with the Maintenance Supervisor, it was acknowledged the spare sprinkler cabinet located in the Boiler/Riser room did not have a minimum of two pendant sprinkler heads with red glass filaments or a sprinkler wrench in the sprinkler box.

Based on observation, interview and record review, the facility failed to regulate the use of 5 of 5 portable space heaters observed in nonresident rooms. This deficient practice could affect all patients in the facility as well as visitors and staff.

Findings include:

Based on observations on 02/12/14 during the tour between 12:05 p.m. to 3:00 p.m. with the Maintenance Supervisor, a portable space heater which was plugged in for use was located in the following areas:
a. Three portable heaters in office room # 211 on second floor
b. One portable heater in office room # 118
c. One portable heater in the IT office on first floor
Based on interview on 02/12/14 concurrent with the observations, it was acknowledged by the Maintenance Supervisor space heaters were allowed in the facility during periods of extreme cold weather conditions. Based on interview on 02/12/14 at 3:30 p.m. with the Maintenance Supervisor, it was stated the facility had not drafted a space heater policy and the facility could not document the space heaters used were equipped with heating elements which would not exceed 212 degrees Fahrenheit.

Based on observation, record review 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 of generator equipment on 02/12/14 at 2:45 p.m. with the Maintenance Supervisor, a remote shut off device was not found for the generator. Based on review of Generator Maintenance records on 02/12/14 at 3:10 p.m. with the Maintenance Supervisor, the generator was installed prior to 2003, however, it was stated the generator was rated at over 100 horsepower and a remote means to shut the generator off was not provided. Based on interview on 02/12/14 at 2:48 p.m. with the Maintenance Supervisor, it was acknowledged the facility was not aware a remote shut off for the generator was required.

Based on observation, record review and interview; the facility failed to ensure 1 of 1 elevator equipment rooms on first floor was provided with sprinkler protection and an electrical shunt trip was provided. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be of ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main power supply to the affected elevator automatically upon, or prior to, the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect any patients as well as visitors and staff while using the elevator.

Findings include:

Based on observation on 02/12/14 at 1:20 p.m. with the Maintenance Supervisor, the Elevator Mechanical room located in the Boiler/Riser room on first floor lacked sprinkler protection. Based on interview at the time of observation, the Maintenance Supervisor acknowledged the lack of sprinkler protection in the Elevator Mechanical room.

Based on observation and interview, the facility failed to ensure 1 of 1 open use areas was separated from the corridor, or met an Exception. LSC 19.3.6.1, Exception # 1, Spaces shall be permitted to be unlimited in area and open to the corridor, provided the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. This deficient practice could affect any patients in the corridor adjacent to the Front Reception office by the front entrance as well as visitors and staff.

Findings include:

Based on observation on 02/12/14 at 12:00 p.m. with the Maintenance Supervisor, the Reception office next to the front entrance had sliding glass windows separating the office from the corridor and was open to the corridor at the time of observation. Furthermore, there was an open space between the glass panes as they slide horizontally along its metal track. Exception # 1, requirement (b) and (c) of the Life Safety Code, Chapter 19.3.6.1 was not met as follows: the open area was not protected by an automatic smoke detection system or arranged to allow direct supervision by facility staff from a continuously staffed area such as a nurses' station and the corridors onto which the spaces open in the same smoke compartment were not protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4. Based on interview on 02/12/14 at 12:04 p.m. with the Maintenance Supervisor, it was acknowledged the Reception office which was open to the corridor without supervision from the nurse's station and was not protected by automatic smoke detection nor did the corridor have smoke detection protection in the same smoke compartment.

Based on observation and interview, the facility failed to ensure the lighting in 1 of 5 exit means of egress was arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness. LSC Section 7.8.1.4 requires illumination be arranged so the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area. This deficient practice could affect all patients on the second floor using the Business exit discharge to reach a public way as well as staff and visitors if the facility were required to evacuate and the single bulb outside failed leaving the area in darkness.

Findings include:

Based on observation on 02/12/14 at 1:45 p.m. with the Maintenance Supervisor, there was an exit light on generator back up located outside the Business exit on the west end of the building which only had a single bulb in the light fixture. Furthermore, the single light bulb fixture was the only light available to illuminate the fifty yards of travel down the sidewalk to a public way. Based on interview on 02/12/14 at 1:50 p.m. it was acknowledged by the Maintenance Supervisor, the outside light providing illumination for the exit discharge out of the west Business exit and the fifty yards of exit sidewalk was equipped with only a single bulb light fixture.

Based on record review and interview, the facility failed to conduct fire drills on all shifts for 2 of 4 quarters for 2013. This deficient practice affects all patients in the facility including staff and visitors.

Findings include:

Based on review of Monthly Fire Drill records on 02/12/14 at 3:15 p.m. with the Maintenance Supervisor, a fire drill report for the second and third shift of the third quarter of 2013 and the third shift of the fourth quarter of 2013 was not available for review. Based on interview on 02/12/14 at 3:17 p.m. with the Maintenance Supervisor, it was acknowledged the fire drills for the aforementioned shifts of the third and fourth quarter of 2013 had not been done.

