HospitalInspections.org

1. Based on observation and interview, the facility failed to ensure an access door to 1 of 8 hazardous areas was held open only with a device which allowed the door to close automatically. This deficient practice could affect visitors, staff and 12 patients on the first floor.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:05 p.m., one of two double doors providing access from the exit corridor into the sprinklered facility mechanical and storage room was equipped with a self closer, however, the door was prevented from closing by a device attached to the wall which held the door open until it was manually pulled free to close. The maintenance director said the device was used to hold the door open for delivering materials into the mechanical and storage rooms but otherwise kept closed. He conceded that when the doorway was initially observed the door was prevented from closing and was wide open, no delivery was in progress, no other staff were in the area and the door should have been closed.

2. Based on observation and interview, the facility failed to ensure 1 of 11 first floor smoke barrier door sets was held open by a device which would allow the doors to close upon activation of the fire alarm system. This deficient practice could affect staff, visitors, and 12 or more patients on the first and second floors.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:15 p.m., the double smoke barrier door set near the dietary department was tested twice with the maintenance director. One door in the door set was held open by the door coordinator which malfunctioned when it stopped the door from closing leaving a four inch gap between the doors. The maintenance director agreed at the time of observation, the faulty door coordinator would not allow the doors to close.

3. Based on observation and interview, the facility failed to ensure access doors to 1 of 5 hazardous areas, such as a storage room larger than 50 square feet, was held open only with a device which allowed the door to close automatically. This deficient practice could affect visitors, staff and 12 patients on the first floor.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:25 p.m., the self closing corridor access door to the unoccupied 12 by 10 foot dietary storage room was prevented from closing by a bungee cord wrapped around the door knob and hooked onto a shelf located behind the door. The maintenance director said at the time of observation, the door should not have been held open in this manner.

Based on observation and interview, the facility failed to ensure openings through smoke barriers on 1 of 2 floors were protected to maintain the fire resistance of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient could affect visitors, staff and all patients on 1 of 2 occupied floors.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:30 p.m., eight penetrations by six, four, and two inch pipes and bundles of cables in the concrete fire wall separating the mechanical and storage rooms from the adjacent corridor and rooms on the first floor were unsealed leaving one to two inch gaps. The maintenance director said at the time of observation, he had never known the penetrations had not been sealed. Although it was evident from the mechanical room side of the smoke barrier, he said he had never looked above the laid in ceiling on the corridor side of the wall.

Based on observation with the maintenance director on 03/07/11 at 1:40 p.m., the concrete block smoke barrier wall separating the unsprinklered dietary service corridor from administrative office access and the dining facilities corridor was in complete. The wall had concrete block removed to allow the passage of one to six inch pipes, and bundles of cable and conduit to pass through the wall above the laid in ceiling. The openings had been unsealed leaving gaps of more than eight inches. The maintenance director agreed at the time of observation, the wall should have been sealed completely.

Based on observation and interview, the facility failed to provide 1 of 11 first floor smoke barrier door sets with the appropriate hardware to allow the door which must close first, to always close first to ensure both doors always close completely. CMS requires smoke barrier doors equipped with an astragal have a coordinator to ensure the door that must close first always closes first. This deficient practice could affect visitors, staff and 12 patients on the first floor.

Findings include:

Based on observation the maintenance director on 03/07/11 between 11:30 a.m. and 3:00 p.m., the smoke barrier doors protecting Unit A were not equipped with a coordinator to assure the doors would close in the proper sequence each time. The maintenance director agreed at the time of observation, door coordinators would ensure the doors closed in the proper sequence every time.

Based on observation and interview, the facility failed to ensure openings in the one hour wall of 2 of 8 hazardous areas were provided with self closing doors. Sprinklered hazardous areas are required to be equipped with self closing doors or with doors that close automatically upon activation of the fire alarm system. This deficient practice could affect visitors, staff and 12 patients in the dining room.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 12:50 p.m., a 36 by 36 inch pass through opening separated the kitchen from the unsprinklered dining room. The opening was protected by a steel door which had to be closed and secured manually. The maintenance director confirmed at the time of observation, the door was not self closing.

