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Based on observation, record review and interview, the facility failed to meet the building construction type and height requirement for 1 of 2 buildings. This deficient practice could affect 11 patients.

Findings include:

Based on observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15, a two foot section of the steel beam above the ceiling tile in patient room 202 was not treated with a fire rated material. Based on an interview with the Compliance Specialist at the time of observation, the remainder of the building was treated with a fire rated material and this section must have been missed.

1. Based on observation and interview, the facility failed to ensure 1 of 3 stairway doors with a one and one half hour rating, closed and latched into the door frame. LSC 18.3.1.1 requires any vertical opening to be enclosed or protected in accordance with LSC 8.2.5. LSC 8.2.5.2 states the vertical opening shall be enclosed as appropriate for the fire resistance rating of the barrier. LSC 8.2.3.3.1 requires a one hour rated door in a one hour vertical opening. NFPA 80, the Standard for Fire Doors and Fire Windows at 2-1.2 requires fire door assemblies to include latches. NFPA 80, 2-1.4 requires fire doors to be closed and latched at the time of fire. This deficient practice could affect any patient near the west stairway door.

Findings include:

Based on an observation with the CEO, Maintenance Director #1 and Maintenance Director #2 on 04/15/15 at 1:45 p.m., the west stairway door failed to latch into the door frame after ten attempts. At the time of observation, the CEO acknowledged the west stairway door failed to latch into the door frame.

2. Based on observation and interview, the facility failed to ensure 3 of 4 stairway enclosure maintained a fire resistance rating of at least one hour. This deficient practice could affect any patient evacuated through the corridor near the west stairway.

Findings include:

Based on observation and interview with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 from 3:40 p.m. to 4:35 p.m., the following unsealed penetrations above the ceiling tile were noted:
a) both second floor stairway enclosures had unsealed penetrations measuring in size from one and one quarter inch to three quarters on an inch
b) at the first floor west stairway enclosure there was an unsealed penetration measuring one and one half inch

Based on observation and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers and 2 of 4 smoke barrier walls were maintained to provide a one hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect all 200 hall occupants.

Findings include:

Based on an observation with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 from 2:13 p.m. to 4:25 p.m., the following unsealed penetrations were noted:
a) the basement mechanical room where the transfer switch for the Onan generator is located had fiberglass insulation stuffed into a ceiling penetration. Based on an interview with Maintenance Director #1 at the time of observation, he was not sure who stuffed the fiberglass insulation into the ceiling penetration.
b) in the one hour smoke barrier wall that continues along the 200 unit the following penetrations were found above the ceiling tile; a three inch penetration across from the EEG room and a twelve inch by six inch penetration above the doors entering the 200 unit.
c) at the second floor one hour smoke barrier floor above the ceiling tile there was an unsealed penetration measuring 12 inches by 12 inches around an HVAC duct.
All unsealed penetrations were acknowledged by Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist at the time of observations.

Based on observation and interview, the facility failed to ensure the corridor doors entering 1 of 1 kitchen and 1 of 1 dry foods storage room, used to store combustibles and measuring over 50 square feet in size, were provided with a self closing device and positive latching hardware. This deficient practice was not in a patient care area but could affect facility staff.

Findings include:

Based on observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 at 1:08 p.m. to 1:18 p.m., the two corridor doors entering the kitchen lacked a self closing device and positive latching hardware and the two corridor doors entering the dry food storage area lacked positive latching hardware. This was acknowledged by the Compliance Specialist at the time of observation.

Based on record review, observation and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 3 of 3 battery operated emergency lights in the facility. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires an annual test to be conducted on every required battery powered emergency lighting system for not less than 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 patients, staff and visitors throughout the facility.

Findings include:

Based on record review and interview on 04/15/15 at 10:56 a.m., Maintenance Director#1 and Maintenance Director #2 acknowledged an annual 90 minute test had not been conducted on the three battery operated emergency light since January 2014.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 completed quarters. This deficient practice could affect all occupants.

