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Based on observation and interview, the facility failed to ensure doors protecting corridor openings in 2 of 12 smoke compartments could automatically latch into the door frame. This deficient practice affects staff, visitors and 10 or more patients in the administrative wing and patient care unit.

Findings include:

Based on observation with the maintenance director on 05/15/14 between 12:30 p.m. and 3:00 p.m., the double door sets providing access to the following areas did not latch automatically into the door frames:
a. the door sets providing access to the conference room and medical records storage room each required one door to latch into the door frame with a manual flush bolt before the second door would latch into the first door and secure them both tightly into their door frames;
b. the door set providing access to the A unit activity room had a double door set without any automatic latch. The door set relied on a key operated deadbolt to secure it tightly into the door frame.
The maintenance director acknowledged at the time of observations, the doors could not latch automatically into their door frames.

1. Based on observation and interview, the facility failed to ensure doors in 3 of 12 smoke barrier door sets were held open only by a device which would allow it to close upon activation of the fire alarm system. This deficient practice could affect staff, visitors, and 10 or more patients on the first and second floors.

Findings include:

Based on observation with the maintenance director on 05/15/14 between 12:30 p.m. and 3:00 p.m., one door in each of the smoke barrier double door sets near the first floor conference room, near A119 and near the second floor activities room failed to close when tested twice to ensure their proper operation. The door coordinators on each door frame held the door with the astragal open, the second door closed and the coordinators failed to release the first doors leaving six inch gaps. The maintenance director acknowledged at the time of observations, the coordinators were malfunctioning.

2. Based on observation and interview, the facility failed to ensure 2 of 4 self closing doors to hazardous areas, such as a kitchen, were held open only by devices which would allow the doors to close upon activation of the fire alarm system. This deficient practice affects visitors, staff and 10 or more patients.

Findings include:

Based on observation with the maintenance director on 05/15/14 at 1:55 p.m., two self closing doors between the food service area and the kitchen stood wide open. Both doors were equipped self closers which, when the doors were pushed wide open, had a feature on the self closers which prevented the doors from closing without being pulled closed. The maintenance supervisor acknowledged at the time of observation, the doors would not automatically close when opened fully.

Based on observation and interview, the facility failed to provide automatic door closers on 6 of 12 doors providing access to hazardous areas such as a kitchen and hazardous materials storage room. Sprinklered hazardous areas are required to be equipped with self closing doors or with doors that close automatically upon activation of the fire alarm system. Furthermore, doors to hazardous areas are required to latch into the door frame when closed to keep the door tightly closed. This deficient practice could affect visitors, staff and 10 or more patients in the center second floor smoke compartment and first floor dining room.

Findings include:

a. Based on observation with the maintenance director on 05/15/14 at 1:55 p.m., a rolling steel door which protected the three by four foot opening between the kitchen and dining room was not self closing. The maintenance director acknowledged at the time of observation, the door had to be manually closed to provide separation between the two spaces.
b. Based on observation with the maintenance director on 05/15/14 at 2:10 p.m., the biohazard materials storage room on the second floor contained three receptacles one half or more full of soiled linens and trash. The receptacles were each larger than 32 gallons in capacity. The door separating the room from the exit corridor had no self closer. The maintenance director acknowledged at the time of observation, the door would not automatically close.
c. Based on observation with the maintenance director on 05/15/14 at 2:15 p.m., four kitchen access doors equipped with self closers each had no automatic positive latch. Instead the doors were equipped with deadbolt latches which required a key to secure them in their door frames. The maintenance director acknowledged at the time of observations, the doors could not latch automatically to secure them in the door frames.

Based on observation and interview, the facility failed to ensure the discharge means of egress for 1 of 3 grade level exits from the second floor were arranged to be accessible. LSC 7.1.3.2.3 requires an exit enclosure shall not be used for any purpose with the potential to interfere with its use as an exit. LSC 7.1.10.1, "Means of egress shall be continuously free of all obstructions or impediments to full instant use in case of fire or other emergency use." This deficient practice affects staff, visitors and 10 or more patients using second floor level exits to grade from the A unit.

Findings include:

Based on observation with the maintenance director on 05/15/14 at 2:15 p.m., the second floor emergency exterior exit from the A units discharged onto a sidewalk. The path of egress was blocked by picnic tables on the north side of the building. The maintenance director said at the time of observation, the picnic tables were not usually located on the sidewalk, they were probably put there by the mowing crew who had not returned them to keep the exit discharge clear.

Based on record review and interview, the facility failed to provide a complete written fire safety plan addressing all items required by NFPA 101, 2000 edition, Section 19.7.2.2. LSC 19.7.2.2 requires a written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all occupants in the event of an emergency when the written fire plan should be immediately available.

