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1. Based on observation and interview, the facility failed to ensure the communicating opening was maintained in 1 of 1 fire barriers in the tenant separation walls on the third floor. LSC 18.1.1.4.2 refers to LSC 8.2. LSC 8.2.3.2.3.1 requires every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Openings in a two hour fire wall are required to have a one and one half fire protection rating. LSC 8.2.3.2.1 states door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with NFPA 80, Standard for Fire Doors and Fire Windows. NFPA 80, 1999 edition, section 2-1.4 states all swinging doors shall be closed and latched at the time of fire. This deficient practice could affect visitors, staff and 13 patients, staff and visitors in the vicinity of the third floor walkway to the Professional Office Building (POB).

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, the set of wood corridor doors in the tenant separation wall at the third floor walkway to the POB had no affixed fire resistance rating and were not equipped with a latching mechanism to latch the door set into the door frame. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned corridor door set in the tenant separation fire barrier did not maintain the fire resistance rating of the fire barrier and did not latch into the door frame.

2. Based on record review, observation and interview, the facility failed to ensure the communicating opening was maintained in 1 of 6 fire barriers on the fourth floor. LSC 18.1.1.4.2 refers to LSC 8.2. LSC 8.2.3.2.3.1 requires every opening in a fire barriers shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Openings in a two hour fire wall are required to have a one and one half fire protection rating. LSC 8.2.3.2.1 states door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with NFPA 80, Standard for Fire Doors and Fire Windows. NFPA 80, 1999 edition, section 2-1.4 states all swinging doors shall be closed and latched at the time of fire. This deficient practice could affect visitors, staff and 23 patients, staff and visitors in the vicinity of the corridor door set by Room 4178 on the fourth floor.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, the set of corridor doors in the fire barrier wall by Room 4178 had a 90 minute fire resistant label affixed to each door and were each equipped with a latching mechanism to latch each door into the door frame but the north door latching mechanism failed to protrude into the latching plate. Based on interview at the time of the observations, the Facility Manager acknowledged the north door in the aforementioned corridor door set did not latch into the door frame. Based on review of facility blueprint information with the Director at 10:30 a.m. on 06/09/16, the fire barrier wall by Room 4178 in which the aforementioned communicating opening door set was installed had a fire resistance rating of two hours.

Based on observation and interview, the facility failed to provide documentation of the flame spread rating for interior finish materials installed in 1 of over 15 rooms. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the electrical room which contains the second automatic transfer switch for the facility had no ceiling which exposed the wood framing in the attic above. In addition, wood particle board was used as an interior finish in the room on each of the four walls of the room from the floor up to where the attic above began in the room. Based on interview at the time of observation, the RNS and the Maintenance Director stated she was unaware of the wood paneling being treated with flame retardant material and acknowledged flame spread rating documentation for the wood particle board in the aforementioned electrical room was not available for review.

1. Based on observation and interview, the facility failed to ensure 7 of over 25 open use areas were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception. LSC 19.3.6.1, Exception #1: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system shall be permitted to have spaces unlimited in size open to the corridor, provided the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, or the smoke compartment in which the space is located is protected throughout by quick response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. This deficient practice could affect over 50 patients, as well as staff and visitors while in any of these open areas.

Findings include:

Based on observations on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities and the Facilities Manager, the Union West Admitting area, the Wound Care Waiting area, the Work Room in PEDS, the three 5th floor Union West Sub Nurses' Stations (no longer in use as Nurses' Stations), and the 5th floor Union West Waiting area, were open to the corridor. Exception #1 requirement (c) of LSC 19.3.6.1 was not met as follows: The Union West Admitting area, the Wound Care Waiting area, the Work Room in PEDS, the three 5th floor Union West Sub Nurses' Stations (no longer in use as Nurses' Stations), and the 5th floor Union West Waiting area were not protected by an electrically supervised automatic smoke detection system, or the entire space was not arranged and located to allow direct supervision by the facility staff from the nurses' station or similar staffed space. This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation.

2. Based on observation and interview, the facility failed to ensure 3 of over 100 offices were separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building or met an Exception. LSC 19-3.6.1, Exception # 6, Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas may be open to the corridor and unlimited in area provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, and (b) Each space is protected by an automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. This deficient practice could affect patients, staff and visitors outside room 317 on the 3rd floor Union West, the empty office at C Wing on 5th floor Union West, and the Security Office 5th floor Union West.

Findings include:

Based on an observations with the Director of Facilities and the Facilities Manager on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility, the following was observed:
A. Union West room 317 office had a 3 ft. by 3 ft. sliding glass window with a 1/2 inch gap between the window panes when closed
B. Union West empty office at C Wing on 5th floor had a 3 ft. by 3 ft. sliding glass window with a 1/2 inch gap between the window panes when closed
C. Union West Security Office on 5th floor had two, 2 1/2 ft. by 2 1/2 ft. sliding glass windows with 1/2 inch gaps between the window panes when closed
Exception # 6, requirement (a) of the LSC Section 19-3.6.1 was not met because the previously mentioned offices were not protected by an electrically supervised automatic smoke detection system. This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation, furthermore, the Director of Facilities said these offices were not 24 hour stations.

Based on observation and interview, the facility failed to ensure 1 of over 25 open use areas were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception. LSC 18-3.6.1, Exception # 1, Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas, and (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers, and (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space, and (d) The space does not obstruct access to required exits. This deficient practice could patients, staff and visitors while in the egress corridor outside the Satellite Cafe.

Findings include:

Based on observation on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, the Union East 1st floor Satellite Cafe was open to the corridor. Exception #1 requirement (c) of LSC 18.3.6.1 was not met as follows: The Union East 1st floor Satellite Cafe was not protected by an electrically supervised automatic smoke detection system, or the entire space was not arranged and located to allow direct supervision by the facility staff from nurses' stations or similar staffed space. This was acknowledged by the Director of Facilities at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of over 200 corridor doors would resist the passage of smoke. This deficient practice could affect 6 patients, staff and visitors in the vicinity of Room 135.

Findings include:

Based on observation with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, a one half inch hole was noted in the corridor door to Room B548 nearest the hinge side of the door which would not resist the passage of smoke. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned corridor door would not resist the passage of smoke.

Based on observation and interview, the facility failed to ensure 2 of 2 sets of double doors to the corridor on the third floor Union West PEDS were equipped with positive latches and latched into the door frame automatically. This deficient practice could affect patients, staff and visitors on the third floor.

Findings include:

Based on observations on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility with Director of Facilities and the Facilities Manager, the sets of double doors to the 3rd floor Union West PEDS storage closet and the 3rd floor Union West PEDS I.T. closet did not positive latch into their door frames automatically. The left side door at each set had to be manually latched at the top of the door. This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation.

Based on observation and interview, the facility failed to ensure 2 of 2 doors likely to be mistaken for a way of exit was identified as "No Exit". LSC 7.10.8.1 requires any door which is neither an exit nor a way of exit access and that is located or arranged so it is likely to be mistaken for an exit shall be identified by a sign that reads: NO EXIT. This deficient practice could affect any patient as well as visitors and staff using the Therapy Gym room.

Findings include:

Based on observations on 06/09/16 at 2:20 p.m. with the Plant Director, the two doors leading to the outside of the Therapy Gym room are identified with exit signs, but the exits discharge into an enclosed courtyard and not to a public way. Based on interview concurrent with the observations it was acknowledged the doors leading out of the Therapy Gym room could be mistaken for exits, but since they do not lead to a public way they should have NO EXIT signs posted to avoid any confusion.

Based on observation and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers was maintained to provide at least a one half hour fire resistance rating. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the following was noted:
a. the electrical room which contains the second automatic transfer switch for the facility had no ceiling which exposed the attic above.
b. the drink storage room was missing a one foot by one foot ceiling tile.
c. the sprinkler riser room was missing four ceiling tiles. Two of the missing tiles each caused an opening measuring four feet by two feet and the remaining two missing tiles each caused an opening measuring four feet by six inches.
Based on interview at the time of the observations, the (RNS) and the Maintenance Director acknowledged the aforementioned openings in the ceiling smoke barrier failed to provide at least a one half hour fire resistance rating.

Based on observation and interview, the facility failed to ensure 1 of 6 smoke barriers was protected to maintain the one half hour 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 be protected, so 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 any patients, visitors or staff near the electrical room on Center hall, if smoke from a fire were to infiltrate the protective barrier.

Findings include:

Based on observation on 06/09/16 at 1:00 p.m. with the Plant Director the ceiling in the Electrical room on Center hall had forty one metal conduits which penetrated the ceiling leaving one half to one inch gaps around the pipes which were not firestopped. Based on interview concurrent with the observation with the Plant Director, it was acknowledged the aforementioned smoke barrier ceiling had numerous openings which were not filled with a fire rated material to maintain a one half hour fire resistance rating.

Based on observation and interview, the facility failed to ensure 2 of over 50 hazardous area room doors to the corridor in the Union East Building, such as supply and Soiled Utility rooms, were equipped with positive latches that automatically latched into the door frames when closed or latches that were functioning properly. This deficient practice could affect patients, staff and visitors while in the vicinity of the Union East Surgery Supply Chain Room and the Union East 4th floor Soiled Utility/Biohazard room.

Findings include:

Based on observations on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, the corridor door to the Union East Surgery Supply Chain Room (B013) was not provided with a positive latch that automatically latched into the door frame when closed, furthermore, the corridor door to the Union East 4th floor Soiled Utility/Biohazard Room (B444) would not latch into the door frame when tested three times. This was acknowledged by the Director of Facilities at the time of each observation.

Based on observation and interview, it was determined the facility failed to provide adequate emergency task lighting for 1 of 4 outside exits. This deficient practice could affect all patients, staff and visitors using the West exit.

Findings include:

Based on observation on 06/09/16 at 2:00 p.m. with the Plant Director the exit located on the west side of the building was not provided with outdoor emergency lighting. Based on interview concurrent with the observation it was acknowledged the West exit lacked an outside emergency light.

