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Based on observation and interview, the facility failed to ensure 1 of 4 doors serving a kitchen, a hazardous area, was held open only by a device arranged to automatically close the door upon activation of the fire alarm system. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the main kitchen is not separated from the Youth dining Room and the entrance door to the Youth Dining Room is self closing but was held open by a door stop which would not allow the door to close automatically upon activation of the fire alarm system. Based on interview at the time of observation, the Physical Plant Director stated the main kitchen is open to the Youth Dining Room and acknowledged the entrance door to the Youth Dining Room was held open by a door stop.

Based on observation and interview, the facility failed to ensure openings through 1 of 5 ceiling smoke barriers were protected to maintain the smoke resistance of each smoke barrier. This deficient practice could affect 10 patients and staff in the vicinity of Room 1-4029.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 2:15 p.m. to 4:30 p.m. on 04/29/13, the attic access door in the ceiling in Building 1, Room 1-4029 was observed in the open position. Based on interview at the time of observation, the Physical Plant Director stated no one was working in the attic and acknowledged an open access door in the ceiling above Room 1-4029 did not maintain the smoke resistance of the smoke barrier.

1. Based on observation and interview, the facility failed to ensure 1 of 5 hazardous areas such as the kitchen was separated from other spaces by smoke resisting partitions and doors. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the main kitchen is open to the Youth Dining Room because there are two passageways into the kitchen directly behind the serving line which were each not equipped with a smoke resistant partition or door. Based on interview at the time of observation, the Physical Plant Director acknowledged the main kitchen is open to the Youth Dining Room because there are two passageways into the kitchen directly behind the serving line which were each not equipped with a smoke resistant partition or door.

2. Based on observation and interview, the facility failed to ensure 1 of 4 doors serving hazardous areas such as the kitchen were self closing and would latch into the door frame. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the entry door to the Youth Dining Room from the kitchen corridor is not provided with a self closing device. Based on interview at the time of observation, the Physical Plant Director acknowledged the entry door to the Youth Dining Room from the kitchen corridor is not provided with a self closing device.

3. Based on observation and interview, the facility failed to ensure the 1 of 2 corridor doors to hazardous areas on the first floor of Building 2 such as a combustible storage room over 50 square feet in size was provided with a self closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect an two patients, staff and visitors.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 and from 10:15 a.m. to 12:15 p.m., the corridor door to Room 2-1003 in Building 2 was not provided with a self closing device. Room 2-1003 measured 252 square feet and was being utilized as a storage room for gloves, paper towels, trash bags and supplies in combustible boxes. Based on interview at the time of observation, the Physical Plant Director acknowledged Room 2-1003 measured greater than fifty square feet, was used to store combustible supplies in boxes and the corridor door was not provided with a self closing device.

4. Based on observation and interview, the facility failed to ensure the 1 of 1 corridor doors to hazardous areas on the first floor of Building 2 such as a trash collection room was provided with a self closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect an two patients, staff and visitors.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 and from 10:15 a.m. to 12:15 p.m., the corridor door to Room 1-1042 in Building 1 was not provided with a self closing device. Room 1-1042 was being utilized as a storage room for ten red bag biohazard waste bins each providing 28 gallons of storage capacity. Based on interview at the time of observation, the Physical Plant Director acknowledged Room 1-1042 was utilized to store trash and the corridor door was not provided with a self closing device.

Based on observation and interview, the facility failed to ensure 1 of over 100 corridor doors did not require more than one releasing operation to open it. LSC Section 7.2.1.5.4 states a latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches, and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. Section A.7.2.1.5.4 states examples of devices that might be arranged to release latches include knobs, levers, and panic bars. This deficient practice could affect 20 patients, staff and visitors.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the corridor door to the Med Room identified as Room 8-2074 in Building 8 has two locks on the door and a key was needed to unlock each lock on the door. Based on interview at the time of observation, the Physical Plant Director acknowledged the corridor door to the Med Room identified as Room 8-2074 in Building 8 has two locks on the door and a key was needed to unlock each lock on the door.

