HospitalInspections.org

Based on observation and interview, the facility failed to ensure three sets of fire doors latched when released from magnetic hold open device, and failed to ensure the integrity of the fire wall that separated the addition from the Beerman Pavilion. This had the potential to affect all patients, staff, and visitors to the facility. The total patient census on the first survey day was 86.

Findings include:

The following fire doors failed to latch when released from the hold open device:

1. On the second floor, on 06/18/13, at 1:52 P.M., a tour conducted with Staff A3, A4, and A6 revealed a set of 1 and 1/2 hour fire rated doors by the locker room near the Pediatric Intensive Care Unit. The facility floor plan identified the doors as 2030.2. One of the doors failed to latch when released from the hold open device.

2. On the first floor, on 06/20/13, fire doors 1055.3, located in a 3 hour fire rated wall failed to latch when released from the hold open device. These doors were located between Building 1 and 2 near Reception Area 1 A and the Support Services Building hallway.

These doors were verified with Staff A3 and A6 at the time of tour.


21521

3. On 06/19/13 at 2:15 P.M. a tour was conducted of the corridor between Beerman Pavilion and Mead Pavilion with Staff A1 and A2.
During the tour, observation above the drop down ceiling of the 3 hour fire wall between the Beerman Pavilion and Mead Pavilion revealed, near double doors 1018.3, a penetrating hole with red wires coming from it.
Observation of the fire doors leading to the cardiology building revealed the doors did not close, with one sticking to the floor.
During the tour, Staff A2 confirmed the observations.

Based on observation and interview, the facility failed to ensure the integrity of the fire wall that separated the surgery addition from the Beerman Pavilion. This had the potential to affect all patients, staff, and visitors to the facility. The total patient census on the first survey day was 86.


Findings include:

On 06/17/13 at 3:15 P.M. a tour was conducted of the second floor of the building with Staff A1 and A2.

1. Observation and review of the floor plans revealed an anesthesia office whose wall, which divided the building from the Beerman Pavilion, was rated at three hours. Observation above the drop down ceiling of that wall revealed two unstopped elbow conduits near door 2848.3.

2. Observation above the drop down ceiling near door 2851.3 of the same 3 hour fire wall that separated the addition from the Beerman Pavilion revealed unstopped three inch, two inch and one inch conduits.

During the 06/17/13 at 3:15 P.M., tour, during an interview, Staff A2 confirmed these findings.

On 06/18/13 at 8:30 A.M. a tour was conducted of the first floor of the building with Staff A1 and A2.

3. Observation of the area above the drop down ceiling above door 1815.3 in the fire wall that separated the surgery addition from the Beerman Pavilion, revealed a two inch open conduit.

4. Observation, of the area above the drop down ceiling of the fire wall which divided the surgery addition from the Beerman Pavilion, near door 1813.2, revealed a one inch open conduit.

5. Observation, of the area above the drop down ceiling of the fire wall which divided the surgery addition from the Beerman Pavilion, near door 1815.3, revealed a one inch conduit with an annular space.

6. Observation, of the area above the drop down ceiling of the fire wall which divided the surgery addition from the Beerman Pavilion, over exam room 17, revealed a one inch open conduit.

7. Observation, of the area above the drop down ceiling of the fire wall which divided the surgery addition from security, revealed a one half inch penetration near door 1808.3.

During the 06/18/13 at 8:30 A.M., tour, Staff A2 confirmed these findings.

On 06/18/13 at 10:10 A.M. a tour was conducted of the ground floor.

8. Observation, of the fire doors that separated the surgery addition from the Beerman Pavilion, revealed the rating of the doors was painted over.

During the 06/18/13 at 10:10 A.M., tour, Staff A2 confirmed the findings in an interview.

Based on observation and interview, the facility failed to ensure each door protecting a corridor opening resisted the passage of smoke. This had the potential to affect all patients, staff, and visitors to the facility. The total patient census on the first survey day was 86.