Findings include:

Based on record review of the "Fire Drill Observer Evacuation" forms with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 at 11:37 a.m., there was no record of a second shift fire drill for the first quarter of 2015. Based on an interview with the Maintenance Director #2 at the time of record review, a second shift fire drill had not been conducted in the first quarter of 2015.

Based on observation and interview, the facility failed to ensure 1 of 2 fire alarm panels located in an area that were not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. NFPA 72 at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice could affect all 15 patients in the 100 unit.

Findings include:

Based on observation with Maintenance Director #1 on 04/15/15 at 12:05 p.m., the 100 unit building main fire alarm panel located in the IT room adjacent the break room was not electrically supervised by a smoke detector or in an area continuously occupied. At the time of observation, Maintenance Director #1 acknowledged the IT room was provided with only a heat detector.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms and 1 of 1 basement clean supply rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. The elevator equipment room and the clean supply room were located in the basement and could affect any number of staff.

Findings include:

Based on an observation and interview on 04/15/15 from 11:20 a.m. to 1:53 p.m., Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist acknowledged the elevator equipment room and the basement clean supply room lacked sprinkler coverage.

1. Based on observation and interview, the facility failed to replace the corroded sprinkler head in 1 of 1 emergency ration storage rooms. 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, 1998 edition, 2-2.1.1 requires any sprinkler shall be replaced which is painted, corroded, damaged, loaded, or in the improper orientation. This deficient practice was not in a resident care area but could affect facility staff.

Findings include:

Based on observation and interview on 04/15/15 at 1:25 p.m., Maintenance Director #1 acknowledged one of two sprinkler heads in the emergency ration storage room was corroded with a green substance.

2. Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers for the automatic sprinkler system in accordance with NFPA 25, 1998 Edition 2-4.1.4 which requires a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. This deficient practice could affect all residents if the sprinkler system had to be shut down because a proper sprinkler wasn't available as a replacement.

Findings include:

Based on observation with Maintenance Director #1 on 04/15/15 at 1:25 p.m., there were green glass bulb sprinkler heads in the 100 unit basement boiler room. At the time of observation, Maintenance Director #1 acknowledged there were no green glass bulb sprinkler heads in the spare sprinkler cabinet .

Based on observation and interview, the facility failed to ensure 1 of 2 fire extinguishers in the 100 unit was readily accessible at all times. NFPA 10, Standard for Portable Fire Extinguishers, Section 1-6.3 requires that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. This deficient practice could affect any of the 11 patients in the 100 unit.

Findings include:

Based on observation with the CEO, Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 from 12:05 p.m. to 12:10 p.m., the fire extinguishers in the 100 unit were in locked wall mounted cabinets. Based on interview with Maintenance Director #2 at the time of observation, all staff members were supposed to be provided with the key. Based on an interview at 12:10 p.m., RN#1 stated she did not have a key to the fire extinguisher cabinets.

Based on observation and interview, the facility failed to enforce 1 of 1 smoking policies for the facility. This deficient practice could affect any occupants evacuated through the back exits from both the 100 unit and the 200 unit near the emergency generators.

Findings include:

Based on an observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 from 12:35 p.m. to 12:36 p.m., the grassy area around both emergency generators was littered with cigarette butts. Based on an interview with Maintenance Director #1 at the time of observation, the entire campus is designated smoke free.

Based on observation and interview, the facility failed to ensure 1 of 1 exterior oxygen supply storage locations was protected from the weather. NFPA 99, 4-3.5.2.2 requires cylinders stored in the open shall be protected against extremes of weather. During winter, cylinders stored in the open shall be protected from against an accumulation of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail. This deficient practice could affect all occupants evacuated through both back exits.