Based on observation with the maintenance director on 03/07/11 at 1:05 p.m., one of two double doors providing access from the exit corridor into the sprinklered facility mechanical and storage room did not self close. The maintenance director said the door was not equipped with a self closing device.

1. Based on observation and interview, the facility failed to ensure the discharge means of egress for 3 of 3 grade level exits from the second floor were arranged to be accessible. LSC 7.1.3.2.3 requires an exit enclosure shall not be used for any purpose with the potential to interfere with its use as an exit. LSC 7.1.10.1 "Means of egress shall be continuously free of all obstructions or impediments to full instant use in case of fire or other emergency use." This deficient practice affects staff, visitors and 8 or more patients using second floor grade level exits from the library, A and D units.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 12:20 p.m., second floor emergency exterior exits from the library, and A and D units discharged onto a sidewalk. The path of egress was blocked by two picnic tables on the north side of the building and on the west side where a large deck box sat. The maintenance director said at the time of observation, the picnic tables were not usually located on the sidewalk, agreed they block the exitway, and he had not known the deck box had been put there.

2. Based on observation and interview, the facility failed to ensure 3 of 3 second floor grade level exits to the outside terminated at a public way such as the parking lot. LSC Section 19-2, Means of Egress Requirements, requires every exit discharge, exit location and access shall be in accordance with LSC Chapter 7. LSC 7-7.1 requires that all exits shall terminate at a public way. This deficient practice affects staff, visitors and 8 or more patients using second floor grade level exits from the library, A and D units.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 12:20 p.m., second floor emergency exits to the outside from the library, and A and D units discharged onto a sidewalk which terminated at the basketball court. The distance between the basketball court and the parking lot evacuation site consisted of a grassy lawn terminating at steps to the parking lot. The maintenance director agreed, the area could not be maintained level, slip resistant and free of snow and ice for patient evacuation.

Based on record review and interview, the facility failed to ensure the facility fire plan provided effective staff training for the protection of 15 of 15 patients. This deficient practice could affect all occupants.

Findings include:

Based on review of the facility Fire Protection Plans (review date May 5, 2010) with the maintenance director on 03/07/11 at 3:00 p.m., the document included Specific Instructions In Case Of Fire on page 2. The instruction noted, "If a small fire (wastebasket), pull alarm, try to extinguish by covering with wool blanket, metal drawer out of bedside table or any similar object (wool or metal). By all means do not pick up basket and run with it." Page 7, 1(d) notes, "try to extinguish the fire if it is not too large." Inpatient Services Department's Fire Instructions, notes "2. If a small fire (wastebasket) extinguish by a fire extinguisher in Inpatient Services area. Do not pick it up and run with it." Instructions for dietary employees were similar. The maintenance director said at the time of record review, there had been no specific training to identify small fires and extinguishing fires had not been practiced. He did not know where wool blankets referenced in the document could be found.

Based on record review and interview, the facility failed to ensure fire drills were conducted at unexpected times during 10 of 12 fire drills. This deficient practice affects all occupants.

Findings include:

Based on a review of Fire Drill Exercise Evaluation records provided for the past year with the maintenance director on 03/07/11 at 2:15 p.m., at least seven fire drills were conducted between the 29th and 31st day of the month on all shifts during the past year. Fire drill times varied less than one hour for the following drills:
a. During the first shift on 03/10/10 at 2:30 p.m., 06/29/10 at 2:34
p.m., on 09/21/10 at 2:42 p.m. and on 11/08/10 at 2:23 p.m.;
a. During the second shift on 03/31/10 at 3:35 p.m., 06/30/10 at
3:37 p.m., and 09/30/10 at 3:22 p.m.;
b. During the third shift on 03/29/10 at 6:28 a.m., 06/29/10 at
6:15 p.m., and 11/08/10 at 6:47 a.m.
The maintenance director agreed at the time of record review, there was a pattern to the fire drills conducted.

