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Based on observation and interview, the facility failed to ensure 8 of 12 patient room corridor doors closed and latched into the door frame. This deficient practice could affect all patients.

Findings include:

Based on observations with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 from 1:20 p.m. to 1:28 p.m., the following patient room doors failed to latch into the door frame: 104, 105, 108, 109, 154, 160, 161 and 162. This was acknowledged by the Safety Manager at the time of observations.

Based on observation and interview, the facility failed to maintain the one hour enclosure surrounding 1 of 1 elevators and 1 of 1 stairways. This deficient practice could affect any patient or staff using the elevator or stairway in the event of an emergency.

Findings include:

Based on observations with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 from 2:16 p.m. to 2:18 p.m., the walls surrounding the elevator shaft and stairway were constructed of concrete blocks. The following unsealed penetrations were observed:
a) in the basement elevator enclosure there was a one fourth inch gap around a conduit and a two inch gap around a sprinkler line.
b) in the basement stairway enclosure there was a one half inch gap around a conduit and a two and one half inch gap around a sprinkler line.
Measurements were provided by the Safety Manager at the time of observations.

1. Based on observation and interview, the facility failed to ensure 2 of 4 exit doors equipped with a magnetic locking system remained unlocked with activation of the building fire protective signaling system. LSC 18.2.1 requires every corridor and exit be in compliance with Chapter 7. LSC 7.2.1.6.1.(a) requires actuation of the fire alarm system shall unlock any doors equipped with approved, listed delayed egress locks in accordance with section 9.6. LSC 9.6.5.2(5) requires the unlocking of the doors with actuation of the fire alarm system. Doors should not relock when the audible alarms are silenced since the rest of the system is still actuated. This deficient practice could affect all patients evacuated through the administration area in the event of an emergency.

Findings include:

Based on observations with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 2:30 p.m., the two front administration exit doors, which were equipped with a magnetic locking system, failed to unlock and remain unlocked when the fire alarm system was activated and then placed in silence mode. This was acknowledged by the Safety Manager at the time of observations.

2. Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 5 main floor exits and 2 of 4 basement exits were readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires the means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affects all patients evacuated through the southeast upper level exit and all patients evacuated through the northeast basement and patio basement exits in the event of an emergency.

Findings include:

Based on observations with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 from 1:35 p.m. to 2:05 p.m., the following exits were not provided an exit discharge which could be maintained during periods of heavy snow or drenching rains:
a) the southeast upper level exit door exited onto an exterior stairway then continued across a stretch of grassy lawn measuring forty five feet to the public way. The grassy surface could not be kept clear and level in the event of snow and/or rain.
b) both the basement northeast exit and the patio exit continued from a concrete slab across a grassy lawn measuring thirty five feet to the public way. The grassy surface could not be kept clear and level in the event of snow and/or rain.
Measurements were provided by the Safety Manager at the time of observations.

Based on observation and interview, the facility failed to ensure 1 of 4 exit doors from the basement had a clear width no less than 32 inches wide. LSC 18.2.3.5 requires the clear width of doors in the means of egress from psychiatric hospitals shall be no less than 32 inches. This deficient practice could affect any patients due to the location of the basement tornado shelter and the basement classroom.

Findings include:

Based on observation with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 2:15 p.m., the north east exit door had a noticeably smaller opening then the other exit doors. Measurements taken by the Safety Manager confirmed the exit door opening clear width was thirty inches.

Based on observation and record review, the facility failed to ensure 3 of 3 emergency lights were tested annually for at least a 1 1/2 hour duration in accordance with LSC 7.9. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment, requires an annual test shall be conducted on every required battery powered emergency light for not less than 1 ? hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the stairway in the event of an emergency.

Findings include:

Based on observation with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 12:10 p.m., three battery operated emergency light were observed in the stairway. During record review with the Safety Manager at 12:10 a.m., a written record of an annual test regarding the battery operated emergency lights was not available review.

Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times for 4 of 4 quarters. This deficient practice affects all occupants.

Findings include:

Based on review of the "Bowen Center Fire Drill Evaluation" forms with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 11:30 a.m., all second shift fire drills took place between 3:01 p.m. and 3:30 p.m. for four of the last four quarters. This was acknowledged by the Safety Manager at the time of record review.

Based on observation and interview, the facility failed to ensure 1 of 1 PIV (post indicator valves) was electronically supervised. This deficient practice affects all occupants.

Findings include:

Based on observation with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 12:55 p.m., the PIV was locked in the open position with a pad lock. No electronic tamper device was observed on the PIV. This was acknowledged by the Safety Manager at the time of observation.

Based on observation and interview, the facility failed to protect 1 of 1 laundry chutes in accordance with 9.5. Section 9.5 requires laundry chutes shall be separately enclosed by walls or partitions in accordance with Section 8.2. Section 8.2 requires vertical openings (shafts) that do not extend to the bottom or the top of the building or structure shall be enclosed at the lowest or highest level of the shaft, respectively, with construction in accordance with 8.2.5.4. Exception: Shafts shall be permitted to terminate in a room or space having a use related to the purpose of the shaft, provided that room or space is separated from the reminder of the building by construction have a fire resistance rating and opening protection in accordance with 8.2.5.4 and 8.2.3.2.3. Section 8.2.5.4 states new construction have a 1 hour fire barrier. This deficient practice affects any patients, clients and staff in the basement in the event of an emergency.

Findings include:

Based on observation with the Safety Manager, Risk Manager and Director of Nursing on 04/28/11 at 1:45 p.m., the laundry chute was open at the ceiling of the basement. A tube continued into the basement laundry room dumping into a laundry bin. The walls for the basement laundry room did not extend to the floor above. The Safety Manager acknowledged the open laundry chute and lack of walls extending to the ceiling at the time of observation.

1. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observations with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 during a tour of the facility from 12:10 p.m. to 2:30 p.m., the facility did not have a remote manual stop for the emergency generator. Based on an interview with the Safety Manager at 2:20 p.m., the generator was installed in 2007.

2. Based on observation, interview and record review; the facility failed to ensure the off site fuel source for 1 of 1 emergency generators was from a reliable source. NFPA 110 1999 Edition, Standard for Emergency and Standby Power Systems, Chapter 3, Emergency Power Supply (EPS), 3-1.1 Energy Sources states the following energy sources shall be permitted for use for the emergency power supply (EPS):
a) Liquid petroleum products at atmospheric pressure
b) Liquifed petroleum gas (liquid or vapor withdrawal)
c) Natural or synthetic gas
Exception: For Level 1 installations in locations where the probability of interruption of off-site fuel supplies is high (e.g., due to earthquake, flood damage or demonstrated utility unreliability), on-site storage of an alternate energy source sufficient to allow full output of the emergency power supply system (EPSS) to be delivered for the class specified shall be required, with the provision for automatic transfer from the primary energy source to the alternate energy source.
CMS (Centers for Medicare/Medicaid Services) requires a letter of reliability from the natural gas vendor regarding the fuel supply that must contain the following:
1. A statement of reasonable reliability of the natural gas delivery.
2. A brief description that supports the statement regarding the reliability.
3. A statement that there is a low probability of interruption of the natural gas.
4. A brief description that supports the statement regarding the low probability of interruption,
5. The signature of a technical person from the natural gas provider.
This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on observation with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 2:20 p.m., the fuel source for the emergency generator was natural gas. Based on record review at 11:45 a.m. on 04/28/11, the facility did have a letter from their natural gas provider (NIPSCO) dated June 19, 2008 but the letter did not include all the items above required for a letter confirming the reliability of a natural gas fuel source for an emergency generator. The letter lacked supporting statements of reliability of natural gas and low probability of interruption of the natural gas service. This was acknowledged by the Safety Manager during the time of record review.

