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Based on record review and interview, the facility failed to develop an emergency preparedness program in accordance with 42 CFR 482.15 that includes the following elements:
a) An Emergency Plan
b) Policies and Procedures
c) A Communication Plan
d) Training and Testing
e) An Emergency and Standby Power System
This deficient practice could affect all occupants.

Findings include:

Based on record review with the Register Nurse #1 and the Maintenance Director on 04/04/18 between 9:44 a.m. and 11:36 a.m., no emergency preparedness plan was available for review. Based on interview at the time of record review, the Register Nurse #1 and the Maintenance Director stated they were in the process in creating the plan.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least annually in accordance with 42 CFR 482.15(a). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Register Nurse #1 and the Maintenance Director on 04/04/18 between 9:44 a.m. and 11:36 a.m., no emergency preparedness plan was available for review. Based on interview at the time of record review, the Register Nurse #1 and the Maintenance Director stated they were in the process in creating the plan.

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 all occupants.

Findings include:

Based on observation with the Register Nurse #1 and the Maintenance Director on 04/04/18 between 11:36 a.m. and 12:56 p.m., the following smoke detectors were discovered fifteen inches near HVAC vents:
a) Main Entrance
b) by room 205
c) by room 201
d) Receiving room
Based on interview at the time of each observation, the Register Nurse #1 and the Maintenance Director acknowledged the smoke detectors were located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening.

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 Register Nurse #1 and the Maintenance Director on 04/04/18 between 9:44 a.m. and 11:36 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the Indiana State Department of Health via the Web Portal. Based on an interview record review, the Register Nurse #1 and the Maintenance Director acknowledged fire watch policy failed to include the web link for contacting the Incident Reporting System located on the Indiana State Department of Health (ISDH) Gateway.

Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 5 corridors in accordance with 19.3.5.1. LSC 19.3.5.1 requires nursing homes 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 and up to 4 patients.

Findings include:

Based on observation with the Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:13 p.m., the corridor had a missing escutcheon outside the Case Manager's office. Based on interview at the time of observation, the Register Nurse #1 and the Maintenance Director acknowledged and confirmed the missing escutcheon.

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 Register Nurse #1 and the Maintenance Director on 04/04/18 between 9:44 a.m. and 11:36 a.m., the sprinkler system was inspected quarterly. No documentation was available for the monthly control valves, weekly dry system gauge and monthly wet system gauge inspection. Based on interview at the time of record review, the Register Nurse #1 and the Maintenance Director acknowledged the lack of documentation.

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 Register Nurse #1 and the Maintenance Director on 04/04/18 between 9:44 a.m. and 11:36 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the Indiana State Department of Health via the Web Portal. Based on an interview record review, the Register Nurse #1 and the Maintenance Director acknowledged fire watch policy failed to include the web link for contacting the Incident Reporting System located on the Indiana State Department of Health (ISDH) Gateway.

Based on observation and interview, the facility failed to maintain protection of corridor doors in 1 of 5 corridors in accordance of 19.3.6.3. This deficient practice could affect staff and at least 4 patients.

Findings include:

Based on observation with the Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:04 p.m., patient room 301 was propped open with a large chair. Based on interview at the time of observation, the Register Nurse #1 and the Maintenance Director acknowledged the aforementioned condition and confirmed the chair should not be propping the door open.

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 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 occupants.

Findings include:

Based on observations with the Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:33 p.m. then again at 12:36 p.m., a half inch gap around wires in the smoke barrier near resident room 101. Then again, a quarter inch gap inside conduit in the smoke barrier near resident room 201. Based on interview at the time of each observation, the Register Nurse #1 and the Maintenance Director acknowledged each aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure 2 of 2 candles were 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 Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:23 p.m., two separate candles with wicks was discovered in the Assistant Director of Nursing office. Based on interview at the time of observation, the Register Nurse #1 and the Maintenance Director confirmed a wick was in each candle.

Based on observation, interview, and record review, the facility failed to enforce 1 of 1 policy for the use of portable space heaters in accordance with 19.7.8. This deficient practice could affect staff only.

Findings include:

Based on observation with the Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:22 a.m., two separate space heaters were discovered in the business office. Based on interview at the time of observation, the Register Nurse #1 and the Maintenance Director acknowledged the space heaters were a violation of the facility's policy.

1. Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 5 of the last 12 months. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110 8.4.2 requires diesel generator sets in service to be exercised at least once monthly, for a minimum of 30 minutes. Chapter 6.4.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:45 p.m., documentation for eight of the last twelve months of generator testing indicated a run time of less than 30 minutes. Based on an interview at the time of record review, the Register Nurse #1 and the Maintenance Director acknowledged the aforementioned condition and was unaware of the issue.

3.1-19(b)

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 Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:45 p.m., the generator log form documented the generator was tested monthly for at least 30 minutes under load, however, there was no documentation on the form that showed the generator had a cool down time following its load test. Based on interview at the time of record review, the Register Nurse #1 and the Maintenance Director acknowledged the lack of documentation.

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 Register Nurse #1 and the Maintenance Director on 04/04/18 at 12:13 p.m. then again at 12:22 p.m., an extension cord was powering a fan in the Case Manager's office. Then again, a surge protector was powering a refrigerator in the Business office. Based on interview at the time of each observation, the Register Nurse #1 and the Maintenance Director acknowledged each aforementioned and removed the extension cord upon discovery.