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Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include a system of medical documentation that preserves resident information, protects confidentiality of resident information, and secures and maintains the availability of records in accordance with 42 CFR 482.15(b)(4). This deficient practice could affect all occupants.

Findings include:

Based on record review and interview with the Director of Facilities on 02/14/18 at 11:44 a.m., a policies and procedure that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records was not available for review.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency in accordance with 42 CFR 482.15(b)(6). This deficient practice could affect all occupants.

Findings include:

Based on record review and interview with the Director of Facilities on 02/14/18 at 10:44 a.m., a policy and procedure that included the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency was not available for review.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include the role of the Hospital facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials in accordance with 42 CFR 482.15(b)(8). This deficient practice could affect all occupants.

Findings include:

Based on record review and interview with the Director of Facilities on 02/14/18 at 10:48 a.m., a policy and procedure for the role of the Hospital facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act was not available for review.

Based on record review and interview, the facility failed to ensure the emergency preparedness training and testing program includes a training program. The Hospital facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles; (ii) Provide emergency preparedness training at least annually; (iii) Maintain documentation of the training; (iv) Demonstrate staff knowledge of emergency procedures in accordance with 42 CFR 482.15(d)(1). This deficient practice could affect all occupants.

Findings include:

Based on record review and interview with the Director of Facilities on 02/14/18 at 10:54 a.m., a training and testing program of emergency preparedness plan was not available for review.

Based on record review and interview, the facility failed to conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The Hospital facility must do all of the following: (i) participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the Hospital facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the Hospital facility is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event; (ii) conduct an additional exercise that may include, but is not limited to the following: (A) a second full-scale exercise that is community-based or individual, facility-based. (B) a tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan; (iii) analyze the Hospital facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the Hospital facility's emergency plan, as needed in accordance with 42 CFR 482.15(d)(2). This deficient practice could affect all occupants.

Findings include:

Based on record review and interview with the Director of Facilities on 02/14/18 at 11:07 a.m., no exercises and testing drills of emergency preparedness was available for review.

1. Based on observation and interview, the facility failed to ensure 1 of 4 exit discharge were constructed of hard packed all-weather travel surface in accordance with LSC 39.2.1.1. LSC 39.2.1.1 states all means of egress shall be in accordance with Chapter 7 and this chapter. LSC 7.7.1.1 states yards, courts, open spaces, or other portions of the exit discharge shall be of the required width and size to provide all occupants with a safe access to a public way. Clarification was also provided on the CMS Survey and Certification Letter 05-38. This deficient practice could all occupants in the Main Dining room.

Findings include:

Based on observation with Director of Facilities on 02/15/18 at 10:35 a.m., the Dining room exit discharge path contained a small cement path for about four feet then grass to the public way. Based on interview at the time of observation, the Director of Facilities acknowledged the lack of a hard clearable surface that led to a public way.

2. Based on record review and interview, the facility failed to maintain at least 1 of 1 battery operated emergency light in accordance with 39.1.1.3. LSC 39. 1.1.3 states the provisions of Chapter 4, General, shall apply. LSC 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall either be maintained or removed. LSC 7.9.3.1.1 testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 ½ hours if the emergency lighting is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the test.
(5) Written records of visual inspections and tests shall be kept by the owner for inspection for the authority having jurisdiction.
This deficient practice could affect all occupants if the facility were required to evacuate in an emergency during a loss of normal power. 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 Director of Facilities on 02/14/18 between 9:55 a.m. and 2:55 p.m., no documentation for the annual ninety minute battery operated emergency lights test. Based on interview at the time of observation, the Director of Facilities acknowledged the lack of testing documentation.

3. Based on observation and interview, the facility failed to install 2 of 2 flexible cords according to LSC 39.5.1 which states utilities shall comply with provisions of LSC 9.1. 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 staff only.

Findings include:

Based on observation with the Director of Facilities on 02/15/18 at 10:41 a.m., an extension cord powering a cell phone was discovered in the upstairs office. Additionally, a surge protector was powering a coffee pot. Based on interview at the time of each observation, the Director of Facilities confirmed the improper extension cord and surge protector use.