1. Based on observation and interview, the facility failed to ensure 1 of 3 fire alarm panels in an area not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at the location before it could be incapacitated by fire. NFPA 72, 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice affects all occupants.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:55 p.m., the main fire alarm control panel (FACP) was located in the mechanical room which was not continuously occupied and was not electrically supervised by a smoke detector. The maintenance director agreed at the time of observation, the panel could be incapacitated by fire before an alarm could be annunciated in the area.

2. Based on observation and interview, the facility failed to ensure a smoke detector connected to the fire alarm system on 1 of 2 floors was properly separated from an air supply. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect visitors, staff, and 15 patients on the second floor.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 2:25 p.m., the smoke detector at the second floor reception area was located 18 inches from an air supply vent. The maintenance director agreed at the time of observation, the air supply could delay smoke detection by the device in the event of fire.

Based on record review and interview, the facility failed to ensure 60 of 60 smoke detectors had been sensitivity tested. LSC Section 9.6.1.3 says the provisions of 9.6 cover the basic functions of the fire alarm system, including fire detection systems. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72 at 7-3.2.1 states, "Detector sensitivity shall be checked within one year after installation and every alternative year thereafter. After the second required calibration test, if sensitivity tests indicate that the detectors have remained within their listed and marked sensitivity ranges, the length of time between calibration tests may be extended to a maximum of five years. If the frequency is extended, records of detector caused nuisance alarms shall be maintained. In zones or areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure each smoke detector is within its listed and marked sensitivity range it shall be tested using the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for the purpose.
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its acceptable sensitivity range.
(5) Other calibrated sensitivity test method acceptable to the authority having jurisdiction.
Detectors found to have sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of aerosol into the detector." This deficient practice affects all occupants.

Findings include:

Based on a review the facility smoke detector Report(s) of Inspection with the maintenance director on 03/07/11 at 2:55 p.m., the last Smoke Detector Sensitivity Test was completed 08/05/08. The maintenance director said at the time of record review he knew the detector sensitivity testing was "late" and he had requested the test be done by the contractor. He said the contractor had not yet notified him when they would be there to do the test.

1. Based on observation and interview, the facility failed to ensure a supply of at least six spare sprinkler heads was kept on the premises in a cabinet. NFPA 25, 2-4.1.4 requires a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 2:05 p.m., three spare sprinkler heads were found by the maintenance director in a cardboard carton located on a shelf in the maintenance shop. The sprinklers were wrapped in a paper bag and stored with other fire system parts. The maintenance director could not say at the time of discovery, if the heads represented all types of sprinklers in the facility and, in fact, he had been uncertain whether there had been any spare heads.

2. Based on observation and interview, the facility failed to ensure a special sprinkler wrench for sprinkler head maintenance was available for use. NFPA 25, 2-4.1.6 requires a special sprinkler wrench shall be provided and kept in the cabinet to be used in removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler. This deficient practice affects all occupants.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 2:05 p.m., there was no special wrench available for maintenance of sprinkler heads. The maintenance director said at the time of observation, he had never seen one.

1. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on review of the generator maintenance records on 03/07/11 at 3:05 p.m. with the maintenance director, there was no documentation available indicating the horsepower of the generator. The maintenance director said at the time of record review, he was not sure of the generator engine's horsepower rating but the generator ran all electrical equipment in the two story facility whenever there was a power outage. Based on observation of generator equipment on 03/07/11 at 1:50 p.m. with the maintenance director, an emergency shut off was located on the generator. The maintenance director said at the time of observation, there was no remotely located emergency generator shut off device.

2. Based on observation, record review 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 patients, visitors and staff.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:45 p.m., a remote alarm annunciator for the emergency generator was provided in the facility mechanical room behind stored material. The maintenance director said at the time of observation, he had never seen it function and did not know if had an audible alarm. He pushed the test button which illuminated all the indicator lights and alarmed. The maintenance director said the area was not continuously occupied and nobody could hear an alarm annunciated from the panel in other areas of the facility. He said the generator had never failed except once, when it did not start due to battery failure. He agreed the annunciator panel should have alarmed to notify staff of the failure before the regular generator test failed.

