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Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include at a minimum, (1) The provision of subsistence needs for staff and residents, whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical, and pharmaceutical supplies. (ii) Alternate sources of energy to maintain - (A) Temperatures to protect resident health and safety and for the safe and sanitary storage of provisions; (B) Emergency lighting; (C) Fire detection, extinguishing, and alarm systems; and (D) Sewage and waste disposal. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, the emergency preparedness plan failed to address the provision of subsistence needs for staff and patients whether they evacuate or shelter in place. Based on interview at the time of record review, the Director of the In-patient Unit was not able to provide the documentation.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include a system to track the location of on-duty staff during and after an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the hospital must document the specific name and location of the receiving facility or other location in accordance with 42 CFR 482.15(b) (2). This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, the emergency preparedness plan included a system to track the location of sheltered patients in the hospital's care during and after an emergency; however, the plan did not address tracking of on-duty staff. Based on interview at the time of record review, the Director of the In-Patient Unit was not able to provide documentation regarding tracking of on-duty staff.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures included means to shelter in place for patients, staff, and volunteers who remain in the facility, in accordance with §482.15(b)(4)
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, documentation of a system to shelter in place for patients, staff, and volunteers who remain in the facility during an emergency was not provided. Based on interview at the time of record review, the Director of the In-Patient Unit was not able to provide documentation addressing a system to shelter in place.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals to address surge needs during an emergency in accordance with 42 CFR 482.15(b)(6).
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, the facility's plan did not address the use of volunteers in an emergency. Based on interview at the time of record review, the Director of the In-Patient Unit said she was not able to locate a policy for the use of volunteers in an emergency.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include the development of arrangements with other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services in accordance with 42 CFR 482.15(b)(7).
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, the emergency preparedness plan provided did not include policies and procedures for the development of arrangements with other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to patients. Based on interview at the time of record review, the Director of the In-Patient Unit stated she was not able to locate documentation of any arrangements with other provider to receive patients.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to ensure staff could demonstrate knowledge of emergency procedures Emergency Preparedness Program (EPP). The facility must do all of the following:
(i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
(iii) Maintain documentation of all emergency preparedness training.
(iv) Demonstrate staff knowledge of emergency procedures.
(v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures.
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, the facility failed to provide documentation of initial training or training of staff every 2-years in emergency preparedness. Based on interview with the Director of the In-Patient Unit, she stated she was not able to provide any documentation of training in the emergency preparedness policies or procedures.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to conduct exercises to test the emergency plan at least twice per year. The facility must do all of the following:
i. Participate in an annual full-scale exercise that is community-based; or
a. When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
b. an individual, facility-based. If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the facility is exempt from engaging in its next required full-scale community-based or individual, facility-based full-scale functional exercise for 1 year following the onset of the actual event.
ii. Conduct an additional exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
iii. Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, the facility was unable to provide documentation of two exercises within the past twelve months. Based on interview at the time of record review, the Director of the In-Patient Unit stated she was not able to locate any documentation of any exercises conducted.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

1) Based on record review, observation and interview; the facility failed to ensure 1 of 1 kitchen fire suppression system was inspected semiannually. NFPA 96, 2011 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 11.2.1 states Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices. Hood exhaust plenums, and the exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every six months. This deficient practice could affect kitchen staff.

Findings include:

Based on record review and interview with the Facilities Director from 9:27 a.m. to 1:44 p.m. and on observation and interview with the Facilities Director from 1:47 p.m. to 3:00 p.m. on 12/05/24, documentation was available of a service and inspection of the kitchen fire suppression system completed on 3/13/24; however, no documentation of any maintenance or inspection six months after was available for review. Based on observation with the Facilities Director, the kitchen contained a fire suppression system. Based on interview at the time of record review, the Facilities Director stated documentation was not available at the time of survey.

2) Based on record review and interview, the facility failed to ensure 1 of 1 kitchen exhaust systems was inspected semiannually. NFPA 96, 2011 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 11.4 states the entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. Table 11.4, Schedule for Inspection for Grease Buildup, requires systems serving moderate volume cooking operations shall be inspected semiannually. NFPA 96, 11.6.1 states, upon inspection, if the exhaust system is found to be contaminated with deposits from grease laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction. Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned, it shall not be coated with powder or other substances. When an exhaust cleaning service is used, a certificate showing the name of the servicing company, the name of the person performing the work, and the date of inspection or cleaning shall be maintained on the premises. This deficient practice could affect kitchen staff.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, documentation of the kitchen hood exhaust system cleaning or inspection was not available during the past twelve months. Based on interview at the time of record review, the Facilities Director said no documentation of the kitchen hood exhaust system cleaning or inspection was available at the time of survey.

