Franciscan Health Rensselaer, Inc.

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 14445 Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with LSC 9.6.1.3, failed to maintain 1 of 1 automatic sprinkler systems, failed to ensure 1 of 1 storage corridor doors on the third floor was provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke, failed to ensure penetrations through 1 of 1 smoke barrier wall was protected to maintain the smoke resistance of each smoke barrier, failed to ensure 1 of 6 sets of barrier doors in the basement area would restrict the movement of smoke for at least 20 minutes. , and failed to ensure 9 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills for the last 4 quarters. The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care in a safe environment.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 14445 Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with LSC 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, Section 14.2.1.2.2 requires that system defects and malfunctions shall be corrected, failed to maintain 1 of 1 automatic sprinkler systems. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test and maintenance required by this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request, failed to ensure 1 of 1 storage corridor doors on the third floor was provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke, failed to ensure penetrations through 1 of 1 smoke barrier wall was 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, failed to ensure 1 of 6 sets of barrier doors in the basement area would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.8 requires doors in smoke barriers shall comply with LSC Section 8.5.4. LSC 8.5.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation, and failed to ensure 9 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Findings include: Based on observations with the Maintenance Supervisor between 09:37 a.m. and 2:34 p.m., the fire alarm control panel had a trouble notification illuminated on the main fire panel. The panel stated listed the trouble as “1FL FSD OR CORR O/S SUB-STER.” Based on interview at the time of observation, the Maintenance Supervisor stated that an actuator for a fire/smoke damper in the sub-sterile room of the operating room was bad and has been awaiting parts to fix the device. Paperwork had been obtained from the facility indicating both the facility and alarm company know about the aforementioned condition. The Maintenance Supervisor later confirmed that the panel is still in trouble and the device still has not been fixed. Based on review of the facility’s quarterly sprinkler system inspection reports on 11/13/23 at 10:10 a.m. with the Maintenance Supervisor present, the quarterly sprinkler report dated 09/19/23 stated “Anti-freeze tested and indicate correct freeze points in the system - FAIL”. When asked if he could show documentation that they had the anti-freeze added to the system, the Maintenance Supervisor stated that they had not seen that item on the aforementioned sprinkler system inspection. Based on further interview at the time of record review, the Maintenance Supervisor stated the anti-freeze has not yet been replaced. Based on observation and interview, the facility failed to maintain the ceiling construction of 1 of 1 CT rooms. The 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. Based on observations during a tour of the facility with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the suspended ceiling of the CT room had a ceiling tile with an approximately four inch hole around a machine that had a pipe running through the ceiling which can lead to a potential delayed response to the nearby sprinkler head. Based on interview at the time of observation, the Maintenance Director stated that the hole does have an escutcheon plate to fill in the space of the ceiling tile, however the plate had slid down the pipe and left the ceiling above the tile exposed. The Maintenance Director confirmed the aforementioned issues. Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems were provided with spare sprinklers, a spare sprinkler cabinet large enough to fit all spare sprinkler heads, and a sprinkler wrench on the premises. 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. Based on observation with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the spare sprinkler cabinets in the riser room were not large enough to contain all sprinkler heads and prevent damage to the sprinkler heads. When the cabinet in riser room was opened, the cabinet contained more sprinkler heads than spots available. Approximately twenty sprinkler heads were unsecured on-top and inside of the sprinkler cabinets. Based on interview at the time of the observations, the Maintenance Supervisor agreed the two cabinets were not large enough to contain all spare sprinkler heads. Based on observation with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the storage double doors across from the third floor nurses station did not latch. The inactive leaf of the door set had a latching device, however when closed, the door would not self-latch or engage after testing three times. Based on interview at the time of observation, the Maintenance Supervisor stated that they were unaware of the issue and agreed the inactive door did not self-latch. The latch was fixed during the survey. Based on observation and interview, the facility failed to ensure 1 of over 100 corridor doors were provided with a means suitable for keeping the door closed, had no impediment to closing, latching, and would resist the passage of smoke. This deficient practice could affect as many as 4 staff. Based on observations made with the Maintenance Supervisor during a tour of the facility at 3:04 p.m. on 12/13/23, the corridor door for the Oncology Suite in the basement had a self-closing device on the corridor door. This door was propped in the open position with flip down door wedge. Based on interview at the time of observation, the Maintenance Director acknowledged the aforementioned corridor door to a patient care area was propped and held in the fully open position with a flip down door wedge. Based on observations with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., above the drop ceiling of the smoke wall separating the old OB wing and the old Alternacare dining room had an approximate half inch gap around conduit that was run through the fire/smoke wall. Based on interview at the time of observation, the Maintenance Supervisor agreed there where unsealed penetrations in the smoke barriers and would seal up the penetrations. Based on observations made with the Maintenance Supervisor during a tour of the facility at 2:56 p.m. on 12/13/23, the set of barrier doors leading to “the old addition” or door set #056272 did not close completely due to air pressure from one side of the doors. There was a one-inch gap between the doors when closed to their fullest. Based on interview during the time of observations, the Maintenance Supervisor acknowledged these smoke barrier doors did not close completely due to air pressure pushing one door slightly open and added that he would adjust the self-closing devices to make sure that they closed fully in an emergency situation. Based on record review of the facility’s fire drill document entitled “Fire Drill Report” with the Maintenance Supervisor present, the documentation for the drills for January 2023 through September of 2023 lacked verification of the transmission of the signal for drills. Based on interview at the time of record review, the Maintenance Supervisor stated that he would advise the Security Department to request from the monitoring company confirmation of the signal being received during his fire drills.”