Findings include:

On 06/17/13 at 4:15 P.M. a tour was conducted of the second floor of the building with Staff A3, A4, and A6.

1. Observation of patient room corridor doors 403, 409, and 415, revealed gaps greater than 1/8 inch at the top of each door when in the closed position.

2. A tour was conducted on inpatient unit 3 West on 06/18/13 at 10:55 A.M. Patient room corridor door 320 was observed with a 1/2 inch gap between the doors leafs when observed in the closed position.

3. A tour was conducted on the second floor Pediatric Intensive Care Unit (PICU) on 06/18/13 between 11:43 A.M. and 11:55 A.M. with Staff A3, A4, and A6.

4. Observation of patient corridor room doors 271, 276, 278, 279A, and 281 revealed each door contained 2 door leafs. The gaps between these door leafs exceeded 1/8 inch gap, measuring from 2/8 inch to 5/16 of a gap (greater than 1/4 inch). These gaps were confirmed with Staff A3 and A6 during this tour.

During the 06/18/13 between 11:43 A.M. and 11:55 A.M., tour, during interview, the aforementioned staff confirmed the door gaps.

Based on observation and interview, the facility failed to ensure each door protecting a corridor opening resisted the passage of smoke. This involved one door near the operating room. This had the potential to affect all patients, staff, and visitors to the facility. The total patient census on the first survey day was 86.

Findings include:

On 06/17/13 at 3:15 P.M. a tour was conducted of the second floor of the building with Staff A1 and A2.

Observation in the corridor near the operating room control room revealed the door that opened from the control room to the corridor had part of its top shaved off for a mechanical closer, thereby creating an opening between the room and the corridor.

During the 06/17/13 at 3:15 P.M., tour, Staff A2 confirmed the finding.

Based on observation and interview, the facility failed to ensure one set of smoke barrier doors, equipped with latching hardware, latched when released from magnetic hold open device. This had the potential to affect all patients, staff, and visitors on the fourth floor of the facility. The total patient census on the first survey day was 86.

Findings include:

On the fourth floor inpatient unit, on 06/17/13, at 4:38 P.M., a tour conducted with Staff A3, A4, and A6 revealed a set of smoke barrier doors labeled 4023. The doors were observed with latching hardware, and were located outside patient room 415. When tested for closure, the doors failed to latch.

This was verified during an interview with the aforementioned staff during the 06/17/13, 4:38 PM, tour.

Based on observation, floor plan review, and interview, the facility failed to ensure two rooms were protected with one hour fire rated protection and the one hour fire rated protection was maintained. This had the potential to affect all patients, staff, and visitors to the facility. The total patient census on the first survey day was 86.

Findings include:

On 06/17/13 at 3:15 P.M. a tour was conducted of the second floor of the building with Staff A1 and A2.

1. Observation and review of the floor plans revealed an orthopedics storage room with a one hour fire rated wall on the left and right of the room as it is entered. Observation of the area above the drop down ceiling revealed a one inch unstopped conduit with a yellow wire extending from the opening.

2. Observation and review of the floor plans revealed the clean storage room shared a three hour fire rated wall with an elevator shaft. Observation of the area above the drop down ceiling revealed an unstopped one inch conduit with a red wire extending from the opening.

3. Observation and review of the floor plans revealed a clean storage room surround by a one hour fire rated wall. Observation of that wall from the area above the drop down ceiling revealed along the northeast wall an unsealed one inch conduit with a white wire extending from the opening.

During the 06/17/13 at 3:15 P.M., tour, these observations were confirmed by Staff A2.

Based on observation and staff interview, the facility failed to ensure one exit access of a procedure room door on the first floor opened with a simple operation. This could affect all patients and staff utilizing this room. The total patient census on the first day of the survey was 86.

Findings include:

A tour was conducted on 06/20/13 at 2:20 P.M. with Staff A1, A3, and A6. The cardiac catheter procedure room, located across the hall from Reception Area 1 A, was observed with a door handle and a deadbolt lock. The deadbolt was observed and measured at 16 inches over the door handle. This door was an exit access door that led to the exit corridor. During the tour, while inside the procedure room, the deadbolt was observed in the locked position. In order to open the door to enter the exit corridor, the deadbolt had to be unlocked, and the door handle then needed to be turned, requiring a 2 step method.

