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Based on observation and interview, the facility failed to ensure 2 of 8 open use areas in the 1932 building were 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 18.3.4, 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 patient using the basement vending machine room, and the second floor human resources office.

Findings include:

Based on observations on 01/07/10 during a tour of the facility from 9:20 a.m. to 1:55 p.m. with the director of plant operations, the 1932 building second floor human resources office had a four foot by four foot sliding glass window, which when closed, left a one inch gap between the human resources office and the corridor and the basement vending machine room, which lacked a door, was open to the corridor. Furthermore, Exception # 1, requirement (c ) of the Life Safety Code, Chapter 19.3.6.1 was not met as follows, the open areas were 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. This was verified by the director of plant operations at the time of observations.

Based on observation and interview, the facility failed to ensure 4 of 4 exit discharge paths in the 1932 building were provided with emergency powered illumination. LSC 7.9.1.1 says the exit discharge shall include only designated stairs, aisles walkways leading to a public way. LSC 7.9.2.1 requires emergency lighting shall be provided for not less than 1 1/2 hours arranged to provide not less than an average of 1 foot candle,and not less than 0.1 foot candles, measured along the path of egress at floor level. Further, LSC 7.9.2.4 allows for battery operated emergency lights to use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged conditions. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code. This deficient practice affect all patients in the facility.

Findings include:

Based on observations on 01/06/09 during a tour of the facility from 9:40 a.m. to 2:20 p.m. with the director of plant operations, the 1932 building 1 East Wing exit, the two 1 West Wing exits, and the 1 North Wing Exit lacked outside emergency lighting outside each exit door. This was verified by the director of plant operations at the time of observations.

Based on record review and interview, the facility failed to ensure 1 of 3 automatic sprinkler piping systems was inspected every five years as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.1. This deficient practice affects all patients in the facility.

Findings include:

Based on review of Sprinkler System Inspection and Testing Reports with the director of plant operations on 01/06/10 at 9:40 a.m., the Sprinkler System Inspection and Testing Report dated 12/01/09, 08/24/09, 09/04/09, 10/20/08, and 07/28/08 did not indicate an internal inspection of the sprinkler system pipes for the 1932 building dry sprinkler system riser was conducted. Based on an interview with the director of plant operations on 01/07/10 at 10:30 a.m., the director of plant operations indicated a 01/07/10 phone conversation with the inspection company at 9:00 a.m. verified an internal pipe inspection of the 1932 building dry sprinkler riser had never been conducted.

Based on observation and interview, the facility failed to ensure 2 of 8 open use areas in the 1932 building were 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 18.3.4, 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 patient using the basement vending machine room, and the second floor human resources office.

Findings include:

Based on observations on 01/07/10 during a tour of the facility from 9:20 a.m. to 1:55 p.m. with the director of plant operations, the 1932 building second floor human resources office had a four foot by four foot sliding glass window, which when closed, left a one inch gap between the human resources office and the corridor and the basement vending machine room, which lacked a door, was open to the corridor. Furthermore, Exception # 1, requirement (c ) of the Life Safety Code, Chapter 19.3.6.1 was not met as follows, the open areas were 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. This was verified by the director of plant operations at the time of observations.

Based on observation and interview, the facility failed to ensure 4 of 4 exit discharge paths in the 1932 building were provided with emergency powered illumination. LSC 7.9.1.1 says the exit discharge shall include only designated stairs, aisles walkways leading to a public way. LSC 7.9.2.1 requires emergency lighting shall be provided for not less than 1 1/2 hours arranged to provide not less than an average of 1 foot candle,and not less than 0.1 foot candles, measured along the path of egress at floor level. Further, LSC 7.9.2.4 allows for battery operated emergency lights to use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged conditions. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code. This deficient practice affect all patients in the facility.

Findings include:

Based on observations on 01/06/09 during a tour of the facility from 9:40 a.m. to 2:20 p.m. with the director of plant operations, the 1932 building 1 East Wing exit, the two 1 West Wing exits, and the 1 North Wing Exit lacked outside emergency lighting outside each exit door. This was verified by the director of plant operations at the time of observations.

Based on record review and interview, the facility failed to ensure 1 of 3 automatic sprinkler piping systems was inspected every five years as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.1. This deficient practice affects all patients in the facility.

Findings include:

Based on review of Sprinkler System Inspection and Testing Reports with the director of plant operations on 01/06/10 at 9:40 a.m., the Sprinkler System Inspection and Testing Report dated 12/01/09, 08/24/09, 09/04/09, 10/20/08, and 07/28/08 did not indicate an internal inspection of the sprinkler system pipes for the 1932 building dry sprinkler system riser was conducted. Based on an interview with the director of plant operations on 01/07/10 at 10:30 a.m., the director of plant operations indicated a 01/07/10 phone conversation with the inspection company at 9:00 a.m. verified an internal pipe inspection of the 1932 building dry sprinkler riser had never been conducted.