Findings include:

Based on observation with Maintenance Director #1 on 04/15/15 at 2:40 p.m., two large liquid oxygen containers, approximately 5 feet tall, were located in a chain link enclosure near the Caterpillar emergency generator. The chain link enclosure did not offer protection from sun, snow, or rain. Maintenance Director #1 agreed at the time of observation, the liquid oxygen containers were exposed to all types of weather conditions.

1. Based on observation and interview, the facility failed to ensure the penetration in 1 of 1 basement fire barrier walls was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.2.3.2.4.2 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet on of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
This deficient practice was not in a patient care area but could affect both basement smoke compartments.

Findings include:

Based on an observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 at 4:35 p.m., at the basement two hour fire barrier doors above the ceiling tile there was an unsealed penetration measuring one inch around a conduit and a one and one half inch unsealed penetration around a sprinkler line. The Compliance Specialist confirmed the wall was a two hour fire barrier wall at the time of observation.

2. Based on observation and interview, the facility failed to ensure the water heaters in 1 of 2 basement boiler/water heater rooms had a current inspection certificate to ensure the water heaters were in safe operating condition. NFPA 101, in 19.1.1.3 requires all health facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of residents. This deficient practice was not in a resident care area but could affect any number of staff in the basement.

Findings include:

Based on observation with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 at 5:30 p.m., the basement water heater with the state registration number 318523 lacked a Certificate of Inspection. Based on an interview with Maintenance Director #1 and Maintenance Director #2 at the time of observation, they were unable to provide documentation to confirm the aforementioned water heater had been inspected and had a Certificate of Inspection.

Based on observation and interview, the facility failed to maintain 1 of 1 master alarm panels in the 100 unit. This deficient practice could affect 15 patients in the 100 unit.

Findings include:

Based on observation with CEO, Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 at 12:20 p.m., the master alarm panel in the 100 unit was not operational. Based on an interview with Maintenance Director #2 at the time of observation, the facility is waiting for a service company from Indianapolis to make the necessary repairs.

Based on observation and interview, the facility failed to ensure the alternate source of power from the 1 of 2 emergency generators was capable of automatically connecting to the load within 10 seconds in the event of failure of normal power. NFPA 99, the Standard for Health Care Facilities, Nursing Home requirements requires essential electrical distribution systems to conform to Type 2 systems as described in Chapter 3 of NFPA 99. NFPA 99, 3-6.3.1.2 requires the emergency system to be arranged so that, in the event of failure of the normal power source, the alternate source of power will automatically connect to the load within 10 seconds. This deficient practice could affect all occupants in the 100 unit in that it could not be assured all patients were safeguarded by the facility with a generator that could operate under load conditions when needed during a power failure.

Findings include:

Based on observation with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 from 12:40 p.m. to 12:50 p.m., the Onan emergency generator failed to start with the transfer switch after two attempts. Based on an interview with Maintenance Director at the time of observation, he was able to manually start the generator and then start the generator with the transfer switch. He stated a relay could have been stuck.

Based on observation and interview, the facility failed to ensure 8 of 8 flexible cords such as extension cord power strips, 2 of 2 multiplug adapters and 1 of 1 extension cords were not used as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice was not in a patient care area but could affect staff.

Findings include:

Based on an observation and interview on 04/15/15 from 1:49 p.m. to 3:17 p.m., Maintenance Director #1 and Maintenance Director #2 acknowledged the following:
a) three extension cord power strips were plugged together and providing power to computer equipment and a copier in the Pharmacy
b) an extension cord was plugged in and continued up through the ceiling in the basement IT room
c) a multiplug adaptor was plugged in and providing power to an extension cord power strip which was plugged in and providing power another extension cord power strip which was providing power to IT equipment in the basement IT room
d) a multiplug adaptor was plugged in and providing power to an extension cord power strip which was providing power to an electric air freshener in the Discharge Planning office
e) an extension cord power strip was plugged in and providing power to another extension cord power strip which was providing power to telephone equipment in the telephone equipment closet on the second floor.

Based on observation, record review and interview, the facility failed to meet the building construction type and height requirement for 1 of 2 buildings. This deficient practice could affect 11 patients.

