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1. Based on observation and interview, the facility failed to ensure 2 of 2 sets of doors, one set to to the activity room and one set to the business office, were smoke tight. This deficient practice could affect any patients in the activity room on the first floor.

Findings include:

Based on observations on 02/21/11 during the tour between 1200 p.m. and 12:20 p.m., the set of doors to the activity room and the set of doors to the business office each had a three eighths inch gap when the doors are closed which would not be smoke resistant. Based on interview on 02/21/11 concurrent with each observation with the Maintenance Director, it was acknowledged the aforementioned sets of doors to the activities room and business office which were not equipped with an astragal were not smoke tight.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sets of doors to the business office did not latch in their frame. This deficient practice could affect staff on first floor.

Findings include:

Based on observations on 02/21/11 during the tour between 1200 p.m. and 12:20 p.m., the set of doors to the business office were not provided with a latching mechanism to keep the doors closed. Based on interview on 02/21/11 at 12:18 p.m. at the time of observation with the Maintenance Director, it was acknowledged the set of doors to the business office did not latch in their frame.

1. Based on record review and interview, the facility failed to ensure fire drills were held at unexpected times under varying conditions, at least quarterly on each shift for 4 of 4 quarters since January of 2010. This deficient practice affects all occupants in the facility including all patients, staff, and visitors.

Findings include:

Based on review of fire drill records on 02/21/11 at 2:15 p.m. with the Maintenance Director, fire drills starting from the fourth quarter 2010 back to the first quarter 2010 were conducted at the following similar times and failed to indicate varying conditions on each fire drill report:
a. First shift fire drill, fourth quarter 2010 was conducted at 7:10 a.m.
b. First shift fire drill, third quarter 2010 was conducted at 8:30 a.m.
c First shift fire drill, second quarter 2010 was conducted at 9:30 a.m.
d First shift fire drill, first quarter 2010 was conducted at 8:05 a.m.
e Second shift fire drill, third quarter of 2010 was conducted at 8:10 p.m.
f Second shift fire drill, second quarter 2010 was conducted at 8:10 p.m.
g Third shift fire drill, third quarter 2010 was conducted at 7:10 a.m.
h Third shift fire drill, second quarter 2010 was conducted at 7:00 a.m.
i Third shift fire drill, first quarter 2010 was conducted at 6:45 a.m.
Based on interview on 02/21/11 at 2:30 p.m. with the Maintenance Director, it was acknowledged the aforementioned fire drill shifts were conducted at similar times.

2. Based on record review and interview, the facility failed to ensure fire drills were held at least quarterly on each shift for 2 of 4 quarters since January of 2010. This deficient practice affects all occupants in the facility including all patients, staff, and visitors.

Findings include:

Based on review of fire drill records on 02/21/11 at 2:15 p.m. with the Maintenance Director, the second shift of the first quarter and the second and third shift of the fourth quarter of 2010 had not been conducted. Based on interview on 02/21/11 at 2:30 p.m. with the Maintenance Director, it was acknowledged the aforementioned fire drills were not conducted and no other documentation could be produced for review.

Based on record review and interview, the facility failed to ensure 1 of 1 sprinkler waterflow alarm devices was tested quarterly. NFPA 25, at 2-3.3 requires waterflow alarm devices including but not limited to mechanical water motor gongs, vane type waterflow devices and pressure switches provide audible or visual signals to be tested quarterly. This deficient practice could affect all patients, visitors and staff.

Findings include:

Based on review of Fire System records on 02/21/11 at 3:05 p.m. with the Maintenance Director, the last sprinkler inspection was August of 2010 and was done annually. In addition, there was no documentation available for quarterly inspections of waterflow alarm devices. Based on interview on 02/21/11 at 3:15 p.m. with the Maintenance Director, it was acknowledged the sprinkler inspections where the waterflow alarms were tested quarterly was not available for review.

Based on record review and interview, the facility failed to ensure 1 of 1 fire dampers in ventilating systems ductwork was inspected and provided necessary maintenance at least every 6 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 (HVAC) 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 6 years, fusible links 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. This deficient practice affects all patients as well as visitors and staff.