“A Life Safety Code Recertification Survey for a Critical Access Hospital was conducted by the Indiana Department of Health in accordance with 42 CFR 485.623(c). Survey Date: 12/13/23 Facility Number: 005072 Provider Number: 151324 AIM Number: 201355970 At this Life Safety Code survey, Franciscan Health Rensselaer, Inc., was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 editions of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) and NFPA 99, Health Care Facilities Code (HCFC). Franciscan Health Rensselaer is comprised of the main Critical Access Hospital in Rensselaer, IN (Building 01) and Franciscan Health & Fitness, located in Wheatfield, IN (Building 02). Franciscan Health Rensselaer main building, Building 01, is a multiple story partially sprinklered Critical Access Hospital of Type II (222) construction. The initial building, including the basement and floors 1-3, was built in 1962. Subsequent additions include the Emergency Department in 1982; the Oncology and OR sections in 2011. The building has a monitored fire alarm system with smoke detection in the corridors and spaces open to the corridors. Building 01 provides overnight care. The building has emergency power provided by three diesel-powered generators. It is a Residential Care facility which was not included in this survey. It is separated from Building 01 by Floor/Ceiling Assemblies with a 2 Hour Fire Resistance Rating and a Fire Wall with a 2 Hour Fire Resistance Rating. Building 01 which has a capacity of 25 and had a census of 9 at the time of this survey, was surveyed with Chapter 19, Existing Health Care Occupancies and Chapter 39, Existing Business Occupancies. Franciscan Health & Fitness, Building 02, which was built in 1981, is a single story building of Type V(000) construction. It is an out-patient facility providing physical and speech therapy. It has a monitored fire alarm system with heat detection and fire suppression in the mechanical room, and manual pull stations located at exits. Building 02 was surveyed with Chapter 39, Existing Business Occupancies. Quality Review completed on 12/20/23”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 46051 Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with LSC 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, Section 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. This deficient practice could affect all occupants. Findings include: Based on observations with the Maintenance Supervisor between 09:37 a.m. and 2:34 p.m., the fire alarm control panel had a trouble notification illuminated on the main fire panel. The panel stated listed the trouble as “1FL FSD OR CORR O/S SUB-STER.” Based on interview at the time of observation, the Maintenance Supervisor stated that an actuator for a fire/smoke damper in the sub-sterile room of the operating room was bad and has been awaiting parts to fix the device. Paperwork had been obtained from the facility indicating both the facility and alarm company know about the aforementioned condition. The Maintenance Supervisor later confirmed that the panel is still in trouble and the device still has not been fixed. Findings were discussed with the Maintenance Supervisor, Director of Engineering, Director of Nursing and Safety Officer at exit conference.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 36620 Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 Informatics office in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 2010 edition, Section 6.2.7.1 states plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. This deficient practice could affect as many as 6 staff. Findings include: Based on observations made with the Maintenance Supervisor during a tour of the facility at 2:37 p.m. on 12/13/23, the Informatics office had an escutcheon that was not smoke tight. There was an annular gap around the escutcheon of approximately three-eighth of an inch in diameter. Based on interview at the time of observation, the Environmental Services Director and the Maintenance Technician #1 confirmed the escutcheon was missing, indicating it had fallen off recently and had not been replaced yet. This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 36620 1) Based on record review and interview, the facility failed to maintain 1 of 1 automatic sprinkler systems. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 Edition, Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test and maintenance required by this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and 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 the facility’s quarterly sprinkler system inspection reports on 11/13/23 at 10:10 a.m. with the Miantenance Supervisor present, the quarterly sprinkler report dated 09/19/23 stated “Anti-freeze tested and indicate correct freeze points in the system - FAIL”. When asked if he could show documentation that they had the anti-freeze added to the system, the Maintenance Supervisor stated that they had not seen that item on the aforementioned sprinkler system inspection. Based on further interview at the time of record review, the Maintenance Supervisor stated the anti-freeze has not yet been replaced. This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m. 46051 2) Based on observation and interview, the facility failed to maintain the ceiling construction of 1 of 1 CT rooms. The 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 affect occupants on the first floor. Findings include: Based on observations during a tour of the facility with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the suspended ceiling of the CT room had a ceiling tile with an approximately four inch hole around a machine that had a pipe running through the ceiling which can lead to a potential delayed response to the nearby sprinkler head. Based on interview at the time of observation, the Maintenance Director stated that the hole does have an escutcheon plate to fill in the space of the ceiling tile, however the plate had slid down the pipe and left the ceiling above the tile exposed. The Maintenance Director confirmed the aforementioned issues. The finding was reviewed with the Maintenance Supervisor, Director of Engineering, Director of Nursing and the Safety Officer at exit conference. 3) Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems were provided with spare sprinklers, a spare sprinkler cabinet large enough to fit all spare sprinkler heads, and a sprinkler wrench on the premises. 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 in the facility. Findings include: Based on observation with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the spare sprinkler cabinets in the riser room were not large enough to contain all sprinkler heads and prevent damage to the sprinkler heads. When the cabinet in riser room was opened, the cabinet contained more sprinkler heads than spots available. Approximately twenty sprinkler heads were unsecured on-top and inside of the sprinkler cabinets. Based on interview at the time of the observations, the Maintenance Supervisor agreed the two cabinets were not large enough to contain all spare sprinkler heads. This finding was reviewed with the Maintenance Supervisor, Director of Engineering, Director of Nursing and Safety Officer during the exit conference.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 46051 1) Based on observation and interview, the facility failed to ensure 1 of 1 storage corridor doors on the third floor was provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke. This deficient practice could affect occupants on the third floor. Findings include: Based on observation with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the storage double doors across from the third floor nurses station did not latch. The inactive leaf of the door set had a latching device, however when closed, the door would not self-latch or engage after testing three times. Based on interview at the time of observation, the Maintenance Supervisor stated that they were unaware of the issue and agreed the inactive door did not self-latch. The latch was fixed during the survey. The finding was reviewed with the Maintenance Supervisor, Safety Officer, Director of Nursing and Director of Engineering during the exit conference. 2) Based on observation and interview, the facility failed to ensure 1 of over 100 corridor doors were provided with a means suitable for keeping the door closed, had no impediment to closing, latching, and would resist the passage of smoke. This deficient practice could affect as many as 4 staff. Findings include: Based on observations made with the Maintenance Supervisor during a tour of the facility at 3:04 p.m. on 12/13/23, the corridor door for the Oncology Suite in the basement had a self-closing device on the corridor door. This door was propped in the open position with flip down door wedge. Based on interview at the time of observation, the Maintenance Director acknowledged the aforementioned corridor door to a patient care area was propped and held in the fully open position with a flip down door wedge. This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 46051 Based on observation and interview, the facility failed to ensure penetrations through 1 of 1 smoke barrier wall was 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 occupants on the second floor. Findings include: Based on observations with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., above the drop ceiling of the smoke wall separating the old OB wing and the old Alternacare dining room had an approximate half inch gap around conduit that was run through the fire/smoke wall. Based on interview at the time of observation, the Maintenance Supervisor agreed there where unsealed penetrations in the smoke barriers and would seal up the penetrations. The finding was reviewed with the Maintenance Supervisor, Safety Officer, Director of Engineering and Director of Nursing during the exit conference.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 36620 Based on observation and interview, the facility failed to ensure 1 of 6 sets of barrier doors in the basement area would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.8 requires doors in smoke barriers shall comply with LSC Section 8.5.4. LSC 8.5.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation. This deficient practice could affect as many as 4 patients, 8 staff, and 1 visitor in the basement. Findings include: Based on observations made with the Maintenance Supervisor during a tour of the facility at 2:56 p.m. on 12/13/23, the set of barrier doors leading to “the old addition” or door set #056272 did not close completely due to air pressure from one side of the doors. There was a one-inch gap between the doors when closed to their fullest. Based on interview during the time of observations, the Maintenance Supervisor acknowledged these smoke barrier doors did not close completely due to air pressure pushing one door slightly open and added that he would adjust the self-closing devices to make sure that they closed fully in an emergency situation. This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 36620 Based on observation and interview, the facility failed to ensure access and working space was maintained in 1 of 3 electrical panel in the Kitchen. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.2.1 states electrical installation shall be in accordance with NFPA 70, National Electric Code. NFPA 70, 2011 Edition, Article 110.26 states access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Working space for equipment operating at 600 volts, nominal, or less and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A) (1), (2) and (3). 110.26(A)(1) states the depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) which the minimum clear distance is 3feet. 110.26(A) (2) states the width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the workspace shall permit at least a 90-degree opening of equipment doors or hinged panels. 