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Based on observation and interview, the facility failed to ensure 1 of 1 basement room in the 1972 nonsprinklered basement addition was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or meet an Exception. LSC 19.3.6.1 Exception No. 6: Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4; and
(b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arranged that a fully developed fire is unlikely to occur; and
(c) The area does not obstruct access to required exits.
This deficient practice could affect any number of patients using the basement cafeteria as well as staff or visitors in the vicinity of this area.

Findings include:

Based on observation with the maintenance supervisor on 01/26/15 at 10:50 a.m., the basement jail cooler room was open to the corridor and the corridor was protected by an electrically supervised automatic detection system but the individual space was not. Furthermore, the open room was used to store two metal refrigerators and had no other storage. Based on interview at the time of observation, the maintenance supervisor acknowledged the jail cooler room was not protected by automatic smoke detectors. This was acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

Based on observation and interview, the facility failed to ensure 2 of over 20 corridor doors on the second floor would resist the passage of smoke and close and latch into the door frame. This deficient practice could affects eight patients, staff and visitors on the second floor.

Findings includes:

Based on observations with the maintenance technician during a tour of the second floor from 11:40 a.m. to 1:10 p.m. on 01/26/15, one 1/4 inch in diameter hole was noted by the door handle in the corridor door to the second floor Doctor's Dictation area and four 1/4 inch in diameter holes were noted by the door handle in the corridor door to Room 208 which would each fail to resist the passage of smoke. This was verified by the maintenance technician at the time of observations acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

Based on observations and interview, the facility failed to ensure the smoke barriers in 1 of 1 basement ceiling and 2 of 12 smoke barrier walls above the smoke barrier doors were constructed to provide at least a one half hour fire resistance rating. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect any number of patients using the basement cafeteria as well as staff or visitors in the vicinity of this area and twenty patients who use the first floor therapy area.

Findings include:

Based on observations with the maintenance supervisor and maintenance technician during a tour of the basement and first floor on 01/26/15 from 10:30 a.m. to 2:45 p.m., the following locations had ceiling and attic smoke barrier penetrations not firestopped or missing drywall;
1. The basement maintenance workshop ceiling had three electrical conduit penetrations with and one cable bundle penetration with one half inch to three inch gaps not fire stopped.
2. The basement jail cooler room ceiling had a one and one half foot by six inch rectangular area of drywall missing around the furnace plenum.
3. The basement sprinkler riser room ceiling had a six inch by two inch rectangular area of drywall missing.
4. The basement cafeteria ceiling had a two inch gap around a soda pop ceiling penetration not fire stopped.
5. The basement emergency generator pump room ceiling had three electrical conduit penetrations with two inch gaps not fire stopped.
6. The basement kitchen smoke barrier wall above the set of smoke barrier doors had a two inch gap around an electrical conduit penetration not fire stopped.
7. The first floor smoke barrier above the therapy room smoke barrier door had six, one inch to two inch gaps around electrical conduit penetrations not fire stopped and a three inch diameter circular area of drywall missing.
The above listed basement and first floor ceiling penetrations not fire stopped and missing drywall was verified by the maintenance supervisor and maintenance technician at the time of observations and acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

1. Based on observation and interview, the facility failed to ensure 3 of 7 hazardous areas such as a soiled linen room, trash collection room, and kitchen, were separated from other areas by self closing doors or provided with latching hardware. Doors to hazardous areas are self closing or close automatically upon activation of the fire alarm system. This deficient practice could affect 8 patients, staff and visitors on the second floor and any number of patients using the basement cafeteria as well as staff or visitors in the vicinity of this area.

Findings include:

Based on observations with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, the corridor door to the second floor Biohazard Room by Outpatient Surgery and the corridor door to the soiled utility room by the Drug Room on the second floor were each not equipped with a self closing device. Furthermore, based on observation at 10:30 a.m. on 01/26/15 with the maintenance supervisor, the maintenance corridor kitchen set of doors lacked latching hardware and had a one inch gap from the bottom to the center of the doors in the closed position. This was verified by the maintenance supervisor and maintenance technician at the time of observations and acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

2. Based on observation and interview, the facility failed to ensure 3 of 5 hazardous areas such as a soiled linen room, trash collection room, and kitchen, were separated from other areas by one hour rated construction. This deficient practice could affect 8 patients, staff and visitors on the first floor and any number of patients using the basement cafeteria as well as staff or visitors in the vicinity of this area.

