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Based on observation and interview, the facility failed to ensure 1 of 3 doors protecting corridor openings to the surgery/recovery room suite would latch into the door frame. This deficient practice affects 8 or more occupants of the surgery/recovery room suite.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 12:05 p.m., the corridor access door adjacent to offices in the surgery/recovery room suite had no latch to secure the door in the door frame. The door relied on an automatic door opening and closing system to secure the door in it's frame. The Manager of Plant Operations acknowledged at the time of observation, the door did not latch.

Based on observation and interview, the facility failed to ensure openings through smoke barriers on 2 of 2 floors were maintained to provide the 1/2 hour fire and smoke resistance of the smoke barriers. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or 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 could affect all occupants

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 between 10:00 a.m. and 4:00 p.m.:
a. A conduit penetration of the smoke barrier door near surgery was unsealed leaving a half inch gap above the laid in corridor ceiling;
b. Two conduit penetrations above the laid in ceiling at the north smoke barrier doors near the lab were unsealed leaving one inch gaps between the two adjacent smoke compartments;
c. A six by twelve inch cut out to allow the passage of cables and wires in the smoke barrier above the laid in ceiling between the emergency room and reception area was unsealed;
d. An unsealed pipe penetration above the laid in ceiling at the smoke barrier separating the physical plant from the main hospital left a half inch gap;
e. Two unsealed penetrations of the east smoke barrier near the lab left half inch gaps;
f. An unsealed penetration by cables through the smoke barrier wall near room 234 left a one inch gap above the laid in ceiling;
g. Cables running between the traction room into the space above the laid in ceiling displaced the ceiling tile leaving a half inch gap;
h. Three penetrations of the smoke barrier above the laid in ceiling near the back nurses station left unsealed gaps of one half to one inch;
i. The cable penetration above the laid in ceiling in the smoke barrier near room 209 was unsealed;
j. The smoke barrier above the laid in ceiling in the Special Care Unit near room 1 was unsealed leaving a one inch gap.
The Manager of Plant Operations agreed at the times of observations, the penetrations should have been sealed with a fire rated material.

1. Based on observation and interview, the facility failed to ensure 3 of 3 doors/partitions to hazardous areas such as a kitchen, closed automatically or upon activation of the fire alarm system. Furthermore, doors to hazardous areas are required to latch in the door frame when closed to keep the door tightly closed. This deficient practice affects 10 or more occupants in the adjacent cafeteria.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 1:25 p.m., two self closing doors between the kitchen and cafeteria had no latches and could not be held tightly in their door frames. In addition, a a 24 by 24 inch opening between the cafeteria and kitchen was protected by a sliding steel partition which had to be manually closed. The Manager of Plant Operations agreed at the time of observations these doors and partition did not meet the requirements for self closing and latching.

2. Based on observation and interview, the facility failed to ensure 1 of 12 hazardous areas such as the kitchen was separated from other spaces by a smoke resistant partition. This practice affects 10 or more occupant of the adjacent cafeteria.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 1:25 p.m., a six inch by eighteen inch opening between the cafeteria and kitchen provided a chute opening to dispose of dining waste. The Manager of Pant Operations agreed at the time of observation, the opening had nothing to separate the kitchen from the cafeteria.

3. Based on observation and interview, the facility failed to provide automatic closers for doors providing access to 1 of 4 second floor hazardous areas such as a combustible materials storage room larger than 50 square feet. 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. This deficient practice could affect visitors, staff and 11 residents on the second floor.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 10:50 a.m., the door separating the ten by eight foot IV supply storage room on the med-surg unit had no self closing device. The room was lined with shelves laden with cardboard and plastic wrapped supplies. The Manager of Plant Operations said at the time of observation, he didn't know the door to this storage room was required to self close.

Based on observation and interview, the facility failed to ensure 2 of 13 exits were arranged so the exit discharged to a readily accessible public way at all times. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. Exterior walking surfaces within the exit discharge are not required to be paved and may be provided by grass or similar surfaces. Where discharging exits into yards, across lawns, or on similar surfaces, in addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect staff and visitors and 11 patients.

