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1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm system installed was maintained. LSC 4.6.12.3 states existing life safety features obvious to the public if not required by the Code shall be maintained. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Facilities Management on 12/06/16 at 11:31 a.m., the last annual inspection for Building 03 was performed on 10/15/13 by Rask Fire and Life Safety. No fire alarm sensitivity documentation was available for review. Based on interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition.

2. Based on observation and interview, the facility failed to protect cooking equipment with a range hood extinguishing system in accordance with 9.2.3. LSC 39.3.2.3 requires cooking equipment to be protected in accordance with LSC 9.2.3 unless the cooking equipment is one of the following: 1) Outdoor equipment 2) Portable equipment not flue connected 3) Equipment used only for food warming. LSC 9.2.3 requires compliance with NFPA 96, 2011 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations in 1 of 1 Kitchen. NFPA 96, 4.1.1 requires cooking equipment that produces smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Maintenance Technician #2 on 12/07/16 at 10:15 a.m., there was a residential style oven/stove top in the Building 03 Dining room without a hood extinguishing equipment. Based on interview at the time of observation, the Adult Case Manager confirmed that bacon and meats are cooked, and occasionally vegetable oil is used.

3. Based on observation and interview, the facility failed to maintain protection and have a self-closing device installed for 1 of 1 Furnace natural gas fuel-fired equipment rooms in accordance of 39.3.2.1. LSC 39.3.2.1, General, requires hazardous doors to be in accordance with 8.7. LSC 8.7.1.1(1) requires enclosing the hazardous area with a fire barrier without windows that has a 1-hour fire resistance rating. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #2 on 12/07/16 at 10:26 a.m., the Furnace room corridor door in Building 03 had a twenty minute fire resistive tag. The corridor door did not have a self-closing device installed. Based on interview at the time of observation, the Maintenance Technician #2 acknowledged the aforementioned condition.

4. Based on observation and interview, the facility failed to maintain an undetermined number of battery operated emergency lights in the facility was maintained for 12 of 12 months. LSC 4.6.12.3 states existing life safety features obvious to the public if not required by the Code shall be maintained. . This deficient practice could affect all occupants.

Findings include:

Based on record review with the Maintenance Technician #2 on 12/06/16 at 11:01 a.m., the Building 03 battery operated emergency light documentation had check boxes on the fire drill forms. Additionally, no annual ninety minute test documentation was available for review. Based on interview at the time of observation, the Director of Facilities Management confirmed that Building 03 lights were just pressed for a couple of seconds to indicate that the light will turn on.

5. Based on observation and interview, the facility failed to ensure materials used as an interior finish on the ceiling in 1 of 1 Front Waiting Area had a flame spread rating of Class A or Class B in accordance with 39.3.3.1. LSC 101 10.2.3.4 states products required to be tested in accordance with ASTM E 84, Standard Test Method For Surface Burning Characteristics of Building Materials or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Maintenance Technician #2 on 12/07/16 at 10:28 a.m., the Front Waiting Area in Building 03 had wood panels on the walls. Based on interview at the time of observation, the Maintenance Technician #2 was unable to provide documentation for a flame spread classification of Class A or B.

6. Based on observation and interview, the facility failed to ensure 1 of 1 Furnace room portable fire extinguishers was installed correctly in accordance with 39.3.5.12. LSC 39.3.5 requires portable fire extinguishers to be provided in every business occupancy in accordance with LSC 9.7.4.1. LSC 9.7.4.1 requires portable fire extinguishers to be selected, installed, inspected and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 6.1.3.8.3 states that in no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 inches. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Maintenance Technician #2 on 12/07/16 at 10:26 a.m., the Furnace room Building 03 fire extinguisher was sitting on the floor unprotected. Based on interview at the time of observation, the Maintenance Technician #2 acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to maintain protection, have no impediments to self-closing, have a self-closing device installed for 3 of 3 natural gas fuel-fired equipment rooms in accordance of 39.3.2.1. LSC 39.3.2.1, General, requires hazardous doors to be in accordance with 8.7. LSC 8.7.1.1(1) requires enclosing the hazardous area with a fire barrier without windows that has a 1-hour fire resistance rating. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/07/16 between 11:34 a.m. and 11:45 a.m., the following was discovered:
a) the North Mechanical room contained fuel-fired equipment. The corridor door contained a 20 minute fire resistive rating tag.
b) the Central Mechanical room contained fuel-fired equipment. The room contained a door stop.
c) the Custodial room contained fuel-fired equipment. The corridor door did not have a fire resistive tag and no self-closure was installed.
Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