Based on record review, observation, and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 2 of 2 battery operated emergency lights. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ½ hour duration. 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 in the facility.

Findings include:

Based on review of "Emergency Lighting Inspection Form" documentation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, monthly functional testing and annual testing for two battery operated emergency lights in the facility were not itemized for tests conducted during the twelve month period from 05/22/12 through 04/10/13. The aforementioned documentation states the "Type of Inspection" as monthly or annual, the "Type of Equipment" tested as "Emergency Lighting" and the "Location of Equipment" as "buildings # 18-10-3-2-1-27-11-8" tested but does not itemize the devices tested. As a result, the total number of battery operated emergency lights in the facility which were tested and the individual device location could not be determined from the aforementioned documentation. Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, one battery operated emergency light was observed at the emergency generator location in Building 27 and one at the second emergency generator location in the powerhouse water softener room in Building 1. Based on interview at the time of record review, the Physical Plant Director acknowledged monthly functional testing and annual testing documentation for two battery operated emergency lights in the facility was not itemized for the aforementioned tests.

Based on record review, observation and interview; the facility failed to include the use of kitchen fire extinguishers in 1 of 1 written fire safety plan for the facility in the event of an emergency. LSC 19.2.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the 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 could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on review of "Fire Response Plan" documentation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, the fire disaster plan did not address the use of the K-class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system. Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, a K-class fire extinguisher was located in the kitchen. Based on interview at the time of record review, the Physical Plant Director acknowledged the written fire safety plan for the facility did not include kitchen staff training to activate the overhead hood extinguishing system to suppress a fire before using the K-class fire extinguisher.

Based on observation and interview, the facility failed to install 1 of over 200 smoke detectors in accordance with NFPA 72. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, smoke detectors shall not be located where airflow prevents operation of the detectors. NFPA 72, A-2-3.5.1 explains smoke detectors should not be located in a direct airflow nor closer than 3 feet from an air supply diffuser or return air opening. This deficient practice could affect 10 patients, staff and visitors.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the smoke detector on the ceiling in the second floor lobby outside Unit 2C by the elevators was located one foot from a return air vent. Based on interview at the time of observation, the Physical Plant Director acknowledged the aforementioned smoke detector location was installed on the ceiling less than three feet from a return air vent.

Based on observation and interview, the facility failed to ensure 8 of over 200 sprinkler heads in the facility were maintained. NFPA 13, Standard for the Installation of Sprinkler Systems, Section 3-2.7.2 states escutcheon plates used with a recessed or flush type sprinkler shall be part of a listed sprinkler assembly. This deficient practice could affect 20 residents, staff and visitors.

Findings include:

Based on observations with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the following sprinkler head locations each had a missing escutcheon plate which left a two inch opening into the ceiling:
a) in Building 1 in the corridor outside Rooms 1-5010, 1-3075, and 1-3004.
b) in Building 1 in Rooms 1-4056, 1-4021 and in the closet identified as Room 1-2052.
c) in Building 8 in the corridor outside Room 8-3025 and Room 8-3074.
Based on interview at the time of the observations, the Physical Plant Director acknowledged the aforementioned sprinkler head locations each had a missing escutcheon plate which left a two inch opening into the ceiling.

1. Based on observation and interview, the facility failed to maintain 1 of 1 portable K-class fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 2-3.2 requires fire extinguishers provided for the protection of cooking appliances using combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 2-3.2.1 requires a placard shall be conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using a portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, a placard was not conspicuously placed near the K-class portable fire extinguisher which states the fire protection system shall be activated prior to using the K-class portable fire extinguisher. Based on interview at the time of observation, the Physical Plant Director acknowledged a placard was not conspicuously placed near the K-class portable fire extinguisher stating the fire protection system shall be activated prior to using the K-class portable fire extinguisher.