Findings include:

Based on Fire Safety record review on 02/21/11 at 1:45 p.m. with the Maintenance Director, there was no documentation available to indicate the fire damper had ever been inspected. Based on interview on 02/21/11 at 1:47 p.m., with the Maintenance Director, it was acknowledged the facility does not have any documentation to verify the single fire damper had ever had a six year maintenance inspection.

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 02/21/11 at 12:33 p.m. with the Maintenance Director, a remote alarm annunciator for the generator was located in the boiler room and not in a regular work station. Based on interview on 02/21/11 at 12:35 p.m. with the Maintenance Director, it was acknowledged the facility did have a remote alarm annunciator for the generator located in the boiler room which is generally unattended instead of a fixed work station which is regularly attended such as a nurses' station.

Based on record review and interview, the facility failed to protect 5 of 5 patients by providing a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for more than 4 hours in a 24 hour period in accordance with LSC, Section 9.7.6.1. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems. NFPA 25, 11-2 requires an appointed sprinkler impairment coordinator. NFPA 25, 11-5 requires a preplanned program to include evacuation or an approved fire watch and 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified and 11-5(f) requires notification of supervisors in the area in addition to those already mentioned and lastly 11-7 requires notification of everyone again when the system is restored. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on Sprinkler record review on 02/21/11 at 3:05 p.m. with the Maintenance Director, the facility did not have a written policy and procedure for an impaired sprinkler system available for review. Based on interview on 02/21/11 at 3:06 p.m. with the Maintenance Director, it was acknowledged the facility did not have a fire watch policy available for review.

Based on record review and interview, the facility failed to provide a complete written fire watch policy in the event the fire alarm system is out of service for more than 4 hours in a 24 hour period for the protection of 5 of 5 patients. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on Fire Alarm record review on 02/21/11 at 3:37 p.m. with the Maintenance Director, the facility did not have a written policy and procedure for an impaired fire protection system available for review. Based on interview on 02/21/11 at 3:38 p.m. with the Maintenance Director, it was acknowledged a fire watch policy was not available for review.

1. Based on observation and interview, the facility failed to ensure 2 of 2 sets of doors, one set to to the activity room and one set to the business office, were smoke tight. This deficient practice could affect any patients in the activity room on the first floor.

Findings include:

Based on observations on 02/21/11 during the tour between 1200 p.m. and 12:20 p.m., the set of doors to the activity room and the set of doors to the business office each had a three eighths inch gap when the doors are closed which would not be smoke resistant. Based on interview on 02/21/11 concurrent with each observation with the Maintenance Director, it was acknowledged the aforementioned sets of doors to the activities room and business office which were not equipped with an astragal were not smoke tight.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sets of doors to the business office did not latch in their frame. This deficient practice could affect staff on first floor.

Findings include:

Based on observations on 02/21/11 during the tour between 1200 p.m. and 12:20 p.m., the set of doors to the business office were not provided with a latching mechanism to keep the doors closed. Based on interview on 02/21/11 at 12:18 p.m. at the time of observation with the Maintenance Director, it was acknowledged the set of doors to the business office did not latch in their frame.

1. Based on record review and interview, the facility failed to ensure fire drills were held at unexpected times under varying conditions, at least quarterly on each shift for 4 of 4 quarters since January of 2010. This deficient practice affects all occupants in the facility including all patients, staff, and visitors.

Findings include:

Based on review of fire drill records on 02/21/11 at 2:15 p.m. with the Maintenance Director, fire drills starting from the fourth quarter 2010 back to the first quarter 2010 were conducted at the following similar times and failed to indicate varying conditions on each fire drill report:
a. First shift fire drill, fourth quarter 2010 was conducted at 7:10 a.m.
b. First shift fire drill, third quarter 2010 was conducted at 8:30 a.m.
c First shift fire drill, second quarter 2010 was conducted at 9:30 a.m.
d First shift fire drill, first quarter 2010 was conducted at 8:05 a.m.
e Second shift fire drill, third quarter of 2010 was conducted at 8:10 p.m.
f Second shift fire drill, second quarter 2010 was conducted at 8:10 p.m.
g Third shift fire drill, third quarter 2010 was conducted at 7:10 a.m.
h Third shift fire drill, second quarter 2010 was conducted at 7:00 a.m.
i Third shift fire drill, first quarter 2010 was conducted at 6:45 a.m.
Based on interview on 02/21/11 at 2:30 p.m. with the Maintenance Director, it was acknowledged the aforementioned fire drill shifts were conducted at similar times.