Findings include:

Based on observations with the maintenance technician and maintenance supervisor during a tour of the facility from 10:20 a.m. to 3:00 p.m. on 01/26/15, the following basement and first floor hazardous areas had either missing drywall or ceiling penetrations not fire stopped;
1. The basement kitchen ceiling had three, one inch circular areas of drywall missing near the oven hood.
2. The basement little boiler room ceiling had eight metal beam penetrations with two inch gaps not fire stopped.
3. The first floor trash room had a one inch annular space surrounding a four inch in diameter pipe which penetrated the ceiling.
4. The first floor soiled linen chute room had a one inch circular gap around a four inch water pipe not fire stopped.
This was verified by the maintenance supervisor and maintenance technician at the time of observations and acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

1. Based on observation and interview, the facility failed to ensure the means of egress through 1 of 4 second floor exits were readily accessible for patients without a clinical diagnosis requiring specialized security measures. LSC 19.2.2.2.4 requires doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side. Exception No. 1 states door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. This deficient practice could affect 8 patients, staff and visitors.

Findings include:

Based on observation with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, the second floor stairwell exit by Room 218 was marked as a facility exit to the public way, the exit door was magnetically locked and could be opened by entering a four digit code but the code was not posted. Based on interview at the time of observation, the maintenance technician stated not all patients on the second floor have a clinical diagnosis requiring specialized security measures and acknowledged the four digit code was not posted at the second floor stairwell exit by Room 218.

2. Based on observation and interview, the facility failed to provide 15 of over 50 corridor room doors with not more than one releasing operation. LSC Section 7.2.1.5.4 states a latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches, and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. Section A.7.2.1.5.4 states examples of devices that might be arranged to release latches include knobs, levers, and panic bars. This deficient practice could affect 2 patients, staff and visitors.

Findings include:

Based on observations with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, each of the following corridor doors were equipped with a door handle and a separate deadbolt which could be locked from the corridor side but not unlocked from the room side of the door:
a. Patient Billing and Billing Printing Room on the first floor.
b. Room 202, Room 206, Biohazard Room by Outpatient Surgery and the Respiratory Therapy Office on the second floor.
c. Payroll Office, Infection Prevention & Quality Liaison Office, Data Analyst & Clinical Information Specialist Office, Lead Quality & Safety Programs Liaison Office, Dumbwaiter Room, Accounts Payable Office, VP of Finance/CFO Office, Air Handler Room and Education Director's Office on the third floor. Based on interview at the time of the observations, the maintenance technician acknowledged the aforementioned corridor doors each required more than one releasing operation to open the door and could not be unlocked from the room side of the door if the deadbolt was locked.

Based on observation and interview, the facility failed to ensure 1 of 16 basement exit signs was continuously illuminated. This deficient practice could affect any number of patients using the basement cafeteria as well as staff or visitors in the vicinity of this area.

Findings include:

Based on observation with the maintenance supervisor on 01/26/15 at 11:50 a.m., the exit sign located at the basement stairwell in the maintenance corridor was not illuminated. Based on interview at the time of observation, the maintenance supervisor indicated the light bulb was burned out. This was acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

Based on record review and interview, the facility failed to conduct quarterly fire drills on all shifts for 1 of 4 quarters over the past year. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on review of Fire Drill Observation Checklists with the maintenance supervisor on 01/26/15 at 9:20 a.m., there was no fire drill documentation for the third shift, second quarter of the year 2014. Additionally, based on interview with the maintenance supervisor during the review of the Fire Drill Observation Checklists, there was no other documentation available for review to verify this drill was conducted. This was verified by the maintenance supervisor at the time of record review and acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

Based on observation and interview, the facility failed to maintain 1 of over 25 smoke detectors in accordance with NFPA 72. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, smoke detectors shall not be located where airflow prevents operation of the detectors. NFPA 72, A-2-3.5.1 explains smoke detectors should not be located in a direct airflow nor closer than 3 feet from an air supply diffuser or return air opening. This deficient practice could affect 8 residents, staff and visitors in the vicinity of Room 216.

