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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 with the Director of Operations and the Compliance Manager on 05/10/18 at 12:30 p.m., a policies and procedure that included a system of medical documentation that preserves resident information, protects confidentiality of resident information, and secures and maintains the availability of records was not available for review. Based on interview at the time of record review, the Compliance Manager immediately confirmed the emergency preparedness plan does not include a system of medical documentation.

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 with the Director of Operations and the Compliance Manager on 05/10/18 at 12:31 p.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 interview at the time of record review, the Compliance Manager confirmed no policy for the use of volunteers was documented but stated it would be a good idea.

Based on record review and interview, the facility failed to ensure the emergency preparedness communication plan includes (4) A method for sharing information and medical documentation for residents under the facility's care, as necessary, with other health care providers to maintain the continuity of care; (5) A means, in the event of an evacuation, to release resident information as permitted under 45 CFR 164.510(b)(1)(ii); (6) A means of providing information about the general condition and location of residents under the facility's care as permitted under 45 CFR 164.510(b)(4) in accordance with 42 CFR 482.15(c)(4). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 at 12:38 p.m., the emergency preparedness plan failed to include a communication plan that included a method for sharing information and medical documentation for residents under the LTC facility's care, as necessary, with other health care providers to maintain the continuity of care. Based on interview at the time of record review, the Compliance Manager immediately confirmed that their emergency preparedness plan does not include a method for sharing information for residents under the facility's care.

Based on record review and interview, the facility failed to ensure the emergency preparedness communication plan includes a means of providing information about the LTC facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee in accordance with 42 CFR 482.15(c)(7). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 at 12:40 p.m., a communication plan that included a means of providing information about the LTC facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee in accordance with 42 CFR 483.73(c)(7) was not available for review. Based on interview at the time of record review and again at the exit conference, the Director of Operations and the Compliance Manager confirmed no documentation was available to review.

1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm system in accordance with 4.5.6. LSC 4.5.6 any fire protection system, building service equipment, feature of protection, or safe-guard provided to achieve the goals of this Code shall be designed, installed, and approved in accordance with applicable NFPA standards. NFPA 72, National Fire Alarm and Signaling Code 10.15* Protection of Fire Alarm System. In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s), notification appliance circuit power extenders, and supervising station transmitting equipment to provide notification of fire at that location. Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 2:55 p.m., the fire alarm control panel was in a locked room with no smoke detector. Based on interview at the time of observation, the Director of Operations and the Compliance Manager confirmed no smoke detector was installed in the room and the room nor the facility is not continuously occupied.

2. Based on observation and interview, the facility failed to protected 1 of 1 Record room in accordance with LSC 39.3.2.1. LSC 39.3.2.1 states hazardous areas shall be protected in accordance with Section 8.7. LSC 8.7.1.1 states protection from any area having a degree of hazard greater than that normal to the general occupancy of the building shall be provided with one of the following (1) enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating (2) protecting the area with automatic extinguishing systems in accordance with Section 9.7. LSC 8.7.1.3 requires doors in barriers required to have a fire resistance rating shall have a minimum ¾ hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8. This deficient practice could affect staff or any patient in the smoke compartment.

Findings include:

Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 2:57 p.m., the Record room was filled with metal filling cabinets open to the room and contained paperwork. The room door was rated 20 minutes. The facility did not have a complete automatic sprinkler system. Based on interview at the time of observation, the Director of Operations and the Compliance Manager acknowledged the rating on the Record room door.

3. Based on observation and interview, the facility failed to install 4 of 4 flexible cords according to 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 Operations and the Compliance Manager on 05/10/18 between 2:52 p.m. and 2:59 p.m., the following was discovered:
a) a surge protector was powering a microwave in the Rehab Service Manager's office
b) a UPS surge protector was powering another surge protector powering phone equipment in the Phone room
c) a surge protector was powering a coffee pot in Office 108
Based on interview at the time of each observation, the Director of Operations and the Compliance Manager confirmed each improper surge protector use.

1. Based on observation and interview, the facility failed to protected 1 of 1 Mechanical room 130 in accordance with LSC 39.3.2.1. LSC 39.3.2.1 states hazardous areas shall be protected in accordance with Section 8.7. LSC 8.7.1.1 states protection from any area having a degree of hazard greater than that normal to the general occupancy of the building shall be provided with one of the following (1) enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating (2) protecting the area with automatic extinguishing systems in accordance with Section 9.7. LSC 8.7.1.3 requires doors in barriers required to have a fire resistance rating shall have a minimum ¾ hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8. This deficient practice could affect staff or any patient in the smoke compartment.

Findings include:

Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 4:18 p.m., the Mechanical room 130 contained a fuel-fired furnace. The Mechanical room door did not have a self-closing device or an automatic sprinkler system. Based on interview at the time of observation, the Director of Operations and the Compliance Manager confirmed the door did not self-close when tested.