Findings include:

Based on observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15, a two foot section of the steel beam above the ceiling tile in patient room 202 was not treated with a fire rated material. Based on an interview with the Compliance Specialist at the time of observation, the remainder of the building was treated with a fire rated material and this section must have been missed.

1. Based on observation and interview, the facility failed to ensure 1 of 3 stairway doors with a one and one half hour rating, closed and latched into the door frame. LSC 18.3.1.1 requires any vertical opening to be enclosed or protected in accordance with LSC 8.2.5. LSC 8.2.5.2 states the vertical opening shall be enclosed as appropriate for the fire resistance rating of the barrier. LSC 8.2.3.3.1 requires a one hour rated door in a one hour vertical opening. NFPA 80, the Standard for Fire Doors and Fire Windows at 2-1.2 requires fire door assemblies to include latches. NFPA 80, 2-1.4 requires fire doors to be closed and latched at the time of fire. This deficient practice could affect any patient near the west stairway door.

Findings include:

Based on an observation with the CEO, Maintenance Director #1 and Maintenance Director #2 on 04/15/15 at 1:45 p.m., the west stairway door failed to latch into the door frame after ten attempts. At the time of observation, the CEO acknowledged the west stairway door failed to latch into the door frame.

2. Based on observation and interview, the facility failed to ensure 3 of 4 stairway enclosure maintained a fire resistance rating of at least one hour. This deficient practice could affect any patient evacuated through the corridor near the west stairway.

Findings include:

Based on observation and interview with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 from 3:40 p.m. to 4:35 p.m., the following unsealed penetrations above the ceiling tile were noted:
a) both second floor stairway enclosures had unsealed penetrations measuring in size from one and one quarter inch to three quarters on an inch
b) at the first floor west stairway enclosure there was an unsealed penetration measuring one and one half inch

Based on observation and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers and 2 of 4 smoke barrier walls were maintained to provide a one hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect all 200 hall occupants.

Findings include:

Based on an observation with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 from 2:13 p.m. to 4:25 p.m., the following unsealed penetrations were noted:
a) the basement mechanical room where the transfer switch for the Onan generator is located had fiberglass insulation stuffed into a ceiling penetration. Based on an interview with Maintenance Director #1 at the time of observation, he was not sure who stuffed the fiberglass insulation into the ceiling penetration.
b) in the one hour smoke barrier wall that continues along the 200 unit the following penetrations were found above the ceiling tile; a three inch penetration across from the EEG room and a twelve inch by six inch penetration above the doors entering the 200 unit.
c) at the second floor one hour smoke barrier floor above the ceiling tile there was an unsealed penetration measuring 12 inches by 12 inches around an HVAC duct.
All unsealed penetrations were acknowledged by Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist at the time of observations.

Based on observation and interview, the facility failed to ensure the corridor doors entering 1 of 1 kitchen and 1 of 1 dry foods storage room, used to store combustibles and measuring over 50 square feet in size, were provided with a self closing device and positive latching hardware. This deficient practice was not in a patient care area but could affect facility staff.

Findings include:

Based on observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 at 1:08 p.m. to 1:18 p.m., the two corridor doors entering the kitchen lacked a self closing device and positive latching hardware and the two corridor doors entering the dry food storage area lacked positive latching hardware. This was acknowledged by the Compliance Specialist at the time of observation.

Based on record review, observation and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 3 of 3 battery operated emergency lights in the facility. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires an annual test to be conducted on every required battery powered emergency lighting system for not less than 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 patients, staff and visitors throughout the facility.

Findings include:

Based on record review and interview on 04/15/15 at 10:56 a.m., Maintenance Director#1 and Maintenance Director #2 acknowledged an annual 90 minute test had not been conducted on the three battery operated emergency light since January 2014.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 completed quarters. This deficient practice could affect all occupants.