This was verified during interview with the aforementioned staff during the 06/20/13 2:20 PM, tour.

Based on observations and staff interviews, the facility failed to ensure three exit discharges were illuminated so that failure of any single lighting fixture (bulb) will not leave the area in darkness, in accordance with the code at 7.8.1.4. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 86.
Findings include:

Main building facility tour took place with staff members A3, A4, A5, and A6, on 06/18/13 between 8:50 A.M. and 10:00 A.M., and on 06/20/13 at 2:55 P.M. During this tour, three designated exit discharges were observed with either one light or no light at the exit discharge.

These exits are as follows:

1. The exit discharge outside the shipping/receiving department in Building 10 was observed with a wooden canopy which measured 14 feet by 8 feet. The exit discharge light was observed located over the roof of the canopy.

2. The exit discharge from the small deli kitchen by the office, and the exit discharge between Buildings 1 and 10, lacked exit discharge lighting.

The lack of exit discharge lighting was verified during the 06/18/13 between 8:50 A.M. and 10:00 A.M., and on 06/20/13 at 2:55 P.M. tours with the aforementioned staff.

Based on observation and interview, the facility failed to have paths of egress marked correctly when the path of egress was not readily apparent. This has the potential to affect all patients, staff, and visitors to the building. The total patient census on the first survey day was 86.
Findings include:
On the fourth floor:
On 06/17/13 between 2:50 P.M. and 4:08 P.M., a tour was conducted with Staff A3, A4, A6, and A7, of the fourth floor. This tour revealed the path of egress lacked exit directional signs when the path of egress was not readily apparent as follows:
1. The Neonatal Intensive Care Unit (NICU) smoke compartment was observed with an open area containing a larger number of neonatal beds, and was verified by Staff A3 to contain 7,840 square feet. An interview with Staff A8 during this On 06/17/13 between 2:50 P.M. and 4:08 P.M, tour revealed there were 40 neonatal beds in this room. The large room opened into smaller rooms labeled Transition, Breast Feeding, Mother's Lounge, Formula, Isolation (2 rooms), and Intravenous. When standing near isolation room 525, the exit signs could not be viewed, until moving into the center of the room by Bed 522, and then could only be partially viewed, due to a drop down decorative ceiling which partly obscured the upper portion of the exit sign. When standing by bed 532, there was no visible exit sign.
2. On 06/17/13 at 3:00 P.M., observation of a group of five offices, containing a waiting/reception area, and a file room, lacked an exit sign at the egress access door to the corridor.
On the second floor:
3. On 06/18/13 at 2:43 P.M. the surgical services office was observed with three offices which contained doors, a supply room, and an open office area. The exit access door to the egress corridor lacked an exit sign.
On the first floor:
4. The stairwell labeled 1042.1, located by the Support Services Building entrance, was observed, when the door was opened from the corridor, with a stairway leading up and down. Inside the door, when moving to the left and standing on the top step leading down, the exit sign at the discharge could be viewed. However, it could not be seen when entering the stairwell. There was no device in place to prevent someone from mistakenly going up the stairs to find the exit discharge.
On the lower level, on 06/19/13 between 9:25 A.M. and 11:15 A.M.:
5. The mechanical room across from the Audiology Department was observed with an exit access door, identified on the floor plan as door L060.1, which lacked an exit sign.
6. Phase II mechanical room 2 was observed with an exit access door which lacked an exit sign.
7. A door located by Elevator 11, by the Audiology office, was observed with an exit sign directing traffic to the door. Upon opening the door, this area was observed to lead to a crawl space, and was verified by Staff A6 as not being an exit.
8. The mechanical room Air Handler 2 room, by electrical room 0025, was observed with three exit access doors. From inside the room, these doors were observed with paper exit signs, which were not illuminated.
9. The exit sign located by room 0019 was observed pointing to this door. The door had to be opened utilizing a code. Staff A3 verified the exit directional sign was pointing the wrong way, and turned the exit sign around to point down the egress corridor.
These observations were verified per interview with Staff A3, A4, and A6 during the on 06/19/13 between 9:25 A.M. and 11:15 A.M. tour.