2. Based on observation and interview, the facility failed to ensure 1 of 1 Building 04 fire alarm system installed was maintained. LSC 4.6.12.3 states existing life safety features obvious to the public if not required by the Code shall be maintained. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Facilities Management on 12/06/16 at 11:31 a.m., no fire alarm sensitivity documentation was available for review. Based on interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition.

3. Based on observation and interview, the facility failed to maintain an undetermined number of battery operated emergency lights in the facility was maintained for 12 of 12 months per 4.6.1.2. LSC 4.6.1.2 states any requirements that are essential for the safety of building occupants and that are not specifically provided by this Code shall be determined by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Maintenance Technician #2 on 12/06/16 at 11:01 a.m., the Building 04 battery operated emergency light documentation had check boxes on the fire drill forms. Additionally, no annual ninety minute test documentation was available for review. Based on interview at the time of observation, the Director of Facilities Management confirmed that Building 04 lights were just pressed for a couple of seconds to indicate that the light will turn on.

Based on record review, observation and interview, the facility failed to ensure 1 of 1 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. 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. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Maintenance Technician #1 and the Director of Facilities Management on 12/07/16, the facility site plans indicated a two hour fire wall near Recovery. Based on observation at 4:36 p.m., the cross corridor door contained a twenty minute fire resistive rating tag. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition.

Based on observation, the facility failed to ensure 3 of 8 corridors access were in accordance with Chapter 7. LSC 7.1.10.2.1 requires no furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 between 2:05 p.m. and 3:06 p.m., the following was discovered:
a) two separate treadmills were in the corridor outside of the office room 256
b) two separate clothes baskets were in the corridor outside of the Laundry room
Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/07/16 at 8:43 a.m.,
c) a trash can was in the corridor near the Front office

Based on interview at the time of each observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged each aforementioned condition.

1. Based on observation and interview, the facility failed to ensure emergency lighting was provided for 8 of 8 exits. LSC 7.9.1.1 Emergency lighting for the means of egress shall be provided. This deficient practice could affect all occupants.

Finding include:

Based on observation with the Maintenance Technician #1 on 12/06/16 at 3:42 p.m., there were exit lights on the exit discharge. Based on interview at the time of observation, the Maintenance Technician #1 was unable to confirm that the exterior lights were on the generator, but did confirm that there were not batteries in the exterior lights.

2. Based on record review and interview; the facility failed to ensure an undetermined number of battery operated emergency lights in the facility was maintained for 12 of 12 months in accordance with LSC 7.9. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment, requires a functional test to be conducted for 30 seconds at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than a 1 ½ hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Maintenance Technician #1 on 12/06/16 at 11:01 a.m., the battery operated emergency light documentation had check boxes on the fire drill forms. Additionally, no annual ninety minute test documentation was available for review. Based on interview at the time of observation, the Director of Facilities Management confirmed that the lights were just pressed for a couple of seconds to indicate that the light will turn on.

Based on observation and interview; the facility failed to install exit signage in 1 of 8 corridors in the facility in accordance with LSC 7.10. LSC 7.10.1.2.1 exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 at 2:37 p.m., the path from the north stairwell and south stairwell is separated by a cross corridor door near the center stairwell. Exits signs were not provided on either side of the cross corridor door. Based on interview at the time of observation, the Director of Facilities Management acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to maintain protection of 1 of 3 stairway in accordance of 19.3.1. LSC 8.6.8 requires convenience openings to be open to only one floor. LSC 8.6.9 requires openings to be separated from corridors. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/07/16 at 8:45 a.m., the 90 minute rated double doors at the bottom of the middle stairwell, which was not considered a part of egress, had a quarter inch gap when closed and lacked positive latching hardware. Based on interview at the time of observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

Based on record review, observation, and interview, the facility failed to maintain protection of 1 of 3 stairway in accordance of 19.3.1. This deficient practice could affect staff only.

