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Based on observation and interview, the facility failed to ensure 1 of 2 cooler/freezer doors in the kitchen were able to open from the inside if locked. LSC 19.2.2.1 states doors complying with 7.2.1 shall be permitted. 7.2.1.5.1 Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied. This deficient practice could affect staff in the kitchen.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 1:12 p.m., the walk in cooler and freezer had doors that could be locked with a deadbolt from the outside and had a deadbolt release on the inside to open the doors if lock. When tested, the deadbolt release on the cooler door did not work. This condition could trap a person inside the cooler if locked from the outside. Based on interview at the time of observation, the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician agreed the cooler deadbolt release was not working and stated the deadbolt release would need to be repaired or removed.

Based on record review and interview, the facility failed to ensure 2 of 2 battery backup lights were tested annually for 90 minutes over the past year to ensure the lights would provide lighting during periods of power outages and a written record of visual inspections and tests was provided. Section 7.9.3.1.1 (1) requires functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants in the facility.

Findings include:

Based on record review with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 10:43 a.m., no annual testing for the emergency battery powered light at the generator and inside the kitchen was available for review. Based on an interview at the time of record review, the Director of Plant Operations stated they knew the test was past due and hired a new company to conduct the annual testing of the emergency lighting.

1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control panel was protected from unauthorized access. LSC states existing life safety features obvious to the public, if not required by the Code, shall be maintained. LSC 9.6.1.3 states fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70 and NFPA 72. NFPA 72 2010 edition, National Fire Alarm and Signaling Code Section 10.10.1 states a means for turning off activated alarm notification appliance(s) shall be permitted only if it complies with 10.10.3 through 10.10.7. Section 10.10.3 states the means shall be key-operated or located within a locked cabinet, or arranged to provide equivalent protection against unauthorized use. This deficient practice could affect all occupants.

Findings include:

Based on observation during a tour of the facility with the Rehab Service Manager, Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/23/19 at 9:15 a.m., the fire control panel located in the entrance to building 2312 was in a cabinet but the door to the cabinet was partially open and the key was in the lock. Based on interview at the time of observations, the Rehab Service Manager, agreed the cabinet door to the fire control panel was not properly locked and the key was stored in the lock on the cabinet door.

2. Based on observation and interview, the facility failed to ensure the spray pattern for 1 of 1 sprinkler head in the electrical closet were not obstructed. LSC 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall be maintained. LSC 9.7.1.1 states each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 2010 edition, Section 8.5.5.1 states sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2 and 8.5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Sections 8.5.5.2 and 8.5.5.3 do not permit continuous or non-continuous obstructions less than or equal to 18 inches below the sprinkler deflector or in a horizontal plane more than 18 inches below the sprinkler deflector that prevent the spray pattern from fully developing. This deficient practice could any occupant near the electrical closet.

Findings include:

Based on observation during a tour of the facility with the Rehab Service Manager, Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/23/19 at 9:45 a.m., in the electrical closet there was a pendant sprinkler above the ceiling tiles. This condition would cause the ceiling tile to obstruct the spry pattern on the sprinkler head. Based on interview at the time of observation, the Rehab Service Manager stated the sprinkler head was obstructed and need to be lowered.

3. Based on record review and interview, the facility failed to provide 1 of 1 written policy for the protection of residents indicating procedures to be followed in the event the fire alarm system has to be placed out of service for more than four hours and the sprinkler system has to be placed out of service for four more than ten hours in a 24 hour period in accordance with LSC 9.7.5. and LSC 9.7.6. LSC 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall be maintained. This deficient practice affects all occupants.

Findings include:

Based on observation during a tour of the facility with the Rehab Service Manager, Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/23/19 at 9:05 a.m., the facility did not provide a fire watch policy during the day of survey. Based on interview during the record review, the Rehab Service Manager stated they would close the facility if the fire protection systems were down but there was no written policy to indicate the facility's procedures.