Based on observation and interview, the facility failed to have paths of egress marked on four of four levels of the building. This has the potential to affect all patients, staff, and visitors to the building. The total patient census on the first survey day was 86.
Findings include:
1. On 06/18/13 at 11:05 A.M. a tour of the Outpatient Center Building was conducted with Staff A1 and A2. During the tour of the fourth floor with Staff A1 and A2, the floor was observed to consist of patient exam rooms and physician offices. During the tour of the exam room's part of the floor, two paths of egress were observed leading from them out into the waiting area, merging into one path of egress that lead out into the corridor. However, standing at the southeastern egress door to the waiting area, the exit sign leading to the corridor was difficult to visualize.
2. At the elevators, an evacuation plan was observed and reviewed. The review revealed a path of egress that when traced lead to a north door that did not have an exit sign above it.
During the 06/18/13 at 11:05 A.M., tour, Staff A2 confirmed the observations.
On 06/18/13 at 11:25 A.M. a tour was conducted of the building's third floor.
3. Review of the evacuation plan located by the elevators revealed a path of egress to a door in the west, above which there was no exit sign.
During the 06/18/13 at 11:25 A.M., tour, Staff A2 confirmed the observations.
4. On 06/18/13 at 11:45 A.M. a tour was conducted of the building's second floor. Observation of the horizontal exit leading to the Taggart Pavilion lacked an exit sign.
During the 06/18/13 at 11:45 A.M., tour, Staff A2 confirmed the observation.
5. On 06/18/13 at 2:00 P.M. a tour was conducted of the first floor. Observation of the path of egress from preparation room A through double doors to the waiting area revealed an exit sign in the waiting area that was difficult to see what direction people should follow to the corridor.
During the 06/18/13 at 2:00 P.M., tour, Staff A2 confirmed the observations.

Based on observation during tour and staff verification, the facility failed to ensure NPFA 101, 9.6.1.4, and NFPA 72, 2-3.5 were followed in regard to smoke detector placement in spaces served by air-handling systems. The facility failed to ensure smoke detectors were not located less than 36 inches from air flow supply or return vents in places where airflow patterns could prevent the normal operation of the detectors. This could affect all patients, staff, and visitors in the facility. The total patient census on the first survey day was 86.

Findings include:

The following was observed during tours conducted with Staff A3, A4, and A6:

On the fourth floor:
On 06/17/13 between 2:50 P.M. and 4:08 P.M., observations revealed the following smoke detector locations too close to air supply/return diffusers:

1. In Building 2 hallway outside room 434, and
2. In the Neonatal Intensive Care Unit (NICU) inside the scrub room by the family waiting room, and in the corridor next to the 6 H-tanks of oxygen located near the soiled utility room.

Tour was conducted with the aforementioned staff on the 3rd floor on 06/18/13 between 8:48 A.M. and 11:30 A.M. These smoke detectors were observed located as follows:

3. In Building 2 hallway outside room 332, and
4. In Building 7 inside the office space next to stairwell labeled 3003.2 and elevators 8 and 9 lobby.

Tour of the 2nd floor was conducted on 06/18/13 between 11:37 A.M. and 3:09 P.M. These smoke detectors were observed located as follows:

5. In Building 2 inside the physician's lounge (door labeled 2044.S), and in the corridor outside this room,
6. In Building 3 inside the Dental Lab office suite in the corridor by the generalist office 131,
7. In Building 7 inside the nursing administrative suite of offices (2 smoke detectors),
8. Inside Building 2, inside the Taggart Clinic, near the exam rooms in the hallway closest to Building 5.

