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Based on record review, observation and interview, the facility failed to ensure 1 of 5 fire barrier walls was protected. LSC 8.3.3.1 states openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies, and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives. Table 8.3.4.2 requires 2 hour fire rated walls and partitions to have fire door assemblies with a rating of at least 1 1/2 hours fire rating. Centers for Medicare & Medicaid Services (CMS) requires sets of smoke barrier doors which swing in the same direction and equipped with an astragal to have a coordinator to ensure the door which must close first always closes first. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 01/30/17, the facility site plans indicated the locations of all barriers which were all two hour fire barriers. Based on observation with the Facility Manager at 12:30 p.m., the Cedar Entrance fire barrier separates the other occupancies of the building. The double doors caught on the coordinating device when tested. Additionally, one of the doors contained manual latching hardware and not positive latching hardware. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned condition.

Based on record review, observation and interview, the facility failed to ensure 3 of 5 fire barrier walls was protected. LSC 8.3.3.1 states openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies, and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives. Table 8.3.4.2 requires 2 hour fire rated walls and partitions to have fire door assemblies with a rating of at least 1 1/2 hours fire rating. Centers for Medicare & Medicaid Services (CMS) requires sets of smoke barrier doors which swing in the same direction and equipped with an astragal to have a coordinator to ensure the door which must close first always closes first. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 01/30/17, the facility site plans indicated the locations of all barriers which were all two hour fire barriers. Based on observation with the Facility Manager between 12:33 p.m. and 1:28 p.m., the following was discovered:
a) the Cedar Entrance B fire barrier double doors swung in the same direction. One of the doors contained an astragal but no coordinating device was installed. Additionally, one of the doors contained manual latching hardware and two slide bolts and not positive latching hardware. Neither door had a fire resistive label.
b) the East fire barrier contained an eighth inch gap when the double doors were closed.
c) the North fire barrier contained an eighth inch gap when the double doors were closed.
d) the Staff Break room portion of the Cedar Entrance B fire barrier door did not have a fire resistive label and failed to self-close when tested. Additionally, two separate two inch and one four inch unsealed penetrations were discovered above the drop ceiling.
Based on interview at the time of each observation, the Facility Manager acknowledged each aforementioned condition.

Based on observation, the facility failed to meet 1 of 4 corridors clear width requirement exception per 19.2.3.4(1). LSC 19.2.3.4(1) requires aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall not be less than 44 inches in clear and unobstructed width. This deficient practice could affect staff only.

Findings include:

Based on observation with the Facility Manager on 01/30/17 at 1:11 p.m., storage of clothing, drawers, shoe rack, and other miscellaneous items were in the service corridor. When measured, the clear width was thirty three inches. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned condition and provided the measurement.

Based on observation and interview, the facility failed to ensure 1 of 1 hazardous room was protected in accordance with 19.3.2.1. LSC 19.3.2.1(5) and (6) requires rooms with soiled linen or collected trash in volume exceeding 64 gallons shall be classified as hazardous. This deficient practice could affect staff only.

Findings include:

Based on observation and intervies, the facility failed to ensure 1 of 1 hazardous room was protected in accordance with 19.3.2.1. LSC 19.3.2.1(5) and (6) requires rooms with soiled linen or collected trash in volume exceeding 64 gallons shall be classified as hazardous. This deficient practice could affect staff only.

Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 7-3.2 requires testing shall be performed in accordance with the Table 14.4.5 Testing Frequencies. NFPA 72, 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation. NPFA 72, 14.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 01/30/17 at 11:55 a.m., no documentation for a fire alarm smoke detector sensitivity test was available for review. Based on interview at the time of record review, the Facility Manager acknowledged the aforementioned condition and confirmed no other documentation was available for review.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of residents indicating 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 twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on record review with the Facility Manager on 01/30/17 at 11:10 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include the person conducting the fire watch shall have no other duties. Based on an interview record review, the Facility Manager acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to provide sprinkler coverage for 1 of 1 Cedar Courtyard exterior canopies which was wider than 4 feet. NFPA 13, 2010 Edition, Section 8-15.7.2 states sprinklers shall be permitted to be omitted where the exterior roofs, canopies, balconies, decks or similar projections exceeding 4 feet in width are noncombustible, limited combustible or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials. This deficient practice could affect staff and up to 4 patients.
Findings include:
Based on observation with the Facility Manager on 01/30/17 at 1:01 p.m., a canopy of wood construction outside of the Cedar Courtyard was not provided with sprinkler protection. The canopy was attached to the building and extended ten feet from the building. Based on interview at the time of observation, the Facility Manager confirmed no documentation was available for review to verify the wooden material was inherently flame retardant and was not provided with sprinkler protection.

1. Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with 19.3.5.3. NFPA 25, 2011 Edition, 14.2.1 states except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 01/30/17 at 11:55 a.m., no internal inspection of piping documentation was available for review. Based on interview at the time of record review, the Facility Manager the sprinkler system was greater than five years old. Additionally, the Facility Manager confirmed with their sprinkler contractor that no internal inspection was performed.

3.1-19(b)

2. Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 01/30/17 at 11:55 a.m., the sprinkler system was inspected quarterly. No documentation was available for the monthly gauges or control valves inspection. Based on interview at the time of record review, the Facility Manager acknowledged the aforementioned condition.

3.1-19(b)

3. Based on observation and interview, the facility failed to maintain a clearance of 1 of 1 sprinkler head in the Document Closet in accordance with LSC 9.7.5. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, 5.2.1.2 requires the minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors. This deficient practice could affect staff only.

Findings include:

Based on observation with the Facility Manager on 01/30/17 at 12:47 p.m., one Styrofoam box was within six inches of the pendant sprinkler head. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned condition and provided the measurement.

3.1-19(b)

Based on record review and interview, the facility failed to provide a 1 of 1 written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 01/30/17 at 11:10 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include the person conducting the fire watch shall have no other duties. Based on an interview record review, the Facility Manager acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 ceiling smoke barrier wall was protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect staff only.

Findings include:

Based on observations with the Facility Manager on 01/30/17 at 1:20 p.m., there were three separate unsealed ceiling penetrations in the Cedar Mechanical room ranging from an eighth of an inch to three quarters of an inch. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned condition and provided the measurements.

Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times for 4 of 4 quarters. This deficient practice affects all occupants.

Findings include:

Based on record review of the "Fire Drill Observation Checklist" form with the Facility Manager on 01/30/17 at 10:43 a.m., three sequential first shift fire drills took place between 1:23 a.m. and 2:00 p.m. for three of the last four quarters. Then again, four sequential second shift fire drills took place between 7:52 p.m. and 8:25 p.m. for four of the last four quarters. Based on interview at the time of record review, the Facility Manager acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure trash receptacles near 1 of 1 Office Room 106 areas was maintained in accordance with 19.7.5.7. This deficient practice could affect staff only.

Findings include:

Based on observation with the Facility Manager on 01/30/17 at 1:08 p.m., there were three separate 32 gallon soiled linen carts off of the corridor near room 106. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned condition and acknowledged the maximum gallons of soiled linen allowed off of the corridor.

Based on observation and interview, the facility failed to ensure 1 of 1 space heaters was in accordance with 19.7.8. This deficient practice could affect staff only.

Findings include:

Based on observation with the Facility Manager on 01/30/17 at 1:10 p.m., a space heater was discovered in the Director of Nursing office. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned condition and was unable to provide documentation that the heating elements do not exceed 212 degrees.

1. Based on record review and interview, the facility failed to ensure 1 of 1 generator was accordance with 6.4.4.1.1.3. 2010 NFPA 110 8.4.2 states diesel generator sets in service shall be exercised at least once monthly for a minimum of 30 minutes. 8.4.2.3 states that diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPSS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 01/30/17 at 9:43 a.m., April and June of 2016 failed to run the generator for more than 20 minutes. No load bank test was available for review. Based on an interview at the time of record review, the Facility Manager acknowledged the aforementioned condition and confirmed the diesel-powered generator was on exercised for 20 minutes on April and June of 2016.

2. Based on record review and interview, the facility failed to ensure 1 of 1 emergency diesel powered generator was allowed a 5 minute cool down period after a load test. NFPA 110 8.4.5(4) requires a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shut down. This delay provides additional engine cool down. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 01/30/17 at 9:43 a.m., the generator log form "Emergency Generator Load Test" failed to show the generator had a cool down time following its load test. Based on interview at the time of record review, the Facility Manager acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 2 of 2 flexible cords were not used as a substitute for fixed wiring according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff only.

Findings include:

Based on observation with the Facility Manager on 01/30/17 at 1:05 p.m. then again at 1:10 p.m., a surge protector was powering a toaster and a microwave in the Staff Break room. Then again, an extension cord was powering a refrigerator in the Director of Nursing office. Based on interview at the time of each observation, the Facility Manager acknowledged each aforementioned condition.