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Based on observation and interview, the facility failed to ensure exit access was arranged so 2 of 15 exits were readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. Such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affect residents using the Men's Wing 400 Hall exit and the Adolescent Living Unit patio door if the facility were required to evacuate in an emergency.

Findings include:

Based on observations with the Director of Quality Improvement and Risk Management during a tour of the facility from 1:00 p.m. to 4:15 p.m. on 12/01/10, the Men's Wing 400 Hall exit door led to a grass covered lawn and the Adolescent Living Unit patio door exit led to a concrete patio next to the building, and neither led to a public way. Based on interview at the time of observations, the Director of Quality Improvement and Risk Management acknowledged each exit did not lead to a public way.

3.1-19(b)

Based on record review, observation and interview; the facility failed to provide metal containers with self closing cover devices into which ashtrays can be emptied in 2 of 2 outdoor resident smoking areas. This deficient practice affects all residents in the vicinity of the Room 311 lounge outdoor smoking area and the Room 412 lounge outdoor smoking area.

Findings include:

Based on review of "Smoking Policy" documentation with the Director of Quality Improvement and Risk Management during record review from 10:00 a.m. to 12:00 p.m. on 12/01/10, only residents are allowed to smoke outside in designated outdoor resident smoking areas. Based on observation with the Director of Quality Improvement and Risk Management during a tour of the facility from 1:00 p.m. to 4:15 p.m. on 12/01/10, the Room 311 lounge outdoor smoking area and the Room 412 lounge outdoor smoking area each have a one foot tall by one foot in diameter metal bucket filled with sand with no self closing cover device which is used as an ashtray, and as a device into which ashtrays can be emptied. Each metal bucket was observed with twenty or more cigarette butts extinguished in the bucket. Based on interview at the time of observation, the Director of Quality Improvement and Risk Management acknowledged the buckets are used as ashtrays and as a device to store extinguished cigarette butts and stated the facility will revise its current smoking policy to be smoke free by January 1, 2011.

3.1-19(b)

Based on observation and interview, the facility failed to ensure the minimum clearance between 1 of 1 deep fryers and the natural gas fired stove in the facility kitchen was maintained. LSC 19.3.2.6 states cooking facilities shall be protected in accordance with 9.2.3. 9.2.3 states commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation and Fire Protection of Commercial Cooking Operations. NFPA 96 Chapter 9-1.2.3 states all deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames from adjacent cooking equipment. Exception: Where a steel or tempered glass baffle plate is installed at a minimum of 8 inches in height between the fryer and surface flames of the adjacent appliance. This deficient practice affects all kitchen staff.

Findings include:

Based on observation with the Director of Quality Improvement and Risk Management during a tour of the facility from 1:00 p.m. to 4:15 p.m. on 12/01/10, the deep fryer in the facility kitchen was sitting right next to the natural gas fired stove, and did not have a baffle installed between each cooking device. Based on interview at the time of observation, the Director of Quality Improvement and Risk Management acknowledged the deep fryer is less than sixteen inches from the natural gas fired stove and does not have a baffle placed between each cooking device.

3.1-19(b)

Based on record review, observation, and interview; the facility failed to ensure 1 of 1 space heaters was equipped with heating elements not exceeding 212 degrees Fahrenheit (F). This deficient practice affects all residents, staff and visitors in the vicinity of Room 420.

Findings include:

Based on interview at the time of record review with the Director of Quality Improvement and Risk Management from 10:00 a.m. to 12:00 p.m. on 12/01/10, the facility has no written space heater policy but does not allow portable space heaters to be used in the facility. Based on observation with the Director of Quality Improvement and Risk Management during a tour of the facility from 1:00 p.m. to 4:15 p.m. on 12/01/10, one portable space heater with a metal coil glowing red was observed in operation in Room 420 which is a nonsleeping staff room. Based on interview at the time of observation, the Director of Quality Improvement and Risk Management acknowledged a space heater was being utilized in Room 420 without documentation of the heating element operating temperature.

3.1-19(b)

Based on observation and interview, the facility failed to ensure 1 of 15 means of egress was continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice could affect any resident using the Adolescent Transitional Living Unit rear exit as well as staff and visitors.

Findings include:

Based on observation with the Director of Quality Improvement and Risk Management during a tour of the facility from 1:00 p.m. to 4:15 p.m. on 12/01/10, the Adolescent Transitional Living Unit rear exit had one picnic table less than five feet from the rear exit door blocking the path of egress to the outside of the facility. Based on interview at the time of observation, the Director of Quality Improvement and Risk Management acknowledged the picnic table blocked the exit path for discharge from the Adolescent Transitional Living Unit rear exit.

3.1-19(b)

Based on record review, observation and interview; the facility failed to provide written documentation of the flame resistance for window curtains in 12 of 12 Adolescent Transitional Living Unit rooms. LSC 10.3.1 states curtains shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. This deficient practice could affect all residents, staff and visitors in the Adolescent Transitional Living Unit.

Findings include:

Based on interview at the time of record review with the Director of Quality Improvement and Risk Management from 10:00 a.m. to 12:00 p.m. on 12/01/10, the facility has no written documentation of the flame resistance for window curtains. Based on observation with the Director of Quality Improvement and Risk Management during a tour of the facility from 1:00 p.m. to 4:15 p.m. on 12/01/10, window curtains in twelve Adolescent Transitional Living Unit rooms were observed with no documentation of the flame resistance for each curtain. Based on interview at the time of observation, the Director of Quality Improvement and Risk Management stated the facility sprays the curtains at regular intervals with a flame resistance coating but does not keep a written record of resistance coatings applications.

3.1-19(b)

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

Findings include:

Based on interview at the time of record review with the Director of Quality Improvement and Risk Management from 10:00 a.m. to 12:00 p.m. on 12/01/1, the Director of Quality Improvement and Risk Management acknowledged the facility has no reliability letter from the natural gas supplier.

3.1-19(b)

2. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires a remote annunciator, storage battery powered, shall be provided to operate outside of the generator location in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
1. Low lubricating oil pressure.
2. Low water temperature.
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overcrank (failed to start).
6. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur but need not display these conditions individually. This deficient practice could affect all residents as well as visitors and staff.

Findings include:

Based on observation with the Director of Quality Improvement and Risk Management during the tour of the facility from 1:00 p.m. to 4:15 p.m., the one emergency generator located outside the facility did not have an alarm annunciator in a location readily observed by operating personnel at all times. Based on interview at the time of observation, the Director of Quality Improvement and Risk Management acknowledged there is one alarm annunciator for the emergency generator located in the Manager of Environmental Services office but the annunciator is not located in an area of the facility readily observed by operating personnel at all times.

3.1-19(b)