Based on observation and interview, the facility failed to ensure a continuously illuminated exit sign, where the exit or way to reach the exit was not apparent, was provided for 1 of 1 ways of exit from the Emergency Department office hallway. LSC 18.2.10.1 refers to 7.10. LSC 7.10.1.4 requires access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not apparent to the occupants. This deficient practice could mostly staff in the Emergency Department office hallway.

Findings include:

Based on observation on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, there was no illuminated exit sign at the north end of the Emergency Department office hallway. This was acknowledged by the Director of Facilities at the time of observation.

Based on record review and interview, the facility failed to document a complete written health care occupancy fire safety plan for 2 of 2 plans which incorporated all items listed in NFPA 101, Section 18.7.2.2.
(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 all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of "Emergency Management" and "Safety Manual: Fire Safety-Evacuation of Patients" documentation with the Compliance/Risk Manager during record review at 11:30 a.m. on 06/07/16, neither written health care occupancy fire safety plan for the facility succinctly stated what procedures the facility would follow in the event of a fire. The written fire safety plans did not state the staff response to fire, the activation of the fire alarm system, the confinement of fire, the extinguishment of fire and the evacuation of affected smoke compartments (RACE) within the facility. Based on interview at the time of record review, the Compliance/Risk Manager stated the written fire safety plans are currently under review for possible revision and acknowledged neither written health care occupancy fire safety plan for the facility succinctly stated what procedures the facility would follow in the event of a fire.

Based on record review and interview, the facility failed to document a complete written health care occupancy fire safety plan for 2 of 2 plans which incorporated all items listed in NFPA 101, Section 19.7.2.2.
(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 all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of "Emergency Management" and "Safety Manual: Fire Safety-Evacuation of Patients" documentation with the Compliance/Risk Manager during record review at 11:30 a.m. on 06/07/16, neither written health care occupancy fire safety plan for the facility succinctly stated what procedures the facility would follow in the event of a fire. The written fire safety plans did not state the staff response to fire, the activation of the fire alarm system, the confinement of fire, the extinguishment of fire and the evacuation of affected smoke compartments (RACE) within the facility. Based on interview at the time of record review, the Compliance/Risk Manager stated the written fire safety plans are currently under review for possible revision and acknowledged neither written health care occupancy fire safety plan for the facility succinctly stated what procedures the facility would follow in the event of a fire.

Based on record review and interview, the facility failed to document fire drills conducted on the first shift for 4 of 4 quarters. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) and the Facility Maintenance Manager from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of a fire drills conducted on the first shift for the third quarter (July, August, September) 2015, the fourth quarter (October, November, December) 2015, the first quarter (January, February, March) 2016 and the second quarter (April, May, June) 2016 was not available for review. Based on interview at the time of record review, the RNS stated fire drill documentation is maintained by Union Hospital at the hospital location and acknowledged fire drill documentation for first shift fire drills for the aforementioned calendar quarters was not available for review. Based on record review with the Union Hospital Facilities Manager Assistant at 2:30 p.m. on 06/09/16, fire drill documentation for first shift fire drills for the aforementioned calendar quarters was not available for review.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control panels, located in an area that was not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. LSC 9.6.2.10 refers to NFPA 72, the National Fire Alarm Code. 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 patients, staff and visitors in the facility.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the facility's main fire alarm control panel was located in a first floor electrical room of the adjoining Providence Medical building which is not continuously occupied and was not provided with automatic smoke protection. Based on interview at the time of observation, the RNS and the Maintenance Director acknowledged the electrical room which contains the facility's main fire alarm control panel is not continuously occupied and was not provided with automatic smoke protection.

1. Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. NFPA 72, 7-3.2 requires testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. Table 7-3.2 shall apply. Table 7-3.2 "Testing Frequencies" requires alarm initiating devices, alarm notification appliances, batteries, and initiating devices to be tested at least annually. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) during record review from 10:25 a.m. to 10:40 a.m. on 06/09/16, fire alarm system testing documentation within the most recent twelve month period was not available for review. Based on interview at the time of record review, the RNS acknowledged fire alarm system testing documentation within the most recent twelve month period was not available for review.

2. Based on record review and interview, the facility failed to ensure all smoke detectors were maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. NFPA 72, 7-3.2 requires detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked); the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) during record review from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of smoke detector sensitivity testing within the most recent two year period was not available for review. Based on interview at the time of record review, the RNS acknowledged sensitivity testing documentation for all facility fire alarm system smoke detectors within the most recent two year period was not available for review.

Based on observation and interview, the facility failed to ensure 26 of over 500 smoke detectors in the Union East Building were not installed where air flow would adversely affect their operation. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect patients, staff and visitors throughout the facility.

Findings include:

Based on observations on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities and the Facilities Manager, the following was observed:
a. There were two ceiling mounted smoke detectors within one foot of air supply vents in the Union East Physicians Lounge.
b. There was a ceiling mounted smoke detector within one foot of an air supply vent in the entrance area of the Union East Visitor/Employee Dining Room.
c. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Surgery Center.
d. There were two ceiling mounted smoke detectors within one foot of an air supply vent and air return vent in the Union East Business Office Hall Surgery Center.
e. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Surgical corridor.
f. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Storage Room (E329).
g. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Soiled Utility Room (E333).
h. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Environmental Services Room (D315).
i. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Med Room (D342).
j. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Clean Utility Room (B252).
k. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 4th floor in room B456.
l. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 4th floor in room B432.
m. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 4th floor in room C441.
n. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 4th floor elevator machine room (D418).
o. There were two ceiling mounted smoke detectors within two feet of air supply vents in the Union East building 4th floor elevator machine room (B457).
p. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor break room (A344).
q. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor Men's Locker Room (A345).
r. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor Women's Locker Room (A345).
s. There was a ceiling mounted smoke detector within one foot of an air return vent in the Union East building 3rd floor Bluebird Closet (A343).
t. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor Supply/Equipment Storage Room (B356).
u. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor Clean Utility Room (D346).
v. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor Family Nourishment Room (E332).
w. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 2nd floor Consultation Room (A258).

This was acknowledged by the Director of Facilities and Facilities Manager at the time of each observation.

Based on observation and interview, the facility failed to ensure 3 of over 500 smoke detectors in the Union West Building were not installed where air flow would adversely affect their operation. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect mostly staff.

Findings include:

Based on observations on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities and the Facilities Manager, the following was observed:
a. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union West Microbiology Lab.
b. There were two ceiling mounted smoke detectors within one foot of air supply vents in the third floor Union West Supply Room.
This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system or alternative automatic extinguishing equipment was provided for 2 of 2 elevator machine rooms in this five story building of Type I (332) construction which is required to be fully sprinklered. This deficient practice could affect ten patients, staff and visitors.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, each of the two fourth floor elevator equipment rooms identified as Room B457 and Room D460 were not provided with sprinkler coverage or alternative automatic extinguishing equipment. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned fourth floor elevator machine rooms were not provided with sprinkler coverage or alternative automatic extinguishing equipment.

1. Based on observation and interview, the facility failed to ensure the ceiling in 1 of over 50 sprinklered smoke compartments were maintained to allow sprinkler heads to function to their full capability. This deficient practice could affect mostly staff in the Union East Decontamination Room.

Findings include:

Based on observation on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, the Union East Decontamination Room had 20 conduits and wire bundles with gaps of 1/4 inch to 1/2 inch through the ceiling which were not fire stopped.
This was acknowledged by the Director of Facilities at the time of observation.

2. Based on record review, observation and interview; the facility failed to ensure 1 of 1 automatic sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, four of four sprinkler gauges on the Helipad sprinkler system riser had a manufacture date of 2009. The sprinkler system gauge on sprinkler piping in the 4th Floor stairwell by the Helipad also had a manufacture date of 2009. In addition, the sprinkler system gauge on sprinkler piping in the Stairwell C exit stairwell by Room 3170 also had a manufacture date of 2009. Based on interview at the time of record review, the Facility Manager stated each of the aforementioned sprinkler systems gauges had been retested within the most recent five year period by comparison with a calibrated gauge, retesting documentation was available at the Facility Manager Office but acknowledged the retesting date was not affixed to each of the gauges. Based on record review with the Union Hospital Facilities Manager Assistant at 2:15 p.m. on 06/09/16, sprinkler system gauge retesting documentation within the most recent five year period was not available for review.

1. Based on record review, observation and interview; the facility failed to ensure quarterly sprinkler inspections were conducted for the sprinkler system for 3 of 4 calendar quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code to be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1-8 requires records of inspections and tests of the sprinkler system and its components shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Tri-State Fire Protection "Fire Sprinkler Inspection Report" documentation dated 12/12/15 with the Registered Nurse Supervisor (RNS) during record review from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of quarterly sprinkler inspection for the third quarter (July, August, September) 2015, the first quarter (January, February, March) 2016 and the second quarter (April, May, June) 2016 was not available for review. Based on observations with the RNS and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, hanging tags affixed to the sprinkler system riser by Tri-State to document sprinkler inspections did not indicate quarterly sprinkler inspections had been documented for the aforementioned three calendar quarters. Based on interview at the time of record review and of the observations, the RNS and the Maintenance Director acknowledged documentation of quarterly sprinkler inspection for the third quarter 2015 and the first and second quarter 2016 was not available for review.

2. Based on observation and interview, the facility failed to ensure 3 of over 10 sprinkler heads was maintained. NFPA 13, Standard for the Installation of Sprinkler Systems, Section 3-2.7.2 states escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the RNS and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the escutcheon plate was missing for the automatic sprinkler located in the instruction room. In addition, the piped gas system room had two automatic sprinkler locations each missing its escutcheon plate. Based on interview at the time of the observations, the RNS and the Maintenance Director acknowledged the escutcheon plate was missing for the aforementioned automatic sprinkler locations.