Findings include:

Based on observation with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, the smoke detector mounted on the ceiling in the corridor outside Room 216 was located eight inches from an air supply vent. Based on interview at the time of observation, the maintenance technician acknowledged the aforementioned smoke detector was located on the ceiling less than three feet from an air supply vent.

Based on observation and interview, the facility failed to ensure 6 of 6 cubicle curtains in the Outpatient Surgery area were flame resistant. This deficient practice could affect six patients, staff and visitors.

Findings include:

Based on observations with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, six cubicle curtains installed in the Outpatient Surgery had no affixed documentation stating each curtain was inherently flame retardant. Based on interview at the time of the observations, the maintenance technician stated the Outpatient Surgery cubicle curtains had not been treated with a flame retardant material and acknowledged Outpatient Surgery cubicle curtain flame resistant documentation was not available for review.

Based on observation and interview, the facility failed to maintain relative humidity of equal to or greater than 35% in two of three operating rooms where general anesthesia is utilized. This deficient practice could affect two patients.

Findings include:

Based on observations with the maintenance technician and the Director of Operating Rooms during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, two of three operating rooms where general anesthesia is used and relative humidity is monitored did not maintain relative humidity of equal to or greater than 35%. At the time of the tour, Operating Room 1 was at 25.8% and Operating Room 2 was at 27.2% relative humidity. Based on interview at the time of the observations, the Director of Operating Rooms stated patients in Operating Room 1 and Operating Room 2 can be sedated using general anesthesia and acknowledged each operating room's relative humidity was not maintained equal to or greater than 35%.

1. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
1. Low lubricating oil pressure.
2. Low water temperature.
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overcrank (failed to start).
6. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur but need not display these conditions individually. This deficient practice could affect all the patients as well as visitors and staff.

Findings include:

Based on observation on 01/26/15 at 1:40 p.m. during a tour of the first floor with the maintenance supervisor, the first floor overnight security office was not provided with a remote alarm annunciator for the two emergency generators in a location readily observed by operating personnel at a regular work station such as a nurses' station. Based on an interview with the maintenance supervisor at the time of observation, it was indicated the facility does not have a remote alarm annunciator for the two emergency generators any where in the facility. The lack of remote alarm annunciator's for the two emergency generators was verified by maintenance supervisor at the time of observation and acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

2. Based on observation 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 shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants in the facility.

Findings include:

Based on observations on 01/26/15 at 2:20 p.m. during a tour of the two emergency generators with the maintenance supervisor, the two emergency generators lacked a remote shut off device. Based on interview with the maintenance supervisor on 01/26/15 at 2:30 p.m. while at the generators, the maintenance supervisor indicated the generators were over 150 Horsepower and verified there was no remote shut off device for the two generators. This was acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

Based on observation and interview, the facility failed to ensure 3 of 3 extension cords including power strips were not used as a substitute for fixed wiring. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect 8 residents, staff and visitors.

Findings include:

Based on observations with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, the following was noted:
a. a microwave oven was plugged into a power strip in the second floor Breakroom.
b. a microwave oven was plugged into a power strip in the third floor Accounts Payable Office.
c. a coffee pot was plugged into a power strip in the third floor Human Resources Office kitchenette.
Based on interview at the time of the observations, the maintenance technician acknowledged a power strip was being used as a substitute for fixed wiring at the aforementioned locations.