4. Based on observation and interview, the facility failed to ensure 1 of 1 upstairs office portable fire extinguishers was installed correctly in accordance with 4.6.12.3. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed. NFPA 10, the Standard for Portable Fire Extinguishers, 7.2.2, Procedures, requires periodic inspection or electronic monitoring of fire extinguishers shall include a check of six items. (3) Pressure gauge reading or indicator in the operable range or position. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities on 02/15/18 at 10:41 a.m., the upstairs office fire extinguisher gauge indicated the fire extinguisher was overcharged. Based on interview at the time of observation, the Director of Facilities confirmed the extinguisher was overcharged.

1. Based on record review and interview, the facility was unable to confirm the building construction type conformed to health care construction limitations in accordance with Table 19.1.6.1. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Facilities on 02/14/18 at 11:43 a.m., the facility was unable to provide construction site plan documentation to review. Based on an interview at the time of record review, the Director of Facilities acknowledged the aforementioned condition and confirmed that the site plans were sent out to be scanned.

2. Based on observation and interview, the facility to maintain 1 of 1 limited noncombustible rating in accordance with Table 19.1.6.1. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Facilities on 02/14/18 at 2:50 p.m., the "Old AGS Storage room" steel support beams had some multiple spots adding up to about one square foot where the protective coating was removed.
Based on observation with the Director of Facilities on 02/15/18 at 9:32 a.m. then again at 9:37 a.m., the Maintenance Storage room steel support beams had some multiple spots adding up to about one square foot where the protective coating was removed. Then again, the Boiler room steel support beams had some multiple spots adding up to about three square feet where the protective coating was removed.
Based on an interview at the time of each observation, the Director of Facilities acknowledged each aforementioned condition and confirmed that bare metal was exposed.

Based on observation and interview, the facility failed to maintain 1 of 3 stairwells and 3 of 6 corridors from obstructions per 19.2.1 LSC 19.2.1 states that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. LSC 7.1.10. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. LSC 7.1.10.2.1 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 Director of Facilities on 02/14/18 between 2:08 p.m. and 2:29 p.m., the following was discovered:
a) a fake tree was in the corridor outside the 2nd floor South Stairwell door
b) a ladder was stored in the 2nd floor North Stairwell
c) two large medical record paper trash cans and another trash can in the corridor outside office room 213
Based on observation with the Director of Facilities on 02/15/18 at 9:27 a.m., the following was discovered:
d) three separate 96 gallon medical record paper trash cans were in the corridor outside IT room
Based on interview at the time of each observation, the Director of Facilities acknowledged that impediments such as the portable fake tree, ladder, trash cans were potential impediments to full use of the means of egress access corridors.

Based on observation, the facility failed to meet 1 of 6 corridors clear width requirement exception per 19.2.3.4(5). LSC 19.2.3.4(5) requires where the corridor width is at least 8 feet, projections into the required width shall be permitted for fixed furniture. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Facilities on 02/14/18 at 2:37 p.m., a chair was located in the corridor outside of office room 217. The corridor width measured 6 feet. Based on interview at the time of observation, the Director of Facilities acknowledged the fixed furniture requirement is for corridors at least 8 feet in width.

Based on observation and interview, the facility failed to ensure the lighting for 1 of 7 exit means of egress were maintained. LSC 7.8.1.4 requires illumination shall be arranged so that that the failure of any single lighting unit does not result in an illumination level of less than 0.2 foot-candle in any designated area. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities on 02/14/18 at 9:04 a.m., the light fixture on the exit discharge from the Training room did not have two bulbs providing light throughout the exit discharge to the public way. Based on observation at the time of interview, the Director of Facilities acknowledged the lack of a second bulb.

Based on record review and interview, the facility failed to maintain at least 1 of 1 battery operated emergency light in accordance with 33.1.1.3. LSC 33. 1.1.3 states the provisions of Chapter 4, General, shall apply. LSC 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall either be maintained or removed. LSC 7.9.3.1.1 testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 ½ hours if the emergency lighting is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the test.
(5) Written records of visual inspections and tests shall be kept by the owner for inspection for the authority having jurisdiction.
This deficient practice could affect all occupants if the facility were required to evacuate in an emergency during a loss of normal power. 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 Director of Facilities on 02/14/18 at 11:37 a.m., no documentation for the annual ninety minute battery operated emergency lights test was available for review. Based on interview at the time of observation, the Director of Facilities acknowledged the lack of testing documentation.