Based on observation, record review and interview, the facility failed to ensure 1 of gauges for the sprinkler system were continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on observation on 06/09/16 at 12:18 p.m. with the Plant Director one pressure gauge on the sprinkler riser system located in the Mechanical riser room had a manufacturer's date of 2006. Based on Sprinkler Inspection Records review on 06/09/16 at 01:45 p.m., documentation did not reveal the sprinkler system gauge had been calibrated or the date of installation. Based on interview concurrent with the observation it was acknowledged the pressure gauge had exceeded the five year calibration or replacement limit.

1. Based on observation and interview, the facility failed to ensure 5 of 5 fire extinguishers in the East Building MR Unit were maintained in accordance with NFPA 10. LSC 4.5.7 says whenever any device, equipment or system are required for compliance with provisions of this Code, such device, equipment or systems shall be thereafter maintained unless the Code exempts such maintenance. NFPA 10, 4-4.3 states every 6 years, stored pressure fire extinguishers that require a 12 year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. 4-4.4.2 states each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a "Verification of Service" collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch. 4-5.5 states each fire extinguisher shall have a tag or label securely attached that indicates the month and year recharging was performed and that identifies the person performing the services. A "Verification of Service" (maintenance or recharging) collar in accordance with 4-4.4.2 shall also be attached to the extinguisher. This deficient practice could affect patients, as well as staff and visitors while in the MR Unit.

Findings include:

Based on observations on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, 5 of 5 fire extinguishers (4 Water Based Fire Extinguishers and 1 ABC Fire Extinguisher) in the East Building MR Unit have not had their six year maintenance since 2007 according to the labels and Verification of Service collars attached to each fire extinguisher. This was acknowledged by the Director of Facilities at the time of each observation.

2. Based on observation and interview, the facility failed to maintain 4 of 4 portable fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 2- 3.2 requires fire extinguishers provided for the protection of cooking appliances using combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 2-3.2.1 requires a placard shall be conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using a portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect mostly staff while working in the kitchen.

Findings include:

Based on observations on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, there were 4 Class K portable fire extinguishers in the kitchen which lacked placards. This was acknowledged by the Director of Facilities at the time of observations.

Based on observation and interview, the facility failed to ensure 32 of 157 fire extinguishers in the West Building were maintained in accordance with NFPA 10. LSC 4.5.7 says whenever any device, equipment or system are required for compliance with provisions of this Code, such device, equipment or systems shall be thereafter maintained unless the Code exempts such maintenance. NFPA 10, 4-4.3 states every 6 years, stored pressure fire extinguishers that require a 12 year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. 4-4.4.2 states each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a "Verification of Service" collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch. 4-5.5 states each fire extinguisher shall have a tag or label securely attached that indicates the month and year recharging was performed and that identifies the person performing the services. A "Verification of Service" (maintenance or recharging) collar in accordance with 4-4.4.2 shall also be attached to the extinguisher. This deficient practice could affect all patients, as well as staff and visitors.

Findings include:

Based on observations on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities and the Facilities Manager, 32 of the 157 fire extinguishers in the West Building have not had their six year maintenance since 2005, 2006 or 2007 according to the labels and Verification of Service collars attached to each fire extinguisher. This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation.

Based on record review and interview, the facility failed to ensure 2 of 3 kitchen exhaust systems was maintained in proper working order. NFPA 96, 10-6.5 requires inspection and testing of the total operation and all safety interlocks in accordance with the manufacturer's instructions shall be performed by qualified service personnel a minimum of once every 6 months or more frequently if required. This deficient practice was not in a resident area but could affect kitchen staff.

Findings include:

Based on record review on 06/07/16 at 3:45 p.m. with the Compliance/Risk Manager present, the 07/16/15 and 01/21/16 kitchen range hood inspection reports noted "Cooking equipment not properly protected by nozzles". This was acknowledged by Compliance/Risk Manager at the time of record review. Based on observation on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities the exhaust system nozzles for the two range hoods located within the kitchen were not properly positioned over the cooking equipment under the hoods. All of the nozzles were pointed in front of the cooking equipment. This was acknowledged by the Director of Facilities at the time of each observation.

Based on observation and interview, the facility failed to ensure 1 of over 30 soiled laundry and trash chute doors was provided with fire doors which were self-closing and latching. This deficient practice could affect mostly staff in the Emergency Department.

Findings include:

Based on observation on 06/08/16 between 9:00 a.m. to 5:30 p.m. during a tour of the facility with the Director of Facilities, the Emergency Department soiled laundry chute door had a broken self-closing device and failed to close and latch into the frame. This was acknowledged by the Director of Facilities at the time of observation.

Based on observation and interview, the facility failed to ensure all cubicle curtains were flame resistant. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, cubicle curtains in the holding area had no affixed flame resistance documentation. Based on interview of the observations, the RNS stated cubicle curtains are not treated with a flame retardant material and acknowledged cubicle curtain flame resistance documentation was not available for review.

Based on observation and interview, the facility failed to ensure 1 of 1 cylinders of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart in the fourth floor Lab. NFPA 99, Health Care Facilities, 8-3.1.11.2(h) requires cylinder or container restraint shall meet NFPA 99, 4-3.5.2.1(b)27 which requires freestanding cylinders be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect 8 patients, staff and visitors in the vicinity of the fourth floor Lab identified as D460.

Findings include:

Based on observation with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, one 'E' type oxygen cylinder was freestanding on the floor in the fourth floor Lab identified as Room D460 without support. Based on interview at the time of observation, the Facility Manager stated the oxygen cylinder was an 'E' type cylinder and acknowledged the oxygen cylinder was freestanding and was not properly chained or supported in a proper cylinder stand or cart.

1. Based on record review, observation and interview; the facility failed to maintain documentation of system integrity for 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99, Section 4-3.4.1.1 states inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, system integrity has been achieved or maintained. The inspection and testing shall include all components of the system. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of system integrity for 1 of 1 piped gas systems was not available for review. Based on observation with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the facility has a piped gas system. Based on interview at the time of the observations, the RNS stated they only currently the vacuum system portion of the piped gas system but acknowledged documentation of system integrity for 1 of 1 piped gas systems was not available for review.

2. Based on record review, observation and interview; the facility failed to maintain 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99, Section 4-3.1.1.2(c) states storage requirements for nonflammable gases locations less than 3000 cubic feet which open onto an exit access corridor shall have a dedicated mechanical ventilation system and shall comply with the requirements of Section 4-3.1.1.2(b) 3 and 4 which requires walls, floors and ceilings to have a fire resistance rating of at least one hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy. NFPA 99, Section 8-3.1.11.3 states nonflammable gas storage locations less than 3000 cubic feet shall have a precautionary sign, readable from a distance of 5 feet, conspicuously displayed on each door of the storage room or enclosure. The sign shall include, at a minimum, CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the following was noted for the facility's piped gas system location:
a. the entry door from the corridor had no oxygen storage sign on the door, had no fire resistance rating affixed to the door and was not equipped with a self-closing device.
b. the walls and ceiling of the storage room consisted of two layers of 3/8th inch drywall which did not provide one hour fire resistance rating for the room.
c. two sprinkler escutcheons were missing which caused a two one inch diameter holes in the ceiling and failed to separate the room from other spaces with one hour fire resistance.
d. the two inch annular space surrounding each of two one inch in diameter pipes which penetrated the wall above the piped gas system were not firestopped which failed to separate the room from other spaces with one hour fire resistance.
e. no mechanical ventilation was provided.
Based on interview at the time of the observations, the RNS stated less than 2200 cubic feet of oxygen is typically stored in the piped gas system room and acknowledged no signage was provided on the door, had no mechanical ventilation and the room was not separated from other spaces with fire resistant construction of at least one hour.

Based on record review and interview, the facility failed to maintain system integrity for 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99 at Chapter 4-3.4.1.1 states inspection and testing shall be performed on all repaired piped gas systems to ensure system integrity has been achieved or maintained. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Artec Environmental Monitoring "Preventive Maintenance Inspection" documentation dated 12/11/15 with the Director and the Facility Manager during record review from 10:30 a.m. to 5:10 p.m. on 06/07/16, a total of 14 deficiencies were listed for the piped gas system's medical oxygen manifold system, medical air manifold system, nitrous oxide manifold system, nitrogen manifold system and station outlets/inlets. Based on interview at the time of record review, the Director and the Facility Manager were unaware of any repairs to the piped gas system on or after 12/11/15 and acknowledged documentation of repairs made to the piped gas system on or after 12/11/15 was not available for review.

Based on record review and interview, the facility failed to maintain system integrity for 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99 at Chapter 4-3.4.1.1 states inspection and testing shall be performed on all repaired piped gas systems to ensure system integrity has been achieved or maintained. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Artec Environmental Monitoring "Preventive Maintenance Inspection" documentation dated 12/11/15 with the Director and the Facility Manager during record review from 10:30 a.m. to 5:10 p.m. on 06/07/16, a total of 28 deficiencies were listed for the piped gas system's medical air compressor system, medical vacuum system, nitrous oxide manifold system, nitrogen manifold system, carbon dioxide manifold system, master alarm signal activation and station outlets/inlets. Based on interview at the time of record review, the Director and the Facility Manager were unaware of any repairs to the piped gas system on or after 12/11/15 and acknowledged documentation of repairs made to the piped gas system on or after 12/11/15 was not available for review.

Based on record review and interview, the facility failed to maintain system integrity for 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99 at Chapter 4-3.4.1.1 states inspection and testing shall be performed on all repaired piped gas systems to ensure system integrity has been achieved or maintained. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Artec Environmental Monitoring "Preventive Maintenance Inspection" documentation dated 12/11/15 with the Director and the Facility Manager during record review from 10:30 a.m. to 5:10 p.m. on 06/07/16, a total of 65 deficiencies were listed for the piped gas system's station outlets/inlets and zone valves. Based on interview at the time of record review, the Director and the Facility Manager were unaware of any repairs to the piped gas system on or after 12/11/15 and acknowledged documentation of repairs made to the piped gas system on or after 12/11/15 was not available for review.