Findings include:

Based on a record review with the maintenance director on 05/15/14 at 3:30 p.m., the Fire Protection plan gave conflicting instruction. Page 2 instructed staff to use the RACE procedure "in the event of fire." The next section of the fire plan titled Specific Instructions In Case Of Fire noted at II., If a small fire, pull alarm, try to extinguish.....; section IV. noted, "If fire of larger area occurs,...." and then gave direction to pull the alarm, close doors and move patients. The maintenance director acknowledged at the time of record review, staff were not trained in fire fighting, there was no such thing as a small fire, and the Specific Instructions conflicted with rescuing patients before any attempt to extinguish a fire they might or might not be able to control. Additionally, the plan failed to identify smoke barriers and the specific evacuation of a smoke compartment, identify the types of fire extinguishers available and address the use of the K-class fire extinguisher located in the kitchen in relationship to activation of the kitchen hood extinguishing system.

Based on record review and interview, the facility failed to conduct fire drills at varied times during 4 of the past 4 quarters. This deficient practice affects all occupants.

Findings include:

Based on a review of monthly Fire Drill Reports with the maintenance director on 05/15/14 at 2:55 p.m., first shift fire drills during the second and third quarters of 2013 were conducted at 2:17 p.m. and 2:00 p.m.; second shift drills during the fourth quarter of 2013 and the first quarter of 2014 were conducted at 3:00 p.m. and 3:10 p.m., third shift drills were conducted at 6:00 a.m., 6:08 a.m. (two quarters), 6:03 a.m., during the second, third, and fourth quarters of 2013 and the first quarter of 2014. The maintenance director acknowledged at the time of record review, there had been little variation in the times for fire drills conducted.

Based on observation and interview, the facility failed to ensure a smoke detector connected to the fire alarm system in 1 of 1 medical records offices was properly separated from an air supply or return vent. NFPA 72, National Fire Alarm Code, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect visitors, staff, and 10 or more patients.

Findings include:

Based on observation with the maintenance director on 05/15/14 at 1:15 p.m., a smoke detector was located 24 inches between two ceiling air vents in the medical records department. The maintenance director confirmed the distance measurement and agreed at the time of observation, the air flow could impede the function of the smoke detector because the vent cover for one of the vents had the louvers directed toward the smoke detector.

Based on record review, observation and interview; the facility failed to electronically supervise 1 of 3 sprinkler system water control valves. LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice could affect all occupants, if the valve was tampered with and not detected.

Findings include:

Based on observation with the maintenance director on 05/15/14 at 2:45 p.m., a sprinkler system water control valve located in the maintenance shop lacked electronic supervision. A review of sprinkler system test and inspection records with the maintenance director on 05/15/14 at 3:05 p.m. revealed the deficiency was noted on a 10/11/13 inspection and test report. The maintenance director acknowledged at the times of observation and record review, there was no electronic supervision of the valve.

1. Based on record review and interview, the facility failed to ensure 1 of 1 range hood's fire extinguishing equipment was inspected and approved every 6 months by properly trained and qualified persons. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 8-2.1 requires the inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire actuated water system shall be made at least every 6 months by properly trained and qualified persons. Furthermore, NFPA 96, 8-2.1.1 requires actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, fire actuated dampers, etc., shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. This deficient practice could affect visitors, staff and 10 or more patients in the adjacent dining room.

Findings include:

Based on a review of contracted Range Hood System Reports with the maintenance director on 05/15/14 at 3:25 p.m., the last inspection and service record for the commercial range hood fire equipment extinguishing system was dated 07/26/13. The record prior to that evidenced inspection and service in 2012. The maintenance director said at the time of record review, he was unaware the time between inspections had exceeded the minimum six months allowed.

2. Based on record review, observation and interview; the facility failed to ensure 1 of 1 kitchen exhaust systems was inspected semiannually. NFPA 96, 1998 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 8-3.1 requires the entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) in accordance with Table 8-3.1. Table 8-3.1, Exhaust System Inspection Schedule, requires systems serving moderate volume cooking operations shall be inspected semiannually. NFPA 96, 8-3.1.1 says, upon inspection, if found to be contaminated with deposits from grease laden vapors, the entire exhaust system shall be cleaned in accordance with Section 8-3. NFPA 8-3.1 requires hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. This deficient practice could affect visitors, staff and 10 or more patients in the adjacent dining room.

