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Based on observation and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers on the first floor were maintained to provide the fire resistance rating of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect 16 patients, staff and visitors in the vicinity of the Phone Room adjacent to Unit 6.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, one four inch in diameter conduit and four one inch in diameter conduits which contained cables and penetrated the ceiling of the Phone Room adjacent to Unit 6 were each firestopped or sealed with expandable foam. Based on interview at the time of observation, the Director of Plant Operations acknowledged the aforementioned conduits which penetrated the ceiling of the Phone Room adjacent to Unit 6 were each firestopped or sealed with expandable foam and lacked documentation demonstrating the expandable foam was an approved material for maintaining the smoke resistance of a smoke barrier.

Based on observation and interview, the facility failed to ensure 2 of 7 doors serving hazardous areas such as combustible storage rooms over fifty square feet in size were provided with self closing devices. This deficient practice could affect 2 staff and visitors.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, the Medical Supply Room on Unit 4 and the Nursing Storage Room each measured greater than fifty feet in size but less was one hundred feet in size and were being utilized to store combustible supplies, boxes and mattresses. The entry door to each of the aforementioned hazardous area storage rooms was not provided with a self closing device. Based on interview at the time of the observations, the Director of Plant Operations acknowledged the entry door to each of the aforementioned hazardous area storage rooms was not provided with a self closing device.

Based on record review, observation and interview; the facility failed to include the use of kitchen K class fire extinguishers in 1 of 1 written fire safety plans for the facility. LSC 18.7.2.2 requires written health care occupancy fire safety plans shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice affects five staff and visitors in the vicinity of the kitchen.

Findings include:

Based on review of "EOC Policy & Procedure Manual: Fire Response Plan" documentation with the Director of Plant Operations during record review from 9:15 a.m. to 12:15 p.m. on 02/05/15, the facility's written fire safety plan did not address the use of the K class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system. Based on interview at the time of record review, the Director of Plant Operations acknowledged the written fire safety plan for the facility did not include the policy to activate the overhead hood extinguishing system to suppress a fire before using a K class fire extinguisher. Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, one K class fire extinguisher was observed installed in the kitchen.

Based on observation and interview, the facility failed to install 3 of 113 smoke detectors in accordance with NFPA 72. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, smoke detectors shall not be located where airflow prevents operation of the detectors. NFPA 72, A-2-3.5.1 explains smoke detectors should not be located in a direct airflow nor closer than 3 feet from an air supply diffuser or return air opening. This deficient practice could affect 2 residents, staff and visitors.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, the following smoke detector locations on the ceiling were each installed less than three feet from air handling systems:
a. in the main lobby one foot from a supply vent.
b. in the Main Server Room six inches from a ceiling mounted forced air heating unit.
c. in the corridor outside the Medical Record Storage Room six inches from a return vent.
Based on interview at the time of the observations, the Director of Plant Operations acknowledged the aforementioned smoke detectors were installed on the ceiling less than three feet from air handling systems.

Based on observation and interview, the facility failed to replace 2 of over 100 sprinklers in the facility which had become corroded, had paint, lint or other foreign materials on them. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected, tested 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 could affect 2 staff and visitors in the vicinity of the loading dock.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, two of four sidewall sprinklers installed at the outdoor loading dock had become green with corrosion and were in need of replacement. Based on interview at the time of observation, the Director of Plant Operations acknowledged the aforementioned automatic sprinklers had become green with corrosion.

Based on observation and interview, the facility failed to ensure cigarette butts were deposited into a noncombustible container with a self closing lid at 1 of 2 outside areas where smoking was permitted. This deficient practice could affect 2 staff and visitors in the vicinity of the loading dock.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, the staff smoking area located outside the building at the loading dock had in excess of 50 extinguished cigarette butts deposited into each of two ashtrays mounted on top of a plastic trash can. A noncombustible container with a self closing cover device into which ashtrays can be emptied was not provided in this area where staff smoking was permitted. Based on interview at the time of observation, the Director of Plant Operations acknowledged a noncombustible ashtray and metal container with a self closing cover device into which ashtrays can be emptied was not provided at the aforementioned outside smoking area.

Based on record review, observation and interview; the facility failed to ensure 1 of 20 fire dampers in the ductwork were provided necessary maintenance at least every 6 years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork (HVAC) and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 6 years in hospitals, fusible links (where applicable) shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all residents, staff and visitors.