2. Based on observation and interview, the facility failed to ensure 1 of over 40 portable fire extinguishers was readily accessible in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 1-6.3 requires fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. This deficient practice could affect 10 patients and staff in the first floor basketball gym.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, a portable fire extinguisher in the first floor basketball gym was in a locked glass cabinet mounted in the wall. The cabinet door could not be unlocked after five repeated attempts because the cabinet door was bent. Based on interview at the time of observation, the Safety Officer acknowledged they could not access the portable fire extinguisher located in the first floor basketball gym.

Based on record review and interview, the facility failed to ensure 1 of 102 fire dampers in the facility was provided necessary maintenance at least every six years in accordance with the Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09. Pursuant to Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09, hospitals may operate under the six year damper testing cycle of the 2007 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives without special application to CMS. This deficient practice affects 20 patients, staff and visitors.

Findings include:

Based on review of "Smoke & Fire Damper Inspection Report" documentation dated 08/10/10 with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, the inspection report for the fire damper identified as B1-M4S-4 had stated "springs are broke won't close" in the comments section for "Damper function." In addition, the aforementioned fire damper inspection report stated "needs work." Based on interview at the time of record review, the Physical Plant Director stated no additional documentation of fire damper testing was available for review and acknowledged documentation for the repair or replacement of the aforementioned fire damper was not available for review.

1. Based on record review, observation and interview; the facility failed to ensure 2 of 2 kitchen hood self contained chemical extinguishing systems was compliant with standard UL 300. LSC 19.3.2.6 requires cooking facilities to be in compliance with LSC 9.2.3 which requires commercial cooking equipment to be in compliance with NFPA 96, 1998 Edition, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96, 7-2.2 states automatic fire extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on review of Koorsen Fire & Security "Restaurant Systems Work Order" documentation dated 08/22/12 and 02/26/13 with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, "No" was listed as the response to "Is System UL 300?" on each of the aforementioned work order documents for two kitchen hood extinguishing systems in the facility. In addition, the "Comments" section of the aforementioned documentation stated "recommend upgrading system." Based on interview at the time of record review, the Physical Plant Director stated each of the two kitchen hood extinguishing systems have not been upgraded to UL 300 and acknowledged restaurant systems work order documentation identified the kitchen hood extinguishing systems as not compliant with UL 300. Based on observations with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, a total of two kitchen hood extinguishing systems were observed in the main kitchen for the facility. In addition, the main kitchen is not separated from the Youth Dining Room by smoke resistant partitions or doors.

2. Based on record review, observation and interview; the facility failed to ensure 2 of 2 kitchen exhaust systems was cleaned semiannually. NFPA 96, 1998 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 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) in accordance with Table 8-3.1. Table 8-3.1 requires systems serving moderate volume cooking operations shall be inspected semiannually. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on review of 360 Services "Invoice" documentation dated 02/21/12 and 08/15/12 with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, semiannual kitchen range hood cleaning documentation after 08/15/12 was not available for review. Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, 360 Services had affixed a semiannual maintenance cleaning sticker dated 08/15/12 to the kitchen range hoods. Based on interview at the time of record review and observation, the Physical Plant Director acknowledged it had been more than six months since the most recent range hood cleanings.

Based on observation and interview, the facility failed to ensure 1 of 1 space heaters was equipped with heating elements not exceeding 212 degrees Fahrenheit (F). This deficient practice affects 10, staff and visitors in the vicinity of the Director's Office on the fifth floor.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 2:15 p.m. to 4:30 p.m. on 04/29/13, one operable portable space heater was observed in operation in the Director's Office (Room 1-5007) on the fifth floor. Based on interview at the time of observation, the Executive Director stated documentation of the heating element operating temperature was not available for review and acknowledged a space heater was being utilized in the Director's Office (Room 1-5007) on the fifth floor.