Based on record review and interview, the facility failed to provide 1 of 1 correct written policy for the protection of residents indicating 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 twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on record review with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 11:20 a.m., the provided fire watch documentation did not contain the following required information:
a) Only individuals trained on fire watch procedures shall conduct a fire watch.
b) The person(s) conducting the fire watch will have no other duties.
c) How often fire watch rounds are conducted.
d) Contacting the facility's monitoring company, administration, insurance company, and Indiana State Department of Health when a fire watch is initiated.
Based on interview during the record review, the Director of Plant Operations, Manager of Plant Operations agreed the facility's fire watch policy was missing the aforementioned information.

1. Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with 19.3.5.3. NFPA 25, 2011 Edition, 14.2.1 states except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 11:12 a.m., the internal inspection of piping documentation from Simplex Grinnell stated the last inspection was completed on 01/15/14. Based on interview at the time of record review, the Director of Plant Operations, Manager of Plant Operations agreed the last internal inspection performed has been more than five years and stated they are scheduling a new internal pipe inspection.


2. Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. NFPA 25, 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly and gauges on dry systems (5.2.4.2) shall be inspected weekly to ensure normal water or air pressure is being maintained. NFPA 25 13.3.2.1 states valves should be inspected weekly or valves secured locks or supervised (13.3.2.1.1) shall be permitted to be inspected monthly. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 11:13 a.m., there was no monthly inspection of the wet pipe sprinkler system's gauges and valves available for review. During an interview at the time of record review, the Lead Maintenance Technician stated the inspection of gauges and valves are not recorded.

3. Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems were provided with a spare sprinkler cabinet that fits all spare sprinkler heads. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers on the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. This deficient practice could affect all occupants.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 1:57 p.m., in the riser room there were two concealed type sprinkler heads sitting on top of the sprinkler storage cabinet. The spare sprinkler cabinet was not design to store concealed sprinkler heads only pendant sprinkler head. This condition does not protect the concealed sprinkler heads from damage. Based on interview at the time of the observations, the Director of Plant Operations agreed the cabinet was not for concealed sprinkler heads and were placed on top of the cabinet.

4. Based on observation and interview, the facility failed to maintain the ceiling construction of 1 of 1 maintenance shops. Ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice affects staff.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 2:45 p.m., in the maintenance shop the ladder opening that went to the roof did not have ceiling tiles or a smoke resistive barrier covering the opening. The sprinkler head measured 17 feet below the top of the opening. This condition could delay the activation of the sprinkler head in event of a fire. Based on interview at the time of the observations, the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician agreed there was no cover to the opening and provide the distance between the top of the opening to the sprinkler head.

Based on record review and interview, the facility failed to provide 1 of 1 correct written policies in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.6 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. A.15.5.2 (4) (b) states a fire watch should consist of trained personnel who continuously patrol the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. This deficient practice could affect all occupants in the facility.

Findings include:

Based on record review with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 11:20 a.m., the provided fire watch documentation did not contain the following required information:
a) Only individuals trained on fire watch procedures shall conduct a fire watch.
b) The person(s) conducting the fire watch will have no other duties.
c) How often fire watch rounds are conducted.
d) Contacting the facility's monitoring company, administration, insurance company, and Indiana State Department of Health when a fire watch is initiated.
Based on interview during the record review, the Director of Plant Operations, Manager of Plant Operations agreed the facility's fire watch policy was missing the aforementioned information.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 2 of 5 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. LSC Section 8.5.2.1 requires smoke barriers to be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.6.2 requires penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the movement of smoke. This deficient practice could affect staff and at least 10 patients in three smoke compartments.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 between 12:30 p.m. and 3:00 p.m., the following unsealed penetrations were discovered:
a) Above the drop ceiling of the SB5 smoke wall there was a six inch pipe sleeve not sealed at the end.
b) Above the drop ceiling of the SB5 smoke wall there were two dry wall patches covering holes but the edges of the drywall patches were not sealed leaving 1/16 inch gap.
c) Above the drop ceiling of the SB10 smoke wall there was a six inch pipe sleeve not completely sealed at the end.
d) Above the drop ceiling of the SB5 smoke wall there were two dry wall patches covering holes but the edges of the drywall patches were not sealed leaving 1/16 inch gap.
Based on interview at the time of observation, the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, acknowledged each aforementioned condition and provided the measurements of the unsealed penetrations.