Findings include:

Based on record review with the Maintenance Technician #1 on 12/07/16, the site plans indicated the stairwells were constructed as a two hour barrier. Based on observation at 8:32 a.m., the 1st floor West stairwell door did not have a fire protection rating tag.
Based on interview at the time of the observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure 1 of 1 Health Information Management storage room greater than fifty square feet was protected in accordance with 19.3.2.1.5. LSC 19.2.1.3 requires doors to hazardous areas shall be self-closing or automatic-closing. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/06/16 at 1:54 p.m., the room contained three open six foot tall cabinets full of paperwork. Additionally, many boxes of paperwork were stacked on the floor making it difficult to walk around. The corridor door did not have a self-closing device installed. Based on interview at the time of observation, the Director of Maintenance and the Maintenance Technician #1 acknowledged the aforementioned condition and confirmed the room was greater than 50 square feet.

2. Based on observation and interview, the facility failed to maintain protection of 1 of 1 Mechanical room in accordance of 19.3.2. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 at 4:47 p.m., the Mechanical room contained natural gas fuel-fire equipment. One of the double corridor doors contained manual latching hardware. Additionally, one of the doors contained an astragal and no coordinating device installed. Inside the room near the corridor door was a wedge-shaped door stop. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned conditions.

3. Based on observation and interview, the facility failed to maintain protection of 1 of 1 Kitchen in accordance of 19.3.2. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/07/16 at 8:31 a.m., the Kitchen contained two forty gallon trash containers. One of the two corridor doors did not have a self-closing device installed. Based on interview at the time of observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to ensure 1 of 1 kitchen exhaust system was completely maintained. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition at 11.2.1 maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. This deficient practice could affect staff only.

Findings include:

Based on record review with the Director of Facilities Management on 11/07/16 between 9:04 a.m. and 10:21 a.m., the kitchen hood was being inspected annually. Based on interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. 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, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/06/16 at 2:20 p.m., the Experiential Therapy room had a smoke detector between two air vents. The closet air vent measured sixteen inches away. Based on interview at the time of record review, the Maintenance Technician #1 acknowledged the aforementioned condition and provided the measurement.

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, 14.4.5.3.5 states smoke detectors or smoke alarms found to have a sensitivity range outside the listed and marked sensitivity range shall be cleaned and recalibrated or to be replaced. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Facilities Management on 12/06/16 at 11:31 a.m., the last fire alarm sensitivity test was performed on 05/08/13 by Rask Fire and Life Safety. The last report indicated five of forty three devices failed sensitivity testing. Based on interview at the time of record review, the Director of Facilities Management 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 patients 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 Director of Facilities Management on 12/06/16 at 10:43 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the insurance company and the person conducting the fire watch shall be trained and have no other duties while performing the fire watch. Additionally, the fire watch plan indicates "if the system is down for a time period greater than 24 hours, the Indiana State Department of Health will be contacted due to an "Unusual Occurrence" instead of contacting ISDH after four hours in a twenty four hour period. Based on an interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure the spray pattern for sprinkler heads were not obstructed in 1 of 1 North Staff Entrance Stairwell and 1 of 9 resident rooms in accordance with 19.3.5.1. NFPA 13, 2010 edition, Section 8.5.5.1, states sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2. and 8.5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Section 8.5.5.2 and 8.5.5.3 do not permit continuous or noncontinuous obstructions less than or equal to 18 in. below the sprinkler deflector that prevent the pattern from fully developing. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/06/16 at 2:59 p.m. then again at 3:21 p.m., the North Staff Entrance Stairwell sprinkler head deflector as above the hole cut out for it in the drop ceiling. Then again, resident room 118 contained two sprinkler heads within four inches of two ceiling box lights. The ceiling box lights were lower than the deflector. Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

2. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with 19.3.5.1. NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, Section 9.1.1.7, Support of Non-System Components, requires sprinkler piping or hangers shall not be used to support non-system components. This deficient practice could affect all occupants.