Tour of the 1st floor was conducted on 6/18/13 between 8:50 A.M. and 9:23 A.M., and on 06/20/13 between 2:02 P.M. and 3:24 P.M. These smoke detectors were located as follows:

9. In Building 10 inside the Interior office/Workspace partitions area,
10. In Building 1 inside the Cafeteria seating area near the dish conveyor,
11. In Building 2, inside the tech area, between x-ray rooms D and E, and inside the cardiac heart catheter control room,
12. In the corridor between Buildings 4 and 7, and
13. Inside the neurology, urology offices.

Tour of the Lower Level was conducted on 06/18/13 at 9:25 A.M. and 11:45 A.M. These smoke detectors were located as follows:

14. In Building 2, inside the laundry room where the washer/dryer were located,
15. Inside the Pharmacy delivery room,
16. Inside the Facility Computer room,
17. In the corridor by the Phase II mechanical room,
18. In Building 4, in the hallway between Audiology and the mechanical room, and
18. In Building 3, by the room with the door labeled L020.1

These smoke detector locations were verified per interview with Staff A3 and A6 during the aforementioned tours. On 06/21/13 at 11:30 AM, an interview was conducted with Staff A9 (who does routine inspections of the fire alarm system) regarding these smoke detector locations. Staff A9 verified the facility uses two types of smoke detectors, and stated although one model can be placed in duct work, they need to programmed for this in order to be used near air supply and vent diffusers. Staff A9 stated he/she spoke with the outside fire alarm service contractor who verified these smoke detectors had not been programmed for this use. Staff A9 stated the all the aforementioned smoke detectors will need to be relocated at least 36 inches from air supply and returns.

Based on observation and interview, the facility failed to maintain a sprinkler system in accordance with NFPA 13, specifically, NFPA 13 5-5.5.2.1. This could affect all patients, staff, and visitors in the facility. The total patient census on the first survey day was 86.
Findings include:
Tour of the facility with Staff A3, A4, and A6 was completed as follows:
1. On 06/18/13 at 3:35 P.M., a medical records room was observed located on the second floor of Building 4 in the Hematology/Oncology suite. This room was observed with 4 shelves of medical records which were stacked less than 18 inches from the sprinkler heads, compromising the sprinkler coverage.
2. On the 3rd floor, on 06/18/13 at 10:50 A.M., Room 306 was observed with a very dirty sprinkler head.
3. On the 1st floor, on 08/18/13 at 9:20 A.M., in the cafeteria serving area, two dirty sprinkler heads were observed over the food serving area.
During the tour, Staff A3 and A6 verified the aforementioned sprinkler heads.

Based on observations and staff interview, the facility failed to ensure all portable fire extinguishers were readily visible to staff. This involved the first floor kitchen and an office area in Building 10. This could affect all staff, patients, and visitors in the facility. The total patient census on the first survey day was 86.

Findings include:

A tour of the main facility kitchen took place with staff members A3, A4, and A6 on 06/18/13 between 8:50 A.M. and 9:23 A.M. This tour revealed:

1. A fire extinguisher, in the main kitchen near the formula room, was observed blocked by a cart of wheels, and could not be seen until the cart was moved.

2. The smaller deli kitchen was observed with a K-type fire extinguisher that was placed almost at ground level next to shelves, and was not readily visible except from one direction. The extinguisher lacked a sign identifying the location. According to Staff A3, during the tour, the kitchen hood extinguishing system in that area is currently non-compliant with the code.

3. Building 10, first floor financial services area, was toured with the same staff on 06/20/13 at 3:15 P.M. A fire extinguisher in this area was observed obscured by shelves. There was no sign identifying the location of the fire extinguisher.

These findings were verified with the aforementioned staff during tour.

Based on staff interview, and review of the fire damper testing logs, the facility failed to ensure fire dampers were tested every 6 years in accordance with the code. This affected 4 of 5 hospital floors and could affect all staff, patients, and visitors. The total patient census on the first survey day was 86.