Based on observation and interview, the facility failed to ensure 1 of 1 electrical wiring did not contain exposed wires. LSC 39.5.1 states utilities shall comply with the provisions of Section 9.1. LSC 9.1.2 states electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70, 2011 Edition. Article 406.5 (F) Exposed Terminals, states receptacles shall be enclosed so that live wiring terminals are not exposed to contact. This deficient practice affects staff in the maintenance office.

Findings include:

Based on observation during a tour of the facility with the Rehab Service Manager, Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/23/19 at 9:35 a.m., in the maintenance office the light fixture hanging from the ceiling contained exposed wires hanging down form the light. Based on interview at the time of observation, the Lead Maintenance Technician stated the light was under repaid and would replace the light.

Based on observation and interview, the facility failed to maintain annual testing of 2 of 2 rolling fire doors in accordance of NFPA 80. LSC 4.5.8 requires any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance. NFPA 80 5.2.1 requires fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. This deficient practice could affect all occupants in the dining room.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 1:19 p.m., there were two rolling fire doors/windows between the kitchen and dining hall. The tags on the rolling fire doors indicated the last annual test was performed in April 2017. Based on interview at the time of observation, the Director of Plant Operations stated the fire doors/windows were past due and the facility was looking into removing them.

Based on observation, record review and interview, the facility failed to ensure electrical receptacles at 17 of 17 patient care locations were tested at least in accordance with NFPA 99. NFPA 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.1 states where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. Section 6.3.4.1.3 states receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. Additionally, Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). This deficient practice could affect all patients.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 between 1:05 p.m. and 3:00 p.m., the facility's 17 patient care rooms contained two red hospital grade receptacles and two white standard receptacles. Based on record review at 10:32 a.m., no documentation was available to show electrical receptacles in resident rooms were tested annually nor initial testing for the hospital grade receptacles. Based on interview at the time of the observations and records review, the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant indicated half of the electrical receptacles in the resident care areas were not hospital-grade and the other half were. The Director of Plant Operations stated there was no documentation of annual testing or initial testing per NFPA 99, Receptacle Testing requirements.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generator annunciator panel was readily observed by operating personnel. This deficient practice could affect all the patients, as well as staff and visitors in the facility.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 1:50 p.m., the generator's annunciator panel was located inside the maintenance shop behind closed doors. The Maintenance shop is only occupied during business hours and not located in an area that is continually observed by staff. This condition would not alert staff if there was a generator malfunction. Based on interview at the time of observation, the Maintenance Technician One stated due to census the rehab unit was closed down and the generator's annunciator panel was no longer in a location that was occupied by staff throughout all shifts.

1. Based on observation and interview, the facility failed to ensure 1 of 1 flexible cords in the dining hall did not provide power to equipment with a high current draw. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used for (1) as a substitute for fixed wiring. This deficient practice could affect up to 15 patients in one smoke compartment.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 1:20 p.m., in the Dining hall a microwave, high current draw equipment, was plugged into and supplied power by an extension cord and power strip. Based on interview at the time of observation, the Director of Plant Operations and Manager of Plant Operations agreed a microwave was plugged into a power strip.

2. Based on observation and interview, the facility failed to ensure 2 of 2 flexible cords were installed properly and used in a safe manor. NFPA 99, Section 10.2.4.2 states adapters and extension cords meeting the requirements of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted. Section 10.2.4.2.3 states the cabling shall comply with 10.2.3. Section 10.2.3.5.1 states cord strain relief shall be provided at the attachment of the power cord to the appliance so that mechanical stress, either pull, twist, or bend, is not transmitted to internal connections. This deficient practice could affect staff in the Project Access office.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 2:13 p.m., in the corner office of the Project Access Offices a power strip was used to power IT equipment. The power strip was not secured and dangling from the equipment on the wall. Also, a second power strip was plugged into the power strip hanger from IT equipment. This condition could cause physical damage and cause overloading of the power strips. Based on interview at the time of observation, the Director of Plant Operations agreed a power strip was dangling, not secured, and had a second power strip plugged into it.