1. Based on observation and interview, the facility failed to ensure an access door to 1 of 8 hazardous areas was held open only with a device which allowed the door to close automatically. This deficient practice could affect visitors, staff and 12 patients on the first floor.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:05 p.m., one of two double doors providing access from the exit corridor into the sprinklered facility mechanical and storage room was equipped with a self closer, however, the door was prevented from closing by a device attached to the wall which held the door open until it was manually pulled free to close. The maintenance director said the device was used to hold the door open for delivering materials into the mechanical and storage rooms but otherwise kept closed. He conceded that when the doorway was initially observed the door was prevented from closing and was wide open, no delivery was in progress, no other staff were in the area and the door should have been closed.

2. Based on observation and interview, the facility failed to ensure 1 of 11 first floor smoke barrier door sets was held open by a device which would allow the doors to close upon activation of the fire alarm system. This deficient practice could affect staff, visitors, and 12 or more patients on the first and second floors.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:15 p.m., the double smoke barrier door set near the dietary department was tested twice with the maintenance director. One door in the door set was held open by the door coordinator which malfunctioned when it stopped the door from closing leaving a four inch gap between the doors. The maintenance director agreed at the time of observation, the faulty door coordinator would not allow the doors to close.

3. Based on observation and interview, the facility failed to ensure access doors to 1 of 5 hazardous areas, such as a storage room larger than 50 square feet, was held open only with a device which allowed the door to close automatically. This deficient practice could affect visitors, staff and 12 patients on the first floor.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:25 p.m., the self closing corridor access door to the unoccupied 12 by 10 foot dietary storage room was prevented from closing by a bungee cord wrapped around the door knob and hooked onto a shelf located behind the door. The maintenance director said at the time of observation, the door should not have been held open in this manner.

Based on observation and interview, the facility failed to ensure openings through smoke barriers on 1 of 2 floors were protected to maintain the fire resistance of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient could affect visitors, staff and all patients on 1 of 2 occupied floors.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:30 p.m., eight penetrations by six, four, and two inch pipes and bundles of cables in the concrete fire wall separating the mechanical and storage rooms from the adjacent corridor and rooms on the first floor were unsealed leaving one to two inch gaps. The maintenance director said at the time of observation, he had never known the penetrations had not been sealed. Although it was evident from the mechanical room side of the smoke barrier, he said he had never looked above the laid in ceiling on the corridor side of the wall.

Based on observation with the maintenance director on 03/07/11 at 1:40 p.m., the concrete block smoke barrier wall separating the unsprinklered dietary service corridor from administrative office access and the dining facilities corridor was in complete. The wall had concrete block removed to allow the passage of one to six inch pipes, and bundles of cable and conduit to pass through the wall above the laid in ceiling. The openings had been unsealed leaving gaps of more than eight inches. The maintenance director agreed at the time of observation, the wall should have been sealed completely.

Based on observation and interview, the facility failed to provide 1 of 11 first floor smoke barrier door sets with the appropriate hardware to allow the door which must close first, to always close first to ensure both doors always close completely. CMS requires smoke barrier doors equipped with an astragal have a coordinator to ensure the door that must close first always closes first. This deficient practice could affect visitors, staff and 12 patients on the first floor.

Findings include:

Based on observation the maintenance director on 03/07/11 between 11:30 a.m. and 3:00 p.m., the smoke barrier doors protecting Unit A were not equipped with a coordinator to assure the doors would close in the proper sequence each time. The maintenance director agreed at the time of observation, door coordinators would ensure the doors closed in the proper sequence every time.

Based on observation and interview, the facility failed to ensure openings in the one hour wall of 2 of 8 hazardous areas were provided with self closing doors. Sprinklered hazardous areas are required to be equipped with self closing doors or with doors that close automatically upon activation of the fire alarm system. This deficient practice could affect visitors, staff and 12 patients in the dining room.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 12:50 p.m., a 36 by 36 inch pass through opening separated the kitchen from the unsprinklered dining room. The opening was protected by a steel door which had to be closed and secured manually. The maintenance director confirmed at the time of observation, the door was not self closing.