Findings include:

Based on observations with the Maintenance Technician #1 and the Director of Facilities Management on 12/07/16 at 4:47 p.m., a conduit was zip tied to the sprinkler pipe outside the Director of Inpatient Care office. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition.

3. Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 IT room and 1 of 1 Director of Inpatient Care in accordance with 19.3.5.1. LSC 19.3.5.3 states where required by LSC 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised, automatic sprinkler system in accordance with Section 9.7. Section 9.7 indicates that automatic sprinkler system requires shall be in accordance with NFPA 13. NFPA 13, 2010 edition, Section 8.5.4.1.1 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/06/16 at 3:08 p.m. then again at 4:41 p.m., two of ten ceiling tiles were exposed in the IT room. Then again, one of thirty four ceiling tiles were not in place in the Director of Inpatient Care. Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

4. Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 Executive Stairwell in accordance with 19.3.5.1. LSC 19.3.5.3 states where required by LSC 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised, automatic sprinkler system in accordance with Section 9.7. Section 9.7 indicates that automatic sprinkler system requires shall be in accordance with NFPA 13. NFPA 13, 2010 edition, Section 6.2.7 states plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic, or shall be listed for use around a sprinkler. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/06/16 at 2:36 p.m., the Executive Stairwell had a missing escutcheon. Based on interview at the time of observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

5. Based on observation and interview, the facility failed to provide sprinkler coverage for 1 of 1 East Entrance 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 only.
Findings include:
Based on observation with the Maintenance Technician #1 on 12/07/16 at 9:04 a.m., a canopy of canvas construction over a metal frame outside of the main entrance was not provided with sprinkler protection. The canopy was attached to the building and extended over 4 feet from the building. Based on interview at the time of observation, the Maintenance Technician #1 confirmed no documentation was available for review to verify the canopy material was inherently flame retardant and was not provided with sprinkler protection.

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 Director of Facilities Management on 12/06/16 between 8:45 a.m. and 1:00 p.m., the sprinkler system was inspected annually. No documentation was available for the monthly gauges or control valves inspection. Additionally, the five year obstruction, internal inspection of piping was not available for review. Based on observation on 12/07/16 at 8:50 a.m., the East Stairwell standpipe gauge was dated on 11/24/09. Based on interview at the time of observation, the Director of Facilities Management acknowledged the sprinkler system should be inspected quarterly, confirmed the sprinkler system was at least five years old, and the sprinkler gauge had not been recalibrated or replaced within five years.

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 Director of Facilities Management on 12/06/16 at 10:43 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the insurance company and the person conducting the fire watch shall be trained and have no other duties while performing the fire watch. Additionally, the fire watch plan indicates "if the system is down for a time period greater than 24 hours, the Indiana State Department of Health will be contacted due to an "Unusual Occurrence" instead of contacting ISDH after four hours in a twenty four hour period. Based on an interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 1 Boiler room and 1 of 1 Kitchen portable fire extinguishers was installed correctly in accordance with 19.3.5.12. NFPA 10, the Standard for Portable Fire Extinguishers, 6.1.3.8.3 in no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 inches. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/06/16 at 2:56 p.m. then again on 12/07/16 at 8:31 a.m., the Boiler room fire extinguisher was sitting on the floor unprotected. Then again, the Kitchen K type fire extinguisher was sitting on the floor unprotected. Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 2 Recovery corridor was separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 19.3.6.1(7). LSC 19.3.6.1(7) states that spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be open to the corridor and unlimited in area, provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, and (b) Each space is protected by an automatic sprinklers, and (c) The space does not to obstruct access to required exits. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/07/16 at 4:28 p.m., the Recovery Administrative office has a turnstile built into the corridor. The turnstile has quarter inch multiple gaps in between the parts. Furthermore, LSC 19.3.6.1(7) was not met because the room was not protected by an electrically supervised automatic smoke detection system. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to maintain protection of 1 of 8 corridor walls in accordance of 18.3.6.2. LSC 18.3.6.2, Construction of Corridor Walls, requires corridor walls shall form a barrier to limit the transfer of smoke. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/07/16 at 4:47 p.m., a one inch by two inch corridor penetration outside of the Director of Inpatient Care office. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to maintain protection of corridor doors and had no impediment to latching in 5 of 8 corridors in accordance of 19.3.6.3. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/06/16 between 3:10 p.m. and 4:41 p.m., the following corridor doors were discovered:
a) two separate supply closets across from resident room 112 had one door latching into another. Both sets of doors contained one door with manual latching hardware and neither door positively latched into the frame.
b) a quarter inch door penetration around the door handle in the Housekeeping closet door
c) a quarter inch door penetration around the door handle in the staff bathroom
d) the Kitchenette double doors contained manual latching hardware and neither door positively latched into the frame. A single Kitchenette door left an eight inch gap when closed.
e) a door stop was on the Cafe Dining room door
f) a door stop was in the Nurses' station medication room
g) a door stop in the Director of Inpatient Care office
Based on observation with the Maintenance Technician #1 on 12/06/16 between 8:42 a.m. and 8:47 a.m., the following corridor doors were discovered:
h) a half inch penetration in the Financial office door
i) four separate quarter inch penetrations in the Group room 1 door
Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

