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Based on findings from observation and interview, 6 out of 8 patient sleeping room doors (for room #s 128, 131, 132, 133, 134, 137) were not operable without using two operations to open the door when the dead bolt was engaged from the patient side of the room.

Findings include:
- Per observations starting at 1:35 pm on 8/14/13, 6 rooms (#s noted above) were found to be equipped with locking dead bolts that were not part of the latch-set handle. As a result, two means of operation could be required to open the doors. LSC 101 (2000), section 7.2.1.5.4, states that doors to patient sleeping rooms shall be operable with not more than one releasing operation.

- The Director of Support Services who was present when these observations were made concurred with these findings.

Based on findings from document review and interview, emergency power supply system (EPSS) tests were not fully documented. NFPA 110 (1999) requires that a written record of EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.

Findings include:

- Per document review at 10:30 am on 8/15/13, only a portion of the required EPSS testing specified under Chapter 6 of NFPA 110 was documented for each weekly test of the EPSS for the past year. Missing items on the test log included, but were not limited to: the load under which the generator was tested, the inspection of all accessory components of the generator (e.g., checking and recording of the electrolyte specific gravity of the batteries, maintenance and testing of the transfer switch, and fuel level).

- Per interview at 10:45 am on 8/15/13, the Director of Support Services was not aware of the requirements of NFPA 110 regarding test documentation and record keeping.

Based on findings from observation and interview, 6 out of 8 patient sleeping room doors (for room #s 128, 131, 132, 133, 134, 137) were not operable without using two operations to open the door when the dead bolt was engaged from the patient side of the room.

Findings include:
- Per observations starting at 1:35 pm on 8/14/13, 6 rooms (#s noted above) were found to be equipped with locking dead bolts that were not part of the latch-set handle. As a result, two means of operation could be required to open the doors. LSC 101 (2000), section 7.2.1.5.4, states that doors to patient sleeping rooms shall be operable with not more than one releasing operation.

- The Director of Support Services who was present when these observations were made concurred with these findings.

Based on findings from document review and interview, emergency power supply system (EPSS) tests were not fully documented. NFPA 110 (1999) requires that a written record of EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.

Findings include:

- Per document review at 10:30 am on 8/15/13, only a portion of the required EPSS testing specified under Chapter 6 of NFPA 110 was documented for each weekly test of the EPSS for the past year. Missing items on the test log included, but were not limited to: the load under which the generator was tested, the inspection of all accessory components of the generator (e.g., checking and recording of the electrolyte specific gravity of the batteries, maintenance and testing of the transfer switch, and fuel level).

- Per interview at 10:45 am on 8/15/13, the Director of Support Services was not aware of the requirements of NFPA 110 regarding test documentation and record keeping.