Based on observation and interview, the facility failed to ensure 8 of 12 patient room corridor doors closed and latched into the door frame. This deficient practice could affect all patients.

Findings include:

Based on observations with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 from 1:20 p.m. to 1:28 p.m., the following patient room doors failed to latch into the door frame: 104, 105, 108, 109, 154, 160, 161 and 162. This was acknowledged by the Safety Manager at the time of observations.

Based on observation and interview, the facility failed to maintain the one hour enclosure surrounding 1 of 1 elevators and 1 of 1 stairways. This deficient practice could affect any patient or staff using the elevator or stairway in the event of an emergency.

Findings include:

Based on observations with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 from 2:16 p.m. to 2:18 p.m., the walls surrounding the elevator shaft and stairway were constructed of concrete blocks. The following unsealed penetrations were observed:
a) in the basement elevator enclosure there was a one fourth inch gap around a conduit and a two inch gap around a sprinkler line.
b) in the basement stairway enclosure there was a one half inch gap around a conduit and a two and one half inch gap around a sprinkler line.
Measurements were provided by the Safety Manager at the time of observations.

1. Based on observation and interview, the facility failed to ensure 2 of 4 exit doors equipped with a magnetic locking system remained unlocked with activation of the building fire protective signaling system. LSC 18.2.1 requires every corridor and exit be in compliance with Chapter 7. LSC 7.2.1.6.1.(a) requires actuation of the fire alarm system shall unlock any doors equipped with approved, listed delayed egress locks in accordance with section 9.6. LSC 9.6.5.2(5) requires the unlocking of the doors with actuation of the fire alarm system. Doors should not relock when the audible alarms are silenced since the rest of the system is still actuated. This deficient practice could affect all patients evacuated through the administration area in the event of an emergency.

Findings include:

Based on observations with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 2:30 p.m., the two front administration exit doors, which were equipped with a magnetic locking system, failed to unlock and remain unlocked when the fire alarm system was activated and then placed in silence mode. This was acknowledged by the Safety Manager at the time of observations.

2. Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 5 main floor exits and 2 of 4 basement exits were readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires the means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affects all patients evacuated through the southeast upper level exit and all patients evacuated through the northeast basement and patio basement exits in the event of an emergency.

Findings include:

Based on observations with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 from 1:35 p.m. to 2:05 p.m., the following exits were not provided an exit discharge which could be maintained during periods of heavy snow or drenching rains:
a) the southeast upper level exit door exited onto an exterior stairway then continued across a stretch of grassy lawn measuring forty five feet to the public way. The grassy surface could not be kept clear and level in the event of snow and/or rain.
b) both the basement northeast exit and the patio exit continued from a concrete slab across a grassy lawn measuring thirty five feet to the public way. The grassy surface could not be kept clear and level in the event of snow and/or rain.
Measurements were provided by the Safety Manager at the time of observations.

Based on observation and interview, the facility failed to ensure 1 of 4 exit doors from the basement had a clear width no less than 32 inches wide. LSC 18.2.3.5 requires the clear width of doors in the means of egress from psychiatric hospitals shall be no less than 32 inches. This deficient practice could affect any patients due to the location of the basement tornado shelter and the basement classroom.

Findings include:

Based on observation with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 2:15 p.m., the north east exit door had a noticeably smaller opening then the other exit doors. Measurements taken by the Safety Manager confirmed the exit door opening clear width was thirty inches.

Based on observation and record review, the facility failed to ensure 3 of 3 emergency lights were tested annually for at least a 1 1/2 hour duration in accordance with LSC 7.9. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment, requires an annual test shall be conducted on every required battery powered emergency light for not less than 1 ? hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the stairway in the event of an emergency.

Findings include:

Based on observation with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 12:10 p.m., three battery operated emergency light were observed in the stairway. During record review with the Safety Manager at 12:10 a.m., a written record of an annual test regarding the battery operated emergency lights was not available review.

Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times for 4 of 4 quarters. This deficient practice affects all occupants.