Findings include:

Based on record review of the "Fire Drill Observer Evacuation" forms with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 at 11:37 a.m., there was no record of a second shift fire drill for the first quarter of 2015. Based on an interview with the Maintenance Director #2 at the time of record review, a second shift fire drill had not been conducted in the first quarter of 2015.

Based on observation and interview, the facility failed to ensure 1 of 2 fire alarm panels located in an area that were not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. NFPA 72 at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice could affect all 15 patients in the 100 unit.

Findings include:

Based on observation with Maintenance Director #1 on 04/15/15 at 12:05 p.m., the 100 unit building main fire alarm panel located in the IT room adjacent the break room was not electrically supervised by a smoke detector or in an area continuously occupied. At the time of observation, Maintenance Director #1 acknowledged the IT room was provided with only a heat detector.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms and 1 of 1 basement clean supply rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. LSC Section 9.7.3.1 allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. The elevator equipment room and the clean supply room were located in the basement and could affect any number of staff.

Findings include:

Based on an observation and interview on 04/15/15 from 11:20 a.m. to 1:53 p.m., Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist acknowledged the elevator equipment room and the basement clean supply room lacked sprinkler coverage.

1. Based on observation and interview, the facility failed to replace the corroded sprinkler head in 1 of 1 emergency ration storage rooms. 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, 1998 edition, 2-2.1.1 requires any sprinkler shall be replaced which is painted, corroded, damaged, loaded, or in the improper orientation. This deficient practice was not in a resident care area but could affect facility staff.

Findings include:

Based on observation and interview on 04/15/15 at 1:25 p.m., Maintenance Director #1 acknowledged one of two sprinkler heads in the emergency ration storage room was corroded with a green substance.

2. Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers for the automatic sprinkler system in accordance with NFPA 25, 1998 Edition 2-4.1.4 which requires a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. This deficient practice could affect all residents if the sprinkler system had to be shut down because a proper sprinkler wasn't available as a replacement.

Findings include:

Based on observation with Maintenance Director #1 on 04/15/15 at 1:25 p.m., there were green glass bulb sprinkler heads in the 100 unit basement boiler room. At the time of observation, Maintenance Director #1 acknowledged there were no green glass bulb sprinkler heads in the spare sprinkler cabinet .

Based on observation and interview, the facility failed to ensure 1 of 2 fire extinguishers in the 100 unit was readily accessible at all times. NFPA 10, Standard for Portable Fire Extinguishers, Section 1-6.3 requires that fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. This deficient practice could affect any of the 11 patients in the 100 unit.

Findings include:

Based on observation with the CEO, Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 from 12:05 p.m. to 12:10 p.m., the fire extinguishers in the 100 unit were in locked wall mounted cabinets. Based on interview with Maintenance Director #2 at the time of observation, all staff members were supposed to be provided with the key. Based on an interview at 12:10 p.m., RN#1 stated she did not have a key to the fire extinguisher cabinets.

Based on observation and interview, the facility failed to enforce 1 of 1 smoking policies for the facility. This deficient practice could affect any occupants evacuated through the back exits from both the 100 unit and the 200 unit near the emergency generators.

Findings include:

Based on an observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 from 12:35 p.m. to 12:36 p.m., the grassy area around both emergency generators was littered with cigarette butts. Based on an interview with Maintenance Director #1 at the time of observation, the entire campus is designated smoke free.

Based on observation and interview, the facility failed to ensure 1 of 1 exterior oxygen supply storage locations was protected from the weather. NFPA 99, 4-3.5.2.2 requires cylinders stored in the open shall be protected against extremes of weather. During winter, cylinders stored in the open shall be protected from against an accumulation of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail. This deficient practice could affect all occupants evacuated through both back exits.

Findings include:

Based on observation with Maintenance Director #1 on 04/15/15 at 2:40 p.m., two large liquid oxygen containers, approximately 5 feet tall, were located in a chain link enclosure near the Caterpillar emergency generator. The chain link enclosure did not offer protection from sun, snow, or rain. Maintenance Director #1 agreed at the time of observation, the liquid oxygen containers were exposed to all types of weather conditions.