1. Based on observation and interview, the facility failed to ensure sprinkler heads were spaced a minimum of 6 feet apart for 1 of 1 automatic sprinkler systems. NFPA 13, Section 5-6.3.4, "Minimum Distance between Sprinklers", states sprinklers shall be spaced not less than 6 feet on center. This deficient practice could affect any patient as well as staff or visitors.

Findings include:

Based on observation on 02/12/14 at 1:15 p.m. with the Maintenance Supervisor, the Maintenance office had three sprinkler heads which were each less than five feet apart.
Based on interview on 02/12/14 concurrent with the observation with the Maintenance Supervisor, it was acknowledged the aforementioned sprinkler heads observed were less than six feet apart.

2. Based on observation and interview, the facility failed to ensure 1 of 3 armover sprinkler pipes observed in the facility was installed in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 1999 edition, Section 6-2.3.4 states the cumulative horizontal length of an unsupported armover to a sprinkler, sprinkler drop, or sprig-up shall not exceed 24 inches for steel pipe or 12 inches for copper tube. This deficient practices could affect all patients as well as staff or visitors.

Findings include:

Based on observation on 02/12/14 at 1:36 p.m. with the Maintenance Supervisor, the Boiler/Riser room at the northwest portion of the building next to the electrical panel had an unsupported steel sprinkler pipe armover which was measured to be thirty one inches in length. Based on interview on 02/12/14 concurrent with the observation with the Maintenance Supervisor, it was acknowledged the aforementioned steel sprinkler pipe armover exceeded twenty four inches in length and was unsupported.

Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers and a sprinkler wrench in 1 of 1 riser rooms in accordance with NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 2-4.1.4 which requires a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. NFPA 25, 2-4.1.6 requires a special sprinkler wrench be provided and kept in the cabinet. This deficient practice could affect all patients throughout the facility as well as staff and visitors if the sprinkler system had to be shut down because a proper sprinkler head wasn't available as a replacement.

Findings include:

Based on observation on 02/12/14 at 1:55 p.m. with the Maintenance Supervisor, the riser room located on the northwest portion of the building on first floor had two glass pendant type sprinkler heads with red filaments located in the front lounge being utilized, however, there were no pendant type sprinkler heads with a red glass filament in the spare sprinkler cabinet located in the Boiler/Riser room on first floor. Furthermore, a sprinkler wrench was not available in the spare sprinkler cabinet. Based on interview on 02/12/14 at 1:56 p.m. with the Maintenance Supervisor, it was acknowledged the spare sprinkler cabinet located in the Boiler/Riser room did not have a minimum of two pendant sprinkler heads with red glass filaments or a sprinkler wrench in the sprinkler box.

Based on observation, interview and record review, the facility failed to regulate the use of 5 of 5 portable space heaters observed in nonresident rooms. This deficient practice could affect all patients in the facility as well as visitors and staff.

Findings include:

Based on observations on 02/12/14 during the tour between 12:05 p.m. to 3:00 p.m. with the Maintenance Supervisor, a portable space heater which was plugged in for use was located in the following areas:
a. Three portable heaters in office room # 211 on second floor
b. One portable heater in office room # 118
c. One portable heater in the IT office on first floor
Based on interview on 02/12/14 concurrent with the observations, it was acknowledged by the Maintenance Supervisor space heaters were allowed in the facility during periods of extreme cold weather conditions. Based on interview on 02/12/14 at 3:30 p.m. with the Maintenance Supervisor, it was stated the facility had not drafted a space heater policy and the facility could not document the space heaters used were equipped with heating elements which would not exceed 212 degrees Fahrenheit.

Based on observation, record review 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 of generator equipment on 02/12/14 at 2:45 p.m. with the Maintenance Supervisor, a remote shut off device was not found for the generator. Based on review of Generator Maintenance records on 02/12/14 at 3:10 p.m. with the Maintenance Supervisor, the generator was installed prior to 2003, however, it was stated the generator was rated at over 100 horsepower and a remote means to shut the generator off was not provided. Based on interview on 02/12/14 at 2:48 p.m. with the Maintenance Supervisor, it was acknowledged the facility was not aware a remote shut off for the generator was required.

Based on observation, record review and interview; the facility failed to ensure 1 of 1 elevator equipment rooms on first floor was provided with sprinkler protection and an electrical shunt trip was provided. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be of ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main power supply to the affected elevator automatically upon, or prior to, the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect any patients as well as visitors and staff while using the elevator.

Findings include:

Based on observation on 02/12/14 at 1:20 p.m. with the Maintenance Supervisor, the Elevator Mechanical room located in the Boiler/Riser room on first floor lacked sprinkler protection. Based on interview at the time of observation, the Maintenance Supervisor acknowledged the lack of sprinkler protection in the Elevator Mechanical room.