Based on observation and interview, the facility failed to ensure 2 of 2 emergency generators were equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break glass station located outside of the room where the prime mover is located. NFPA 110, 7-1 states NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, contains mandatory requirements for emergency generators and shall be considered part of the requirements of this standard. NFPA 37, 8-2.2(c) requires emergency generators of 100 horsepower of more have provisions for shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, a remote shut off device was not found for the 200 kW diesel fired emergency generator (Generator #1) or the 295 kW diesel fired emergency generator (Generator # 2). Generator # 1 is located in the softener room for the Powerhouse in Building 1 and Generator # 2 is located in Building 27. Each of the aforementioned emergency generators had a manual stop button at the engine location but did not have a remote manual stop outside of the room where the emergency generator was located. Based on interview at the time of the observations, the Physical Plant Director stated each emergency generator was installed prior to 2003 and acknowledged there is no remote emergency shut off device for each of the two aforementioned emergency generators.

Based on record review and interview, the facility failed to provide a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1 in order to protect 130 of 130 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(c) states where a required fire protection system is out of service for more than 4 hours in a 24 hour period, an impairment coordinator shall evacuate the building or establish an approved fire watch. Section 11-5(d) requires the local fire department be notified of sprinkler impairment and Section 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Fire Response Plan" documentation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period was not available for review. Based on interview at the time of record review, the Physical Plant Director acknowledged a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period was not available for review.

Based on record review and interview, the facility failed to provide a written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 130 of 130 patients. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Fire Response Plan" documentation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, a written policy containing procedures to be followed in the event the fire alarm system system has to be placed out of service for four hours or more in a 24 hour period was not available for review. Based on interview at the time of record review, the Physical Plant Director acknowledged a written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period was not available for review.

Based on observation and interview, the facility failed to ensure 1 of 4 doors serving a kitchen, a hazardous area, was held open only by a device arranged to automatically close the door upon activation of the fire alarm system. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the main kitchen is not separated from the Youth dining Room and the entrance door to the Youth Dining Room is self closing but was held open by a door stop which would not allow the door to close automatically upon activation of the fire alarm system. Based on interview at the time of observation, the Physical Plant Director stated the main kitchen is open to the Youth Dining Room and acknowledged the entrance door to the Youth Dining Room was held open by a door stop.

Based on observation and interview, the facility failed to ensure openings through 1 of 5 ceiling smoke barriers were protected to maintain the smoke resistance of each smoke barrier. This deficient practice could affect 10 patients and staff in the vicinity of Room 1-4029.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 2:15 p.m. to 4:30 p.m. on 04/29/13, the attic access door in the ceiling in Building 1, Room 1-4029 was observed in the open position. Based on interview at the time of observation, the Physical Plant Director stated no one was working in the attic and acknowledged an open access door in the ceiling above Room 1-4029 did not maintain the smoke resistance of the smoke barrier.

1. Based on observation and interview, the facility failed to ensure 1 of 5 hazardous areas such as the kitchen was separated from other spaces by smoke resisting partitions and doors. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the main kitchen is open to the Youth Dining Room because there are two passageways into the kitchen directly behind the serving line which were each not equipped with a smoke resistant partition or door. Based on interview at the time of observation, the Physical Plant Director acknowledged the main kitchen is open to the Youth Dining Room because there are two passageways into the kitchen directly behind the serving line which were each not equipped with a smoke resistant partition or door.

2. Based on observation and interview, the facility failed to ensure 1 of 4 doors serving hazardous areas such as the kitchen were self closing and would latch into the door frame. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the entry door to the Youth Dining Room from the kitchen corridor is not provided with a self closing device. Based on interview at the time of observation, the Physical Plant Director acknowledged the entry door to the Youth Dining Room from the kitchen corridor is not provided with a self closing device.