These findings were reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually: a. Control unit trouble signals b. Remote annunciators c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.) d. Notification appliances e. Magnetic hold-open devices. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director from 9:27 a.m. to 1:44 p.m. on 12/05/24, no documentation could be provided regarding a visual semi-annual fire alarm system inspection. Based on interview at the time of record review, when the Facilities Director was asked if there was documentation of a visual semi-annual fire alarm system inspection he stated "Don't have that."

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 39.3.4.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually: a. Control unit trouble signals b. Remote annunciators c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.) d. Notification appliances e. Magnetic hold-open devices This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director, Director of Kosciusko County, Facility Regional Coordinator, Executive Director of North-East Region, Facilities Coordinator and the Facilities Administrative Assistant from 11:33 a.m. to 12:39 p.m. on 12/06/24, no documentation could be provided regarding a visual semi-annual fire alarm system inspection. Based on interview at the time of record review, when the Facilities Director was asked if there was documentation of a visual semi-annual fire alarm system inspection he stated, "Don't have that."

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 39.3.4.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually: a. Control unit trouble signals b. Remote annunciators c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.) d. Notification appliances e. Magnetic hold-open devices This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director, Executive Director of North-East Region, the Office Manager, Facilities Coordinator and the Facilities Administrative Assistant from 9:00 a.m. to 11:00 a.m. on 12/06/24, no documentation could be provided regarding a visual semi-annual fire alarm system inspection. Based on interview at the time of record review, when the Facilities Director was asked if there was documentation of a visual semi-annual fire alarm system inspection he stated, "Don't have that."

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to provide 1 of 1 correct written policy for the protection of patients 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 could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and the Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, the facility's fire watch plan titled "Fire Watch" stated "1. If the fire/sprinkler system becomes inoperable or placed in test mode, we must initiate a Fire Watch." The fire-watch plan failed to indicate when the system is out of service for 4 or more hours in a twenty-four-hour period, that the person(s) assigned to fire watch was to be trained, or that no other duties may be assigned to the person(s) conducting fire watch. Based on interview with the Director of the In-Patient Unit, when asked if the document provided was the fire watch plan or if there was anything additional to the fire watch plan, she stated the policy provided was the only plan.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on observation and interview, the facility failed to ensure that a complete automatic sprinkler system or documentation of fire retardant material was provided for 1 of 1 canvas canopies. NFPA 13-2010 Edition, Section 8.15.7.1 states sprinklers shall be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding 4 ft. (1.2 m) in width. Section 8.15.7.2 states sprinklers shall be permitted to be omitted where the canopies, roofs, porte-cocheres, balconies, decks, or similar projections are constructed with materials that are noncombustible or limited-combustible, or fire retardant. Textiles such as canvas used as an awning shall meet NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. This deficient practice could affect , staff and visitors using the service entrance.

Findings include:

Based on observation and interview with the Facilities Director from 1:47 p.m. to 3:00 p.m. on 12/05/24, there was a canvas canopy in excess of 4 feet in width not sprinkled and attached to the building outside of the kitchen and service entrance. Based on interview at the time of observation the Facilities Director acknowledged there was no sprinkler coverage for the canopy.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to ensure 1 of 1 automatic sprinkler piping systems was examined for internal obstructions where conditions exist that could cause obstructed piping as required by NFPA 25, 2011 Edition, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 14.2.1. Section 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 affects all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director from 9:27 a.m. to 1:44 p.m. on 12/05/24, no documentation was available to show that an internal pipe inspection had been completed in the past five years. Based on interview with the Facilities Director at the time of record review, he stated there was no documentation for an internal pipe inspection available at the time of survey.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to ensure 1 of 1 sprinkler piping systems was examined for internal obstructions where conditions exist that could cause obstructed piping as required by NFPA 25, as required by NFPA 13 Section 26.1 and LSC 101 Sections 39.1.3.2.2 and 9.7.1.1(1). NFPA 25, 2011 Edition, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 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 affects all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director, Director of Kosciusko County, Facility Regional Coordinator, Executive Director of North-East Region, Facilities Coordinator and Facilities Administrative Assistant from 11:33 a.m. to 12:39 p.m. on 12/06/24, no documentation was available to show that an internal pipe inspection had been completed in the past five years. Based on interview with the Facilities Director at the time of record review, he stated there was no documentation for an internal pipe inspection available at the time of survey.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