Based on record review and interview; the facility failed to provide 1 of 7 1st floor exterior exit doors that was obvious and clearly identifiable as an exit 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 Director of Facilities on 02/14/18 at 2:38 p.m., the exit door at the rear of the Front Office contained an illuminated EXIT sign directing occupants to exit. The exit door contained a sign stating "Door is Alarmed DO NOT USE" indicating to occupants to not use the exit. Based on interview at the time of observation, the Director of Facilities acknowledged the sign could deter an occupant from using the exit in an emergency.

1. Based on observation and interview, the facility failed to maintain protection of 1 of 1 stairway in accordance of 19.3.1. LSC 19.3.1.1 requires where an enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Facilities on 02/14/18 at 2:08 p.m., the 2nd floor South stairwell door did not have a fire resistance rating. Based on interview at the time of observation, the Director of Facilities confirmed no fire resistance rating could be found.


2. Based on observation and interview, the facility failed to maintain protection of 2 of 3 ceiling barriers and 1 of 3 stairwells in accordance of 19.3.1. LSC 19.3.1 requires protection of vertical openings. LSC 19.3.1 requires vertical openings shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 19.3.1.1 requires where an enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities on 02/14/18 between 1:43 p.m. and 2:35 p.m., the following was discovered:
a) three separate three eighths inch gap around piping in the ACS drywall ceiling
b) six separate quarter inch gaps inside conduit in the Front Office Storage drywall ceiling
Based on observation with the Director of Facilities on 02/15/18 at 9:21 a.m., the following was discovered:
c) three separate five eighths inch gaps inside conduit in the 1st floor East Stairwell
Based on interview at the time of each observation, the Director of Facilities was unaware of the penetrations and provided the measurements.

Based on observation and interview, the facility failed to maintain protection of 1 of 1 Boiler room in accordance of 19.3.2. LSC 19.3.2, Protection from Hazards, requires doors to be self-closing or automatic closing. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities on 02/15/18 at 9:40 a.m., the Boiler room contained fuel-fired equipment. The Boiler room corridor door failed to latch into the frame when tested. Additionally, a door stop was installed on the bottom of the corridor door. Based on interview at the time of observation, the Director of Facilities acknowledged the door failed to latch into the frame and acknowledged the hazardous room door could be propped open.

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, 14.4.5 Testing Frequencies. NFPA 72, 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation. NFPA 72, 14.4.5.3.2 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 Director of Facilities on 02/14/18 at 1:13 p.m., fire alarm smoke detector sensitivity test was not available for review. Based on interview at the time of record review, the Director of Facilities 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 Director of Facilities on 02/15/18 at 10:15 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 Director of Facilities 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.

1. Based on observation and interview, the facility failed to ensure the spray pattern for sprinkler heads was not obstructed in 1 of 1 ACU Room D 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 staff and at least 1 patient.

Findings include:

Based on observation with the Director of Facilities on 02/14/18 at 1:50 p.m., ACU Room D sprinkler head deflector was higher than the drywall. Based on interview at the time of observation, the Director of Facilities acknowledged the aforementioned condition and confirmed the sprinkler head was obstructed.

2. Based on observation and interview, the facility failed to provide sprinkler coverage for 1 of 1 ACU Water Heater room in accordance with 19.3.5.1. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities on 02/14/18 at 1:43 p.m., the ACU Water Heater room did not have sprinkler protection installed at this fully automatic sprinklered building. Based on interview at the time of observation, the Maintenance Technician #1 confirmed the room did not have sprinkler protection installed.