3. Based on observation and interview, the facility failed to ensure the 1 of 2 corridor doors to hazardous areas on the first floor of Building 2 such as a combustible storage room over 50 square feet in size was provided with a self closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect an two patients, staff and visitors.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 and from 10:15 a.m. to 12:15 p.m., the corridor door to Room 2-1003 in Building 2 was not provided with a self closing device. Room 2-1003 measured 252 square feet and was being utilized as a storage room for gloves, paper towels, trash bags and supplies in combustible boxes. Based on interview at the time of observation, the Physical Plant Director acknowledged Room 2-1003 measured greater than fifty square feet, was used to store combustible supplies in boxes and the corridor door was not provided with a self closing device.

4. Based on observation and interview, the facility failed to ensure the 1 of 1 corridor doors to hazardous areas on the first floor of Building 2 such as a trash collection room was provided with a self closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect an two patients, staff and visitors.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13 and from 10:15 a.m. to 12:15 p.m., the corridor door to Room 1-1042 in Building 1 was not provided with a self closing device. Room 1-1042 was being utilized as a storage room for ten red bag biohazard waste bins each providing 28 gallons of storage capacity. Based on interview at the time of observation, the Physical Plant Director acknowledged Room 1-1042 was utilized to store trash and the corridor door was not provided with a self closing device.

Based on observation and interview, the facility failed to ensure 1 of over 100 corridor doors did not require more than one releasing operation to open it. LSC Section 7.2.1.5.4 states a latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches, and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. Section A.7.2.1.5.4 states examples of devices that might be arranged to release latches include knobs, levers, and panic bars. This deficient practice could affect 20 patients, staff and visitors.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the corridor door to the Med Room identified as Room 8-2074 in Building 8 has two locks on the door and a key was needed to unlock each lock on the door. Based on interview at the time of observation, the Physical Plant Director acknowledged the corridor door to the Med Room identified as Room 8-2074 in Building 8 has two locks on the door and a key was needed to unlock each lock on the door.

Based on record review, observation, and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 2 of 2 battery operated emergency lights. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ½ hour duration. 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 in the facility.

Findings include:

Based on review of "Emergency Lighting Inspection Form" documentation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, monthly functional testing and annual testing for two battery operated emergency lights in the facility were not itemized for tests conducted during the twelve month period from 05/22/12 through 04/10/13. The aforementioned documentation states the "Type of Inspection" as monthly or annual, the "Type of Equipment" tested as "Emergency Lighting" and the "Location of Equipment" as "buildings # 18-10-3-2-1-27-11-8" tested but does not itemize the devices tested. As a result, the total number of battery operated emergency lights in the facility which were tested and the individual device location could not be determined from the aforementioned documentation. Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, one battery operated emergency light was observed at the emergency generator location in Building 27 and one at the second emergency generator location in the powerhouse water softener room in Building 1. Based on interview at the time of record review, the Physical Plant Director acknowledged monthly functional testing and annual testing documentation for two battery operated emergency lights in the facility was not itemized for the aforementioned tests.

Based on record review, observation and interview; the facility failed to include the use of kitchen fire extinguishers in 1 of 1 written fire safety plan for the facility in the event of an emergency. LSC 19.2.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the 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 could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on review of "Fire Response Plan" documentation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, the fire disaster plan did not address the use of the K-class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system. Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, a K-class fire extinguisher was located in the kitchen. Based on interview at the time of record review, the Physical Plant Director acknowledged the written fire safety plan for the facility did not include kitchen staff training to activate the overhead hood extinguishing system to suppress a fire before using the K-class fire extinguisher.

Based on observation and interview, the facility failed to install 1 of over 200 smoke detectors in accordance with NFPA 72. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, smoke detectors shall not be located where airflow prevents operation of the detectors. NFPA 72, A-2-3.5.1 explains smoke detectors should not be located in a direct airflow nor closer than 3 feet from an air supply diffuser or return air opening. This deficient practice could affect 10 patients, staff and visitors.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the smoke detector on the ceiling in the second floor lobby outside Unit 2C by the elevators was located one foot from a return air vent. Based on interview at the time of observation, the Physical Plant Director acknowledged the aforementioned smoke detector location was installed on the ceiling less than three feet from a return air vent.