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 sprinkler system has to be placed out of service for ten or more hours in a twenty-four-hour period in accordance with LSC, Section 9.6.1.6. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and the Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, the facility's fire watch plan titled "Fire Watch" stated "1. If the fire/sprinkler system becomes inoperable or placed in test mode, we must initiate a Fire Watch." The fire-watch plan failed to indicate when the sprinkler system is out of service for 10 or more hours in a twenty-four-hour period, that the person(s) assigned to fire watch was to be trained, or that no other duties may be assigned to the person(s) conducting fire watch. Based on interview with the Director of the In-Patient Unit, when asked if the document provided was the fire watch plan or if there was anything additional to the fire watch plan, she stated the policy provided was the only plan.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on observation and interview, the facility failed to ensure 8 of 8 patient sleeping room doors had no impediment to closing and latching into the door frame and would resist the passage of smoke. LSC section 19.3.6.3.5 states: Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation and interview with the Facilities Director from 1:47 p.m. to 3:00 p.m. on 12/05/24, none of the patient sleeping rooms were provided with a latching device. Based on interview at the time of exit, the CEO/President stated the requirement for latching patient sleeping room doors in the in-patient facility was an issue the facility had discussions about from previous surveys and he believed there was a conflict in requirements with different authorities.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on observation and interview, the facility failed to ensure receptacles within 6 feet from a sink were provided with ground fault circuit interrupter (GFCI) protection against electric shock. LSC 39.5.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code. NFPA 70, NEC 2011 Edition at 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, states, ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location. (B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel. (1) Bathrooms, (2) Kitchens, (3) Rooftops, (4) Outdoors, (5) Sinks - where receptacles are installed within 1.8 m (6 ft.) of the outside edge of the sink. (6) Indoor wet locations, (7) Locker rooms with associated showering facilities, (8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect male patients, staff, and visitors using the public restroom in the basement.

Findings include:

Based on record review and interview with the Facilities Director, Director of Kosciusko County, Facility Regional Coordinator, Executive Director of North-East Region, Facilities Coordinator and Facilities Administrative Assistant from 12:40 p.m. to 2:00 p.m. on 12/06/24, there was an electric receptacle within 6 feet from a sink in the male public restroom located in the basement. The electric receptacle was not GFCI protected and did not trip when tested. Based on interview at the time of observation, the Facilities Manager and Facilities Coordinator agreed the electric receptacle was not GFCI protected. The Director of Kosciusko County stated the basement is used by the public for routine use.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to provide a written plan that addressed all components in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, the fire safety plan titled "Fire" failed to provide all of the required information. The plan failed to address: Transmission of alarm to fire department, Isolation of fire, or Extinguishment of fire. Based on interview with the Director of the In-Patient Unit, when asked if the document provided was the fire safety plan or if there was anything additional to the fire safety plan, she stated the policy provided was the only plan.


This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on record review and interview, the facility failed to conduct fire drills on each shift for 2 of 4 quarters. LSC 19.7.1.6 states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, the following shifts were missing documentation of a completed fire drill: a) A first shift fire drill in the second quarter of 2024. b) A second shift fire drill in the third quarter of 2024. Based on interview at the time of record review, the Facilities Director stated no additional documentation of fire drills was available.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on observation, records review, and interview, the facility failed to ensure annual inspection and testing of 2 of 2 fire door assemblies were completed in accordance with LSC 19.1.1.4.1.1. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states 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. NFPA 80, 5.2.3.1 states functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, no annual inspection of the fire door assemblies for Room 503 identified as "Linen Supply" and Room 502 identified as "Laundry Room" were available for review. Based on observation from 1:47 p.m. to 3:00 p.m. on 12/05/24, the fire door assemblies were in a two hour fire barrier. Based on interview at the time of records review, the Facilities Director acknowledged an annual inspection was not conducted for the fire door assemblies in the last year and confirmed the doors were in a two hour fire barrier as identified in the floor plan provided by the facility.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on observation, record review and interview, the facility failed to ensure all nonhospital-grade electrical receptacles at resident room locations were tested at least annually. NFPA 99, Health Care Facilities Code 2012 Edition, 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, staff and visitors.