Findings include:

Based on observations with the Manager of Plant Operations on 11/14/12 between 10:00 a.m. and 4:00 p.m., two east stairway exits discharged onto three by three foot concrete slabs. Discharge from the slabs required crossing a two foot area of round stones and then a grassy lawn to reach the public way. The Manager of Plant Operations acknowledged at the time of observations, the discharge surface could not be maintained free of snow and ice.

Based on observation and interview, the facility failed to ensure 2 of 5 first floor fire door sets were arranged to automatically close and latch. LSC 7.2.4.3.8 requires fire barrier doors to be self closing or automatic closing in accordance with 7.2.1.8. NFPA 80, the Standard for fire Doors and Fire Windows at 2-4.1.4 requires all closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so positive latching is achieved on each door operation. This deficient practice could affect visitors, staff and 4 or more patients on the first floor.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 10:20 a.m., two fire door sets in the physical plant operations corridor were tested twice manually. One door in each fire door set failed to latch each time the doors were released to close. The Manager of Plant Operations acknowledged at the times of observations, there were problems with the latching mechanisms.

Based on record review and interview, the facility failed to provide a fire plan which included the identification of and evacuation of the smoke compartments, the types of fire extinguishers available, or the use of the K-class fire extinguisher in conjunction with the overhead hood system in the written fire plan for the protection of all occupants. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
1. Use of alarms.
2. Transmission of alarms to 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 affects all residents, staff and visitors in the event of an emergency.

Findings include:

Based on record review with the Manager of Plant Operations on 11/14/12 3:25 p.m., the fire safety plan was incomplete. There was no direction to remove endangered residents to another smoke compartment if indicated and no identification of smoke zones as places of refuge and their location. In addition, the fire safety plan did not identify available fire extinguishers and address the K-class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system. The Manager of Plant Operations acknowledged at the time of record review, these elements were not addressed in the fire plan.

1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm panels in an area not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at the location before it could be incapacitated by fire. LSC 9.6.2.10.1 requires smoke alarms shall be in accordance with NFPA 72, National Fire Alarm Code. NFPA 72, 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice affects all occupants.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 10:10 a.m., the main fire alarm control panel (FACP) was located in the Plant Operations office, an area not continuously occupied. The area was not electrically supervised by a smoke detector. The Manager of Plant Operations acknowledged at the time of observation, the panel could be incapacitated by fire before an alarm could be annunciated in the area.

2. Based on observation and interview, the facility failed to ensure smoke detectors connected to the fire alarm system in 2 of 7 first floor smoke compartments were properly separated from an air supply. NFPA 72, 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 4 or more patients on the first floor.

Findings include:e

Based on observation with the Manager of Plant Operations on 11/14/12 at 2:15 p.m., two corridor smoke detectors near the physical plant offices and general storage rooms and a third corridor smoke detector at the smoke barrier in the adjacent smoke compartment were located eight inches from air supply vents. The Manager of Plant Operations confirmed the distance measurements and acknowledged at the time of observations, the air flow could impede the function of the smoke detectors.

Based on record review and interview, the facility failed to ensure dampers in the ductwork serving 9 of 9 smoke compartments were inspected and and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 19.5.2.1 refers to Section 9.2. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. Damper maintenance in hospitals has been extended to every 6 years per CMS waiver. This deficient practice affects all occupants.

Findings include:

Based on a review of preventive maintenance records with the Manager of Plant Operations on 11/14/12 at 3:40 p.m., records of smoke damper inspections by the facility maintenance crew was limited to monthly checks to ensure no obstruction to closing was evident. No record of a verification of their operation and maintenance performed was found. The Manager of Plant Operations said at the time of record review, operation of the dampers or other maintenance had not been performed.

1. Based on observation and interview, the facility failed to provide the minimum protection between 2 of 2 commercial cooking appliances in the kitchen. NFPA 96, 9-1.2.3 requires deep fat fryers shall be installed with at least a 16 inch space between the fryer and the adjacent cook top surface from adjacent cooking equipment except where a steel or tempered glass baffle plate is installed at a minimum of eight inches in height between the adjacent appliances. This deficient practice could affect 4 kitchen staff and 4 or more occupants of the adjacent cafeteria.

Findings include:

Based on observation of the commercial cooking appliances in the kitchen with the maintenance director on 11/14/12 at 1:45 p.m., the minimum separation of 16 inches, or separation by a steel or tempered glass baffle plate, was not provided between the gas range and fryer located side by side. The maintenance director said at the time of observation, the gas range had been recently replaced and the separation plate had been omitted in the installation.