Findings include:

Based on review of Pro Clean Exhaust System Cleaning documentation with the maintenance director on 05/15/14 at 3:20 p.m., the last documented inspection and cleaning was done in February 2014. The cleaning was also noted on a sticker affixed to the range hood during a tour with the maintenance director on 05/15/14 at 1:50 p.m. The previous record for the exhaust system cleaning evidenced cleaning in February of 2013. The maintenance director said at the time of observation, if there was no record in the binder containing the records, a six month cleaning/service had not been done.

Based on observation and interview, the facility failed to provide evidence 1 of 1 space heaters was equipped with a heating element which would not exceed 212 degrees Fahrenheit (F). This deficient practice could affect visitors, staff and 10 or more patients.

Findings include:

Based on observation with the maintenance director on 05/15/14 at 12:30 p.m., a space heater was operating at the reception desk. The maintenance director said at the time of observation, he had no evidence the space heater element would not exceed the 212 F degree limit, he thought it was a fan. The receptionist confirmed at the time of observation the device was blowing warm air. During record review on 05/15/14 at 3:10 p.m., the maintenance director said he had no written policy for the use of space heaters but they were generally prohibited everywhere in the building.

1. Based on record review and interview, the facility failed to provide evidence monthly generator load tests were performed for during 11 of the past 12 months using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Generator Check Lists with the maintenance director on 05/15/14 at 3:10 p.m., there were no records of generator load tests for the past year except the preventive maintenance test conducted by the generator contractor on 02/28/14. The maintenance director said at the time of record review, the engineer responsible for performing the tests had taken another job during the past week and he was unable to locate the most recent generator testing information.

2. Based on interview and record review, the facility failed to provide documentation for weekly testing 1 of 1 emergency generators providing power to the emergency lighting systems. LSC 7.9.2.3 and NFPA 99, Health Care Facilities, 3-4.4.1.1(a) requires weekly maintenance of the emergency generator set shall be in accordance with NFPA 110, the Standard for Emergency and Standby Power Systems. NFPA 110, 6-3.6 requires storage batteries used for generator sets in Level 1 and 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of Generator Check Lists with the maintenance director on 05/15/14 at 3:10 p.m., there were no records of weekly generator inspections for the past year except the preventive maintenance test and inspection conducted by the generator contractor on 02/28/14. The maintenance director said at the time of record review, the engineer responsible for performing the tests had taken another job during the past week and he was unable to locate the most recent generator testing information.

Based on observation and interview, the facility failed to ensure doors protecting corridor openings in 2 of 12 smoke compartments could automatically latch into the door frame. This deficient practice affects staff, visitors and 10 or more patients in the administrative wing and patient care unit.

Findings include:

Based on observation with the maintenance director on 05/15/14 between 12:30 p.m. and 3:00 p.m., the double door sets providing access to the following areas did not latch automatically into the door frames:
a. the door sets providing access to the conference room and medical records storage room each required one door to latch into the door frame with a manual flush bolt before the second door would latch into the first door and secure them both tightly into their door frames;
b. the door set providing access to the A unit activity room had a double door set without any automatic latch. The door set relied on a key operated deadbolt to secure it tightly into the door frame.
The maintenance director acknowledged at the time of observations, the doors could not latch automatically into their door frames.

1. Based on observation and interview, the facility failed to ensure doors in 3 of 12 smoke barrier door sets were held open only by a device which would allow it to close upon activation of the fire alarm system. This deficient practice could affect staff, visitors, and 10 or more patients on the first and second floors.

Findings include:

Based on observation with the maintenance director on 05/15/14 between 12:30 p.m. and 3:00 p.m., one door in each of the smoke barrier double door sets near the first floor conference room, near A119 and near the second floor activities room failed to close when tested twice to ensure their proper operation. The door coordinators on each door frame held the door with the astragal open, the second door closed and the coordinators failed to release the first doors leaving six inch gaps. The maintenance director acknowledged at the time of observations, the coordinators were malfunctioning.

2. Based on observation and interview, the facility failed to ensure 2 of 4 self closing doors to hazardous areas, such as a kitchen, were held open only by devices which would allow the doors to close upon activation of the fire alarm system. This deficient practice affects visitors, staff and 10 or more patients.

Findings include:

Based on observation with the maintenance director on 05/15/14 at 1:55 p.m., two self closing doors between the food service area and the kitchen stood wide open. Both doors were equipped self closers which, when the doors were pushed wide open, had a feature on the self closers which prevented the doors from closing without being pulled closed. The maintenance supervisor acknowledged at the time of observation, the doors would not automatically close when opened fully.