1. Based on observation and interview, the facility failed to ensure the penetration in 1 of 1 basement fire barrier walls was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.2.3.2.4.2 requires pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet on of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
This deficient practice was not in a patient care area but could affect both basement smoke compartments.

Findings include:

Based on an observation with Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 at 4:35 p.m., at the basement two hour fire barrier doors above the ceiling tile there was an unsealed penetration measuring one inch around a conduit and a one and one half inch unsealed penetration around a sprinkler line. The Compliance Specialist confirmed the wall was a two hour fire barrier wall at the time of observation.

2. Based on observation and interview, the facility failed to ensure the water heaters in 1 of 2 basement boiler/water heater rooms had a current inspection certificate to ensure the water heaters were in safe operating condition. NFPA 101, in 19.1.1.3 requires all health facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of residents. This deficient practice was not in a resident care area but could affect any number of staff in the basement.

Findings include:

Based on observation with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 at 5:30 p.m., the basement water heater with the state registration number 318523 lacked a Certificate of Inspection. Based on an interview with Maintenance Director #1 and Maintenance Director #2 at the time of observation, they were unable to provide documentation to confirm the aforementioned water heater had been inspected and had a Certificate of Inspection.

Based on observation and interview, the facility failed to maintain 1 of 1 master alarm panels in the 100 unit. This deficient practice could affect 15 patients in the 100 unit.

Findings include:

Based on observation with CEO, Maintenance Director #1, Maintenance Director #2 and the Compliance Specialist on 04/15/15 at 12:20 p.m., the master alarm panel in the 100 unit was not operational. Based on an interview with Maintenance Director #2 at the time of observation, the facility is waiting for a service company from Indianapolis to make the necessary repairs.

Based on observation and interview, the facility failed to ensure the alternate source of power from the 1 of 2 emergency generators was capable of automatically connecting to the load within 10 seconds in the event of failure of normal power. NFPA 99, the Standard for Health Care Facilities, Nursing Home requirements requires essential electrical distribution systems to conform to Type 2 systems as described in Chapter 3 of NFPA 99. NFPA 99, 3-6.3.1.2 requires the emergency system to be arranged so that, in the event of failure of the normal power source, the alternate source of power will automatically connect to the load within 10 seconds. This deficient practice could affect all occupants in the 100 unit in that it could not be assured all patients were safeguarded by the facility with a generator that could operate under load conditions when needed during a power failure.

Findings include:

Based on observation with Maintenance Director #1 and Maintenance Director #2 on 04/15/15 from 12:40 p.m. to 12:50 p.m., the Onan emergency generator failed to start with the transfer switch after two attempts. Based on an interview with Maintenance Director at the time of observation, he was able to manually start the generator and then start the generator with the transfer switch. He stated a relay could have been stuck.

Based on observation and interview, the facility failed to ensure 8 of 8 flexible cords such as extension cord power strips, 2 of 2 multiplug adapters and 1 of 1 extension cords were not used as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice was not in a patient care area but could affect staff.

Findings include:

Based on an observation and interview on 04/15/15 from 1:49 p.m. to 3:17 p.m., Maintenance Director #1 and Maintenance Director #2 acknowledged the following:
a) three extension cord power strips were plugged together and providing power to computer equipment and a copier in the Pharmacy
b) an extension cord was plugged in and continued up through the ceiling in the basement IT room
c) a multiplug adaptor was plugged in and providing power to an extension cord power strip which was plugged in and providing power another extension cord power strip which was providing power to IT equipment in the basement IT room
d) a multiplug adaptor was plugged in and providing power to an extension cord power strip which was providing power to an electric air freshener in the Discharge Planning office
e) an extension cord power strip was plugged in and providing power to another extension cord power strip which was providing power to telephone equipment in the telephone equipment closet on the second floor.