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Based on observation and interview, the facility failed to ensure 1 of 16 patient room corridor doors closed and latched into the door frame. This deficient practice could affect 1 of 9 patients.

Findings include:

Based on observation with the Administrator and the Maintenance Foreman on 05/14/14 at 2:05 p.m., the corridor door to patient room 111 failed to latch into the door frame. This was acknowledged by the Maintenance Foreman at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 7 exit access corridors was readily accessible and unobstructed at all times. This deficient practice could affect patients evacuated through the 100 hall in the event of an emergency.

Findings include:

Based on an observation with the Administrator, the Maintenance Foreman and the Maintenance Coordinator on 05/14/14 at 2:25 p.m., when exiting from the inpatient unit into the 100 hall there was a copier, file cabinet and a table stored in the 100 hall corridor. The was acknowledged by the Administrator and the Maintenance Foreman at the time of observation.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 3 of the last 4 completed quarters. This deficient practice could affect all occupants.

Findings include:

Based on record review of the "Fire Drill Report Form" with the Administrator on 05/14/14 at 12:30 p.m., a fire drill had not been conducted for the following:
a. first, second and third shifts for the fourth quarter of 2013.
b. first and second shifts for the third quarter of 2013
c. first, second and third shifts for the second quarter of 2013.
Based on an interview with the Administrator at the time of record review, he acknowledged the facility had not conducted the required number of fire drills.

Based on record review and interview, the facility failed to ensure sprinkler waterflow alarm devices were tested quarterly for 1 of 4 quarters. LSC 4.5.7 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance. LSC 4.6.12 requires maintenance and testing of the automatic sprinkler system are made at specified intervals in accordance with applicable NFPA standards. NFPA 25, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, at 2-3.3 requires waterflow alarm devices including, but not limited to, mechanical water motor gongs, and pressure switches provide audible or visual signals shall be tested quarterly. Vane type waterflow devices may be tested semi-annually. NFPA 25, 9-4.4.2.1 requires the priming level shall be tested quarterly. NFPA 25, 9-7.1 requires the fire department connections shall be inspected quarterly. NFPA 25, 1-8.1 requires records shall indicate the procedure performed (inspection, test, or maintenance), the organization performed the work, the results and the date. Finally, NFPA 25, 1-8 requires records of inspection, test, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to valve inspections, flow, drain, and pump tests; and trip tests of dry pipe, deluge and preaction valves. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Administrator, the Maintenance Foreman and the Maintenance Coordinator on 05/14/14 at 2:15 p.m., the facility was unable to provide documentation of a sprinkler inspection for the third quarter of 2013. After a telephone call was placed to the sprinkler inspection company, SimplexGrinnell, it was confirmed by the Maintenance Coordinator that a sprinkler inspection had not been conducted in the third quarter of 2013.

Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 8 of the last 12 months. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating conditions or not less than 30 percent of the EPS nameplate rating, whichever is greater, at least monthly, for a minimum of 30 minutes. NFPA 99, Section 3-4.1.1.8 states the generator set shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

a. Based on record review of the untitled generator log with the Maintenance Foreman and the Maintenance Coordinator on 05/14/14 at 12:40 p.m., a generator load test was conducted quarterly. Based on an interview with the Maintenance Foreman at the time of record review, he thought the facility was only required to do a quarterly load test.
b. Based on record review of the untitled generator log with the Maintenance Foreman and the Maintenance Coordinator on 05/14/14 at 12:42 p.m., the emergency generator was tested quarterly under load for at least 30 minutes, however, the load test record did not include the time for the transfer of power from the main source to the generator, the amps and the volts. This was acknowledged by the Maintenance Foreman.

Based on observation and interview, the facility failed to ensure 1 of 16 patient room corridor doors closed and latched into the door frame. This deficient practice could affect 1 of 9 patients.

Findings include:

Based on observation with the Administrator and the Maintenance Foreman on 05/14/14 at 2:05 p.m., the corridor door to patient room 111 failed to latch into the door frame. This was acknowledged by the Maintenance Foreman at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 7 exit access corridors was readily accessible and unobstructed at all times. This deficient practice could affect patients evacuated through the 100 hall in the event of an emergency.

Findings include:

Based on an observation with the Administrator, the Maintenance Foreman and the Maintenance Coordinator on 05/14/14 at 2:25 p.m., when exiting from the inpatient unit into the 100 hall there was a copier, file cabinet and a table stored in the 100 hall corridor. The was acknowledged by the Administrator and the Maintenance Foreman at the time of observation.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 3 of the last 4 completed quarters. This deficient practice could affect all occupants.

Findings include:

Based on record review of the "Fire Drill Report Form" with the Administrator on 05/14/14 at 12:30 p.m., a fire drill had not been conducted for the following:
a. first, second and third shifts for the fourth quarter of 2013.
b. first and second shifts for the third quarter of 2013
c. first, second and third shifts for the second quarter of 2013.
Based on an interview with the Administrator at the time of record review, he acknowledged the facility had not conducted the required number of fire drills.

Based on record review and interview, the facility failed to ensure sprinkler waterflow alarm devices were tested quarterly for 1 of 4 quarters. LSC 4.5.7 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance. LSC 4.6.12 requires maintenance and testing of the automatic sprinkler system are made at specified intervals in accordance with applicable NFPA standards. NFPA 25, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, at 2-3.3 requires waterflow alarm devices including, but not limited to, mechanical water motor gongs, and pressure switches provide audible or visual signals shall be tested quarterly. Vane type waterflow devices may be tested semi-annually. NFPA 25, 9-4.4.2.1 requires the priming level shall be tested quarterly. NFPA 25, 9-7.1 requires the fire department connections shall be inspected quarterly. NFPA 25, 1-8.1 requires records shall indicate the procedure performed (inspection, test, or maintenance), the organization performed the work, the results and the date. Finally, NFPA 25, 1-8 requires records of inspection, test, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to valve inspections, flow, drain, and pump tests; and trip tests of dry pipe, deluge and preaction valves. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Administrator, the Maintenance Foreman and the Maintenance Coordinator on 05/14/14 at 2:15 p.m., the facility was unable to provide documentation of a sprinkler inspection for the third quarter of 2013. After a telephone call was placed to the sprinkler inspection company, SimplexGrinnell, it was confirmed by the Maintenance Coordinator that a sprinkler inspection had not been conducted in the third quarter of 2013.

Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 8 of the last 12 months. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, chapter 6-4.2. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised under operating conditions or not less than 30 percent of the EPS nameplate rating, whichever is greater, at least monthly, for a minimum of 30 minutes. NFPA 99, Section 3-4.1.1.8 states the generator set shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

a. Based on record review of the untitled generator log with the Maintenance Foreman and the Maintenance Coordinator on 05/14/14 at 12:40 p.m., a generator load test was conducted quarterly. Based on an interview with the Maintenance Foreman at the time of record review, he thought the facility was only required to do a quarterly load test.
b. Based on record review of the untitled generator log with the Maintenance Foreman and the Maintenance Coordinator on 05/14/14 at 12:42 p.m., the emergency generator was tested quarterly under load for at least 30 minutes, however, the load test record did not include the time for the transfer of power from the main source to the generator, the amps and the volts. This was acknowledged by the Maintenance Foreman.