Based on observation and interview, the facility failed to provide automatic door closers on 6 of 12 doors providing access to hazardous areas such as a kitchen and hazardous materials storage room. Sprinklered hazardous areas are required to be equipped with self closing doors or with doors that close automatically upon activation of the fire alarm system. Furthermore, doors to hazardous areas are required to latch into the door frame when closed to keep the door tightly closed. This deficient practice could affect visitors, staff and 10 or more patients in the center second floor smoke compartment and first floor dining room.

Findings include:

a. Based on observation with the maintenance director on 05/15/14 at 1:55 p.m., a rolling steel door which protected the three by four foot opening between the kitchen and dining room was not self closing. The maintenance director acknowledged at the time of observation, the door had to be manually closed to provide separation between the two spaces.
b. Based on observation with the maintenance director on 05/15/14 at 2:10 p.m., the biohazard materials storage room on the second floor contained three receptacles one half or more full of soiled linens and trash. The receptacles were each larger than 32 gallons in capacity. The door separating the room from the exit corridor had no self closer. The maintenance director acknowledged at the time of observation, the door would not automatically close.
c. Based on observation with the maintenance director on 05/15/14 at 2:15 p.m., four kitchen access doors equipped with self closers each had no automatic positive latch. Instead the doors were equipped with deadbolt latches which required a key to secure them in their door frames. The maintenance director acknowledged at the time of observations, the doors could not latch automatically to secure them in the door frames.

Based on observation and interview, the facility failed to ensure the discharge means of egress for 1 of 3 grade level exits from the second floor were arranged to be accessible. LSC 7.1.3.2.3 requires an exit enclosure shall not be used for any purpose with the potential to interfere with its use as an exit. LSC 7.1.10.1, "Means of egress shall be continuously free of all obstructions or impediments to full instant use in case of fire or other emergency use." This deficient practice affects staff, visitors and 10 or more patients using second floor level exits to grade from the A unit.

Findings include:

Based on observation with the maintenance director on 05/15/14 at 2:15 p.m., the second floor emergency exterior exit from the A units discharged onto a sidewalk. The path of egress was blocked by picnic tables on the north side of the building. The maintenance director said at the time of observation, the picnic tables were not usually located on the sidewalk, they were probably put there by the mowing crew who had not returned them to keep the exit discharge clear.

Based on record review and interview, the facility failed to provide a complete written fire safety plan addressing all items required by NFPA 101, 2000 edition, Section 19.7.2.2. LSC 19.7.2.2 requires a written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all occupants in the event of an emergency when the written fire plan should be immediately available.

Findings include:

Based on a record review with the maintenance director on 05/15/14 at 3:30 p.m., the Fire Protection plan gave conflicting instruction. Page 2 instructed staff to use the RACE procedure "in the event of fire." The next section of the fire plan titled Specific Instructions In Case Of Fire noted at II., If a small fire, pull alarm, try to extinguish.....; section IV. noted, "If fire of larger area occurs,...." and then gave direction to pull the alarm, close doors and move patients. The maintenance director acknowledged at the time of record review, staff were not trained in fire fighting, there was no such thing as a small fire, and the Specific Instructions conflicted with rescuing patients before any attempt to extinguish a fire they might or might not be able to control. Additionally, the plan failed to identify smoke barriers and the specific evacuation of a smoke compartment, identify the types of fire extinguishers available and address the use of the K-class fire extinguisher located in the kitchen in relationship to activation of the kitchen hood extinguishing system.

Based on record review and interview, the facility failed to conduct fire drills at varied times during 4 of the past 4 quarters. This deficient practice affects all occupants.

Findings include:

Based on a review of monthly Fire Drill Reports with the maintenance director on 05/15/14 at 2:55 p.m., first shift fire drills during the second and third quarters of 2013 were conducted at 2:17 p.m. and 2:00 p.m.; second shift drills during the fourth quarter of 2013 and the first quarter of 2014 were conducted at 3:00 p.m. and 3:10 p.m., third shift drills were conducted at 6:00 a.m., 6:08 a.m. (two quarters), 6:03 a.m., during the second, third, and fourth quarters of 2013 and the first quarter of 2014. The maintenance director acknowledged at the time of record review, there had been little variation in the times for fire drills conducted.

Based on observation and interview, the facility failed to ensure a smoke detector connected to the fire alarm system in 1 of 1 medical records offices was properly separated from an air supply or return vent. NFPA 72, National Fire Alarm Code, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect visitors, staff, and 10 or more patients.

Findings include:

Based on observation with the maintenance director on 05/15/14 at 1:15 p.m., a smoke detector was located 24 inches between two ceiling air vents in the medical records department. The maintenance director confirmed the distance measurement and agreed at the time of observation, the air flow could impede the function of the smoke detector because the vent cover for one of the vents had the louvers directed toward the smoke detector.