Based on observation and interview, the facility failed to ensure 1 of 1 basement room in the 1972 nonsprinklered basement addition was separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building, or meet an Exception. LSC 19.3.6.1 Exception No. 6: Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be permitted to be open to the corridor and unlimited in area, provided that the following criteria are met:
(a) The space and the corridors onto which it opens, where located in the same smoke compartment, are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4; and
(b) Each space is protected by automatic sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimum quantity and arranged that a fully developed fire is unlikely to occur; and
(c) The area does not obstruct access to required exits.
This deficient practice could affect any number of patients using the basement cafeteria as well as staff or visitors in the vicinity of this area.

Findings include:

Based on observation with the maintenance supervisor on 01/26/15 at 10:50 a.m., the basement jail cooler room was open to the corridor and the corridor was protected by an electrically supervised automatic detection system but the individual space was not. Furthermore, the open room was used to store two metal refrigerators and had no other storage. Based on interview at the time of observation, the maintenance supervisor acknowledged the jail cooler room was not protected by automatic smoke detectors. This was acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

Based on observation and interview, the facility failed to ensure 2 of over 20 corridor doors on the second floor would resist the passage of smoke and close and latch into the door frame. This deficient practice could affects eight patients, staff and visitors on the second floor.

Findings includes:

Based on observations with the maintenance technician during a tour of the second floor from 11:40 a.m. to 1:10 p.m. on 01/26/15, one 1/4 inch in diameter hole was noted by the door handle in the corridor door to the second floor Doctor's Dictation area and four 1/4 inch in diameter holes were noted by the door handle in the corridor door to Room 208 which would each fail to resist the passage of smoke. This was verified by the maintenance technician at the time of observations acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

Based on observations and interview, the facility failed to ensure the smoke barriers in 1 of 1 basement ceiling and 2 of 12 smoke barrier walls above the smoke barrier doors were constructed to provide at least a one half hour fire resistance rating. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect any number of patients using the basement cafeteria as well as staff or visitors in the vicinity of this area and twenty patients who use the first floor therapy area.

Findings include:

Based on observations with the maintenance supervisor and maintenance technician during a tour of the basement and first floor on 01/26/15 from 10:30 a.m. to 2:45 p.m., the following locations had ceiling and attic smoke barrier penetrations not firestopped or missing drywall;
1. The basement maintenance workshop ceiling had three electrical conduit penetrations with and one cable bundle penetration with one half inch to three inch gaps not fire stopped.
2. The basement jail cooler room ceiling had a one and one half foot by six inch rectangular area of drywall missing around the furnace plenum.
3. The basement sprinkler riser room ceiling had a six inch by two inch rectangular area of drywall missing.
4. The basement cafeteria ceiling had a two inch gap around a soda pop ceiling penetration not fire stopped.
5. The basement emergency generator pump room ceiling had three electrical conduit penetrations with two inch gaps not fire stopped.
6. The basement kitchen smoke barrier wall above the set of smoke barrier doors had a two inch gap around an electrical conduit penetration not fire stopped.
7. The first floor smoke barrier above the therapy room smoke barrier door had six, one inch to two inch gaps around electrical conduit penetrations not fire stopped and a three inch diameter circular area of drywall missing.
The above listed basement and first floor ceiling penetrations not fire stopped and missing drywall was verified by the maintenance supervisor and maintenance technician at the time of observations and acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

1. Based on observation and interview, the facility failed to ensure 3 of 7 hazardous areas such as a soiled linen room, trash collection room, and kitchen, were separated from other areas by self closing doors or provided with latching hardware. Doors to hazardous areas are self closing or close automatically upon activation of the fire alarm system. This deficient practice could affect 8 patients, staff and visitors on the second floor and any number of patients using the basement cafeteria as well as staff or visitors in the vicinity of this area.