1. Based on observation and interview, the facility failed to ensure 6 of 6 automatic sprinkler system's gauges were continuously maintained in reliable operating condition, inspected and tested periodically. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, five sprinkler gauges at the sprinkler system riser each had manufacture dates of greater than five years old listed on the gauge. One gauge was listed as 2005, two were listed as 2006 and two were listed as 2007. In addition, the sprinkler gauge on sprinkler piping in the exit stairwell on the first floor by the elevator machine room had a manufacture date of 2006. Based on interview at the time of record review, the Facility Manager stated each of the aforementioned sprinkler systems gauges had been retested within the most recent five year period by comparison with a calibrated gauge, retesting documentation was available at the Facility Manager Office but acknowledged the retesting date was not affixed to each of the gauges. Based on record review with the Union Hospital Facilities Manager Assistant at 2:15 p.m. on 06/09/16, sprinkler system gauge retesting documentation within the most recent five year period was not available for review.

2. Based on observation and interview, the facility failed to ensure 1 of over 20 sprinkler heads was maintained. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 13, Standard for the Installation of Sprinkler Systems, Section 3-2.7.2 states escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, the escutcheon plate was missing for the automatic sprinkler located in the second floor corridor near the southeast stairwell. Based on interview at the time of observation, the Facility Manager acknowledged the escutcheon plate was missing for the aforementioned automatic sprinkler location.

3. Based on observation and interview, the facility failed to maintain 3 of over 15 smoke detectors in accordance with NFPA 72. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. 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 patients, staff and visitors on the ground floor.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, the smoke detector on the ceiling in the CT Simulation Room on the ground floor was located one foot from an air supply vent. In addition, each of two smoke detectors installed on the ceiling in Room 104 on the ground floor was located one foot from an air supply vent. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned smoke detector locations were installed less than three feet from an air supply vent.

4. Based on observation and interview, the facility failed to ensure 2 of over 10 alcohol based hand sanitizers was not installed over an ignition source. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 101, in 19.1.1.3 requires all health facilities to be designed, constructed, maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. This deficient practice could affect over 10 staff and visitors.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, an alcohol based hand sanitizer was installed directly above a light switch in the reception area for Patient Accounts and at the entrance to Patient Accounts by the stairwell on the lower level. Each of the aforementioned two hand sanitizers had ethyl alcohol stated as an ingredient on its packaging. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned hand sanitizer locations were alcohol based and were installed over an ignition source.

5. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage locations of greater than 3,000 cubic feet was enclosed with separation of 1 hour fire resistive construction. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 8.2.3.2.1 requires doors in fire barriers shall be of an approved type with the appropriate fire protection rating. Further, 8.2.3.2.1(b) requires fire doors to be self-closing or automatic closing in accordance with 7.2.1.8. This deficient practice could affect 1 patient, staff and visitors in the vicinity of the first floor oxygen storage and transfilling room by the southeast stairwell.

Findings include:

Based on observation with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, one liquid oxygen container was stored in the first floor oxygen storage and transfilling room by the southeast stairwell. The corridor door to the room had no affixed fire resistance rating label. Based on interview at the time of observation, the Facility Manager acknowledged the corridor entry door to the oxygen storage and transfilling room did not enclose the area one hour fire resistive construction.

Based on observation and interview, the facility failed to ensure at least two hour tenant separation from adjoining occupancies. NFPA 101, Section 19.1.1.3 requires all health facilities to be designed constructed, maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Section 19.1.2.3 states health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, a two foot high by three foot long section of drywall was missing above the suspended ceiling at the main entrance to the facility. In addition, a two foot high by six foot long section of drywall and a two foot high by four foot long section of drywall was missing above the suspended ceiling by the clean storage room. Based on interview at the time of the observations, the RNS and the Maintenance Director acknowledged the aforementioned openings in the tenant separation fire barrier above the suspended ceiling failed to separate the facility from adjoining occupancies with a fire resistance rating of not less than two hours.

1. Based on record review and interview, the facility failed to ensure a monthly load test for the emergency generator was conducted for 12 of 12 months using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall 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 Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of monthly load testing for the most recent twelve month period was not available for review. Based on interview at the time of record review, the Maintenance Director acknowledged documentation of monthly load testing for the most recent twelve month period was not available for review.

2. Based on record review and interview, the facility failed to ensure a complete written record of weekly inspections of the starting batteries for the emergency generator was maintained for 52 of 52 weeks. Chapter 3-4.4.1.3 of NFPA 99 requires storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Furthermore, NFPA 110, 6-3.6 requires checking storage batteries, including electrolyte levels, at intervals of not more than 7 days. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of weekly inspections of the starting batteries for the emergency generator for the most recent 52 week period was not available for review. Based on interview at the time of record review, the Maintenance Director acknowledged documentation of weekly inspections of the starting batteries for the emergency generator for the most recent 52 week period was not available for review.

3. Based on record review and interview, the facility failed to ensure emergency power would be transferred to the emergency generator within 10 seconds of building power loss for 12 of 12 months. NFPA 99, 3-4.1.1.8 states generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of emergency generator transfer time for the most recent twelve month period was not available for review. Based on interview at the time of record review, the Maintenance Director acknowledged emergency generator transfer time for the most recent twelve month period was not available for review.

4. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level II 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, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the 100 kW emergency generator located outside the building lacked a remote shut off device. Manufacturer's information affixed to the nameplate of the emergency generator indicated the unit was manufactured March 2007. Based on interview at the time of observation, the Maintenance Director acknowledged there was no remote shut off device for the emergency generator.

5. Based on record review, observation and interview; the facility failed to ensure documentation of the reliability for the offsite fuel source for 1 of 1 emergency generators was available for review. 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) Liquefied petroleum gas (liquid or vapor withdrawal)
c) Natural or synthetic gas
Exception: For Level 1 installations in locations where the probability of interruption of offsite 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 provision for automatic transfer from the primary energy source to the alternate energy source. This deficient practice could affect all clients, staff and visitors.
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 as well as staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of reliability from the offsite natural gas supplier for the emergency generator was not available for review. Based on observation with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the facility emergency generator is fueled by natural gas only. Based on interview at the time of record review and observation, the Maintenance Director stated the fuel source for the emergency generator was natural gas and acknowledged documentation of reliability from the natural gas provider was not available for review.

Based on observation and interview, the facility failed to provide emergency task lighting in and around 1 of 1 generator sets in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 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 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery powered emergency lighting. This deficient practice could affect all residents as well as staff and visitors.

Findings include:

Based on observation on 06/09/16 at 3:15 p.m. with the Plant Director, the generator set location outside the north side of the building lacked battery powered emergency lighting in or around the generator. Based on interview concurrent with the observation was acknowledged by the Plant Director there was no battery powered emergency light available for the generator.

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 II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. 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 the shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation of generator equipment on 06/09/16 at 1:45 p.m. with the Plant Director, a remote shut off device was not found for the generator located at the southeast corner of the building. The generator were installed new after 2003 and would require an emergency stop. Based on interview concurrent with the observation with the Plant Director, it was acknowledged the facility was not aware a remote shut off for the generator was required.

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 234 of 234 patients. 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 "Alternate Life Safety Measures" with the Director and the Facility Manager during record review from 10:30 a.m. to 5:00 p.m. on 06/07/16, the written fire watch policy for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH) which is the authority having jurisdiction. Based on interview at the time of record review, the Director and the Facility Manager acknowledged the written fire watch policy for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH.

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 234 of 234 patients. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Alternate Life Safety Measures" with the Director and the Facility Manager during record review from 10:30 a.m. to 5:00 p.m. on 06/07/16, the written fire watch policy for the facility in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH) which is an authority having jurisdiction. Based on interview at the time of record review, the Director and the Facility Manager acknowledged the written fire watch policy for the facility in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH.

Based on record review and interview, the facility failed to document elevator inspections and maintain current Certificate of Inspection documentation from the State of Indiana for 2 of 4 elevators. This deficient practice could affect three patients, staff and visitors in the facility.

Findings include:

Based on record review with the Facility Manager 10:30 a.m. to 5:00 p.m. on 06/07/16, elevators identified as 113350 and 113352 each had an expiration date of 12/08/15 listed on Certificate of Inspection documentation from the State of Indiana. Based on interview at the time of record review, the Facility Manager stated additional elevator inspection documentation was not available for review and acknowledged each of the aforementioned elevators had expired Certificate of Inspection documentation from the State of Indiana.

Based on record review and interview, the facility failed to document elevator inspections and maintain current Certificate of Inspection documentation from the State of Indiana for 9 of 9 elevators. This deficient practice could affect nine patients, staff and visitors in the facility.

Findings include:

Based on record review with the Facility Manager 10:30 a.m. to 5:00 p.m. on 06/07/16, the elevator identified as 39657 had an expiration date of 01/18/16 listed on Certificate of Inspection documentation from the State of Indiana. The elevator identified as 39672 had an expiration date of 02/02/16 listed on Certificate of Inspection documentation from the State of Indiana. In addition, 03/19/16 was listed as the expiration date on Certificate of Inspection documentation for elevators identified as 39651, 39652, 39653, 39654, 39657, 39672 and 46486. Based on interview at the time of record review, the Facility Manager stated additional elevator inspection documentation was not available for review and acknowledged each of the aforementioned elevators had expired Certificate of Inspection documentation from the State of Indiana.

1. Based on observation and interview, the facility failed to ensure the communicating opening was maintained in 1 of 1 fire barriers in the tenant separation walls on the third floor. LSC 18.1.1.4.2 refers to LSC 8.2. LSC 8.2.3.2.3.1 requires every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Openings in a two hour fire wall are required to have a one and one half fire protection rating. LSC 8.2.3.2.1 states door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with NFPA 80, Standard for Fire Doors and Fire Windows. NFPA 80, 1999 edition, section 2-1.4 states all swinging doors shall be closed and latched at the time of fire. This deficient practice could affect visitors, staff and 13 patients, staff and visitors in the vicinity of the third floor walkway to the Professional Office Building (POB).

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, the set of wood corridor doors in the tenant separation wall at the third floor walkway to the POB had no affixed fire resistance rating and were not equipped with a latching mechanism to latch the door set into the door frame. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned corridor door set in the tenant separation fire barrier did not maintain the fire resistance rating of the fire barrier and did not latch into the door frame.