Based on record review, observation and interview; the facility failed to electronically supervise 1 of 3 sprinkler system water control valves. LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice could affect all occupants, if the valve was tampered with and not detected.

Findings include:

Based on observation with the maintenance director on 05/15/14 at 2:45 p.m., a sprinkler system water control valve located in the maintenance shop lacked electronic supervision. A review of sprinkler system test and inspection records with the maintenance director on 05/15/14 at 3:05 p.m. revealed the deficiency was noted on a 10/11/13 inspection and test report. The maintenance director acknowledged at the times of observation and record review, there was no electronic supervision of the valve.

1. Based on record review and interview, the facility failed to ensure 1 of 1 range hood's fire extinguishing equipment was inspected and approved every 6 months by properly trained and qualified persons. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 8-2.1 requires the inspection and servicing of the fire extinguishing system and listed exhaust hoods containing a constant or fire actuated water system shall be made at least every 6 months by properly trained and qualified persons. Furthermore, NFPA 96, 8-2.1.1 requires actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, fire actuated dampers, etc., shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. This deficient practice could affect visitors, staff and 10 or more patients in the adjacent dining room.

Findings include:

Based on a review of contracted Range Hood System Reports with the maintenance director on 05/15/14 at 3:25 p.m., the last inspection and service record for the commercial range hood fire equipment extinguishing system was dated 07/26/13. The record prior to that evidenced inspection and service in 2012. The maintenance director said at the time of record review, he was unaware the time between inspections had exceeded the minimum six months allowed.

2. Based on record review, observation and interview; the facility failed to ensure 1 of 1 kitchen exhaust systems was inspected semiannually. NFPA 96, 1998 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 8-3.1 requires the entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) in accordance with Table 8-3.1. Table 8-3.1, Exhaust System Inspection Schedule, requires systems serving moderate volume cooking operations shall be inspected semiannually. NFPA 96, 8-3.1.1 says, upon inspection, if found to be contaminated with deposits from grease laden vapors, the entire exhaust system shall be cleaned in accordance with Section 8-3. NFPA 8-3.1 requires hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. This deficient practice could affect visitors, staff and 10 or more patients in the adjacent dining room.

Findings include:

Based on review of Pro Clean Exhaust System Cleaning documentation with the maintenance director on 05/15/14 at 3:20 p.m., the last documented inspection and cleaning was done in February 2014. The cleaning was also noted on a sticker affixed to the range hood during a tour with the maintenance director on 05/15/14 at 1:50 p.m. The previous record for the exhaust system cleaning evidenced cleaning in February of 2013. The maintenance director said at the time of observation, if there was no record in the binder containing the records, a six month cleaning/service had not been done.

Based on observation and interview, the facility failed to provide evidence 1 of 1 space heaters was equipped with a heating element which would not exceed 212 degrees Fahrenheit (F). This deficient practice could affect visitors, staff and 10 or more patients.

Findings include:

Based on observation with the maintenance director on 05/15/14 at 12:30 p.m., a space heater was operating at the reception desk. The maintenance director said at the time of observation, he had no evidence the space heater element would not exceed the 212 F degree limit, he thought it was a fan. The receptionist confirmed at the time of observation the device was blowing warm air. During record review on 05/15/14 at 3:10 p.m., the maintenance director said he had no written policy for the use of space heaters but they were generally prohibited everywhere in the building.

1. Based on record review and interview, the facility failed to provide evidence monthly generator load tests were performed for during 11 of the past 12 months using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Generator Check Lists with the maintenance director on 05/15/14 at 3:10 p.m., there were no records of generator load tests for the past year except the preventive maintenance test conducted by the generator contractor on 02/28/14. The maintenance director said at the time of record review, the engineer responsible for performing the tests had taken another job during the past week and he was unable to locate the most recent generator testing information.

2. Based on interview and record review, the facility failed to provide documentation for weekly testing 1 of 1 emergency generators providing power to the emergency lighting systems. LSC 7.9.2.3 and NFPA 99, Health Care Facilities, 3-4.4.1.1(a) requires weekly maintenance of the emergency generator set shall be in accordance with NFPA 110, the Standard for Emergency and Standby Power Systems. NFPA 110, 6-3.6 requires storage batteries used for generator sets in Level 1 and 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of Generator Check Lists with the maintenance director on 05/15/14 at 3:10 p.m., there were no records of weekly generator inspections for the past year except the preventive maintenance test and inspection conducted by the generator contractor on 02/28/14. The maintenance director said at the time of record review, the engineer responsible for performing the tests had taken another job during the past week and he was unable to locate the most recent generator testing information.