Findings include:

Based on observations with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, the corridor door to the second floor Biohazard Room by Outpatient Surgery and the corridor door to the soiled utility room by the Drug Room on the second floor were each not equipped with a self closing device. Furthermore, based on observation at 10:30 a.m. on 01/26/15 with the maintenance supervisor, the maintenance corridor kitchen set of doors lacked latching hardware and had a one inch gap from the bottom to the center of the doors in the closed position. This was verified by the maintenance supervisor and maintenance technician at the time of observations and acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

2. Based on observation and interview, the facility failed to ensure 3 of 5 hazardous areas such as a soiled linen room, trash collection room, and kitchen, were separated from other areas by one hour rated construction. This deficient practice could affect 8 patients, staff and visitors on the first floor and any number of patients using the basement cafeteria as well as staff or visitors in the vicinity of this area.

Findings include:

Based on observations with the maintenance technician and maintenance supervisor during a tour of the facility from 10:20 a.m. to 3:00 p.m. on 01/26/15, the following basement and first floor hazardous areas had either missing drywall or ceiling penetrations not fire stopped;
1. The basement kitchen ceiling had three, one inch circular areas of drywall missing near the oven hood.
2. The basement little boiler room ceiling had eight metal beam penetrations with two inch gaps not fire stopped.
3. The first floor trash room had a one inch annular space surrounding a four inch in diameter pipe which penetrated the ceiling.
4. The first floor soiled linen chute room had a one inch circular gap around a four inch water pipe not fire stopped.
This was verified by the maintenance supervisor and maintenance technician at the time of observations and acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

1. Based on observation and interview, the facility failed to ensure the means of egress through 1 of 4 second floor exits were readily accessible for patients without a clinical diagnosis requiring specialized security measures. LSC 19.2.2.2.4 requires doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side. Exception No. 1 states door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. This deficient practice could affect 8 patients, staff and visitors.

Findings include:

Based on observation with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, the second floor stairwell exit by Room 218 was marked as a facility exit to the public way, the exit door was magnetically locked and could be opened by entering a four digit code but the code was not posted. Based on interview at the time of observation, the maintenance technician stated not all patients on the second floor have a clinical diagnosis requiring specialized security measures and acknowledged the four digit code was not posted at the second floor stairwell exit by Room 218.

2. Based on observation and interview, the facility failed to provide 15 of over 50 corridor room doors with not more than one releasing operation. LSC Section 7.2.1.5.4 states a latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches, and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. Section A.7.2.1.5.4 states examples of devices that might be arranged to release latches include knobs, levers, and panic bars. This deficient practice could affect 2 patients, staff and visitors.

Findings include:

Based on observations with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, each of the following corridor doors were equipped with a door handle and a separate deadbolt which could be locked from the corridor side but not unlocked from the room side of the door:
a. Patient Billing and Billing Printing Room on the first floor.
b. Room 202, Room 206, Biohazard Room by Outpatient Surgery and the Respiratory Therapy Office on the second floor.
c. Payroll Office, Infection Prevention & Quality Liaison Office, Data Analyst & Clinical Information Specialist Office, Lead Quality & Safety Programs Liaison Office, Dumbwaiter Room, Accounts Payable Office, VP of Finance/CFO Office, Air Handler Room and Education Director's Office on the third floor. Based on interview at the time of the observations, the maintenance technician acknowledged the aforementioned corridor doors each required more than one releasing operation to open the door and could not be unlocked from the room side of the door if the deadbolt was locked.

Based on observation and interview, the facility failed to ensure 1 of 16 basement exit signs was continuously illuminated. This deficient practice could affect any number of patients using the basement cafeteria as well as staff or visitors in the vicinity of this area.

Findings include:

Based on observation with the maintenance supervisor on 01/26/15 at 11:50 a.m., the exit sign located at the basement stairwell in the maintenance corridor was not illuminated. Based on interview at the time of observation, the maintenance supervisor indicated the light bulb was burned out. This was acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

Based on record review and interview, the facility failed to conduct quarterly fire drills on all shifts for 1 of 4 quarters over the past year. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on review of Fire Drill Observation Checklists with the maintenance supervisor on 01/26/15 at 9:20 a.m., there was no fire drill documentation for the third shift, second quarter of the year 2014. Additionally, based on interview with the maintenance supervisor during the review of the Fire Drill Observation Checklists, there was no other documentation available for review to verify this drill was conducted. This was verified by the maintenance supervisor at the time of record review and acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

Based on observation and interview, the facility failed to maintain 1 of over 25 smoke detectors in accordance with NFPA 72. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, smoke detectors shall not be located where airflow prevents operation of the detectors. NFPA 72, A-2-3.5.1 explains smoke detectors should not be located in a direct airflow nor closer than 3 feet from an air supply diffuser or return air opening. This deficient practice could affect 8 residents, staff and visitors in the vicinity of Room 216.