2. Based on record review, observation and interview; the facility failed to ensure 1 of 1 kitchen exhaust hoods, grease removal devices, fans, ducts, and other appurtenances were cleaned to bare metal at frequent intervals. NFPA 96, 1998 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, section 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. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1. This deficient practice could affect 4 kitchen staff and 4 or more occupants of the adjacent cafeteria.

Findings include:

Based on review of preventive maintenance records provided with the Manager of Plant Operations on 11/14/12 at 3:10 p.m., a record for cleaning the kitchen hood exhaust system duct was not found. The kitchen manager interviewed on 11/14/12 at 12:50 p.m. said the hood was cleaned regularly but had no documentation of a service cleaning of the exhaust duct. A service sticker usually applied to the hood at the time of service was not found. The Manager of Plant Operations said at the time of record review, he could not provide evidence the service had been provided.

1. Based on observation and interview, the facility failed to ensure 2 of 2 generators serving as the alternate source of power were maintained and capable of automatically connecting to the load within 10 seconds in the event of failure of normal power. NFPA 101, 12.3.3.2 requires equipment required for compliance with the provisions of the Code shall be continuously maintained. NFPA 99, the Standard for Health Care Facilities, Hospital requirements at 12-3.3.2 requires essential electrical distribution systems to conform to Type 1 systems as described in Chapter 3 of NFPA 99. NFPA 99, 3-4..1.1.8 requires the emergency system to be arranged so, in the event of failure of the normal power source, the alternate source of power will automatically connect to the load within 10 seconds. This deficient practice affects all occupants.

Findings include:

Based on record review and interview with the Manager of Plant Operations on 11/14/12 at 3:10 p.m., there was nothing to evidence the Level I and II generators started and connected to a load within 10 seconds. An observation of the Level I emergency generator # 1 with the Manager of Plant during a test demonstration on 11/14/12 at 1:05 p.m. showed generator # 1 started within 10 seconds. The Level II generator # 2 had a 05/31/12 load bank test reviewed at 3:10 p.m. which noted it started within the 10 second time required. The Level II generator required manual transfer of the load. The Manager of Plant Operations acknowledged at the time of record review there was no other record to confirm the 10 second load transfer and the Level II generator could not transfer a load automatically.

2. Based on observation, record review, and interview; the facility failed to ensure load monthly testing of the Level II generator was performed 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 residents, staff and visitors.

Findings include:

Based on review of Work Orders for testing Level I and Level II emergency generators with the Manager of Plant Operations on 11/14/12 at 3:10 p.m., a generator load test was conducted one time in May 2012 during the past year on the Level II generator during a contracted load bank test. The Manager of Plant said at the time of record review, the generator did not transfer automatically and the manual transfer of the load was a safety concern.

1. Based on observation and interview, the facility failed to electrical outlets supplied by emergency power in 1 of 1 surgery and recovery room suites were readily identifiable. NFPA 99, 3-5.2.2.4(b) requires the cover plates for the electrical receptacles or the receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identified. This deficient practice could affect 8 or more occupants of the surgery and recovery room suite.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 12:10 p.m., electrical outlets in all areas of the surgery and recovery room suite had no distinct marking to identify those supplied with emergency power. The Manager of Plant Operations said at the time of observations, electrical outlets supplied with emergency powered had red marking. None were found.

2. Based on observation and interview, the facility failed to ensure 3 of 3 flexible cords were not used as a substitute for fixed wiring. NFPA 70 National Electrical Code, 1999 Edition, 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 2 or more staff in the education department.

Findings include:

a. Based on observation with the Manager of Plant Operations on 11/14/12 at 11:50 a.m., two power strip extension cords were piggy backed to supply power to multiple computers and attached equipment. The Manager of Plant Operations said at the time of observation, the practice was forbidden.
b. Based on observation with the Manager of Plant Operations on 11/14/12 at 1:50 a.m., a power strip extension cord was used to supply power to a microwave, coffee pot and toaster in a storage room in the radiology department. The Manager of Plant Operations said at the time of observation, the practice was forbidden.