Findings include:

1. On 06/19/13, a review was conducted of the facility's fire damper maintenance log. According to the log, fire dampers for the heating and ventilation system were not inspected since 2006 for the following areas: the lower level, first floor, second floor, and fourth floor, in areas involving mechanical areas, surgery, post anesthesia recovery area, and pediatric intensive care.

2. During an interview, on 06/19/13 at 4:00 P.M., Staff A3 verified these fire dampers were tested in 2006 and were due to be tested this year 2013. This employee also verified the maintenance testing log was missing the year 2008, making it appear as if the damper testing was due in 2013. However, when the surveyor pointed out the year 2008, was missing from the log, Staff A3 verified the damper testing was overdue and should have been completed in 2012 for the aforementioned areas.

Based on observation and staff interview it was determined this facility failed to one ensure one of two suppression systems in the kitchen area were updated to UL-300 compliance at the six year maintenance or when the hydrostatic testing was due. This had the potential to affect all those utilizing this area of the facility. The total patient census was 86 at the beginning of the survey.
Findings include:
1. The Main building facility tour took place with staff members A3, A4, and A6 on 06/18/13 between 8:50 A.M. and 9:23 A.M. During the tour of the kitchen area, observation revealed two kitchen hood suppression systems, one located in the main kitchen and one in the the smaller deli kitchen. This was verified with the aforementioned staff during tour.
2. On 06/20/13, the inspection reports for the outside service company were reviewed in regard to these two ansul systems. These inspection reports, dated 11/28/12, and 05/20/13, stated the Ansul R102-G, located over the deli grill, was Non UL300 compliant. This was verified with Staff A1 and A3 on 06/21/13 at 10:22 A.M. Staff A1 stated the noncompliant ansul system is scheduled for renovation in August 2013, in order to ensure it is UL300 compliant.

Based on observations and staff interviews, the facility failed to store medical gas in accordance with NFPA 99, Standards for Health Care Facilities. This affected three inpatient units of the facility. The total patient census on the first survey day was 86.

Findings include:


1. On 06/17/13 between 2:50 P.M. and 4:08 P.M., a tour was conducted with Staff A3, A4, A6, and A7, of the fourth floor. This tour revealed an open storage area of 6 H-tank cylinders of oxygen located in the exit access corridor, inside the smoke compartment of the Neonatal Intensive Care Unit (NICU) unit. This smoke compartment was observed with a large open area containing forty neonatal beds, and was verified by Staff A3 to contain 7,840 square feet.

2. 12 additional E-Tanks of oxygen were located inside this smoke compartment. Eleven of the tanks were located in an open room near neonatal beds 514 and 515. An interview with Staff A8, during this tour, revealed there were 40 neonatal beds in this room.

3. On 06/18/13, at 11:00 A.M., the respiratory therapy work room located across from patient room 317, on the 3 West unit, was observed with 13 E-tanks of oxygen. The door and room lacked signs indicating this was a medical gas storage room.

4. On 06/18/13 at 11:43 A.M., a medical gas storage room, located in the Critical Care Complex hallway adjacent to the Pediatric Intensive Care Unit, was observed with 6 H-sized cylinders of oxygen. The double doors to the hallway from this room were observed with a 3 hour fire resistance rating and were quipped with a coordinator. When tested, the coordinator failed to allow the doors to close and latch properly, leaving the doors open to the egress corridor.

The aforementioned findings were verified with the Staff A3, A4, and A6 on tour.

These observations were confirmed during interviews with Staff A3, A4,and A6 at the time of tour.

Based on observations and staff interviews, the facility failed to ensure five of five exit discharges were illuminated so that failure of any single lighting fixture (bulb) would not leave the area in darkness in accordance with the code at 7.8.1.4. This had the potential to affect all those utilizing these areas of the facility. The patient census at the beginning of the survey was 86.
Findings include:

Tour of this facility took place with Staff A4 and A10 on 06/20/13 between 10:06 A.M. and 11:05 A.M. During this tour, five of five designated exit discharges were observed with either one light at the exit discharge.