Findings include:

Based on review of the "Bowen Center Fire Drill Evaluation" forms with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 11:30 a.m., all second shift fire drills took place between 3:01 p.m. and 3:30 p.m. for four of the last four quarters. This was acknowledged by the Safety Manager at the time of record review.

Based on observation and interview, the facility failed to ensure 1 of 1 PIV (post indicator valves) was electronically supervised. This deficient practice affects all occupants.

Findings include:

Based on observation with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 12:55 p.m., the PIV was locked in the open position with a pad lock. No electronic tamper device was observed on the PIV. This was acknowledged by the Safety Manager at the time of observation.

Based on observation and interview, the facility failed to protect 1 of 1 laundry chutes in accordance with 9.5. Section 9.5 requires laundry chutes shall be separately enclosed by walls or partitions in accordance with Section 8.2. Section 8.2 requires vertical openings (shafts) that do not extend to the bottom or the top of the building or structure shall be enclosed at the lowest or highest level of the shaft, respectively, with construction in accordance with 8.2.5.4. Exception: Shafts shall be permitted to terminate in a room or space having a use related to the purpose of the shaft, provided that room or space is separated from the reminder of the building by construction have a fire resistance rating and opening protection in accordance with 8.2.5.4 and 8.2.3.2.3. Section 8.2.5.4 states new construction have a 1 hour fire barrier. This deficient practice affects any patients, clients and staff in the basement in the event of an emergency.

Findings include:

Based on observation with the Safety Manager, Risk Manager and Director of Nursing on 04/28/11 at 1:45 p.m., the laundry chute was open at the ceiling of the basement. A tube continued into the basement laundry room dumping into a laundry bin. The walls for the basement laundry room did not extend to the floor above. The Safety Manager acknowledged the open laundry chute and lack of walls extending to the ceiling at the time of observation.

1. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observations with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 during a tour of the facility from 12:10 p.m. to 2:30 p.m., the facility did not have a remote manual stop for the emergency generator. Based on an interview with the Safety Manager at 2:20 p.m., the generator was installed in 2007.

2. Based on observation, interview and record review; the facility failed to ensure the off site fuel source for 1 of 1 emergency generators was from a reliable source. NFPA 110 1999 Edition, Standard for Emergency and Standby Power Systems, Chapter 3, Emergency Power Supply (EPS), 3-1.1 Energy Sources states the following energy sources shall be permitted for use for the emergency power supply (EPS):
a) Liquid petroleum products at atmospheric pressure
b) Liquifed petroleum gas (liquid or vapor withdrawal)
c) Natural or synthetic gas
Exception: For Level 1 installations in locations where the probability of interruption of off-site fuel supplies is high (e.g., due to earthquake, flood damage or demonstrated utility unreliability), on-site storage of an alternate energy source sufficient to allow full output of the emergency power supply system (EPSS) to be delivered for the class specified shall be required, with the provision for automatic transfer from the primary energy source to the alternate energy source.
CMS (Centers for Medicare/Medicaid Services) requires a letter of reliability from the natural gas vendor regarding the fuel supply that must contain the following:
1. A statement of reasonable reliability of the natural gas delivery.
2. A brief description that supports the statement regarding the reliability.
3. A statement that there is a low probability of interruption of the natural gas.
4. A brief description that supports the statement regarding the low probability of interruption,
5. The signature of a technical person from the natural gas provider.
This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on observation with the Safety Manager, Risk Manager and the Director of Nursing on 04/28/11 at 2:20 p.m., the fuel source for the emergency generator was natural gas. Based on record review at 11:45 a.m. on 04/28/11, the facility did have a letter from their natural gas provider (NIPSCO) dated June 19, 2008 but the letter did not include all the items above required for a letter confirming the reliability of a natural gas fuel source for an emergency generator. The letter lacked supporting statements of reliability of natural gas and low probability of interruption of the natural gas service. This was acknowledged by the Safety Manager during the time of record review.