Based on record review and interview, the facility failed to maintain annual testing of 1 of 1 rolling fire door in accordance of 19.3.6.3.3. LSC 19.3.6.3.3 requires compliance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80 5.2.1 requires fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. This deficient practice could affect staff only.

Findings include:

Based on record review with the Director of Facilities Management on 12/07/16 between 9:04 a.m. and 10:21 a.m., no documentation was available for the annual testing of the Kitchen's rolling fire door. Based on interview, the Director of Facilities Management acknowledged the aforementioned condition and confirmed no documentation was available for review.

Based on observation and interview; the facility failed to ensure 2 of 2 elevator equipment rooms was provided with an electrical shunt trip when provided with sprinkler coverage in accordance with 19.5.3. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. This deficient practice would affect staff only.

Findings include: Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 at 2:57 p.m. then again at 4:47 p.m., the North elevator equipment room contained 1 sprinkler head and no smoke or heat detector. Then again, the South elevator equipment room contained 1 sprinkler head. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management was unable to confirm the elevator equipment was provided with an elevator shunt trip.

Based on record review and interview, the facility failed to provide a written plan that addressed all components in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
This deficient practice could affect all occupants.

Findings include:

Based on a record review and interview on 12/07/16 at 3:51 p.m., the Maintenance Technician #1 and the Director of Facilities Management acknowledged the "Disaster Plan" did not address (9) Extinguishment of fire. The plan indicated to staff to use a fire extinguisher, but failed to indicate how to use a fire extinguisher.

1. Based on record review and interview, the facility failed to conduct quarterly fire drills for 4 of 4 quarters. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions. This deficient practice could affect all occupants.

Findings include:

Based on record review of the "Fire and Disaster Drill Report" form with the Director of Facilities Management on 12/06/16 at 10:16 a.m., there was no documentation for any third shift fire drills. Based on interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition.

2. Based on record review and interview, the facility failed to ensure 12 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters. This deficient practice could affect all occupants.

Findings include:

Based on record review of titled "Fire and Disaster Drill Report" with the Director of Facilities Management on 12/06/16 at 10:16 a.m., the documentation for the drills for the past twelve months lacked verification of the transmission of the signal for drills. Based on interview at the time of record review, the Director of Facilities Management confirmed no documentation was available showing the times when the monitoring company received the fire alarm signal.

Based on observation and interview, the facility failed to ensure 1 of 1 East Entrance Overhang was maintained in accordance with 19.7.5.1. LSC 19.7.5.1 requires draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/07/16 at 9:04 a.m., the East Entrance Overhang is constructed of a cloth material secured to the facility. Based on interview at the time of observation, the Maintenance Technician #1 acknowledged the aforementioned condition and was unable to provide documentation showing the East Entrance Overhang NFPA 701 certification.