Based on observation and interview, the facility failed to ensure 1 of 1 manifolds for gas cylinders systems were stored in an enclosure used only for the intended purpose. NFPA 99 (2012 edition) 5.2.3.4, states Category 2 central supply systems shall comply with section 5.1.3.5. Section 5.1.3.5.10.1 states the manifolds in this category shall be located in accordance with 5.1.3.3.1 and shall meet the following:
(1) If located outdoors, they shall be installed in an enclosure used only for this purpose and sited to comply with minimum distance requirements in NFPA 55.
(2) If located indoors, they shall be installed within a room used only for enclosure of such manifolds.
This deficient practice could affect mostly staff, visitors and delivery personnel outside the back of the building.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 1:45 p.m., there was a concrete block enclosure outside the back of the facility with seven H size oxygen tanks and seven large liquid medical oxygen tanks that were part of the facility's piped medical gas system that was within 15 feet from the diesel-powered generator. Based on interview at the time of observation, Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician acknowledged the piped medical gas supply system was in the same enclosure as the generator and not exclusively in its own enclosure.

1. Based on observation and interview, the facility failed to ensure a minimum distance of at least five feet separated combustible materials from oxygen storage equipment in 1 of 1 oxygen storage areas. NFPA 99, 11.3.2.3 requires oxidizing gases such as oxygen shall be separated from combustibles by one of the following: (1) a minimum distance of 20 feet. (2) a minimum distance of 5 feet if the required storage location is protected by an automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour. This deficient practice could affect staff in and around the oxygen trans-filling room.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 10:10 a.m., in the oxygen trans-filling room the liquid oxygen containers were next to a wooden cover on the floor and the trim around the bottom of the room was constructed of vinyl that was falling off and loose in spots. Based on interview at the time of observation, the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician agreed a combustible cover and wall trim were within five feet of stationary liquid oxygen containers.

2. Based on observation and interview, the facility failed to ensure 1 of 1 oxygen storage/transfer procedures comply with 11.5.2.3 Trans-filling Liquid Oxygen. Trans-filling of liquid oxygen shall comply with 11.5.2.3.1 or 11.5.2.3.2, as applicable. 11.5.2.3.1 Trans-filling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa (50 psi) shall include the following:
(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.
(2) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring.
(3) The area is posted with signs indicating that Trans-filling is occurring and that smoking in the immediate area is not permitted.
(4) The individual Trans-filling the container(s) has been properly trained in the Trans-filling procedures.
This deficient practice could affect staff in and around the oxygen trans-filling room.

Findings include:

(A) Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 10:15 a.m., the oxygen storage/transfer room had liquid oxygen containers and was used for the trans-filling of oxygen. The door to this room lacked a sign indicating when transferring of oxygen occurs at this location.
(B) Based on record review with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 11:45 a.m., the new hire staff training documentation provided did not indicate if the individual trans-filling containers had been properly trained in the trans-filling procedures. Also, the Liquid oxygen filling policy stated not to fill portables in close proximity and away from the patient instead of in a designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.
Based on interview at the time of observation, the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician agreed the oxygen storage/transfer room lacked a sign stating when the trans-filling of oxygen occurs, and the policy did not indicate filling in a room separated from other areas of the facility.

3. Based on observation and interview, the facility failed to ensure 1 of 1 electrical outlets in the oxygen trans-filling room was protected. 2012 NFPA 99 Health Care Facilities Code 5.1.3.3.2 (5) and 5.1.3.3.2 (10) both requires locations for central supply systems and the storage of positive-pressure gases to protect electrical devices from physical damage. A.5.1.3.3.2 (5) states electrical devices should be physically protected, such as by use of a protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing physical damage to the cylinders or containers. For example, the device could be located at or above 5 feet above finished floor or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device as required by this section.
This deficient practice could affect staff in and around the oxygen trans-filling room.

Findings include:

Based on observation during a tour of the facility with the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, and the Administrative Assistant on 05/22/19 at 10:15 a.m., there was one electrical outlet and a light switch on the wall in the oxygen trans-filling room under 5 feet from the ground with only a plastic cover plate installed. Based on interview at the time of observation, the Director of Plant Operations, Manager of Plant Operations, Lead Maintenance Technician, acknowledged the electrical outlet and light switch was not protected by a protective barrier and was less than 5 feet above the floor.