Findings include:

Based on review of "Fire/Smoke Damper Maintenance Record" documentation dated 03/24/14 with the Director of Plant Operations from 9:15 a.m. to 12:15 a.m. on 02/05/15, the fire damper listed as "1H" was stated as "propped open, needs bus link" as the result of the most recent documented facility fire damper inspection and maintenance. Based on interview at the time of record review, the Director of Plant Operations stated no additional fire damper inspection and maintenance documentation was available for review. Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, the shutter for the fire damper in the HVAC system above the ceiling of the Clean Utility Room by the kitchen had been released and was in the fully closed position. No fusible link was in place to ensure the fire damper was being properly maintained. Based on interview at the time of observation, the Director of Plant Operations stated the aforementioned fire damper is identified as "1H" and acknowledged no fusible link was in place to ensure it was being properly maintained.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period in order to protect 28 of 28 residents. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "EOC Policy & Procedure Manual: Fire Sprinkler System" documentation with the Director of Plant Operations during record review from 9:15 a.m. to 12:15 p.m. on 02/05/15, the fire watch policy did not include notification of the Indiana State Department of Health, local fire department, the insurance carrier, alarm company and the building owner in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period. A review of "EOC Policy & Procedure Manual: Fire Alarm System Failure" documentation noted the automatic sprinkler system was not expressly stated as a component of the facility fire alarm system and, therefore, not part of sprinkler impairment procedures upon fire alarm system failure. Based on interview at the time of record review, the Maintenance Director stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include notification of the Indiana State Department of Health, local fire department, the insurance carrier, alarm company and the building owner in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period.

Based on record review and interview, the facility failed to provide a complete written policy containing 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 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 28 of 28 residents. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "EOC Policy & Procedure Manual: Fire Alarm System Failure" documentation with the Director of Plant Operations during record review from 9:15 a.m. to 12:15 p.m. on 02/05/15, the fire watch policy did not include notification of the Indiana State Department of Health in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period. Based on interview at the time of record review, the Director of Plant Operations stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include notification of the Indiana State Department of Health in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period.

Based on observation and interview, the facility failed to ensure the elevator equipment in 1 of 1 elevator equipment rooms which is sprinklered was provided with a shunt trip. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect two patients, staff and visitors in the elevator if the sprinkler system was activated in the elevator equipment room on the second floor.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, the elevator equipment room on the second floor was provided with a sprinkler head. No evidence of shunt trip installation, which is designed to automatically disconnect power to the affected elevator, was noted in the facility. Based on interview at the time of observation, the Director of Plant Operations stated he was unaware if a shunt trip had been installed in the aforementioned elevator equipment room.

Based on observation and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers on the first floor were maintained to provide the fire resistance rating of the smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect 16 patients, staff and visitors in the vicinity of the Phone Room adjacent to Unit 6.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, one four inch in diameter conduit and four one inch in diameter conduits which contained cables and penetrated the ceiling of the Phone Room adjacent to Unit 6 were each firestopped or sealed with expandable foam. Based on interview at the time of observation, the Director of Plant Operations acknowledged the aforementioned conduits which penetrated the ceiling of the Phone Room adjacent to Unit 6 were each firestopped or sealed with expandable foam and lacked documentation demonstrating the expandable foam was an approved material for maintaining the smoke resistance of a smoke barrier.

Based on observation and interview, the facility failed to ensure 2 of 7 doors serving hazardous areas such as combustible storage rooms over fifty square feet in size were provided with self closing devices. This deficient practice could affect 2 staff and visitors.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, the Medical Supply Room on Unit 4 and the Nursing Storage Room each measured greater than fifty feet in size but less was one hundred feet in size and were being utilized to store combustible supplies, boxes and mattresses. The entry door to each of the aforementioned hazardous area storage rooms was not provided with a self closing device. Based on interview at the time of the observations, the Director of Plant Operations acknowledged the entry door to each of the aforementioned hazardous area storage rooms was not provided with a self closing device.

Based on record review, observation and interview; the facility failed to include the use of kitchen K class fire extinguishers in 1 of 1 written fire safety plans for the facility. LSC 18.7.2.2 requires written health care occupancy fire safety plans shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice affects five staff and visitors in the vicinity of the kitchen.

Findings include:

Based on review of "EOC Policy & Procedure Manual: Fire Response Plan" documentation with the Director of Plant Operations during record review from 9:15 a.m. to 12:15 p.m. on 02/05/15, the facility's written fire safety plan did not address the use of the K class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system. Based on interview at the time of record review, the Director of Plant Operations acknowledged the written fire safety plan for the facility did not include the policy to activate the overhead hood extinguishing system to suppress a fire before using a K class fire extinguisher. Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, one K class fire extinguisher was observed installed in the kitchen.