Based on observation and interview, the facility failed to ensure 1 of 3 doors protecting corridor openings to the surgery/recovery room suite would latch into the door frame. This deficient practice affects 8 or more occupants of the surgery/recovery room suite.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 12:05 p.m., the corridor access door adjacent to offices in the surgery/recovery room suite had no latch to secure the door in the door frame. The door relied on an automatic door opening and closing system to secure the door in it's frame. The Manager of Plant Operations acknowledged at the time of observation, the door did not latch.

Based on observation and interview, the facility failed to ensure openings through smoke barriers on 2 of 2 floors were maintained to provide the 1/2 hour fire and smoke resistance of the smoke barriers. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or 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 could affect all occupants

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 between 10:00 a.m. and 4:00 p.m.:
a. A conduit penetration of the smoke barrier door near surgery was unsealed leaving a half inch gap above the laid in corridor ceiling;
b. Two conduit penetrations above the laid in ceiling at the north smoke barrier doors near the lab were unsealed leaving one inch gaps between the two adjacent smoke compartments;
c. A six by twelve inch cut out to allow the passage of cables and wires in the smoke barrier above the laid in ceiling between the emergency room and reception area was unsealed;
d. An unsealed pipe penetration above the laid in ceiling at the smoke barrier separating the physical plant from the main hospital left a half inch gap;
e. Two unsealed penetrations of the east smoke barrier near the lab left half inch gaps;
f. An unsealed penetration by cables through the smoke barrier wall near room 234 left a one inch gap above the laid in ceiling;
g. Cables running between the traction room into the space above the laid in ceiling displaced the ceiling tile leaving a half inch gap;
h. Three penetrations of the smoke barrier above the laid in ceiling near the back nurses station left unsealed gaps of one half to one inch;
i. The cable penetration above the laid in ceiling in the smoke barrier near room 209 was unsealed;
j. The smoke barrier above the laid in ceiling in the Special Care Unit near room 1 was unsealed leaving a one inch gap.
The Manager of Plant Operations agreed at the times of observations, the penetrations should have been sealed with a fire rated material.

1. Based on observation and interview, the facility failed to ensure 3 of 3 doors/partitions to hazardous areas such as a kitchen, closed automatically or upon activation of the fire alarm system. Furthermore, doors to hazardous areas are required to latch in the door frame when closed to keep the door tightly closed. This deficient practice affects 10 or more occupants in the adjacent cafeteria.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 1:25 p.m., two self closing doors between the kitchen and cafeteria had no latches and could not be held tightly in their door frames. In addition, a a 24 by 24 inch opening between the cafeteria and kitchen was protected by a sliding steel partition which had to be manually closed. The Manager of Plant Operations agreed at the time of observations these doors and partition did not meet the requirements for self closing and latching.

2. Based on observation and interview, the facility failed to ensure 1 of 12 hazardous areas such as the kitchen was separated from other spaces by a smoke resistant partition. This practice affects 10 or more occupant of the adjacent cafeteria.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 1:25 p.m., a six inch by eighteen inch opening between the cafeteria and kitchen provided a chute opening to dispose of dining waste. The Manager of Pant Operations agreed at the time of observation, the opening had nothing to separate the kitchen from the cafeteria.

3. Based on observation and interview, the facility failed to provide automatic closers for doors providing access to 1 of 4 second floor hazardous areas such as a combustible materials storage room larger than 50 square feet. 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. This deficient practice could affect visitors, staff and 11 residents on the second floor.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 10:50 a.m., the door separating the ten by eight foot IV supply storage room on the med-surg unit had no self closing device. The room was lined with shelves laden with cardboard and plastic wrapped supplies. The Manager of Plant Operations said at the time of observation, he didn't know the door to this storage room was required to self close.

Based on observation and interview, the facility failed to ensure 2 of 13 exits were arranged so the exit discharged to a readily accessible public way at all times. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. Exterior walking surfaces within the exit discharge are not required to be paved and may be provided by grass or similar surfaces. Where discharging exits into yards, across lawns, or on similar surfaces, in addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect staff and visitors and 11 patients.

Findings include:

Based on observations with the Manager of Plant Operations on 11/14/12 between 10:00 a.m. and 4:00 p.m., two east stairway exits discharged onto three by three foot concrete slabs. Discharge from the slabs required crossing a two foot area of round stones and then a grassy lawn to reach the public way. The Manager of Plant Operations acknowledged at the time of observations, the discharge surface could not be maintained free of snow and ice.