2. Based on observation and interview, the facility failed to ensure 1 of 4 basement exit discharges were constructed of hard packed all-weather travel surface in accordance with LSC 39.2.1.1. LSC 21.2.1.1 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 affect staff only.

Findings include:

Based on observation with Director of Operations and the Compliance Manager on 05/10/18 at 4:19 p.m., the #4 exit door by the Mechanical room 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 Operations and the Compliance Manager acknowledged the lack of a hard clearable surface that led to a public way.

3. Based on observation and interview, the facility failed to install 1 of 1 multiplug and 2 of 2 flexible cords according to 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 Operations and the Compliance Manager on 05/10/18 between 3:54 p.m. and 4:06 p.m., the following was discovered:
a) a surge protector was powering a coffee pot in the Pharmacy
b) a surge protector was powering a refrigerator in the Break room
c) a multiplug was powering a refrigerator in office room 207
Based on interview at the time of each observation, the Director of Operations and the Compliance Manager confirmed the improper multiplug and surge protector use.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 occupancy separation wall was protected in accordance with 19.1.3.3. LSC 19.1.3.3 states sections of health care facilities shall be permitted to be classified as other occupancies, provided they meet all the of following conditions: (2) they are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 between 10:34 a.m. and 11:53 a.m., the facility site plans indicated a two hour occupancy separation wall near the nurse's station. Based on observation the following was discovered:
a) the rolling steel door is held open with a fusible link
b) the Kitchen door does not have a fire resistive label on the door nor on the door frame
c) the Doctor Evaluation room does not have a self-closure
d) seven separate penetrations in the barrier near Office Room 200 above the drop ceiling
e) nine separate penetrations in the barrier near Office Room 114 above the drop ceiling
f) four separate penetrations in the barrier near Office Room 130 above the drop ceiling
g) four separate penetrations in the barrier near the Kitchen above the drop ceiling
Based on interview at the time of each observation, the Maintenance Technician #1 and the Director of Facilities Management confirmed the rolling steel door does not release with the fire alarm, confirmed the lack of a self-closure, was unable to locate the two fire ratings on the Kitchen door and frame, and confirmed the lack of fire stopping material in the barrier.

Based on observation and interview, the facility failed to ensure the means of egress through 1 of 9 exits were accessible. This deficient practice could affect staff and up to 8 patients.

Findings include:

Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 9:34 a.m., the Director of Operations was unable to open the exit door by patient room 306. Based on interview at the time of the observation, the Director of Operations and the Compliance Manager confirmed the door lock would not release with the key.

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

Findings include:

Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 10:04 a.m., the Kitchen contained a UL 300 hood system. Based on interview, the Patient Supported Technician was asked what she would do if there was a grease fire underneath the hood. She replied she would turn off the burner, tell staff, and grab a K class fire extinguisher. She failed to indicate pulling the Ansul hood pull station. Based on interview, the Director of Operations and the Compliance Manager acknowledged her response and were unaware of the Ansul pull station requirement.

2. Based on observation and interview, the facility failed to ensure 1 of 1 UL 300 manual activation pull station was readily accessible. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition at 10.5.1 states, a readily accessible means for manual activation shall be located between 42 inches and 48 inches above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected. This deficient practice was not in a resident area but could affect kitchen staff.

Findings include:

Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 10:04 a.m., a cooking appliance was directly in front of the UL 300 manual activation pull station. Based on interview at the time of observation, the Director of Operations and the Compliance Manager confirmed the method of pulling manual activation pull stations directly back would be difficult.

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, 17.7.3.1.2 requires the location and spacing requirements shall be based on six factors. (2) Ceiling height. (5) Compartment ventilation. NFPA 72 17.7.3.2.1 spot-type smoke detectors shall be located on the ceiling, or, if on a sidewall, between the ceiling and 12 inches down from the ceiling to the top of the detector. This deficient practice could affect staff and any patients in the waiting area.

Findings include:

Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 9:14 a.m., the Main Entry waiting area contained two smoke detectors seventeen feet from the peak of the ceiling. Based on interview at the time of observation, the Director of Operations and the Compliance Manager acknowledged the smoke detectors location and provided the measurement from the peak of the slanted ceiling to the smoke detectors on each side.

1. 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, 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 at 10:58 a.m., the last fire alarm report dated 09/06/17 by Cottage Watchman Security Systems indicated "Fire doors released upon alarm but east doors do not close all the way and are locked. West doors do not close all the way." Based on interview at the time of record review, the Director of Operations and the Compliance Manager acknowledged the issues and was unable to show documentation showing repairs have been made.

