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Based on observation and interview, the facility failed to ensure 1 of 7 patient room doors protecting an opening to the corridor on the second floor had no impediment to closing. This deficient practice could affect visitors, staff and 4 patients on the second floor.

Findings include:

Based on observation with the safety officer on 01/12/11 at 12:20 p.m., the door to patient room 2317 had a linen receptacle and straight backed chair positioned in front of the open door. The impediments remained in the same position on 01/12/11 during the tour at 3:10. The safety officer agreed at the time of observations, the equipment posed an impediment to closing the door.

Based on observation and interview, the facility failed to ensure a smoke detector connected to the fire alarm system on 1 of 2 floors smoke was properly separated from an air supply. LSC 9.6.1.4 refers to NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where airflow affects operation of the detectors. This deficient practice could affect staff, visitors and 4 patient on the second floor.

Findings include:

Based on observation with the safety officer on 01/12/11 at 3:30 p.m., the corridor smoke detector near patient room 2329 was located 24 inches from an air vent. The safety officer said at the time of observation, he hadn't noticed the proximity of the smoke detector to the source of air flow.

Based on interview and record review, the facility failed to ensure documentation for inspection, testing and maintenance for 4 of 4 emergency generators providing Level 1 emergency power service was accurate and complete. LSC 7.9.2.3 and NFPA 99, Health Care Facilities, 3-4.4.1.1(a) requires monthly testing of the generator set shall be in accordance with NFPA 110, the Standard for Emergency and Standby Power Systems. NFPA 110, 6-4.2 requires generator sets in Level 1 and 2 service shall be exercised under operating conditions or not less than 30 percent of the EPS (Emergency Power Supply) nameplate rating monthly for a minimum of 30 minutes. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice affects all occupants.

Findings include:

Based on review of emergency generator inspection, service, testing and maintenance records by contracted venders and building maintenance staff with the safety officer and maintenance engineering supervisor (MES), building maintenance records did not reflect conditions which were noted by outside vendors and should have been noted and addressed on weekly generator checks. An Emergency Generator Maintenance Schedule Weekly Procedure sheet was identified as the record for weekly maintenance and testing for the emergency generators. The record listed the Component (task performed), Visual Inspection, Check, Change, Clean, Test, Date, and Service Person in columns. A single sheet was used for all four emergency generators with no separation of inspection results for each generator. Aside from weekly date changes, there was no variation in the notations made for the condition of the generators during the past year. In addition, it appeared the condition entries documented since August 2010 had been made by a copier and dates and service person entries entered with pencil. The MES said at the time of record review, the record accurately reflected the condition of all four generators and they never had any trouble with them, but if they did a contractor was called immediately to make repairs. Weekly maintenance reports for the past year showed no repairs or maintenance were required. The MES said nothing was needed. When asked about oil changes and routine maintenance he said the oil didn't need to be changed more frequently than every 200 hours and the generators could go for years since they were run only 50 hours per year. He said the fuel was checked annually for contaminants which would necessitate changing the fuel and there had been no need. A review was then made of the semiannual outside generator contractor reports with the safety officer, MES, and maintenance generator operator. The Generator Paralleling Control Gear Reports listed each generator, conditions for each and noted any adjustments, repairs needed, and observations requiring attention. The reports indicated conditions which should have been noted on the weekly inspection report prepared by the facility generator operator. For example, the facility report dated 03/22/10 found no problems, however, the outside contractor report dated 03/23/10 noted the oil level was low on Generator # 4 and low coolant levels for generators # 3 and # 4. The MES and Generator operator agreed these were operating conditions which should have been checked weekly. Other contractor reports reflected conditions not noted on the weekly reports, such as battery cable corrosion. The generator operator said at the time of record review, he had copied a previously prepared sheet for the generators report and used it after he ran out of blank sheets. He also said generator # 4 "blew" oil regularly and there was a drum adjacent to it for refilling. The MES agreed the maintenance sheets did not accurately reflect generator conditions.