Based on observation and interview, the facility failed to install 3 of 113 smoke detectors in accordance with NFPA 72. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, smoke detectors shall not be located where airflow prevents operation of the detectors. NFPA 72, A-2-3.5.1 explains smoke detectors should not be located in a direct airflow nor closer than 3 feet from an air supply diffuser or return air opening. This deficient practice could affect 2 residents, staff and visitors.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, the following smoke detector locations on the ceiling were each installed less than three feet from air handling systems:
a. in the main lobby one foot from a supply vent.
b. in the Main Server Room six inches from a ceiling mounted forced air heating unit.
c. in the corridor outside the Medical Record Storage Room six inches from a return vent.
Based on interview at the time of the observations, the Director of Plant Operations acknowledged the aforementioned smoke detectors were installed on the ceiling less than three feet from air handling systems.

Based on observation and interview, the facility failed to replace 2 of over 100 sprinklers in the facility which had become corroded, had paint, lint or other foreign materials on them. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected, tested 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 could affect 2 staff and visitors in the vicinity of the loading dock.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, two of four sidewall sprinklers installed at the outdoor loading dock had become green with corrosion and were in need of replacement. Based on interview at the time of observation, the Director of Plant Operations acknowledged the aforementioned automatic sprinklers had become green with corrosion.

Based on observation and interview, the facility failed to ensure cigarette butts were deposited into a noncombustible container with a self closing lid at 1 of 2 outside areas where smoking was permitted. This deficient practice could affect 2 staff and visitors in the vicinity of the loading dock.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, the staff smoking area located outside the building at the loading dock had in excess of 50 extinguished cigarette butts deposited into each of two ashtrays mounted on top of a plastic trash can. A noncombustible container with a self closing cover device into which ashtrays can be emptied was not provided in this area where staff smoking was permitted. Based on interview at the time of observation, the Director of Plant Operations acknowledged a noncombustible ashtray and metal container with a self closing cover device into which ashtrays can be emptied was not provided at the aforementioned outside smoking area.

Based on record review, observation and interview; the facility failed to ensure 1 of 20 fire dampers in the ductwork were provided necessary maintenance at least every 6 years in accordance with NFPA 90A. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork (HVAC) and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 1999 Edition, 3.4.7, Maintenance, requires at least every 6 years in hospitals, fusible links (where applicable) shall be removed; all dampers shall be operated to verify they fully close; the latch, if provided, shall be checked, and moving parts shall be lubricated as necessary. This deficient practice affects all residents, staff and visitors.

Findings include:

Based on review of "Fire/Smoke Damper Maintenance Record" documentation dated 03/24/14 with the Director of Plant Operations from 9:15 a.m. to 12:15 a.m. on 02/05/15, the fire damper listed as "1H" was stated as "propped open, needs bus link" as the result of the most recent documented facility fire damper inspection and maintenance. Based on interview at the time of record review, the Director of Plant Operations stated no additional fire damper inspection and maintenance documentation was available for review. Based on observation with the Director of Plant Operations during a tour of the facility from 1:20 p.m. to 3:20 p.m. on 02/05/15, the shutter for the fire damper in the HVAC system above the ceiling of the Clean Utility Room by the kitchen had been released and was in the fully closed position. No fusible link was in place to ensure the fire damper was being properly maintained. Based on interview at the time of observation, the Director of Plant Operations stated the aforementioned fire damper is identified as "1H" and acknowledged no fusible link was in place to ensure it was being properly maintained.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period in order to protect 28 of 28 residents. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "EOC Policy & Procedure Manual: Fire Sprinkler System" documentation with the Director of Plant Operations during record review from 9:15 a.m. to 12:15 p.m. on 02/05/15, the fire watch policy did not include notification of the Indiana State Department of Health, local fire department, the insurance carrier, alarm company and the building owner in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period. A review of "EOC Policy & Procedure Manual: Fire Alarm System Failure" documentation noted the automatic sprinkler system was not expressly stated as a component of the facility fire alarm system and, therefore, not part of sprinkler impairment procedures upon fire alarm system failure. Based on interview at the time of record review, the Maintenance Director stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include notification of the Indiana State Department of Health, local fire department, the insurance carrier, alarm company and the building owner in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period.

Based on record review and interview, the facility failed to provide a complete written policy containing 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 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 28 of 28 residents. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "EOC Policy & Procedure Manual: Fire Alarm System Failure" documentation with the Director of Plant Operations during record review from 9:15 a.m. to 12:15 p.m. on 02/05/15, the fire watch policy did not include notification of the Indiana State Department of Health in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period. Based on interview at the time of record review, the Director of Plant Operations stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include notification of the Indiana State Department of Health in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period.