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Based on observation and interview, the facility failed to ensure 1 of 1 fire door sets was 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 any patient, staff, and visitors on the patient unit.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations on 01/21/14 at 3:20 p.m., the fire door set near the Psychiatrist office was tested three times with the Director of Plant Operations. One door in the fire door set failed to latch each time the doors were released to close. Based on interview at the time of observation, the Director of Plant Operations acknowledged the doors should latch and needed adjustment.

Based on record review, observation and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 3 of 3 battery operated emergency lights in the facility. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted for 30 seconds at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ? 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. This deficient practice could affect all patients, staff and visitors throughout the facility.

Findings include:

Based on review of "Emergency Lights - 2013" documentation with the Director of Plant Operations during record review at 2:55 p.m. on 01/21/14, functional testing of the three battery operated emergency lights in the facility was indicated by a check mark for each month on 2013. Based on interview at the time of record review, the Director of Plant Operations acknowledged the battery operated emergency lights documentation did not specify the duration of the monthly test or document the annual 90 minute test. Based on observations with the Director of Plant Operations during a tour of the facility from 3:00 p.m. to 4:00 p.m. on 01/21/14, the three battery operated emergency lights observed in the facility were functional.

Based on record review and interview, the facility failed to conduct fire drills at unexpected times under varying conditions in 4 of 4 second shift fire drills. This deficient practice affects all patients in the facility including staff.

Findings include:

Based on review of "Fire Drill Report" documentation with the Director of Plant Operations on 01/21/14 during paperwork review from 1:15 a.m. to 3:00 p.m., four second shift fire drills were conducted between 4:30 p.m. and 5:30 p.m. and near the same date of the month as follows:
a. 02/22/13; 5:00 p.m.
b. 05/25/13; 5:10 p.m.
c. 08/22/13; 4:30 p.m.
d. 11/20/13; 5:00 p.m.
Based on interview during the time of record review, the days and times the second shift fire drills were conducted were acknowledged by the Director of Plant Operations.

Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on observation with the Director of Plant Operations from 3:00 p.m. to 4:00 p.m. on 01/21/14, the sprinkler system located in the sprinkler riser room had two pressure gauges with 06/08 written on the gauges. Based on interview at the time of observation, the Director of Plant Operations acknowledged the date written on the gauges was when the gauges were last checked.

Based on observation and interview, the facility failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring to provide power for equipment with a high current draw. 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 was not in a patient care area but could affect staff.

Findings include:

Based on observation with the Director of Plant Operations on 01/21/14 at 3:15 p.m., the psychiatrist's office had a coffee maker plugged into an extension cord which was plugged into a power strip. Based on interview at the time of observation, the aforementioned condition was acknowledged by the Director of Plant Operations.

Based on observation and interview, the facility failed to ensure 1 of 1 fire door sets was 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 any patient, staff, and visitors on the patient unit.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations on 01/21/14 at 3:20 p.m., the fire door set near the Psychiatrist office was tested three times with the Director of Plant Operations. One door in the fire door set failed to latch each time the doors were released to close. Based on interview at the time of observation, the Director of Plant Operations acknowledged the doors should latch and needed adjustment.

Based on record review, observation and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 3 of 3 battery operated emergency lights in the facility. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted for 30 seconds at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ? 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. This deficient practice could affect all patients, staff and visitors throughout the facility.

Findings include:

Based on review of "Emergency Lights - 2013" documentation with the Director of Plant Operations during record review at 2:55 p.m. on 01/21/14, functional testing of the three battery operated emergency lights in the facility was indicated by a check mark for each month on 2013. Based on interview at the time of record review, the Director of Plant Operations acknowledged the battery operated emergency lights documentation did not specify the duration of the monthly test or document the annual 90 minute test. Based on observations with the Director of Plant Operations during a tour of the facility from 3:00 p.m. to 4:00 p.m. on 01/21/14, the three battery operated emergency lights observed in the facility were functional.

Based on record review and interview, the facility failed to conduct fire drills at unexpected times under varying conditions in 4 of 4 second shift fire drills. This deficient practice affects all patients in the facility including staff.

Findings include:

Based on review of "Fire Drill Report" documentation with the Director of Plant Operations on 01/21/14 during paperwork review from 1:15 a.m. to 3:00 p.m., four second shift fire drills were conducted between 4:30 p.m. and 5:30 p.m. and near the same date of the month as follows:
a. 02/22/13; 5:00 p.m.
b. 05/25/13; 5:10 p.m.
c. 08/22/13; 4:30 p.m.
d. 11/20/13; 5:00 p.m.
Based on interview during the time of record review, the days and times the second shift fire drills were conducted were acknowledged by the Director of Plant Operations.

Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on observation with the Director of Plant Operations from 3:00 p.m. to 4:00 p.m. on 01/21/14, the sprinkler system located in the sprinkler riser room had two pressure gauges with 06/08 written on the gauges. Based on interview at the time of observation, the Director of Plant Operations acknowledged the date written on the gauges was when the gauges were last checked.

Based on observation and interview, the facility failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring to provide power for equipment with a high current draw. 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 was not in a patient care area but could affect staff.

Findings include:

Based on observation with the Director of Plant Operations on 01/21/14 at 3:15 p.m., the psychiatrist's office had a coffee maker plugged into an extension cord which was plugged into a power strip. Based on interview at the time of observation, the aforementioned condition was acknowledged by the Director of Plant Operations.