Based on observation and interview, the facility failed to ensure 2 of 5 first floor fire door sets were arranged to automatically close and latch. LSC 7.2.4.3.8 requires fire barrier doors to be self closing or automatic closing in accordance with 7.2.1.8. NFPA 80, the Standard for fire Doors and Fire Windows at 2-4.1.4 requires all closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so positive latching is achieved on each door operation. This deficient practice could affect visitors, staff and 4 or more patients on the first floor.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 10:20 a.m., two fire door sets in the physical plant operations corridor were tested twice manually. One door in each fire door set failed to latch each time the doors were released to close. The Manager of Plant Operations acknowledged at the times of observations, there were problems with the latching mechanisms.

Based on record review and interview, the facility failed to provide a fire plan which included the identification of and evacuation of the smoke compartments, the types of fire extinguishers available, or the use of the K-class fire extinguisher in conjunction with the overhead hood system in the written fire plan for the protection of all occupants. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
1. Use of alarms.
2. Transmission of alarms to 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 affects all residents, staff and visitors in the event of an emergency.

Findings include:

Based on record review with the Manager of Plant Operations on 11/14/12 3:25 p.m., the fire safety plan was incomplete. There was no direction to remove endangered residents to another smoke compartment if indicated and no identification of smoke zones as places of refuge and their location. In addition, the fire safety plan did not identify available fire extinguishers and address the K-class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system. The Manager of Plant Operations acknowledged at the time of record review, these elements were not addressed in the fire plan.

1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm panels in an area not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at the location before it could be incapacitated by fire. LSC 9.6.2.10.1 requires smoke alarms shall be in accordance with NFPA 72, National Fire Alarm Code. NFPA 72, 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice affects all occupants.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 10:10 a.m., the main fire alarm control panel (FACP) was located in the Plant Operations office, an area not continuously occupied. The area was not electrically supervised by a smoke detector. The Manager of Plant Operations acknowledged at the time of observation, the panel could be incapacitated by fire before an alarm could be annunciated in the area.

2. Based on observation and interview, the facility failed to ensure smoke detectors connected to the fire alarm system in 2 of 7 first floor smoke compartments were properly separated from an air supply. NFPA 72, 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 4 or more patients on the first floor.

Findings include:e

Based on observation with the Manager of Plant Operations on 11/14/12 at 2:15 p.m., two corridor smoke detectors near the physical plant offices and general storage rooms and a third corridor smoke detector at the smoke barrier in the adjacent smoke compartment were located eight inches from air supply vents. The Manager of Plant Operations confirmed the distance measurements and acknowledged at the time of observations, the air flow could impede the function of the smoke detectors.

Based on record review and interview, the facility failed to ensure dampers in the ductwork serving 9 of 9 smoke compartments were inspected and and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 19.5.2.1 refers to Section 9.2. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. Damper maintenance in hospitals has been extended to every 6 years per CMS waiver. This deficient practice affects all occupants.

Findings include:

Based on a review of preventive maintenance records with the Manager of Plant Operations on 11/14/12 at 3:40 p.m., records of smoke damper inspections by the facility maintenance crew was limited to monthly checks to ensure no obstruction to closing was evident. No record of a verification of their operation and maintenance performed was found. The Manager of Plant Operations said at the time of record review, operation of the dampers or other maintenance had not been performed.

1. Based on observation and interview, the facility failed to provide the minimum protection between 2 of 2 commercial cooking appliances in the kitchen. NFPA 96, 9-1.2.3 requires deep fat fryers shall be installed with at least a 16 inch space between the fryer and the adjacent cook top surface from adjacent cooking equipment except where a steel or tempered glass baffle plate is installed at a minimum of eight inches in height between the adjacent appliances. This deficient practice could affect 4 kitchen staff and 4 or more occupants of the adjacent cafeteria.

Findings include:

Based on observation of the commercial cooking appliances in the kitchen with the maintenance director on 11/14/12 at 1:45 p.m., the minimum separation of 16 inches, or separation by a steel or tempered glass baffle plate, was not provided between the gas range and fryer located side by side. The maintenance director said at the time of observation, the gas range had been recently replaced and the separation plate had been omitted in the installation.

