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Based on observation and interview, the facility failed to ensure 1 of 3 exit corridors was continuously maintained free of obstructions. This deficient practice could affect only staff in the basement.

Findings include:

Based on observation on 06/25/19 during a tour of the facility between 12:06 p.m. to 2:00 p.m. with the Maintenance Supervisor (MS), the exit corridor in the basement was used to store eight boxes and seven file cabinets. This would reduce the available width of the corridor used by staff who would use the corridor to exit from the basement. Based on interview at the time of the observation with the MS, it was acknowledged the basement corridor exit was not maintained free of all obstructions.

Based on observation and interview, the facility failed to ensure 1 of 6 hazardous areas observed such as Storage rooms over 100 square feet, would latch in their frame and be provided with a self-closing device. This deficient practice could affect 14 residents, staff and visitors on 200 hall.

Findings include:

Based on observation on 06/25/19 during a tour of the facility between 11:47 a.m. to 3:30 p.m. with the Maintenance Supervisor (MS), there were thirty nine cardboard boxes stored in the Breakroom located in the basement and there was no self closing device on the corridor door. Based on interview at the time of observation with the MS it was acknowledged the corridor door protecting a hazardous area from an escape route corridor was not provided with a self closing device. It was further acknowledged the Storage room was over 100 square feet.

Based on observation and interview, the facility failed to ensure staff were instructed in the use of the UL 300 hood system in 1 of 1 Kitchens. NFPA 96, 11.1.4 states instructions for manually operating the fire extinguishing system shall be posted conspicuously in the kitchen and shall be reviewed with employees by management. This deficient practice could affect all kitchen staff.

Findings include:

Based on observation on 06/25/19 during a tour of the facility between 1:31 p.m., to 3:00 p.m. the Kitchen contained a UL 300 hood system above the electric stove. Based on interview, one Kitchen staff was asked "what is the first and second thing to do if there was a grease fire on the stove underneath the Ansul hood system". Staff did not know about first pulling the ring to activate the ansul system to extinguish the fire and subsequently the "K" cylinder if the UL 300 system did not put out the fire.

Based on observation and interview, the facility failed to ensure 2 of 2 sprinkler system gauges were replaced every 5 years or documented as tested every 5 years by comparison with a calibrated gauge. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.3.2.1 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. This deficient practice could affect all residents, staff, and visitors in the facility.

Findings include:

Based on observation with the Maintenance Supervisor (MS) on 06/25/19 at 12:10 p.m., the sprinkler riser room which supplies sprinkler protection for the basement and perimeter around the Administration unit had two sprinkler gauges on the dry sprinkler riser with dates of 06/04/14, which is a period over the five year testing or replacement requirement. This was confirmed by the MS at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 1 smoke barrier walls observed had a minimum of a 1/2 hour fire resistive rating and the penetrations caused by the passage of wire and/or conduit the smoke barrier walls were 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 all residents on IDDT Unity House including visitors and staff.

Findings include:

Based on observation on 06/25/19 during the tour of the facility between 1:05 p.m. to 3:00 with the Maintenance Supervisor (MS), above the suspended ceiling at the smokewall there was at least ten communication wires penetrating the smokewall with a one inch opening at the bottom of the penetration which was not firestopped. Based on interview with the MS it was confirmed the observation was valid and stated he would take care of it.

Based on observation and interview, the facility failed to ensure 1 of 1 resident corridors containing electrical panels was secured from non-authorized personnel per LSC 19.5.1.1. LSC 19.5.1.1 states utilities shall comply with the provisions of Section 9.1. LSC 9.1.2 states electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70 Section 110.27(A) states live parts of electrical equipment over 50 volts or more shall be guarded against accidental contact by approved closures or by any of the following means: (1) by location in a room, vault, or similar enclosure that is accessible only to qualified persons. This deficient practice could affect 9 residents, visitors and staff.

Findings include:

Based on observation on 06/25/19 during the tour between 11:00 a.m. to 3:00 p.m. with the Maintenance Supervisor (MS) there was one electrical panel in the corridor wall next to the Nurse's station which was not secured against non-authorized personnel. Based on interview during the observations, the MS confirmed the electrical panel could be opened by anyone and stated he was in the process of putting locks on the panels.

Based on observation and interview, the facility failed to ensure access and working space was maintained in enclosures housing electrical apparatus in 1 of 1 electrical rooms. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.2.1 states electrical installation shall be in accordance with NFPA 70, National Electric Code. NFPA 70, 2011 Edition, Article 110.26 states working space for equipment operating at 600 volts, nominal, or less and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (2) and (3). Distances shall be measured from the live parts if such parts are exposed or from the enclosure front or opening if such are enclosed. Article 110.26(B) states the working space required by this section shall not be used for storage. This deficient practice could affect only staff in the electrical room.

Findings include:

Based on observation on 06/25/19 during the tour between 1:39 p.m. to 3:30 p.m. with the Maintenance Supervisor (MS), the Electric room located in the basement stored a utility cart, two cardboard boxes, a floor buffer, two large ceiling lights and a television with cart in front of the electrical panels. Based on interview at the time of the observation, the MS acknowledged the stored items were present and would be removed.