2. 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, Table 14.4.5(15)(e) Testing Frequencies indicates that heat detectors be tested annually. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 at 10:58 a.m., the last fire alarm report dated 09/06/17 by Cottage Watchman Security Systems indicated "Heat detectors tested every 5 years." Based on interview at the time of record review, the Administrator and the Maintenance Director 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 Operations and the Compliance Manager on 05/10/18 at 11:44 a.m., the fire watch plan indicated calling the Warsaw fire department. The plan failed to include contacting the insurance company and Indiana State Department of Health via the Web Portal. Based on an interview at the time of record review, the Director of Operations and the Compliance Manager confirmed the fire watch policy was from their old location.

Based on observation and interview, the facility failed to provide sprinkler coverage for 1 of 1 Kitchen Entrance exterior canopies which was wider than 4 feet. NFPA 13, 2010 Edition, Section 8.15.7.3 states sprinklers shall be permitted to be omitted from below the canopies, roofs, porte-cocheres, balconies, decks, or similar projections of combustible construction, provided the exposed finish material on the roofs, canopies, or porte-cocheres 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, and the roofs, canopies, or porte-cocheres contain only sprinklered concealed spaces or any of the following unsprinklered combustible concealed spaces: (1) Combustible concealed spaces filled entirely with noncombustible insulation (2) Light of ordinary hazard occupancies where noncombustible or limited-combustible ceilings are directly attached to the bottom of solid wood joists so as to create enclosed joist spaces 160 cubic feet or less in volume, including space below insulation that is laid directly on top or within the ceiling joists in an otherwise sprinklered attic (3) Concealed spaces over isolated small roofs, canopies, or porte-cocheres not exceeding 55 square feet in area. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 9:52 a.m., the Kitchen entrance overhang extended over 4 feet from the building, was attached outside of the Front Entrance and was not provided with sprinkler protection. Based on interview at the time of observation, the Director of Operations and the Compliance Manager confirmed no documentation was available for review to verify the fabric material was noncombustible or limited-combustible.

3.1-19(b)

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 Operations and the Compliance Manager on 05/10/18 at 11:40 a.m., no documentation was available for the fourth quarter 2017 sprinkler inspection. Additionally, no documentation was available for the monthly control valves and monthly wet system gauge inspection. Based on interview at the time of record review, the Director of Operations and the Compliance Manager acknowledged the lack of documentation and was unable to provide further documentation at the time of the exit conference.

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 Operations and the Compliance Manager on 05/10/18 at 11:44 a.m., the fire watch plan indicated calling the Warsaw fire department. The plan failed to include contacting the insurance company and Indiana State Department of Health via the Web Portal. Based on an interview at the time of record review, the Director of Operations and the Compliance Manager confirmed the fire watch policy was from their old location.

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 05/10/18 at 11:11 a.m., the Director of Operations and the Compliance Manager acknowledged the "Fire Safety Plan" did not address (3) Emergency phone call to fire department.

1. Based on record review and interview, the facility failed to conduct quarterly fire drills for 2 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 occupants.

Findings include:

Based on record review of the "Fire Drill Evaluation" forms with the Director of Operations and the Compliance Manager on 05/10/18 at 10:47 a.m., there was no documentation for a first shift fire drill in the first quarter of 2018. Additionally, there was no documentation for a first, second, or third shift fire drill in the fourth quarter of 2017. Based on interview at the time of record review, the Director of Operations and the Compliance Manager 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 occupants.

Findings include:

Based on record review of titled "Fire Drill Evaluation" with the Director of Operations and the Compliance Manager on 05/10/18 at 10:46 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 confirmed verification of the transmission of the fire alarm signal is not performed.

Based on observation, records review, and interview; the facility failed to ensure annual inspection and testing of 2 of 2 fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states 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. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all patients.

Findings include:

Based on record review with the Director of Operations and the Compliance Manager on 05/10/18 at 11:40 a.m., the site plans indicated the 2 hour occupancy separation wall. The two hour wall traveled down two sides of the Kitchen. Based on interview at the time of record review, the Director of Operations and the Compliance Manager provided fire door assembly inspections on all doors except the two doors in the Kitchen.

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

Findings include:

Based on observation with the Director of Operations and the Compliance Manager on 05/10/18 at 10:10 a.m., a space heater was discovered in the EDT office. Based on interview at the time of observation, the Director of Operations and the Compliance Manager was unaware the space heater was in the building and confirmed no documentation was available to provide the heating element does not exceed 212 degrees.

1. 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 patients, staff and visitors.

Findings include:

Based on record review with the Director of Operations and the Compliance Manager on 05/11/18 at 11:06 a.m., no weekly inspection documentation was available for review. Based on an interview at the time of record review, the Director of Operations and the Compliance Manager contacted their staff member who maintains the generator and confirmed no weekly inspection is documented.

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 Director of Operations and the Compliance Manager on 05/10/18 at 11:06 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 Operations and the Compliance Manager 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 Director of Operations and the Compliance Manager on 05/10/18 at 10:25 a.m., a surge protector was powering another surge protector powering phone equipment in the Phone room. Based on interview at the time of observation, the Director of Operations and the Compliance Manager confirmed the surge protector was powering another surge protector.