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Based on observation and interview, the facility failed to ensure 1 of 12 patient room corridor doors closed and latched into the door frame. This deficient practice could affect 1 of 7 patients.

Findings include:

Based on an observation with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 2:45 p.m., the corridor door to patient room 104 failed to latch into the door frame. This was acknowledged by Maintenance Technician # 1 at the time of observation.

Based on observation, record review and interview; the facility failed to ensure 5 of 5 emergency light fixtures of at least 1½ hour duration were tested annually in accordance with LSC 7.9. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires an annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 ½ hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. In addition, NFPA 110, Section 5-3.1 requires EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting. This deficient practice was not in a patient care area but could affect staff.

Findings include:

Based on observations with the Vice President of Risk Management, Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 during a tour of the facility from 2:00 p.m. to 4:00 p.m., three battery operated emergency lights were observed in the stairway and two in the basement. Based on record review at 4:03 p.m. on 05/12/14 with the Vice President of Risk Management, there was no documentation of an annual ninety minute test on the battery operated lights. This was confirmed by the Vice President of Risk Management at the time of record review.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 completed quarters. This deficient practice could affect all occupants.

Findings include:

Based on review of the "Fire Drill Evacuation" with the Vice President of Risk Management and the Nursing Supervisor on 05/12/14 at 12:50 p.m., there was no record of a third shift fire drill for the third quarter of 2013. Based on an interview with the Vice President of Risk Management at the time of record review, no other documentation was available for review to verify this drill was conducted.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 ADL closets in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. This deficient practice could affect 3 or 4 patients in the TV area.

Findings include:

Based on an observation with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 3:00 p.m., the ADL supply closet lacked a sprinkler head. This was confirmed by the Nursing Supervisor at 3:30 p.m.

Based on observation and interview, the facility failed to enforce 1 of 1 smoking policies for the facility. This deficient practice could affect occupants evacuated through the side exit where the emergency generator is located.

Findings include:

Based on an observation with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 2:18 p.m., there were at least fifty cigarette butts in the gravel near the emergency generator. Based on an interview with the Vice President of Risk Management at the time of observation, the entire campus is designated smoke free.

Based on observation and interview, the facility failed to ensure 2 of 2 water heaters had a current inspection certificate to ensure the water heaters were in safe operating condition. NFPA 101, in 19.1.1.3 requires all health facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of patients. This deficient practice was not in a resident care area but could affect any number of staff in the basement.

Findings include:

Based on observation with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 3:30 p.m., the two basement water heaters lacked a Certificate of Inspection. Based on an interview with the Vice President of Risk Management at the time of observation, the water heaters were rated at 150,00 BTU's.

1. Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 1 of 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. 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 patients.

Findings include:

Based on review of the generator log "Inpatient Unit Generator Test" with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 1:30 p.m., there was no documentation available of a generator load test for the month of April, 2014. At the time of record review, the Vice President of Risk Management stated the person who conducted the generator load test recently quit and the documentation could not be found.

2. Based on observation and interview, the facility failed to provide adequate emergency task lighting in and around 1 of 1 generator sets in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 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 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery powered emergency lighting. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 2:20 p.m., the emergency generator enclosure lacked a battery powered emergency light. This was confirmed by Maintenance Technician # 1 at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 12 patient room corridor doors closed and latched into the door frame. This deficient practice could affect 1 of 7 patients.

Findings include:

Based on an observation with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 2:45 p.m., the corridor door to patient room 104 failed to latch into the door frame. This was acknowledged by Maintenance Technician # 1 at the time of observation.

Based on observation, record review and interview; the facility failed to ensure 5 of 5 emergency light fixtures of at least 1½ hour duration were tested annually in accordance with LSC 7.9. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires an annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 ½ hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. In addition, NFPA 110, Section 5-3.1 requires EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting. This deficient practice was not in a patient care area but could affect staff.

Findings include:

Based on observations with the Vice President of Risk Management, Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 during a tour of the facility from 2:00 p.m. to 4:00 p.m., three battery operated emergency lights were observed in the stairway and two in the basement. Based on record review at 4:03 p.m. on 05/12/14 with the Vice President of Risk Management, there was no documentation of an annual ninety minute test on the battery operated lights. This was confirmed by the Vice President of Risk Management at the time of record review.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 completed quarters. This deficient practice could affect all occupants.

Findings include:

Based on review of the "Fire Drill Evacuation" with the Vice President of Risk Management and the Nursing Supervisor on 05/12/14 at 12:50 p.m., there was no record of a third shift fire drill for the third quarter of 2013. Based on an interview with the Vice President of Risk Management at the time of record review, no other documentation was available for review to verify this drill was conducted.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 ADL closets in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. This deficient practice could affect 3 or 4 patients in the TV area.

Findings include:

Based on an observation with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 3:00 p.m., the ADL supply closet lacked a sprinkler head. This was confirmed by the Nursing Supervisor at 3:30 p.m.

Based on observation and interview, the facility failed to enforce 1 of 1 smoking policies for the facility. This deficient practice could affect occupants evacuated through the side exit where the emergency generator is located.

Findings include:

Based on an observation with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 2:18 p.m., there were at least fifty cigarette butts in the gravel near the emergency generator. Based on an interview with the Vice President of Risk Management at the time of observation, the entire campus is designated smoke free.

Based on observation and interview, the facility failed to ensure 2 of 2 water heaters had a current inspection certificate to ensure the water heaters were in safe operating condition. NFPA 101, in 19.1.1.3 requires all health facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of patients. This deficient practice was not in a resident care area but could affect any number of staff in the basement.

Findings include:

Based on observation with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 3:30 p.m., the two basement water heaters lacked a Certificate of Inspection. Based on an interview with the Vice President of Risk Management at the time of observation, the water heaters were rated at 150,00 BTU's.

1. Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 1 of 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. 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 patients.

Findings include:

Based on review of the generator log "Inpatient Unit Generator Test" with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 1:30 p.m., there was no documentation available of a generator load test for the month of April, 2014. At the time of record review, the Vice President of Risk Management stated the person who conducted the generator load test recently quit and the documentation could not be found.

2. Based on observation and interview, the facility failed to provide adequate emergency task lighting in and around 1 of 1 generator sets in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 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 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery powered emergency lighting. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Vice President of Risk Management, the Nursing Supervisor and Maintenance Technician # 1 on 05/12/14 at 2:20 p.m., the emergency generator enclosure lacked a battery powered emergency light. This was confirmed by Maintenance Technician # 1 at the time of observation.