Based on observation with the maintenance director on 03/07/11 at 1:05 p.m., one of two double doors providing access from the exit corridor into the sprinklered facility mechanical and storage room did not self close. The maintenance director said the door was not equipped with a self closing device.

1. Based on observation and interview, the facility failed to ensure the discharge means of egress for 3 of 3 grade level exits from the second floor were arranged to be accessible. LSC 7.1.3.2.3 requires an exit enclosure shall not be used for any purpose with the potential to interfere with its use as an exit. LSC 7.1.10.1 "Means of egress shall be continuously free of all obstructions or impediments to full instant use in case of fire or other emergency use." This deficient practice affects staff, visitors and 8 or more patients using second floor grade level exits from the library, A and D units.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 12:20 p.m., second floor emergency exterior exits from the library, and A and D units discharged onto a sidewalk. The path of egress was blocked by two picnic tables on the north side of the building and on the west side where a large deck box sat. The maintenance director said at the time of observation, the picnic tables were not usually located on the sidewalk, agreed they block the exitway, and he had not known the deck box had been put there.

2. Based on observation and interview, the facility failed to ensure 3 of 3 second floor grade level exits to the outside terminated at a public way such as the parking lot. LSC Section 19-2, Means of Egress Requirements, requires every exit discharge, exit location and access shall be in accordance with LSC Chapter 7. LSC 7-7.1 requires that all exits shall terminate at a public way. This deficient practice affects staff, visitors and 8 or more patients using second floor grade level exits from the library, A and D units.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 12:20 p.m., second floor emergency exits to the outside from the library, and A and D units discharged onto a sidewalk which terminated at the basketball court. The distance between the basketball court and the parking lot evacuation site consisted of a grassy lawn terminating at steps to the parking lot. The maintenance director agreed, the area could not be maintained level, slip resistant and free of snow and ice for patient evacuation.

Based on record review and interview, the facility failed to ensure the facility fire plan provided effective staff training for the protection of 15 of 15 patients. This deficient practice could affect all occupants.

Findings include:

Based on review of the facility Fire Protection Plans (review date May 5, 2010) with the maintenance director on 03/07/11 at 3:00 p.m., the document included Specific Instructions In Case Of Fire on page 2. The instruction noted, "If a small fire (wastebasket), pull alarm, try to extinguish by covering with wool blanket, metal drawer out of bedside table or any similar object (wool or metal). By all means do not pick up basket and run with it." Page 7, 1(d) notes, "try to extinguish the fire if it is not too large." Inpatient Services Department's Fire Instructions, notes "2. If a small fire (wastebasket) extinguish by a fire extinguisher in Inpatient Services area. Do not pick it up and run with it." Instructions for dietary employees were similar. The maintenance director said at the time of record review, there had been no specific training to identify small fires and extinguishing fires had not been practiced. He did not know where wool blankets referenced in the document could be found.

Based on record review and interview, the facility failed to ensure fire drills were conducted at unexpected times during 10 of 12 fire drills. This deficient practice affects all occupants.

Findings include:

Based on a review of Fire Drill Exercise Evaluation records provided for the past year with the maintenance director on 03/07/11 at 2:15 p.m., at least seven fire drills were conducted between the 29th and 31st day of the month on all shifts during the past year. Fire drill times varied less than one hour for the following drills:
a. During the first shift on 03/10/10 at 2:30 p.m., 06/29/10 at 2:34
p.m., on 09/21/10 at 2:42 p.m. and on 11/08/10 at 2:23 p.m.;
a. During the second shift on 03/31/10 at 3:35 p.m., 06/30/10 at
3:37 p.m., and 09/30/10 at 3:22 p.m.;
b. During the third shift on 03/29/10 at 6:28 a.m., 06/29/10 at
6:15 p.m., and 11/08/10 at 6:47 a.m.
The maintenance director agreed at the time of record review, there was a pattern to the fire drills conducted.