2. Based on record review and interview, the facility failed to ensure fire drills were held at least quarterly on each shift for 2 of 4 quarters since January of 2010. This deficient practice affects all occupants in the facility including all patients, staff, and visitors.

Findings include:

Based on review of fire drill records on 02/21/11 at 2:15 p.m. with the Maintenance Director, the second shift of the first quarter and the second and third shift of the fourth quarter of 2010 had not been conducted. Based on interview on 02/21/11 at 2:30 p.m. with the Maintenance Director, it was acknowledged the aforementioned fire drills were not conducted and no other documentation could be produced for review.

Based on record review and interview, the facility failed to ensure 1 of 1 sprinkler waterflow alarm devices was tested quarterly. NFPA 25, at 2-3.3 requires waterflow alarm devices including but not limited to mechanical water motor gongs, vane type waterflow devices and pressure switches provide audible or visual signals to be tested quarterly. This deficient practice could affect all patients, visitors and staff.

Findings include:

Based on review of Fire System records on 02/21/11 at 3:05 p.m. with the Maintenance Director, the last sprinkler inspection was August of 2010 and was done annually. In addition, there was no documentation available for quarterly inspections of waterflow alarm devices. Based on interview on 02/21/11 at 3:15 p.m. with the Maintenance Director, it was acknowledged the sprinkler inspections where the waterflow alarms were tested quarterly was not available for review.

Based on record review and interview, the facility failed to ensure 1 of 1 fire dampers in ventilating systems ductwork was inspected and provided necessary maintenance at least every 6 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 (HVAC) 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 6 years, fusible links 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. This deficient practice affects all patients as well as visitors and staff.

Findings include:

Based on Fire Safety record review on 02/21/11 at 1:45 p.m. with the Maintenance Director, there was no documentation available to indicate the fire damper had ever been inspected. Based on interview on 02/21/11 at 1:47 p.m., with the Maintenance Director, it was acknowledged the facility does not have any documentation to verify the single fire damper had ever had a six year maintenance inspection.

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 02/21/11 at 12:33 p.m. with the Maintenance Director, a remote alarm annunciator for the generator was located in the boiler room and not in a regular work station. Based on interview on 02/21/11 at 12:35 p.m. with the Maintenance Director, it was acknowledged the facility did have a remote alarm annunciator for the generator located in the boiler room which is generally unattended instead of a fixed work station which is regularly attended such as a nurses' station.

Based on record review and interview, the facility failed to protect 5 of 5 patients by providing a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for more than 4 hours in a 24 hour period in accordance with LSC, Section 9.7.6.1. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems. NFPA 25, 11-2 requires an appointed sprinkler impairment coordinator. NFPA 25, 11-5 requires a preplanned program to include evacuation or an approved fire watch and 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified and 11-5(f) requires notification of supervisors in the area in addition to those already mentioned and lastly 11-7 requires notification of everyone again when the system is restored. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on Sprinkler record review on 02/21/11 at 3:05 p.m. with the Maintenance Director, the facility did not have a written policy and procedure for an impaired sprinkler system available for review. Based on interview on 02/21/11 at 3:06 p.m. with the Maintenance Director, it was acknowledged the facility did not have a fire watch policy available for review.

Based on record review and interview, the facility failed to provide a complete written fire watch policy in the event the fire alarm system is out of service for more than 4 hours in a 24 hour period for the protection of 5 of 5 patients. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on Fire Alarm record review on 02/21/11 at 3:37 p.m. with the Maintenance Director, the facility did not have a written policy and procedure for an impaired fire protection system available for review. Based on interview on 02/21/11 at 3:38 p.m. with the Maintenance Director, it was acknowledged a fire watch policy was not available for review.