The lack of exit discharge lighting was verified during tour with the aforementioned staff.

.
Based on observation and interview, the facility failed to maintain a sprinkler system in accordance with NFPA 13, specifically, NFPA 13 5-5.5.2.1. This could affect all patients, staff, and visitors in the facility. The total patient census on the first survey day was 86.
Findings include:
Tour of the basement of the building was completed at 2:45 P.M. on 06/18/13. During the tour, at least 10 stacks of medical records were observed in the center of a room equipped with sprinklers. The stacks were of a sliding type, so that at any one time, only one pathway existed between them. Because the stacks were only approximately five inches from the ceiling, and because most of the time each stack was right next to the other, sprinkler coverage was compromised.
During the 06/18/13 at 2:45 P.M., tour, Staff A2 confirmed the observations.

Based on observation and interview, the facility failed to ensure the riser room of the building contained a box with six spare sprinklers and wrench. This has the potential to affect all patients, staff, and visitors to the building. The total patient census on the first survey day was 86.
Findings include:
On 06/20/13 at 8:00 A.M. a tour was conducted of the riser room with Staff A1 and Staff A2. During the tour of the riser room of the sprinklers, there was a box with spare sprinklers and a corresponding wrench, however, it did not contain spare sprinkler heads of the type used in the building.
During the 8:00 AM, tour, Staff A2 confirmed this finding.

Based on observation and interview, the facility failed to ensure the riser room of the building contained a box with spare sprinklers and a wrench. This has the potential to affect all patients, staff, and visitors to the building. The total patient census on the first survey day was 86.
Findings include:
On 06/19/13 at 8:30 A.M. a tour was conducted of the first floor of the building with Staff A1 and Staff A2. During the tour of the riser room of the sprinklers, a box with spare sprinklers and a corresponding wrench was not observed.
In an interview during the tour, Staff A2 confirmed the findings.

Based on staff interviews and review of the three generator maintenance and testing logs, the facility failed to ensure the generators started within 10 seconds of activation of the automatic switch, and failed to provide maintenance logs for March, April, and May 2013. This could affect all patients, staff, and visitors in the facility. The total patient census the first survey day was 86.

Findings include:

1. On 06/21/13, a review of the generator maintenance and testing logs revealed the facility has three generators onsite for the main campus buildings. These logs stated the following under the monthly engine/switchgear loaded checks: Transfer critical or life safety automatic transfer switch(es) to start generators. Record time in seconds when engine(s) connected to loads (must be under 10 seconds).

2. Review of these logs revealed the transfer was 12 seconds for generator number 3 on 02/07/13. The testing logs for all three generators revealed this transfer exceeded 10 seconds on 06/12/13.

3. The facility was unable to find the generator testing logs for weekly inspections and monthly load testing for the period of time of 03/28/13 to 05/14/13.

The aforementioned findings were verified with Staff A3 during an interview on 06/21/13 at 2:30 P.M.

Based on staff interviews and review of the three generator maintenance and testing logs, the facility failed to ensure the generators started within 10 seconds, and failed to provide maintenance logs for March, April, and May 2013. This could affect all patients, staff, and visitors in the facility. The total patient census the first survey day was 86.

Findings include:

1. On 06/21/13, a review of the generator maintenance and testing logs revealed the facility had three generators onsite for the main campus buildings. These logs stated the following under the monthly engine/switchgear loaded checks: Transfer critical or life safety automatic transfer switch(es) to start generators. Record time in seconds when engine(s) connected to loads (must be under 10 seconds).

2. These logs revealed the transfer was 12 seconds for generator #3 on 02/07/13. The testing logs for all three generators revealed the transfer exceeded 10 seconds on 06/12/13.

3. The facility was unable to find the generator testing logs for weekly inspections and monthly load testing for the period of time from 03/28/13 to 05/14/13.

The aforementioned findings were verified with Staff A3 during an interview on 06/21/13 at 2:30 P.M.