2. Based on record review, observation and interview, the facility failed to ensure the communicating opening was maintained in 1 of 6 fire barriers on the fourth floor. LSC 18.1.1.4.2 refers to LSC 8.2. LSC 8.2.3.2.3.1 requires every opening in a fire barriers shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Openings in a two hour fire wall are required to have a one and one half fire protection rating. LSC 8.2.3.2.1 states door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with NFPA 80, Standard for Fire Doors and Fire Windows. NFPA 80, 1999 edition, section 2-1.4 states all swinging doors shall be closed and latched at the time of fire. This deficient practice could affect visitors, staff and 23 patients, staff and visitors in the vicinity of the corridor door set by Room 4178 on the fourth floor.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, the set of corridor doors in the fire barrier wall by Room 4178 had a 90 minute fire resistant label affixed to each door and were each equipped with a latching mechanism to latch each door into the door frame but the north door latching mechanism failed to protrude into the latching plate. Based on interview at the time of the observations, the Facility Manager acknowledged the north door in the aforementioned corridor door set did not latch into the door frame. Based on review of facility blueprint information with the Director at 10:30 a.m. on 06/09/16, the fire barrier wall by Room 4178 in which the aforementioned communicating opening door set was installed had a fire resistance rating of two hours.

Based on observation and interview, the facility failed to provide documentation of the flame spread rating for interior finish materials installed in 1 of over 15 rooms. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the electrical room which contains the second automatic transfer switch for the facility had no ceiling which exposed the wood framing in the attic above. In addition, wood particle board was used as an interior finish in the room on each of the four walls of the room from the floor up to where the attic above began in the room. Based on interview at the time of observation, the RNS and the Maintenance Director stated she was unaware of the wood paneling being treated with flame retardant material and acknowledged flame spread rating documentation for the wood particle board in the aforementioned electrical room was not available for review.

1. Based on observation and interview, the facility failed to ensure 7 of over 25 open use areas were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception. LSC 19.3.6.1, Exception #1: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system shall be permitted to have spaces unlimited in size open to the corridor, provided the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, or the smoke compartment in which the space is located is protected throughout by quick response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. This deficient practice could affect over 50 patients, as well as staff and visitors while in any of these open areas.

Findings include:

Based on observations on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities and the Facilities Manager, the Union West Admitting area, the Wound Care Waiting area, the Work Room in PEDS, the three 5th floor Union West Sub Nurses' Stations (no longer in use as Nurses' Stations), and the 5th floor Union West Waiting area, were open to the corridor. Exception #1 requirement (c) of LSC 19.3.6.1 was not met as follows: The Union West Admitting area, the Wound Care Waiting area, the Work Room in PEDS, the three 5th floor Union West Sub Nurses' Stations (no longer in use as Nurses' Stations), and the 5th floor Union West Waiting area were not protected by an electrically supervised automatic smoke detection system, or the entire space was not arranged and located to allow direct supervision by the facility staff from the nurses' station or similar staffed space. This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation.

2. Based on observation and interview, the facility failed to ensure 3 of over 100 offices were separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building or met an Exception. LSC 19-3.6.1, Exception # 6, Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas may be open to the corridor and unlimited in area provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, and (b) Each space is protected by an automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. This deficient practice could affect patients, staff and visitors outside room 317 on the 3rd floor Union West, the empty office at C Wing on 5th floor Union West, and the Security Office 5th floor Union West.

Findings include:

Based on an observations with the Director of Facilities and the Facilities Manager on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility, the following was observed:
A. Union West room 317 office had a 3 ft. by 3 ft. sliding glass window with a 1/2 inch gap between the window panes when closed
B. Union West empty office at C Wing on 5th floor had a 3 ft. by 3 ft. sliding glass window with a 1/2 inch gap between the window panes when closed
C. Union West Security Office on 5th floor had two, 2 1/2 ft. by 2 1/2 ft. sliding glass windows with 1/2 inch gaps between the window panes when closed
Exception # 6, requirement (a) of the LSC Section 19-3.6.1 was not met because the previously mentioned offices were not protected by an electrically supervised automatic smoke detection system. This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation, furthermore, the Director of Facilities said these offices were not 24 hour stations.

Based on observation and interview, the facility failed to ensure 1 of over 25 open use areas were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception. LSC 18-3.6.1, Exception # 1, Spaces shall be permitted to be unlimited in area and open to the corridor, provided that the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas, and (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers, and (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 18.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space, and (d) The space does not obstruct access to required exits. This deficient practice could patients, staff and visitors while in the egress corridor outside the Satellite Cafe.

Findings include:

Based on observation on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, the Union East 1st floor Satellite Cafe was open to the corridor. Exception #1 requirement (c) of LSC 18.3.6.1 was not met as follows: The Union East 1st floor Satellite Cafe was not protected by an electrically supervised automatic smoke detection system, or the entire space was not arranged and located to allow direct supervision by the facility staff from nurses' stations or similar staffed space. This was acknowledged by the Director of Facilities at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of over 200 corridor doors would resist the passage of smoke. This deficient practice could affect 6 patients, staff and visitors in the vicinity of Room 135.

Findings include:

Based on observation with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, a one half inch hole was noted in the corridor door to Room B548 nearest the hinge side of the door which would not resist the passage of smoke. Based on interview at the time of observation, the Facility Manager acknowledged the aforementioned corridor door would not resist the passage of smoke.

Based on observation and interview, the facility failed to ensure 2 of 2 sets of double doors to the corridor on the third floor Union West PEDS were equipped with positive latches and latched into the door frame automatically. This deficient practice could affect patients, staff and visitors on the third floor.

Findings include:

Based on observations on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility with Director of Facilities and the Facilities Manager, the sets of double doors to the 3rd floor Union West PEDS storage closet and the 3rd floor Union West PEDS I.T. closet did not positive latch into their door frames automatically. The left side door at each set had to be manually latched at the top of the door. This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation.

Based on observation and interview, the facility failed to ensure 2 of 2 doors likely to be mistaken for a way of exit was identified as "No Exit". LSC 7.10.8.1 requires any door which is neither an exit nor a way of exit access and that is located or arranged so it is likely to be mistaken for an exit shall be identified by a sign that reads: NO EXIT. This deficient practice could affect any patient as well as visitors and staff using the Therapy Gym room.

Findings include:

Based on observations on 06/09/16 at 2:20 p.m. with the Plant Director, the two doors leading to the outside of the Therapy Gym room are identified with exit signs, but the exits discharge into an enclosed courtyard and not to a public way. Based on interview concurrent with the observations it was acknowledged the doors leading out of the Therapy Gym room could be mistaken for exits, but since they do not lead to a public way they should have NO EXIT signs posted to avoid any confusion.

Based on observation and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers was maintained to provide at least a one half hour fire resistance rating. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the following was noted:
a. the electrical room which contains the second automatic transfer switch for the facility had no ceiling which exposed the attic above.
b. the drink storage room was missing a one foot by one foot ceiling tile.
c. the sprinkler riser room was missing four ceiling tiles. Two of the missing tiles each caused an opening measuring four feet by two feet and the remaining two missing tiles each caused an opening measuring four feet by six inches.
Based on interview at the time of the observations, the (RNS) and the Maintenance Director acknowledged the aforementioned openings in the ceiling smoke barrier failed to provide at least a one half hour fire resistance rating.

Based on observation and interview, the facility failed to ensure 1 of 6 smoke barriers was protected to maintain the one half hour 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 be protected, so 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 any patients, visitors or staff near the electrical room on Center hall, if smoke from a fire were to infiltrate the protective barrier.

Findings include:

Based on observation on 06/09/16 at 1:00 p.m. with the Plant Director the ceiling in the Electrical room on Center hall had forty one metal conduits which penetrated the ceiling leaving one half to one inch gaps around the pipes which were not firestopped. Based on interview concurrent with the observation with the Plant Director, it was acknowledged the aforementioned smoke barrier ceiling had numerous openings which were not filled with a fire rated material to maintain a one half hour fire resistance rating.

Based on observation and interview, the facility failed to ensure 2 of over 50 hazardous area room doors to the corridor in the Union East Building, such as supply and Soiled Utility rooms, were equipped with positive latches that automatically latched into the door frames when closed or latches that were functioning properly. This deficient practice could affect patients, staff and visitors while in the vicinity of the Union East Surgery Supply Chain Room and the Union East 4th floor Soiled Utility/Biohazard room.

Findings include:

Based on observations on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, the corridor door to the Union East Surgery Supply Chain Room (B013) was not provided with a positive latch that automatically latched into the door frame when closed, furthermore, the corridor door to the Union East 4th floor Soiled Utility/Biohazard Room (B444) would not latch into the door frame when tested three times. This was acknowledged by the Director of Facilities at the time of each observation.

Based on observation and interview, it was determined the facility failed to provide adequate emergency task lighting for 1 of 4 outside exits. This deficient practice could affect all patients, staff and visitors using the West exit.

Findings include:

Based on observation on 06/09/16 at 2:00 p.m. with the Plant Director the exit located on the west side of the building was not provided with outdoor emergency lighting. Based on interview concurrent with the observation it was acknowledged the West exit lacked an outside emergency light.

Based on observation and interview, the facility failed to ensure a continuously illuminated exit sign, where the exit or way to reach the exit was not apparent, was provided for 1 of 1 ways of exit from the Emergency Department office hallway. LSC 18.2.10.1 refers to 7.10. LSC 7.10.1.4 requires access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not apparent to the occupants. This deficient practice could mostly staff in the Emergency Department office hallway.

Findings include:

Based on observation on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, there was no illuminated exit sign at the north end of the Emergency Department office hallway. This was acknowledged by the Director of Facilities at the time of observation.