1. Based on observation and interview, the facility failed to ensure 1 of 3 fire alarm panels in an area not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at the location before it could be incapacitated by fire. NFPA 72, 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice affects all occupants.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:55 p.m., the main fire alarm control panel (FACP) was located in the mechanical room which was not continuously occupied and was not electrically supervised by a smoke detector. The maintenance director agreed at the time of observation, the panel could be incapacitated by fire before an alarm could be annunciated in the area.

2. Based on observation and interview, the facility failed to ensure a smoke detector connected to the fire alarm system on 1 of 2 floors was properly separated from an air supply. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect visitors, staff, and 15 patients on the second floor.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 2:25 p.m., the smoke detector at the second floor reception area was located 18 inches from an air supply vent. The maintenance director agreed at the time of observation, the air supply could delay smoke detection by the device in the event of fire.

Based on record review and interview, the facility failed to ensure 60 of 60 smoke detectors had been sensitivity tested. LSC Section 9.6.1.3 says the provisions of 9.6 cover the basic functions of the fire alarm system, including fire detection systems. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72 at 7-3.2.1 states, "Detector sensitivity shall be checked within one year after installation and every alternative year thereafter. After the second required calibration test, if sensitivity tests indicate that the detectors have remained within their listed and marked sensitivity ranges, the length of time between calibration tests may be extended to a maximum of five years. If the frequency is extended, records of detector caused nuisance alarms shall be maintained. In zones or areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure each smoke detector is within its listed and marked sensitivity range it shall be tested using the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for the purpose.
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its acceptable sensitivity range.
(5) Other calibrated sensitivity test method acceptable to the authority having jurisdiction.
Detectors found to have sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of aerosol into the detector." This deficient practice affects all occupants.

Findings include:

Based on a review the facility smoke detector Report(s) of Inspection with the maintenance director on 03/07/11 at 2:55 p.m., the last Smoke Detector Sensitivity Test was completed 08/05/08. The maintenance director said at the time of record review he knew the detector sensitivity testing was "late" and he had requested the test be done by the contractor. He said the contractor had not yet notified him when they would be there to do the test.

1. Based on observation and interview, the facility failed to ensure a supply of at least six spare sprinkler heads was kept on the premises in a cabinet. NFPA 25, 2-4.1.4 requires a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 2:05 p.m., three spare sprinkler heads were found by the maintenance director in a cardboard carton located on a shelf in the maintenance shop. The sprinklers were wrapped in a paper bag and stored with other fire system parts. The maintenance director could not say at the time of discovery, if the heads represented all types of sprinklers in the facility and, in fact, he had been uncertain whether there had been any spare heads.

2. Based on observation and interview, the facility failed to ensure a special sprinkler wrench for sprinkler head maintenance was available for use. NFPA 25, 2-4.1.6 requires a special sprinkler wrench shall be provided and kept in the cabinet to be used in removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler. This deficient practice affects all occupants.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 2:05 p.m., there was no special wrench available for maintenance of sprinkler heads. The maintenance director said at the time of observation, he had never seen one.

1. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on review of the generator maintenance records on 03/07/11 at 3:05 p.m. with the maintenance director, there was no documentation available indicating the horsepower of the generator. The maintenance director said at the time of record review, he was not sure of the generator engine's horsepower rating but the generator ran all electrical equipment in the two story facility whenever there was a power outage. Based on observation of generator equipment on 03/07/11 at 1:50 p.m. with the maintenance director, an emergency shut off was located on the generator. The maintenance director said at the time of observation, there was no remotely located emergency generator shut off device.

2. Based on observation, record review 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 patients, visitors and staff.

Findings include:

Based on observation with the maintenance director on 03/07/11 at 1:45 p.m., a remote alarm annunciator for the emergency generator was provided in the facility mechanical room behind stored material. The maintenance director said at the time of observation, he had never seen it function and did not know if had an audible alarm. He pushed the test button which illuminated all the indicator lights and alarmed. The maintenance director said the area was not continuously occupied and nobody could hear an alarm annunciated from the panel in other areas of the facility. He said the generator had never failed except once, when it did not start due to battery failure. He agreed the annunciator panel should have alarmed to notify staff of the failure before the regular generator test failed.