110.26(A)(3) states the workspace shall be clear and extend from the grade, floor, or platform to a height of 6 and 1/2 feet or the height of the equipment, whichever is greater. Article 110.26(B) states the working space required by this section shall not be used for storage. This deficient practice could affect as many as 6 staff working in the kitchen. Findings include: Based on observations made with the Maintenance Supervisor during a tour of the facility at 2:50 p.m. on 12/13/23, there were two electrical panels located on the wall in the Kitchen. One of these electrical panels was obstructed by a plastic cart that was stored immediately in front of the electrical panels. Based on interview at the time of the observations, the Maintenance Supervisor agreed that the plastic cart was stored directly in front of the electrical panels and stated he would have the cart removed immediately. This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 36620 Based on record review and interview, the facility failed to ensure 9 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice affects all patients in the facility as well as staff and visitors. Findings include: Based on record review of the facility’s fire drill document entitled “Fire Drill Report” with the Miantenance Supervisor present, the documentation for the drills for January 2023 through September of 2023 lacked verification of the transmission of the signal for drills. Based on interview at the time of record review, the Maintenance Supervisor stated that he would advise the Security Department to request from the monitoring company confirmation of the signal being received during his fire drills. This finding was reviewed with the Maintenance Supervisor, the Director of Engineering, and the Safety Officer and the Director of Nursing on 12/13/23 at 4:00 p.m.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 46051 Based on observation and interview, the facility failure to ensure 2 of 2 non-approved portable space heaters were used in the facility. This deficient practice could affect occupants on the second floor. Findings include: Based on observation during a tour of the facility with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., two portable space heaters were located in the Patient Access and the Patient Financial Counselors offices on the second floor. During record review earlier during the survey, a policy was provided to the surveyor that stated only an approved foot board heater is allowed in offices only. The space heaters found in both offices were unapproved and not part of the designated maintenance program. Based on interview at the time of observations, the Maintenance Supervisor confirmed the space heaters in the offices and stated that the ones found are unregulated and not allowed to be in the facility. Findings were discussed with the Maintenance Supervisor, Director of Engineering, Director of Nursing and Safety Officer at exit conference.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 46051 1. 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 as many as 3 patients, 3 staff, and 1 visitor in the facility Findings include: Based on observation with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:45 p.m., the Nuclear Medicine office contained a power strip used to power equipment, was not secured, and was dangling from a light fixture power cord. This condition could put stress on the power cord causing damage to the power cord. Based on interview at the time of observations, the Maintenance Supervisor agreed the power strip was dangling, not secured, and stated the power strip will need to be mounted or set on the floor. The power strip was secured and fixed during the survey. This finding was reviewed with the Maintenance Supervisor, Safety Officer, Director of Nursing and the Director of Engineering during the exit conference. 2. Based on observation and interview, the facility failed to ensure 2 of 2 power cord daisy chains were not used as and as a substitute for fixed wiring. 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. Article 400.8 (1) prohibits daisy chains, because the first extension cord (or power strip) is now acting as a substitute for the fixed wiring of a structure. This deficient practice could affect as many as 4 patients, 3 staff, and 1 visitor in the facility. Findings include: Based on observations during a tour of the facility with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., in the Utilization Management office, on the third floor, contained a power strip that was plugged into and supplied power by another power strip that also powered computer equipment and a printer. Based on interview at the time of observation, the Maintenance Supervisor agreed there were daisy chained power strips under the desk and improperly used. The power strips were separated and fixed during the observation. Findings were discussed with the Maintenance Supervisor, Safety Officer, Director of Engineering and Director of Nursing at exit conference. 3. Based on observation and interview, the facility failed to ensure 4 of 4 power strips were not used as a substitute for fixed wiring to provide power 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 all occupants on the third and second floors. Findings include: Based on observations during a tour of the facility with the Maintenance Supervisor on 12/13/23 between 09:37 a.m. and 2:34 p.m., the following deficiencies were noted: a) The social services and patient financial counselor offices both contained a power strip that was powering an approved space heater. This was fixed upon observation b) The med surge Managers and education offices both contained a minifridge that was plugged into a power strip. Both were fixed upon observation. Based on interview at the time of observations, the Maintenance Supervisor confirmed all of the aforementioned issues and stated they were improperly used. Findings were discussed with the Maintenance Supervisor, Safety Officer, Director of Engineering and Director of Nursing at exit conference.”