Based on record review and interview, the facility failed to document a complete written health care occupancy fire safety plan for 2 of 2 plans which incorporated all items listed in NFPA 101, Section 18.7.2.2.
(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 all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of "Emergency Management" and "Safety Manual: Fire Safety-Evacuation of Patients" documentation with the Compliance/Risk Manager during record review at 11:30 a.m. on 06/07/16, neither written health care occupancy fire safety plan for the facility succinctly stated what procedures the facility would follow in the event of a fire. The written fire safety plans did not state the staff response to fire, the activation of the fire alarm system, the confinement of fire, the extinguishment of fire and the evacuation of affected smoke compartments (RACE) within the facility. Based on interview at the time of record review, the Compliance/Risk Manager stated the written fire safety plans are currently under review for possible revision and acknowledged neither written health care occupancy fire safety plan for the facility succinctly stated what procedures the facility would follow in the event of a fire.

Based on record review and interview, the facility failed to document a complete written health care occupancy fire safety plan for 2 of 2 plans which incorporated all items listed in NFPA 101, Section 19.7.2.2.
(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 all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of "Emergency Management" and "Safety Manual: Fire Safety-Evacuation of Patients" documentation with the Compliance/Risk Manager during record review at 11:30 a.m. on 06/07/16, neither written health care occupancy fire safety plan for the facility succinctly stated what procedures the facility would follow in the event of a fire. The written fire safety plans did not state the staff response to fire, the activation of the fire alarm system, the confinement of fire, the extinguishment of fire and the evacuation of affected smoke compartments (RACE) within the facility. Based on interview at the time of record review, the Compliance/Risk Manager stated the written fire safety plans are currently under review for possible revision and acknowledged neither written health care occupancy fire safety plan for the facility succinctly stated what procedures the facility would follow in the event of a fire.

Based on record review and interview, the facility failed to document fire drills conducted on the first shift for 4 of 4 quarters. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) and the Facility Maintenance Manager from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of a fire drills conducted on the first shift for the third quarter (July, August, September) 2015, the fourth quarter (October, November, December) 2015, the first quarter (January, February, March) 2016 and the second quarter (April, May, June) 2016 was not available for review. Based on interview at the time of record review, the RNS stated fire drill documentation is maintained by Union Hospital at the hospital location and acknowledged fire drill documentation for first shift fire drills for the aforementioned calendar quarters was not available for review. Based on record review with the Union Hospital Facilities Manager Assistant at 2:30 p.m. on 06/09/16, fire drill documentation for first shift fire drills for the aforementioned calendar quarters was not available for review.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control panels, located in an area that was not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. LSC 9.6.2.10 refers to NFPA 72, the National Fire Alarm Code. 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 patients, staff and visitors in the facility.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the facility's main fire alarm control panel was located in a first floor electrical room of the adjoining Providence Medical building which is not continuously occupied and was not provided with automatic smoke protection. Based on interview at the time of observation, the RNS and the Maintenance Director acknowledged the electrical room which contains the facility's main fire alarm control panel is not continuously occupied and was not provided with automatic smoke protection.

1. Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. NFPA 72, 7-3.2 requires testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. Table 7-3.2 shall apply. Table 7-3.2 "Testing Frequencies" requires alarm initiating devices, alarm notification appliances, batteries, and initiating devices to be tested at least annually. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) during record review from 10:25 a.m. to 10:40 a.m. on 06/09/16, fire alarm system testing documentation within the most recent twelve month period was not available for review. Based on interview at the time of record review, the RNS acknowledged fire alarm system testing documentation within the most recent twelve month period was not available for review.

2. Based on record review and interview, the facility failed to ensure all smoke detectors were maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. NFPA 72, 7-3.2 requires detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked); the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) during record review from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of smoke detector sensitivity testing within the most recent two year period was not available for review. Based on interview at the time of record review, the RNS acknowledged sensitivity testing documentation for all facility fire alarm system smoke detectors within the most recent two year period was not available for review.

Based on observation and interview, the facility failed to ensure 26 of over 500 smoke detectors in the Union East Building were not installed where air flow would adversely affect their operation. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect patients, staff and visitors throughout the facility.

Findings include:

Based on observations on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities and the Facilities Manager, the following was observed:
a. There were two ceiling mounted smoke detectors within one foot of air supply vents in the Union East Physicians Lounge.
b. There was a ceiling mounted smoke detector within one foot of an air supply vent in the entrance area of the Union East Visitor/Employee Dining Room.
c. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Surgery Center.
d. There were two ceiling mounted smoke detectors within one foot of an air supply vent and air return vent in the Union East Business Office Hall Surgery Center.
e. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Surgical corridor.
f. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Storage Room (E329).
g. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Soiled Utility Room (E333).
h. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Environmental Services Room (D315).
i. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Med Room (D342).
j. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East Clean Utility Room (B252).
k. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 4th floor in room B456.
l. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 4th floor in room B432.
m. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 4th floor in room C441.
n. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 4th floor elevator machine room (D418).
o. There were two ceiling mounted smoke detectors within two feet of air supply vents in the Union East building 4th floor elevator machine room (B457).
p. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor break room (A344).
q. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor Men's Locker Room (A345).
r. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor Women's Locker Room (A345).
s. There was a ceiling mounted smoke detector within one foot of an air return vent in the Union East building 3rd floor Bluebird Closet (A343).
t. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor Supply/Equipment Storage Room (B356).
u. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor Clean Utility Room (D346).
v. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 3rd floor Family Nourishment Room (E332).
w. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union East building 2nd floor Consultation Room (A258).

This was acknowledged by the Director of Facilities and Facilities Manager at the time of each observation.

Based on observation and interview, the facility failed to ensure 3 of over 500 smoke detectors in the Union West Building were not installed where air flow would adversely affect their operation. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect mostly staff.

Findings include:

Based on observations on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities and the Facilities Manager, the following was observed:
a. There was a ceiling mounted smoke detector within one foot of an air supply vent in the Union West Microbiology Lab.
b. There were two ceiling mounted smoke detectors within one foot of air supply vents in the third floor Union West Supply Room.
This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system or alternative automatic extinguishing equipment was provided for 2 of 2 elevator machine rooms in this five story building of Type I (332) construction which is required to be fully sprinklered. This deficient practice could affect ten patients, staff and visitors.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, each of the two fourth floor elevator equipment rooms identified as Room B457 and Room D460 were not provided with sprinkler coverage or alternative automatic extinguishing equipment. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned fourth floor elevator machine rooms were not provided with sprinkler coverage or alternative automatic extinguishing equipment.

1. Based on observation and interview, the facility failed to ensure the ceiling in 1 of over 50 sprinklered smoke compartments were maintained to allow sprinkler heads to function to their full capability. This deficient practice could affect mostly staff in the Union East Decontamination Room.

Findings include:

Based on observation on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, the Union East Decontamination Room had 20 conduits and wire bundles with gaps of 1/4 inch to 1/2 inch through the ceiling which were not fire stopped.
This was acknowledged by the Director of Facilities at the time of observation.

2. Based on record review, observation and interview; the facility failed to ensure 1 of 1 automatic sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, four of four sprinkler gauges on the Helipad sprinkler system riser had a manufacture date of 2009. The sprinkler system gauge on sprinkler piping in the 4th Floor stairwell by the Helipad also had a manufacture date of 2009. In addition, the sprinkler system gauge on sprinkler piping in the Stairwell C exit stairwell by Room 3170 also had a manufacture date of 2009. Based on interview at the time of record review, the Facility Manager stated each of the aforementioned sprinkler systems gauges had been retested within the most recent five year period by comparison with a calibrated gauge, retesting documentation was available at the Facility Manager Office but acknowledged the retesting date was not affixed to each of the gauges. Based on record review with the Union Hospital Facilities Manager Assistant at 2:15 p.m. on 06/09/16, sprinkler system gauge retesting documentation within the most recent five year period was not available for review.

1. Based on record review, observation and interview; the facility failed to ensure quarterly sprinkler inspections were conducted for the sprinkler system for 3 of 4 calendar quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code to be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1-8 requires records of inspections and tests of the sprinkler system and its components shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Tri-State Fire Protection "Fire Sprinkler Inspection Report" documentation dated 12/12/15 with the Registered Nurse Supervisor (RNS) during record review from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of quarterly sprinkler inspection for the third quarter (July, August, September) 2015, the first quarter (January, February, March) 2016 and the second quarter (April, May, June) 2016 was not available for review. Based on observations with the RNS and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, hanging tags affixed to the sprinkler system riser by Tri-State to document sprinkler inspections did not indicate quarterly sprinkler inspections had been documented for the aforementioned three calendar quarters. Based on interview at the time of record review and of the observations, the RNS and the Maintenance Director acknowledged documentation of quarterly sprinkler inspection for the third quarter 2015 and the first and second quarter 2016 was not available for review.

2. Based on observation and interview, the facility failed to ensure 3 of over 10 sprinkler heads was maintained. NFPA 13, Standard for the Installation of Sprinkler Systems, Section 3-2.7.2 states escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the RNS and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the escutcheon plate was missing for the automatic sprinkler located in the instruction room. In addition, the piped gas system room had two automatic sprinkler locations each missing its escutcheon plate. Based on interview at the time of the observations, the RNS and the Maintenance Director acknowledged the escutcheon plate was missing for the aforementioned automatic sprinkler locations.

Based on observation, record review and interview, the facility failed to ensure 1 of gauges for the sprinkler system were continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on observation on 06/09/16 at 12:18 p.m. with the Plant Director one pressure gauge on the sprinkler riser system located in the Mechanical riser room had a manufacturer's date of 2006. Based on Sprinkler Inspection Records review on 06/09/16 at 01:45 p.m., documentation did not reveal the sprinkler system gauge had been calibrated or the date of installation. Based on interview concurrent with the observation it was acknowledged the pressure gauge had exceeded the five year calibration or replacement limit.