Based on observation and interview, the facility failed to ensure 8 of over 200 sprinkler heads in the facility were maintained. NFPA 13, Standard for the Installation of Sprinkler Systems, Section 3-2.7.2 states escutcheon plates used with a recessed or flush type sprinkler shall be part of a listed sprinkler assembly. This deficient practice could affect 20 residents, staff and visitors.

Findings include:

Based on observations with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, the following sprinkler head locations each had a missing escutcheon plate which left a two inch opening into the ceiling:
a) in Building 1 in the corridor outside Rooms 1-5010, 1-3075, and 1-3004.
b) in Building 1 in Rooms 1-4056, 1-4021 and in the closet identified as Room 1-2052.
c) in Building 8 in the corridor outside Room 8-3025 and Room 8-3074.
Based on interview at the time of the observations, the Physical Plant Director acknowledged the aforementioned sprinkler head locations each had a missing escutcheon plate which left a two inch opening into the ceiling.

1. Based on observation and interview, the facility failed to maintain 1 of 1 portable K-class fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 2-3.2 requires fire extinguishers provided for the protection of cooking appliances using combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 2-3.2.1 requires a placard shall be conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using a portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, a placard was not conspicuously placed near the K-class portable fire extinguisher which states the fire protection system shall be activated prior to using the K-class portable fire extinguisher. Based on interview at the time of observation, the Physical Plant Director acknowledged a placard was not conspicuously placed near the K-class portable fire extinguisher stating the fire protection system shall be activated prior to using the K-class portable fire extinguisher.

2. Based on observation and interview, the facility failed to ensure 1 of over 40 portable fire extinguishers was readily accessible in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 1-6.3 requires fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. This deficient practice could affect 10 patients and staff in the first floor basketball gym.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, a portable fire extinguisher in the first floor basketball gym was in a locked glass cabinet mounted in the wall. The cabinet door could not be unlocked after five repeated attempts because the cabinet door was bent. Based on interview at the time of observation, the Safety Officer acknowledged they could not access the portable fire extinguisher located in the first floor basketball gym.

Based on record review and interview, the facility failed to ensure 1 of 102 fire dampers in the facility was provided necessary maintenance at least every six years in accordance with the Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09. Pursuant to Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09, hospitals may operate under the six year damper testing cycle of the 2007 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives without special application to CMS. This deficient practice affects 20 patients, staff and visitors.

Findings include:

Based on review of "Smoke & Fire Damper Inspection Report" documentation dated 08/10/10 with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, the inspection report for the fire damper identified as B1-M4S-4 had stated "springs are broke won't close" in the comments section for "Damper function." In addition, the aforementioned fire damper inspection report stated "needs work." Based on interview at the time of record review, the Physical Plant Director stated no additional documentation of fire damper testing was available for review and acknowledged documentation for the repair or replacement of the aforementioned fire damper was not available for review.

1. Based on record review, observation and interview; the facility failed to ensure 2 of 2 kitchen hood self contained chemical extinguishing systems was compliant with standard UL 300. LSC 19.3.2.6 requires cooking facilities to be in compliance with LSC 9.2.3 which requires commercial cooking equipment to be in compliance with NFPA 96, 1998 Edition, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96, 7-2.2 states automatic fire extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on review of Koorsen Fire & Security "Restaurant Systems Work Order" documentation dated 08/22/12 and 02/26/13 with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, "No" was listed as the response to "Is System UL 300?" on each of the aforementioned work order documents for two kitchen hood extinguishing systems in the facility. In addition, the "Comments" section of the aforementioned documentation stated "recommend upgrading system." Based on interview at the time of record review, the Physical Plant Director stated each of the two kitchen hood extinguishing systems have not been upgraded to UL 300 and acknowledged restaurant systems work order documentation identified the kitchen hood extinguishing systems as not compliant with UL 300. Based on observations with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, a total of two kitchen hood extinguishing systems were observed in the main kitchen for the facility. In addition, the main kitchen is not separated from the Youth Dining Room by smoke resistant partitions or doors.