Findings include:

Based on observation with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, the smoke detector mounted on the ceiling in the corridor outside Room 216 was located eight inches from an air supply vent. Based on interview at the time of observation, the maintenance technician acknowledged the aforementioned smoke detector was located on the ceiling less than three feet from an air supply vent.

Based on observation and interview, the facility failed to ensure 6 of 6 cubicle curtains in the Outpatient Surgery area were flame resistant. This deficient practice could affect six patients, staff and visitors.

Findings include:

Based on observations with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, six cubicle curtains installed in the Outpatient Surgery had no affixed documentation stating each curtain was inherently flame retardant. Based on interview at the time of the observations, the maintenance technician stated the Outpatient Surgery cubicle curtains had not been treated with a flame retardant material and acknowledged Outpatient Surgery cubicle curtain flame resistant documentation was not available for review.

Based on observation and interview, the facility failed to maintain relative humidity of equal to or greater than 35% in two of three operating rooms where general anesthesia is utilized. This deficient practice could affect two patients.

Findings include:

Based on observations with the maintenance technician and the Director of Operating Rooms during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, two of three operating rooms where general anesthesia is used and relative humidity is monitored did not maintain relative humidity of equal to or greater than 35%. At the time of the tour, Operating Room 1 was at 25.8% and Operating Room 2 was at 27.2% relative humidity. Based on interview at the time of the observations, the Director of Operating Rooms stated patients in Operating Room 1 and Operating Room 2 can be sedated using general anesthesia and acknowledged each operating room's relative humidity was not maintained equal to or greater than 35%.

1. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
1. Low lubricating oil pressure.
2. Low water temperature.
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overcrank (failed to start).
6. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur but need not display these conditions individually. This deficient practice could affect all the patients as well as visitors and staff.

Findings include:

Based on observation on 01/26/15 at 1:40 p.m. during a tour of the first floor with the maintenance supervisor, the first floor overnight security office was not provided with a remote alarm annunciator for the two emergency generators in a location readily observed by operating personnel at a regular work station such as a nurses' station. Based on an interview with the maintenance supervisor at the time of observation, it was indicated the facility does not have a remote alarm annunciator for the two emergency generators any where in the facility. The lack of remote alarm annunciator's for the two emergency generators was verified by maintenance supervisor at the time of observation and acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

2. Based on observation 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 shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants in the facility.

Findings include:

Based on observations on 01/26/15 at 2:20 p.m. during a tour of the two emergency generators with the maintenance supervisor, the two emergency generators lacked a remote shut off device. Based on interview with the maintenance supervisor on 01/26/15 at 2:30 p.m. while at the generators, the maintenance supervisor indicated the generators were over 150 Horsepower and verified there was no remote shut off device for the two generators. This was acknowledged by the director of maintenance at the exit conference on 01/26/15 at 3:00 p.m.

Based on observation and interview, the facility failed to ensure 3 of 3 extension cords including power strips were not used as a substitute for fixed wiring. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect 8 residents, staff and visitors.

Findings include:

Based on observations with the maintenance technician during a tour of the facility from 11:00 a.m. to 2:10 p.m. on 01/26/15, the following was noted:
a. a microwave oven was plugged into a power strip in the second floor Breakroom.
b. a microwave oven was plugged into a power strip in the third floor Accounts Payable Office.
c. a coffee pot was plugged into a power strip in the third floor Human Resources Office kitchenette.
Based on interview at the time of the observations, the maintenance technician acknowledged a power strip was being used as a substitute for fixed wiring at the aforementioned locations.