3. Based on observation and interview, the facility failed to install sprinkler head deflectors within 12 inches of the ceiling in 1 of 1 "Old AGS Storage room." NFPA 13, 2010 Edition, Section 8.6.4.1.1.1 under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches throughout the area of coverage of the sprinkler. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities on 02/14/18 at 2:50 p.m., the "Old AGS Storage room" contains a sprinkler head deflector was estimated at 48 inches from the ceiling. Based on interview at the time of observation, the Director of Facilities acknowledged the aforementioned condition and provided the estimated measurement.

4. Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 Library in accordance with 19.3.5.1. LSC 19.3.5.3 requires where required by 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 Director of Facilities on 02/14/18 at 2:04 p.m., the Library had a missing escutcheon. Based on interview at the time of observation, the Director of Facilities acknowledged the missing escutcheon.

1. Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 ACU Rounds room. The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 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 Director of Facilities on 02/14/18 at 2:01 p.m., the ACU Rounds room was missing a ceiling tile. Based on interview at the time of observation, the Director of Facilities Director was unaware of the missing ceiling tile.

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 Director of Facilities on 02/14/18 at 11:28 a.m., the sprinkler system was inspected quarterly. No documentation was available for the monthly control valves and the monthly wet system gauge inspection. Based on interview at the time of record review, the Director of Facilities 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 Director of Facilities on 02/15/18 at 10:15 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 Director of Facilities 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, interview and record review, the facility failed to maintain 1 of 1 Front Office portable fire extinguishers was maintained correctly in accordance with 19.3.5.12. NFPA 10, the Standard for Portable Fire Extinguishers, 7.3.1.2.1 Six-Year Internal Examination. Every 6 years, stored-pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable internal examination procedures as detailed in the manufacturer's service manual and this standard. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities on 02/14/18 at 2:45 p.m., the Front Office fire extinguisher hydrostatic date printed on the extinguisher was 05/2007. The fire extinguisher did have a neck collar installed but the dates were not punched out indicating when the last six year internal inspection took place. Based on interview at the time of observation, the Director of Facilities acknowledged the aforementioned condition and confirmed the neck collar does not indicate the last internal inspection date.

Based on observation and interview, the facility failed to maintain protection of corridor doors in 1 of 6 corridors in accordance of 19.3.6.3. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities on 02/15/18 at 9:10 a.m., the office room 121 contained a wooden door stop. Based on interview at the time of observation, the Director of Facilities confirmed the door was impeded by a door stop.

Based on record review and observation, the facility failed to ensure at least 1 of 1 smoke/fire dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC) ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. Section 19.4.1.1 states the test and inspection frequency shall be every 4 years except for hospitals where the frequency is every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Facilities on 02/15/18, the Director of Facilities stated that he did not believe dampers were in the facility. Based on observation at 9:39 a.m., the Maintenance room contained a damper in the HVAC vent.

Based on observation and interview; the facility failed to ensure 1 of 1 elevator equipment room was provided with smoke detection in accordance with ASME/ANSI A17.3. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities on 02/15/18 at 9:39 a.m., the elevator equipment room contained 1 sprinkler head, a heat detector but no smoke detector. Based on interview at the time of observation, the Director of Facilities confirmed no smoke detector was present in the elevator equipment room.

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 02/15/18 at 10:12 a.m., the Director of Facilities acknowledged the "Fire Emergency Procedure" policy did not address (3) Emergency phone call to fire department, (7) Evacuation of smoke compartment, or (9) Extinguishment of fire.

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 affects all staff and residents.

Findings include:

Based on record review of the "Fire Drill Checklist" form with the Director of Facilities on 02/14/18 at 11:15 a.m., there was no documentation for a second shift fire drill in the second, third, and fourth quarter of 2017. Additionally, there was no documentation for a third shift fire drill in the first and second quarter of 2017. Based on interview at the time of record review, the Director of Facilities were unable to provide further documentation.

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 and simulation of emergency fire conditions for the last 4 quarters. This deficient practice affects all patients in the facility as well as staff and visitors.

Findings include:

Based on record review of titled "Fire Drill Checklist" with the Director of Facilities on 02/14/18 at 11:15 a.m., the documentation for the drills for the past twelve months lacked verification of the transmission of the signal for drills. Additionally, no documentation indicated the simulation of emergency fire conditions. Based on interview at the time of record review, the Director of Facilities confirmed no documentation was available showing the times when the monitoring company received the fire alarm signal nor simulation of emergency fire conditions.

