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Based on observation the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with the LSC sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4. This deficient practice could potentially affect all occupants of the facility Findings include:
On 06/07/2010, the following observations were made:

-At approximately 10:21 AM observed a penetration by a 3/4"conduit without fire stopping on the corridor wall above the door to the mechanical room 3rd floor across from room 325. The Maintenance Director witnessed this penetration.
-At approximately 10:35AM observed a large penetration approximately 2'x3'. The penetration appears to be two types of fire stopping material used, the material in use could not be identified as fire rated. The Director of Maintenance advised that the facility did not have any documentation to support an engineering judgment. The penetration is above the door to a storage room labeled Materials Management across from room 324.
-At approximately 10:39 AM observed an approximately 2" hole in the corridor wall next to room 335 above the ceiling. This was witnessed by the Maintenance Director.
-At approximately 11:11 AM observed a penetration by a 3/4"conduit without fire stopping in the smoke barrier wall behind the nurse's station. The pipe was also opened. This was witnessed by the Maintenance Director
-At approximately 11:18 AM observed a penetration by a 3/4"conduit and 5 data cables without fire rated stopping material, 3rd floor above the gas valve shut down panel, behind the nurse's station. Witnessed by the Maintenance Director.
-At approximately 11:25 AM observed above the soiled utility room door, a 2'x 5' penetration of the corridor wall, also witnessed by the Maintenance Director.

Based on observation the facility failed to provide a fire alarm system in accordance with the LSC section 9.6.1.4. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 06/08/2010 , the following observations were made:
-At approximately 12:10 PM observed through staff interviews that records for the annual Fire Alarm Inspection and test by a certified firm were unavailable. The Maintenance Director is aware of this finding.

Based on observation and/or review of records the facility failed to provide and/or maintain a sprinkler system in accordance with the LSC section 19.3.5. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 06/08/2010, the following observations were made:
-At approximately 10:12 AM observed at missing escutcheon plate in the hallway leading into the North Sprinkler riser room. This was observed by the Maintenance Director.
-At approximately 10:15 AM observed that the sprinkler riser had no hydraulic name plate. This was observed by the Maintenance Director.
-At approximately 10:21 AM observed that the spare sprinkler box did not have at least two spare sprinkler heads for each type, in particular a 386 degree head and a 256 degree sprinkler head.
-At approximately 10:29 AM observed that sprinkler heads above the temperature of 163 Degree Fahrenheit shall be tested every five rears NFPA 25 1998 Edition Chapter 2.3.1.1-Exception No. 3. The Maintenance Director indicated that records for these type heads were unavailable.
-At approximately 11: 03 AM observed through record review and staff interview that the Annual Sprinkler System test/inspection by a certified firm was unavailable. The Maintenance Director was informed of this missing documentation.

The facility failed to maintain the emergency generator in accordance with NFPA 110.

NFPA 110 SEC. 6.4.1 AND 6.4.2, LEVEL 1 AND LEVEL 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. This deficient practice could potentially affect all occupants of the facility.

Findings Include:


On 06/08/2010, the following observations were made:
-At approximately 09:37 AM through record review of the annual inspection by Cummins Bridgeway, it was noted the generator needs new belts, vent lines, air cleaner, coolant hoses, and the coolant changed. The Inspection was done on 2/18/2010 , Maintenance Director witnessed these documents.

Based on observation the facility failed to provide the electrical system in accordance with the LSC section 9.1.2. This deficient practice could potentially affect all occupants of the facility.

Findings include:

On 06/07/2010, the following observations were made:
-At approximately 11:45 AM observed two electrical boxes open above the ceiling near the soiled utility room, this was witnessed by the Maintenance Director.
-At approximately 12:15 PM observed an open electrical box over the East Fire/Smoke doors 3rd floor, this was witnessed by the Maintenance Director.