2. Based on record review, observation and interview; the facility failed to ensure 2 of 2 kitchen exhaust systems was cleaned semiannually. NFPA 96, 1998 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 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) in accordance with Table 8-3.1. Table 8-3.1 requires systems serving moderate volume cooking operations shall be inspected semiannually. This deficient practice could affect 15 patients in the Youth Dining Room and all kitchen staff.

Findings include:

Based on review of 360 Services "Invoice" documentation dated 02/21/12 and 08/15/12 with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, semiannual kitchen range hood cleaning documentation after 08/15/12 was not available for review. Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, 360 Services had affixed a semiannual maintenance cleaning sticker dated 08/15/12 to the kitchen range hoods. Based on interview at the time of record review and observation, the Physical Plant Director acknowledged it had been more than six months since the most recent range hood cleanings.

Based on observation and interview, the facility failed to ensure 1 of 1 space heaters was equipped with heating elements not exceeding 212 degrees Fahrenheit (F). This deficient practice affects 10, staff and visitors in the vicinity of the Director's Office on the fifth floor.

Findings include:

Based on observation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 2:15 p.m. to 4:30 p.m. on 04/29/13, one operable portable space heater was observed in operation in the Director's Office (Room 1-5007) on the fifth floor. Based on interview at the time of observation, the Executive Director stated documentation of the heating element operating temperature was not available for review and acknowledged a space heater was being utilized in the Director's Office (Room 1-5007) on the fifth floor.

Based on observation and interview, the facility failed to ensure 2 of 2 emergency generators were equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break glass station located outside of the room where the prime mover is located. NFPA 110, 7-1 states NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, contains mandatory requirements for emergency generators and shall be considered part of the requirements of this standard. NFPA 37, 8-2.2(c) requires emergency generators of 100 horsepower of more have provisions for shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Physical Plant Director, Maintenance Supervisor and Safety Officer during a tour of the facility from 1:00 p.m. to 3:50 p.m. on 04/30/13, a remote shut off device was not found for the 200 kW diesel fired emergency generator (Generator #1) or the 295 kW diesel fired emergency generator (Generator # 2). Generator # 1 is located in the softener room for the Powerhouse in Building 1 and Generator # 2 is located in Building 27. Each of the aforementioned emergency generators had a manual stop button at the engine location but did not have a remote manual stop outside of the room where the emergency generator was located. Based on interview at the time of the observations, the Physical Plant Director stated each emergency generator was installed prior to 2003 and acknowledged there is no remote emergency shut off device for each of the two aforementioned emergency generators.

Based on record review and interview, the facility failed to provide a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1 in order to protect 130 of 130 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(c) states where a required fire protection system is out of service for more than 4 hours in a 24 hour period, an impairment coordinator shall evacuate the building or establish an approved fire watch. Section 11-5(d) requires the local fire department be notified of sprinkler impairment and Section 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Fire Response Plan" documentation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period was not available for review. Based on interview at the time of record review, the Physical Plant Director acknowledged a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period was not available for review.

Based on record review and interview, the facility failed to provide a written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 130 of 130 patients. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Fire Response Plan" documentation with the Physical Plant Director, Maintenance Supervisor and Safety Officer during record review from 9:45 a.m. to 12:10 p.m. on 04/29/13, a written policy containing procedures to be followed in the event the fire alarm system system has to be placed out of service for four hours or more in a 24 hour period was not available for review. Based on interview at the time of record review, the Physical Plant Director acknowledged a written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period was not available for review.