3. Based on record review and interview the facility failed to ensure staff was familiar with procedures in case of fire for 12 of 12 fire drills. This deficient practice affects all occupants.

Findings included:

Based on record review with the Director of Facilities on 02/14/18 at 11:15 a.m., twelve of the last twelve fire drills lacked documented signatures only included four staff members. Based on interview at the time of review, the Director of Facilities confirmed more staff are present during the drills but do not include their signature on the fire drill documentation.

Based on observation and interview, the facility failed to ensure 1 of 1 area where smoking was permitted for staff was maintained in accordance with 19.7.4. LSC 19.7.4 requires ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. Metal containers with a self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas were smoking is permitted. This deficient practice could affect staff only.

Findings include:

Based on observations with the Director of Facilities on 02/14/18 at 2:42 p.m., there were at least 30 cigarette butts on the ground in the Staff smoking area. Based on interview at the time of observation, the Director of Facilities acknowledged the aforementioned condition and provided the number of cigarette butts on the ground.

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 Director of Facilities on 02/14/18 at 2:26 p.m., office room 209 contained a candle with three wicks. Based on interview at the time of observation, the Director of Facilities confirmed a wick was in the 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 Director of Facilities on 02/14/18 at 2:15 p.m., a space heater was discovered in the office room 218. Based on interview and record review at the time of observation, the Director of Facilities acknowledged the space heater and confirmed that the facility's space heater policy does not allow space heaters in the facility.

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 on 02/14/18 at 10:24 a.m., the monthly testing documentation did not specify a load percentage. Based on an interview at the time of record review, the Director of Facilities confirmed no load bank test documentation was available to review.

2. Based on record review and interview, the facility failed to document the transfer time to the alternate power source on the monthly load tests for 12 of the past 12 months to ensure the alternate power supply was capable of supplying service within 10 seconds. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on record review with the Director of Facilities on 02/14/18 at 10:24 a.m., the monthly Generator Load Tests lacked the generator's transfer time from normal power to emergency power. Based on interview at the time of record review, the Director of Facilities acknowledged the lack of documentation.

3. Based on record review and interview, the facility failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 52 of 52 weeks. Chapter 8.3.7 of NFPA 99 requires storage batteries, including electrolyte levels or battery voltage, used in connection with essential electrical systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. 8.3.7.2 requires defective batteries shall be repaired or replaced immediately upon discovery of defects. 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 residents, staff and visitors.

Findings include:

Based on record review with the Director of Facilities on 02/14/18 at 10:24 a.m., no weekly documentation was not available for review. Based on an interview at the time of record review, the Director of Facilities acknowledged the lack of documentation.

3.1-19(b)

4. 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 Director of Facilities on 02/14/18 at 10:24 a.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 Director of Facilities acknowledged the lack of documentation.

Based on observation and interview, the facility failed to ensure 19 of 19 power cords was not used as a substitute for fixed wiring according to 33.2.5.1. LSC 33.2.5.1 states utilities shall comply with Section 9.1. 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 Director of Facilities on 02/14/18 between 1:40 p.m. and 2:27 p.m., the following was discovered:
a) a surge protector was powering a coffee pot in the "CSS Half wall"
b) an extension cord was powering a microwave in the ACU Case Management office
c) a surge protector was powering a coffee pot, toaster, and microwave in the ACU Rounds room
d) a surge protector was powering another surge protector powering a refrigerator and a microwave in office room 220
e) a surge protector was powering a microwave and a refrigerator in office room 213
Based on observation with the Director of Facilities on 02/15/18 between 9:21 a.m. and 10:15 a.m., the following was discovered:
f) a surge protector was powering another surge protector powering computer components in the "unmanned IT office"
g) four separate surge protector was powering another surge protector in the "MF office"
h) a surge protector was powering a microwave in the IT room
i) a surge protector was powering a refrigerator in the Transportation room. Additionally, a surge protector was powering a microwave and a coffee pot
Based on interview at the time of observation, the Director of Facilities was unaware of regulation and acknowledged each interconnected surge protector.