1. Based on observation and interview, the facility failed to ensure 5 of 5 fire extinguishers in the East Building MR Unit were maintained in accordance with NFPA 10. LSC 4.5.7 says whenever any device, equipment or system are required for compliance with provisions of this Code, such device, equipment or systems shall be thereafter maintained unless the Code exempts such maintenance. NFPA 10, 4-4.3 states every 6 years, stored pressure fire extinguishers that require a 12 year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. 4-4.4.2 states each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a "Verification of Service" collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch. 4-5.5 states each fire extinguisher shall have a tag or label securely attached that indicates the month and year recharging was performed and that identifies the person performing the services. A "Verification of Service" (maintenance or recharging) collar in accordance with 4-4.4.2 shall also be attached to the extinguisher. This deficient practice could affect patients, as well as staff and visitors while in the MR Unit.

Findings include:

Based on observations on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, 5 of 5 fire extinguishers (4 Water Based Fire Extinguishers and 1 ABC Fire Extinguisher) in the East Building MR Unit have not had their six year maintenance since 2007 according to the labels and Verification of Service collars attached to each fire extinguisher. This was acknowledged by the Director of Facilities at the time of each observation.

2. Based on observation and interview, the facility failed to maintain 4 of 4 portable fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 2- 3.2 requires fire extinguishers provided for the protection of cooking appliances using combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 2-3.2.1 requires a placard shall be conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using a portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect mostly staff while working in the kitchen.

Findings include:

Based on observations on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities, there were 4 Class K portable fire extinguishers in the kitchen which lacked placards. This was acknowledged by the Director of Facilities at the time of observations.

Based on observation and interview, the facility failed to ensure 32 of 157 fire extinguishers in the West Building were maintained in accordance with NFPA 10. LSC 4.5.7 says whenever any device, equipment or system are required for compliance with provisions of this Code, such device, equipment or systems shall be thereafter maintained unless the Code exempts such maintenance. NFPA 10, 4-4.3 states every 6 years, stored pressure fire extinguishers that require a 12 year hydrostatic test shall be emptied and subjected to the applicable maintenance procedures. 4-4.4.2 states each extinguisher that has undergone maintenance that includes internal examination or that has been recharged shall have a "Verification of Service" collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch. 4-5.5 states each fire extinguisher shall have a tag or label securely attached that indicates the month and year recharging was performed and that identifies the person performing the services. A "Verification of Service" (maintenance or recharging) collar in accordance with 4-4.4.2 shall also be attached to the extinguisher. This deficient practice could affect all patients, as well as staff and visitors.

Findings include:

Based on observations on 06/07/16 between 9:15 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities and the Facilities Manager, 32 of the 157 fire extinguishers in the West Building have not had their six year maintenance since 2005, 2006 or 2007 according to the labels and Verification of Service collars attached to each fire extinguisher. This was acknowledged by the Director of Facilities and the Facilities Manager at the time of each observation.

Based on record review and interview, the facility failed to ensure 2 of 3 kitchen exhaust systems was maintained in proper working order. NFPA 96, 10-6.5 requires inspection and testing of the total operation and all safety interlocks in accordance with the manufacturer's instructions shall be performed by qualified service personnel a minimum of once every 6 months or more frequently if required. This deficient practice was not in a resident area but could affect kitchen staff.

Findings include:

Based on record review on 06/07/16 at 3:45 p.m. with the Compliance/Risk Manager present, the 07/16/15 and 01/21/16 kitchen range hood inspection reports noted "Cooking equipment not properly protected by nozzles". This was acknowledged by Compliance/Risk Manager at the time of record review. Based on observation on 06/08/16 between 9:00 a.m. and 5:30 p.m. during a tour of the facility with the Director of Facilities the exhaust system nozzles for the two range hoods located within the kitchen were not properly positioned over the cooking equipment under the hoods. All of the nozzles were pointed in front of the cooking equipment. This was acknowledged by the Director of Facilities at the time of each observation.

Based on observation and interview, the facility failed to ensure 1 of over 30 soiled laundry and trash chute doors was provided with fire doors which were self-closing and latching. This deficient practice could affect mostly staff in the Emergency Department.

Findings include:

Based on observation on 06/08/16 between 9:00 a.m. to 5:30 p.m. during a tour of the facility with the Director of Facilities, the Emergency Department soiled laundry chute door had a broken self-closing device and failed to close and latch into the frame. This was acknowledged by the Director of Facilities at the time of observation.

Based on observation and interview, the facility failed to ensure all cubicle curtains were flame resistant. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, cubicle curtains in the holding area had no affixed flame resistance documentation. Based on interview of the observations, the RNS stated cubicle curtains are not treated with a flame retardant material and acknowledged cubicle curtain flame resistance documentation was not available for review.

Based on observation and interview, the facility failed to ensure 1 of 1 cylinders of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart in the fourth floor Lab. NFPA 99, Health Care Facilities, 8-3.1.11.2(h) requires cylinder or container restraint shall meet NFPA 99, 4-3.5.2.1(b)27 which requires freestanding cylinders be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect 8 patients, staff and visitors in the vicinity of the fourth floor Lab identified as D460.

Findings include:

Based on observation with the Facility Manager during a tour of the facility from 1:50 p.m. to 4:40 p.m. on 06/08/16, one 'E' type oxygen cylinder was freestanding on the floor in the fourth floor Lab identified as Room D460 without support. Based on interview at the time of observation, the Facility Manager stated the oxygen cylinder was an 'E' type cylinder and acknowledged the oxygen cylinder was freestanding and was not properly chained or supported in a proper cylinder stand or cart.

1. Based on record review, observation and interview; the facility failed to maintain documentation of system integrity for 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99, Section 4-3.4.1.1 states inspection and testing shall be performed on all new piped gas systems, additions, renovations, temporary installations, or repaired systems, to assure the facility, by a documented procedure, system integrity has been achieved or maintained. The inspection and testing shall include all components of the system. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of system integrity for 1 of 1 piped gas systems was not available for review. Based on observation with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the facility has a piped gas system. Based on interview at the time of the observations, the RNS stated they only currently the vacuum system portion of the piped gas system but acknowledged documentation of system integrity for 1 of 1 piped gas systems was not available for review.

2. Based on record review, observation and interview; the facility failed to maintain 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99, Section 4-3.1.1.2(c) states storage requirements for nonflammable gases locations less than 3000 cubic feet which open onto an exit access corridor shall have a dedicated mechanical ventilation system and shall comply with the requirements of Section 4-3.1.1.2(b) 3 and 4 which requires walls, floors and ceilings to have a fire resistance rating of at least one hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy. NFPA 99, Section 8-3.1.11.3 states nonflammable gas storage locations less than 3000 cubic feet shall have a precautionary sign, readable from a distance of 5 feet, conspicuously displayed on each door of the storage room or enclosure. The sign shall include, at a minimum, CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the following was noted for the facility's piped gas system location:
a. the entry door from the corridor had no oxygen storage sign on the door, had no fire resistance rating affixed to the door and was not equipped with a self-closing device.
b. the walls and ceiling of the storage room consisted of two layers of 3/8th inch drywall which did not provide one hour fire resistance rating for the room.
c. two sprinkler escutcheons were missing which caused a two one inch diameter holes in the ceiling and failed to separate the room from other spaces with one hour fire resistance.
d. the two inch annular space surrounding each of two one inch in diameter pipes which penetrated the wall above the piped gas system were not firestopped which failed to separate the room from other spaces with one hour fire resistance.
e. no mechanical ventilation was provided.
Based on interview at the time of the observations, the RNS stated less than 2200 cubic feet of oxygen is typically stored in the piped gas system room and acknowledged no signage was provided on the door, had no mechanical ventilation and the room was not separated from other spaces with fire resistant construction of at least one hour.

Based on record review and interview, the facility failed to maintain system integrity for 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99 at Chapter 4-3.4.1.1 states inspection and testing shall be performed on all repaired piped gas systems to ensure system integrity has been achieved or maintained. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Artec Environmental Monitoring "Preventive Maintenance Inspection" documentation dated 12/11/15 with the Director and the Facility Manager during record review from 10:30 a.m. to 5:10 p.m. on 06/07/16, a total of 14 deficiencies were listed for the piped gas system's medical oxygen manifold system, medical air manifold system, nitrous oxide manifold system, nitrogen manifold system and station outlets/inlets. Based on interview at the time of record review, the Director and the Facility Manager were unaware of any repairs to the piped gas system on or after 12/11/15 and acknowledged documentation of repairs made to the piped gas system on or after 12/11/15 was not available for review.

Based on record review and interview, the facility failed to maintain system integrity for 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99 at Chapter 4-3.4.1.1 states inspection and testing shall be performed on all repaired piped gas systems to ensure system integrity has been achieved or maintained. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Artec Environmental Monitoring "Preventive Maintenance Inspection" documentation dated 12/11/15 with the Director and the Facility Manager during record review from 10:30 a.m. to 5:10 p.m. on 06/07/16, a total of 28 deficiencies were listed for the piped gas system's medical air compressor system, medical vacuum system, nitrous oxide manifold system, nitrogen manifold system, carbon dioxide manifold system, master alarm signal activation and station outlets/inlets. Based on interview at the time of record review, the Director and the Facility Manager were unaware of any repairs to the piped gas system on or after 12/11/15 and acknowledged documentation of repairs made to the piped gas system on or after 12/11/15 was not available for review.

Based on record review and interview, the facility failed to maintain system integrity for 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99 at Chapter 4-3.4.1.1 states inspection and testing shall be performed on all repaired piped gas systems to ensure system integrity has been achieved or maintained. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Artec Environmental Monitoring "Preventive Maintenance Inspection" documentation dated 12/11/15 with the Director and the Facility Manager during record review from 10:30 a.m. to 5:10 p.m. on 06/07/16, a total of 65 deficiencies were listed for the piped gas system's station outlets/inlets and zone valves. Based on interview at the time of record review, the Director and the Facility Manager were unaware of any repairs to the piped gas system on or after 12/11/15 and acknowledged documentation of repairs made to the piped gas system on or after 12/11/15 was not available for review.