Based on observation and interview, the facility failed to ensure 1 of 1 candle was maintained in accordance with 19.7.5.6. LSC 19.7.5.6 prohibits combustible decorations unless an exception was met. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/07/16 at 10:21 a.m., a candle with a wick was discovered in the Financial office. Based on interview at the time of observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure trash receptacles near 1 of 1 gym and 1 of 1 Dining room maintained in accordance with 19.7.5.7. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 at 4:32 p.m. then again on 12/07/16 at 8:35 a.m., there was a very large trash cart off of the corridor near the gym. Then again, the Dining room contained a forty gallon trash container off of the corridor. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition and confirmed the very large containers would hold more than 32 gallons of trash.

Based on observation and interview, the facility failed to ensure 24 of 24 space heaters was equipped with a heating element which would not exceed 212 degrees Fahrenheit (F) in accordance with 19.7.8. LSC 19.7.8 requires portable space-heating elements do not exceed 212 degrees. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/06/16 between 2:14 p.m. and 4:28 p.m., the following was discovered:
a) twenty separate space heaters in Housekeeping Storage
b) a space heater in the Exam room
c) a space heater in the Recovery Administrator office
Based on observation with the Maintenance Technician #1 on 12/07/16 between 8:32 a.m. and 8:56 a.m., the following was discovered:
d) a space heater in the Director of Community Support Services office
e) a space heater in the Receptionist area
Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition and was unable to provide documentation confirming the space heaters heating element 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 8.4.2.3 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 Director of Facilities Management on 12/06/16 at 11:08 a.m., the monthly documentation indicated that the generator failed to exercise with a load over thirty percent for the last twelve months. Based on an interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition and confirmed no load bank test was available for review.

2. Based on record review and interview, the facility failed to ensure a written record of weekly inspections for the generator was maintained for 28 of 52 weeks and a testing record of monthly inspections for the generator was maintained for 11 of 12 months. NFPA 99, 6.4.4.1.3 requires onsite generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 8.4.1 requires an Emergency Power Supply System (EPSS) including all appurtenant components, shall be inspected weekly and exercised monthly. NFPA 99, 6.4.4.2 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Facilities Management on 12/06/16 at 11:08 a.m., the following was discovered:
a) no monthly testing for February 2016 was available for review
b) monthly testing form failed to include transfer time and a cool down period
c) twenty eight of fifty two weeks of weekly inspections were not available for review. Based on an interview at the time of record review, the Maintenance Supervisor acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure 16 of 16 flexible cords were not used as a substitute for fixed wiring nor with a high current draw 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 could affect all occupants.

Findings include:

Based on observation with the Maintenance Technician #1 on 12/06/16 between 2:02 p.m. and 3:40 p.m., the following was discovered:
a) an extension cord was powering a fan in the Marketing office
b) an extension cord was powering a fan in Office room 256
c) an extension cord was powering a calculator in the Accounting Storage room
d) an extension cord was powering a fan in the Experiential Therapy office
e) an extension cord was powering a calculator in the Accounting office. Additionally, a surge protector was powering two separate surge protectors powering computer components.
f) an extension cord was powering a compressor bladder in the Boiler room
g) an extension cord was powering a refrigerator in the Kitchenette
h) a surge protector was powering a refrigerator in the Therapist office
Based on observation with the Maintenance Technician #1 on 12/07/16 between 8:31 a.m. and 8:51 a.m., the following was discovered:
i) a surge protector was powering a microwave, toaster, and blender in the Kitchen
j) a surge protector was powering a microwave in Group room 3
k) a surge protector was powering another surge protector powering television equipment in the IT room
l) an extension cord was powering a white noise machine in the Clinical Coordinator's office
Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

2. Based on observation and interview, the facility failed to ensure 1 of 1 Staff Bathroom was provided with a ground fault circuit interrupter (GFCI) protection against electric shock. LSC sections 9.1.2 requires all electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, Article 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, in 210.8(A), Dwelling Units, requires ground-fault circuit-interrupter (GFCI) protection for all personnel in bathrooms and kitchens where the receptacles are intended to serve the countertop surfaces. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 at 3:28 p.m., the Staff Bathroom had one receptacle within inches of the toilet bowl. When the GFCI tester button was pressed, power was not interrupted. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition.