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Based on observation and interview, the facility failed to ensure 1 of 1 doors to room 1-3007 in Building 1, a soiled linen room, closed and latched to prevent the passage of smoke. This deficient practice could affect any patient or staff using the Building 1, third floor corridor.

Findings include:

Based on observation on 05/18/10 at 10:25 a.m. with the Maintenance Supervisor and Assistant Superintendent, the door to the personal laundry room (1-3007) storing soiled linen in two 35 gallon containers was not provided with a door closer and failed to close and latch into the frame. Based on interview, the Maintenance Supervisor and Assistant Superintendent acknowledged at the time of observation, the door was not provided with a door closer.

Based on observation and interview, the facility failed to ensure the means of egress through 1 of 14 exits were readily accessible for patients and staff. LSC 19.2.2.2.4 requires doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side. Exception No. 1 requires door locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided staff can readily unlock such doors at all times. This deficient practice affects any patient or staff using the gymnasium.

Findings include:

Based on observation on 05/17/10 at 3:25 p.m. with the Maintenance Supervisor and Assistant Superintendent, a pair of exit doors leading to the exterior of the gymnasium were magnetically locked and had a key override pad adjacent to the doors. When the Maintenance Supervisor attempted to override the lock with the key all employees carry, the key turned but the magnets did not release. Based on interview at the time of observation, the Maintenance Supervisor and Assistant Superintendent acknowledged the magnets did not release.

Based on observation and interview, the facility failed to ensure illumination for the exit discharge for 1 of 14 exits was provided. This deficient practice could affect any of patient, staff and visitors using the Building 8, stairwell #1 exit.

Findings include:

Based on observation on 05/17/10 at 2:45 p.m. with the Maintenance Supervisor and Assistant Superintendent, the exit discharge for the Building 8, stairwell #1, first floor exit discharge lacked a light source. Based on interview at the time of observation, the Maintenance Supervisor and Assistant Superintendent acknowledged lighting was not provided outside this stairwell exit.

Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was continuously maintained in reliable operating condition. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Report of Inspection/Test" documentation from the facility's fire alarm contractor dated 08/29/2009 at 12:30 p.m. on 05/17/10 with the Maintenance Supervisor and Assistant Superintendent, the Annual Alarm Inspection/Test form indicated four devices were incorrectly addressed in the panel and indicated the facility would need to contact the manufactures to correct the programming. Devices 5M2-19 and 5M2-20 were entered as 5M2-18, while 5M2-27 and 5M2-29 were entered as 5M2-2. Based on interview at the time of record review, the Maintenance Supervisor and Assistant Superintendent indicated the devices have not been reprogrammed.

Based on observation and interview, the facility failed to electronically supervise 1 of 1 Post Indicator Valves (PIV) serving the hospital health care occupancy portion of the facility. LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice could affect all patients as well as staff and visitors, if the water to the sprinkler system was shut off and not detected due to lack of supervision.

Findings include:

Based on observation and interview with the Maintenance Supervisor on 05/18/10 at 11:00 a.m., the PIV serving Buildings 1 and 2 (health care occupancy), including the fire pump, was not mechanically secured and lacked electronic supervision.

Based on record review and interview, the facility failed to ensure 1 of 1 wet sprinkler systems was continuously maintained in reliable operating condition. NFPA 25, 1998 Edition, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 2-3.2 states gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. NFPA 25, Section 9-3.4.3 states valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one-fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position. This deficient practice would directly affect all patients, staff and visitors.

Findings include:

Based on review of "Report of Inspection/Test" documentation from the facility's sprinkler contractor dated 03/01/2010 at 12:45 p.m. on 05/17/10 with the Maintenance Supervisor and Assistant Superintendent, the deficiency summary of the report indicated the following:
a) Gauges all need replaced. Interview with the Maintenance Supervisor at the time of review indicated there were 70 gauges.
b) The control valve with seal/color OS&Y 2-1/2 inch, 1-148, Building 1, fifth floor, stairway 2, 1-148 tamper failed.
c) The control valve with seal/color OS&Y 6 inch, fire pump 13-16, Building 2, Boiler room did not report to panel.
d) The control valve with seal/color OS&Y 4 inch, fire pump 13-16, Building 2, Boiler room did not report to panel.
e) The control valve with seal/color OS&Y 1-1/4 inch, jockey pump 13-16, Building 2, Boiler room did not report to panel.
f) The control valve with seal/color Butterfly 4 inch, fire pump, Building 2, Boiler room device was not wired up.
g) The control valve with seal/color Butterfly 3 inch, Building 8, Basement HVAC office, 5M1-35 tamper failed to report to panel.
h) The control valve with seal/color OS&Y 2-1/2 inch, Building 8, third floor, west stairwell, 5M2-197 control valve packing has a leak.
i) The control valve with seal/color OS&Y 2-1/2 inch, Building 8, first floor, west stairwell, 5M1-91 control valve is corroded and leaking.
j) The control valve with seal/color Butterfly 3 inch, Building 8, Stairwell across from Gym, 5M1-97 tamper switch failed.
k) The control valve with seal/color OS&Y 2-1/2 inch, Building 8, second floor, east stairwell, 5M1-107 control valve packing leaks.
l) The inspector's test valve, Building 1, third floor, stairway 3 has a leak on sideflow of ITV 1-1/4 inch thread.
m) Flow test, Building 1, fourth floor, stairway 1, 1-109 has no gauge on the riser.
n) The inspector's test valve, Building 1, fourth floor, stairway 1 has a leak on sideflow of ITV 1-1/4 inch thread.
o) Flow test, Building 2, first floor, o/s Rm. 2-1024, 3M1-171 alarm did not actuate.
p) The inspector's test valve, Building 2, first floor, o/s Rm. 2-1024, 3M1-171 flow switch did not go into alarm.
q) Flow test, Building 8, second floor, o/s Rm. 8-2020, 5M1-38 alarm did not actuate.
r) The inspector's test valve, Building 8, second floor, o/s Rm. 2-2020, 5M1-381 flow switch failed.
s) Flow test, Building 8, stairwell across from Gym, 5M1-97 had a leak in pipe. Could not flow water for main drain test.
t) The inspector's test valve, Building 8, stairwell across from Gym, 5M1-97 had a leak in pipe. Could not flow water for main drain test.
u) Antifreeze System, Positive Temperature reading. Needs to be in the negatives.
v) Valve supervisory switches failed to indicate movement as required by NFPA 25, 9-3.4.3
"Tamper failed for OSY 2 1/2 inch address 1-148 (Potter OSYSU-2). Tamper butterfly 3 inch, Building 8, basement HVAC office, 5M1-37 failed to report. Tamper for Building 2, Boiler Rm. sub, the Maintenance Supervisor a-basement main, 3M1-39 comes into panel as an alarm. Building 1, fifth floor, stair #2 tamper switch failed 1-97."
Based on interview during the time of record review, the Maintenance Supervisor and Assistant Superintendent indicated the items listed in the "Deficiency Summary" of the March 01, 2010 Semi-Annual Sprinkler report had not been corrected.

Based on record review and interview, the facility failed to ensure all fire dampers in the hospital heating and ventilating system were tested and and provided necessary maintenance at least every six years years in accordance with the Centers for Medicaid and State Operations/Survey and Certification Group memorandum dated October 30th, 2009. (Ref: S&C-10-04-LSC) This memorandum permits hospitals to apply the NFPA 6 year testing interval for fire and smoke dampers in hospital heating and ventilating systems, so long as the hospitals testing system conforms to the testing requirements under the 2007 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives and NFPA 105, Standard for the Installation of Smoke Door Assemblies. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of "2009 Statement of Condition, Plan for Improvement" documentation with the Maintenance Supervisor and Assistant Superintendent on 05/18/10 at 11:15 a.m., the facility has a "Plan for Improvement" to identify and test all fire dampers located in the hospital HVAC system. Additionally, based on interview with the Maintenance Supervisor and Assistant Superintendent, at the time of record review, there was no documentation to indicate previous testing or maintenance on the fire dampers had been conducted.

Based on record review and interview, the facility failed to ensure the two generators were inspected weekly for 40 of 52 weeks. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems be installed, tested and Maintained in accordance with NFPA 11, Standard for Emergency and Standby Power Systems. NFPA 110, 6-4-1 requires Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly. Chapter 3-4.4.1.3 of NFPA 99 requires storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Furthermore, NFPA 110, 6-3.6 requires checking storage batteries, including electrolyte levels, at intervals of not more than 7 days. NFPA Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Larue Carter Memorial Hospital Weekly and Monthly Generator Test" documentation with the Maintenance Supervisor and Assistant Superintendent on 05/17/10 at 12:55 p.m., an inspection of the generators occurred once a month which was the monthly load test. Based on interview at the time of record review, the Maintenance Supervisor and Assistant Superintendent acknowledged the generators were run under load once a month but not inspected weekly.