1. Based on observation and interview, the facility failed to ensure 6 of 6 automatic sprinkler system's gauges were continuously maintained in reliable operating condition, inspected and tested periodically. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, five sprinkler gauges at the sprinkler system riser each had manufacture dates of greater than five years old listed on the gauge. One gauge was listed as 2005, two were listed as 2006 and two were listed as 2007. In addition, the sprinkler gauge on sprinkler piping in the exit stairwell on the first floor by the elevator machine room had a manufacture date of 2006. Based on interview at the time of record review, the Facility Manager stated each of the aforementioned sprinkler systems gauges had been retested within the most recent five year period by comparison with a calibrated gauge, retesting documentation was available at the Facility Manager Office but acknowledged the retesting date was not affixed to each of the gauges. Based on record review with the Union Hospital Facilities Manager Assistant at 2:15 p.m. on 06/09/16, sprinkler system gauge retesting documentation within the most recent five year period was not available for review.

2. Based on observation and interview, the facility failed to ensure 1 of over 20 sprinkler heads was maintained. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 13, Standard for the Installation of Sprinkler Systems, Section 3-2.7.2 states escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, the escutcheon plate was missing for the automatic sprinkler located in the second floor corridor near the southeast stairwell. Based on interview at the time of observation, the Facility Manager acknowledged the escutcheon plate was missing for the aforementioned automatic sprinkler location.

3. Based on observation and interview, the facility failed to maintain 3 of over 15 smoke detectors in accordance with NFPA 72. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. 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 patients, staff and visitors on the ground floor.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, the smoke detector on the ceiling in the CT Simulation Room on the ground floor was located one foot from an air supply vent. In addition, each of two smoke detectors installed on the ceiling in Room 104 on the ground floor was located one foot from an air supply vent. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned smoke detector locations were installed less than three feet from an air supply vent.

4. Based on observation and interview, the facility failed to ensure 2 of over 10 alcohol based hand sanitizers was not installed over an ignition source. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 101, in 19.1.1.3 requires all health facilities to be designed, constructed, maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. This deficient practice could affect over 10 staff and visitors.

Findings include:

Based on observations with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, an alcohol based hand sanitizer was installed directly above a light switch in the reception area for Patient Accounts and at the entrance to Patient Accounts by the stairwell on the lower level. Each of the aforementioned two hand sanitizers had ethyl alcohol stated as an ingredient on its packaging. Based on interview at the time of the observations, the Facility Manager acknowledged the aforementioned hand sanitizer locations were alcohol based and were installed over an ignition source.

5. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage locations of greater than 3,000 cubic feet was enclosed with separation of 1 hour fire resistive construction. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 8.2.3.2.1 requires doors in fire barriers shall be of an approved type with the appropriate fire protection rating. Further, 8.2.3.2.1(b) requires fire doors to be self-closing or automatic closing in accordance with 7.2.1.8. This deficient practice could affect 1 patient, staff and visitors in the vicinity of the first floor oxygen storage and transfilling room by the southeast stairwell.

Findings include:

Based on observation with the Facility Manager during a tour of the facility from 10:30 a.m. to 12:40 p.m. on 06/08/16, one liquid oxygen container was stored in the first floor oxygen storage and transfilling room by the southeast stairwell. The corridor door to the room had no affixed fire resistance rating label. Based on interview at the time of observation, the Facility Manager acknowledged the corridor entry door to the oxygen storage and transfilling room did not enclose the area one hour fire resistive construction.

Based on observation and interview, the facility failed to ensure at least two hour tenant separation from adjoining occupancies. NFPA 101, Section 19.1.1.3 requires all health facilities to be designed constructed, maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Section 19.1.2.3 states health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on observations with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, a two foot high by three foot long section of drywall was missing above the suspended ceiling at the main entrance to the facility. In addition, a two foot high by six foot long section of drywall and a two foot high by four foot long section of drywall was missing above the suspended ceiling by the clean storage room. Based on interview at the time of the observations, the RNS and the Maintenance Director acknowledged the aforementioned openings in the tenant separation fire barrier above the suspended ceiling failed to separate the facility from adjoining occupancies with a fire resistance rating of not less than two hours.

1. Based on record review and interview, the facility failed to ensure a monthly load test for the emergency generator was conducted for 12 of 12 months using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall 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 Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of monthly load testing for the most recent twelve month period was not available for review. Based on interview at the time of record review, the Maintenance Director acknowledged documentation of monthly load testing for the most recent twelve month period was not available for review.

2. Based on record review and interview, the facility failed to ensure a complete written record of weekly inspections of the starting batteries for the emergency generator was maintained for 52 of 52 weeks. Chapter 3-4.4.1.3 of NFPA 99 requires storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Furthermore, NFPA 110, 6-3.6 requires checking storage batteries, including electrolyte levels, at intervals of not more than 7 days. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of weekly inspections of the starting batteries for the emergency generator for the most recent 52 week period was not available for review. Based on interview at the time of record review, the Maintenance Director acknowledged documentation of weekly inspections of the starting batteries for the emergency generator for the most recent 52 week period was not available for review.

3. Based on record review and interview, the facility failed to ensure emergency power would be transferred to the emergency generator within 10 seconds of building power loss for 12 of 12 months. NFPA 99, 3-4.1.1.8 states generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of emergency generator transfer time for the most recent twelve month period was not available for review. Based on interview at the time of record review, the Maintenance Director acknowledged emergency generator transfer time for the most recent twelve month period was not available for review.

4. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. NFPA 99, Health Care Facilities, 3-4.1.1.4 requires generator sets installed as alternate power sources shall meet the requirements of NFPA 110, Standard for Emergency Standby Power Systems. NFPA 110, 3-5.5.6 requires Level II 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, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the 100 kW emergency generator located outside the building lacked a remote shut off device. Manufacturer's information affixed to the nameplate of the emergency generator indicated the unit was manufactured March 2007. Based on interview at the time of observation, the Maintenance Director acknowledged there was no remote shut off device for the emergency generator.

5. Based on record review, observation and interview; the facility failed to ensure documentation of the reliability for the offsite fuel source for 1 of 1 emergency generators was available for review. 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) Liquefied petroleum gas (liquid or vapor withdrawal)
c) Natural or synthetic gas
Exception: For Level 1 installations in locations where the probability of interruption of offsite 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 provision for automatic transfer from the primary energy source to the alternate energy source. This deficient practice could affect all clients, staff and visitors.
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 as well as staff and visitors.

Findings include:

Based on record review with the Registered Nurse Supervisor (RNS) and the Maintenance Director from 10:25 a.m. to 10:40 a.m. on 06/09/16, documentation of reliability from the offsite natural gas supplier for the emergency generator was not available for review. Based on observation with the Registered Nurse Supervisor (RNS) and the Maintenance Director during a tour of the facility from 10:40 a.m. to 11:55 a.m. on 06/09/16, the facility emergency generator is fueled by natural gas only. Based on interview at the time of record review and observation, the Maintenance Director stated the fuel source for the emergency generator was natural gas and acknowledged documentation of reliability from the natural gas provider was not available for review.

Based on observation and interview, the facility failed to provide emergency task lighting in and around 1 of 1 generator sets in accordance with NFPA 101, 2000 Edition, Life Safety Code. LSC Section 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 Section 5-3.1 requires the EPS (Emergency Power Supply) equipment location shall be provided with battery powered emergency lighting. This deficient practice could affect all residents as well as staff and visitors.

Findings include:

Based on observation on 06/09/16 at 3:15 p.m. with the Plant Director, the generator set location outside the north side of the building lacked battery powered emergency lighting in or around the generator. Based on interview concurrent with the observation was acknowledged by the Plant Director there was no battery powered emergency light available for the generator.

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 II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. 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 the shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation of generator equipment on 06/09/16 at 1:45 p.m. with the Plant Director, a remote shut off device was not found for the generator located at the southeast corner of the building. The generator were installed new after 2003 and would require an emergency stop. Based on interview concurrent with the observation with the Plant Director, it was acknowledged the facility was not aware a remote shut off for the generator was required.

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 234 of 234 patients. 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 "Alternate Life Safety Measures" with the Director and the Facility Manager during record review from 10:30 a.m. to 5:00 p.m. on 06/07/16, the written fire watch policy for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH) which is the authority having jurisdiction. Based on interview at the time of record review, the Director and the Facility Manager acknowledged the written fire watch policy for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH.

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 234 of 234 patients. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Alternate Life Safety Measures" with the Director and the Facility Manager during record review from 10:30 a.m. to 5:00 p.m. on 06/07/16, the written fire watch policy for the facility in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH) which is an authority having jurisdiction. Based on interview at the time of record review, the Director and the Facility Manager acknowledged the written fire watch policy for the facility in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH.

Based on record review and interview, the facility failed to document elevator inspections and maintain current Certificate of Inspection documentation from the State of Indiana for 2 of 4 elevators. This deficient practice could affect three patients, staff and visitors in the facility.

Findings include:

Based on record review with the Facility Manager 10:30 a.m. to 5:00 p.m. on 06/07/16, elevators identified as 113350 and 113352 each had an expiration date of 12/08/15 listed on Certificate of Inspection documentation from the State of Indiana. Based on interview at the time of record review, the Facility Manager stated additional elevator inspection documentation was not available for review and acknowledged each of the aforementioned elevators had expired Certificate of Inspection documentation from the State of Indiana.

Based on record review and interview, the facility failed to document elevator inspections and maintain current Certificate of Inspection documentation from the State of Indiana for 9 of 9 elevators. This deficient practice could affect nine patients, staff and visitors in the facility.

Findings include:

Based on record review with the Facility Manager 10:30 a.m. to 5:00 p.m. on 06/07/16, the elevator identified as 39657 had an expiration date of 01/18/16 listed on Certificate of Inspection documentation from the State of Indiana. The elevator identified as 39672 had an expiration date of 02/02/16 listed on Certificate of Inspection documentation from the State of Indiana. In addition, 03/19/16 was listed as the expiration date on Certificate of Inspection documentation for elevators identified as 39651, 39652, 39653, 39654, 39657, 39672 and 46486. Based on interview at the time of record review, the Facility Manager stated additional elevator inspection documentation was not available for review and acknowledged each of the aforementioned elevators had expired Certificate of Inspection documentation from the State of Indiana.