2. Based on record review, observation and interview; the facility failed to ensure 1 of 1 kitchen exhaust hoods, grease removal devices, fans, ducts, and other appurtenances were cleaned to bare metal at frequent intervals. NFPA 96, 1998 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, section 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. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1. This deficient practice could affect 4 kitchen staff and 4 or more occupants of the adjacent cafeteria.

Findings include:

Based on review of preventive maintenance records provided with the Manager of Plant Operations on 11/14/12 at 3:10 p.m., a record for cleaning the kitchen hood exhaust system duct was not found. The kitchen manager interviewed on 11/14/12 at 12:50 p.m. said the hood was cleaned regularly but had no documentation of a service cleaning of the exhaust duct. A service sticker usually applied to the hood at the time of service was not found. The Manager of Plant Operations said at the time of record review, he could not provide evidence the service had been provided.

1. Based on observation and interview, the facility failed to ensure 2 of 2 generators serving as the alternate source of power were maintained and capable of automatically connecting to the load within 10 seconds in the event of failure of normal power. NFPA 101, 12.3.3.2 requires equipment required for compliance with the provisions of the Code shall be continuously maintained. NFPA 99, the Standard for Health Care Facilities, Hospital requirements at 12-3.3.2 requires essential electrical distribution systems to conform to Type 1 systems as described in Chapter 3 of NFPA 99. NFPA 99, 3-4..1.1.8 requires the emergency system to be arranged so, in the event of failure of the normal power source, the alternate source of power will automatically connect to the load within 10 seconds. This deficient practice affects all occupants.

Findings include:

Based on record review and interview with the Manager of Plant Operations on 11/14/12 at 3:10 p.m., there was nothing to evidence the Level I and II generators started and connected to a load within 10 seconds. An observation of the Level I emergency generator # 1 with the Manager of Plant during a test demonstration on 11/14/12 at 1:05 p.m. showed generator # 1 started within 10 seconds. The Level II generator # 2 had a 05/31/12 load bank test reviewed at 3:10 p.m. which noted it started within the 10 second time required. The Level II generator required manual transfer of the load. The Manager of Plant Operations acknowledged at the time of record review there was no other record to confirm the 10 second load transfer and the Level II generator could not transfer a load automatically.

2. Based on observation, record review, and interview; the facility failed to ensure load monthly testing of the Level II generator was performed 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 residents, staff and visitors.

Findings include:

Based on review of Work Orders for testing Level I and Level II emergency generators with the Manager of Plant Operations on 11/14/12 at 3:10 p.m., a generator load test was conducted one time in May 2012 during the past year on the Level II generator during a contracted load bank test. The Manager of Plant said at the time of record review, the generator did not transfer automatically and the manual transfer of the load was a safety concern.

1. Based on observation and interview, the facility failed to electrical outlets supplied by emergency power in 1 of 1 surgery and recovery room suites were readily identifiable. NFPA 99, 3-5.2.2.4(b) requires the cover plates for the electrical receptacles or the receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identified. This deficient practice could affect 8 or more occupants of the surgery and recovery room suite.

Findings include:

Based on observation with the Manager of Plant Operations on 11/14/12 at 12:10 p.m., electrical outlets in all areas of the surgery and recovery room suite had no distinct marking to identify those supplied with emergency power. The Manager of Plant Operations said at the time of observations, electrical outlets supplied with emergency powered had red marking. None were found.

2. Based on observation and interview, the facility failed to ensure 3 of 3 flexible cords were not used as a substitute for fixed wiring. NFPA 70 National Electrical Code, 1999 Edition, 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 2 or more staff in the education department.

Findings include:

a. Based on observation with the Manager of Plant Operations on 11/14/12 at 11:50 a.m., two power strip extension cords were piggy backed to supply power to multiple computers and attached equipment. The Manager of Plant Operations said at the time of observation, the practice was forbidden.
b. Based on observation with the Manager of Plant Operations on 11/14/12 at 1:50 a.m., a power strip extension cord was used to supply power to a microwave, coffee pot and toaster in a storage room in the radiology department. The Manager of Plant Operations said at the time of observation, the practice was forbidden.