Findings include:

Based on observation with the Facilities Director from 1:47 p.m. to 3:00 p.m. on 12/05/24, 3 of 8 resident sleeping rooms contained non-hospital grade electrical receptacles. Based on record review and interview no documentation of annual testing per NFPA 99, Receptacle Testing requirements was available for review at the time of survey.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

1) Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 5 of the last 12 months. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110 8.4.2 requires diesel generator sets in service to be exercised at least once monthly, for a minimum of 30 minutes. Chapter 6.4.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, no documentation of monthly generator load testing was available for March 2024 or April 2024; documentation of monthly generator load tests for June 2024, July 2024, and August 2024 only stated "Pass" with no other information available. Based on an interview at the time of record review, the Facilities Director stated the facility contracts the service and acknowledged the missing and incomplete documentation.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

3.1-19(b)

2) Based on record review, observation, and interview; the facility failed to document a 36-month period emergency generator testing for 1 of 1 emergency generators in accordance with NFPA 99 and NFPA 110. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.4.1.1.6.1 states Type 1 and Type 2 essential electrical system power sources (EPSS) shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110. NFPA 110, the Standard for Emergency and Standby Powers Systems, 2010 Edition, Section 8.4.9 states Level 1 EPSS shall be tested at least once within every 36 months. Section 8.4.9.1 states Level 1 EPSS shall be tested continuously for the duration of its assigned class (See Section 4.2). Section 8.4.9.2 states where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours. Section 8.4.9.5 states the minimum load for this test shall be specified in 8.4.9.5.1, 8.4.9.5.2, or 8.4.9.5.3. Section 8.4.9.5.3 states for spark-ignited EPS's, loading shall be the available EPSS load. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on record review and interview with the Facilities Director and Director of the In-Patient Unit from 9:27 a.m. to 1:44 p.m. on 12/05/24, no documentation of a thirty-six-month period emergency generator load test for four continuous hours for the diesel emergency generator was available for review. Based on interview at the time of record review, the Facilities Director stated the facility contracts the generator service and acknowledged no documentation was available at the time of survey. Based on observation with the Facilities Director the facaility has a 150kw diesel emergency generator located outside the building.

3) Based on record review and interview, the facility failed to exercise the generator annually to meet the requirements of NFPA 110, 2010 Edition, the Standard for Emergency and Standby Powers Systems, Chapter 8.4.2. Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS (Emergency Power Supply) nameplate kW rating.
Section 8.4.2.3 states diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS (Emergency Power Supply System) load and shall be exercised annually with supplemental loads (Load Bank Test) at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. This deficient practice could affect all occupants.

Findings include:

Based on record review and interview with the Facilities Director from 9:27 a.m. to 1:44 p.m. on 12/05/24, the load percentage recorded on May 22, 2024, was 10 percent, the load percentage recorded on February 22, 2024, was 15 percent, the load percent recorded on October 18, 2024, was 5 percent. Based on interview at the time of record review, the Facilities Director acknowledged the documentation and stated, "I would dispute the load percentage."

These findings were reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 1 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 only.

Findings include:

Based on observation with the Facilities Director from 1:47 p.m. to 3:00 p.m. on 12/05/24, there was a power strip located under the nurses station desk, used to power computer equipment, but it was dangling from the connected power cords. This condition could put stress on the power cord causing damage to the power cord. Based on interview at the time of observation, the Facilities Director confirmed that the power strip was dangling.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.

Based on observation and interview, the facility failed to ensure power strips were not used as a substitute for fixed wiring in staff only areas. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 2011 Edition. NFPA 70, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect staff in the lab.

Findings include:

Based on observation with the Facilities Director, Executive Director of North-East Region, the Office Manager, Facilities Coordinator and the Facilities Administrative Assistant from 10:00 a.m. to 11:00 a.m. on 12/06/24, a refrigerator was plugged into a power strip in the Lab. Based on interview at the time of observation, the Facilities Director acknowledged the use of the power strip to supply power to the refrigerator and disconnected the refrigerator and relocated it to another wall and plugged the refrigerator directly into a wall receptacle.

This finding was reviewed with the President/CEO, Facilities Director, Facilities Regional Coordinator, Facilities Coordinator, Facilities Administrative Assistant, Executive Director of North-East Region, Director of Kosciusko County, and other executive staff at the exit conference.