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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 and sheltered patients in the hospital's care 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 occupants

Findings include:

Based on record review with the Director of Compliance (DOC) on 04/20/21 at 11:55 a.m., no policies and procedures that include a system to track the location of on-duty staff and sheltered patients in the facility's care during and after an emergency was available for review. Based on interview during the exit conference, the DOC confirmed no additional information or evidence could be provided contrary to this deficient finding.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include the role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials in accordance with 42 CFR 482.15(b)(8). This deficient practice could affect all occupants.

Findings include:

Based on record review on 04/20/21 at 11:27 a.m. with the Director of Compliance (DOC), the Emergency Preparedness Policy (EPP) did not consider the facility's role under a waiver declared by the Secretary. Based on interview at the time of record review the DOC was unaware of the 1135 waiver and would have to add this to the EPP. This was discussed with the DOC during the exit conference.

Based on record review and interview, the hospital failed to conduct exercises to test the emergency plan at least twice per year. The hospital 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 includes a group discussion 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 hospital's emergency plan, as needed in accordance with 42 CFR 482.15(d)(2). This deficient practice could affect all occupants.

Findings include:

Based on record review on 04/20/21 at 11:39 p.m. with the Director of Compliance (DOC) the facility documented an exercise of choice (tabletop) but did not document a required full-scale exercise or actual event for the past year. Based on interview concurrent with record review with the DOC it was stated she did not believe the facility participated in a full-scale exercise which implemented the EPP for the past twelve months. This was discussed with the DOC during the exit conference.

Based on record review and interview, the facility failed to implement emergency and standby power systems based on the emergency plan set forth in 42 CFR 482.15(a) in accordance with 42 CFR 482.15(e). This deficient practice could affect all occupants.

Findings include:

Based on review of the Emergency Preparedness Plan (EPP) with the Director of Compliance (DOC) and the Director of Facilities and Safety (DFS) on 04/20/21 at 11:30 a.m., the facility has a generator, but there was no documentation to indicate the generator was tested under load once per month. Based on an interview concurrent with record review with the DFS it was acknowledged, Maintenance used to do the monthly load test along with the weekly inspections, but they don't work here anymore, and the records are missing. This was discussed with the DFS and the DOC during the exit conference.

Based on observation, the facility failed to meet the clear width requirement for 1 of 4 corridors or met an exception per 19.2.3.4(5). LSC 19.2.3.4(5) states where the corridor width is at least 8 feet, projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) the fixed furniture is securely attached to the floor or to the wall.
(b) the fixed furniture does not reduce the clear unobstructed corridor width to less than six feet, except as permitted by 19.2.3.4(2).
(c) the fixed furniture is located only on one side of the corridor.
(d) the fixed furniture is grouped such that each grouping does not exceed an area of 50 square feet.
(e) the fixed furniture groupings addressed in 19.2.3.4(5) (d) are separated from each other by a distance of at least 10 feet.
(f) the fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurse's station or similar space.
(h) the smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8
This deficient practice could affect all staff on Trans hall.

Findings include:

Based on observation on 04/20/21 at 1:27 p.m. with the Director of Facilities and Safety (DFS), the Trans hall corridor on the first floor measured six feet wide and contained two large 30 gallon plastic garbage cans which limited the corridor width to less than three feet. Based on interview at the time of the observation and measurement with the DFS it was acknowledged the items stored in the corridor limited corridor access to less than four feet. This finding was reviewed with the DFS and the Director of Compliance during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 2 Staff office doors was provided with only one latching mechanism to release the door and open. 33.2.2.5.7 refers to 7.2.1.5.10 which states a latch or other fastening device on a door leaf shall be provided with a releasing device that has an obvious method of operation and that is readily operated under all lighting conditions. 7.2.1.5.10.4 states the releasing mechanism shall open the door leaf with not more than one releasing operation. 7.2.1.5.10.1 states the releasing mechanism for any latch shall be located not less than 34 inches, and not more than 48 inches, above the finished floor. This deficient practice could affect all occupants in the facility.

Findings include:

Based on observations on 04/21/21 during the tour between at 1:10 p.m. to 2:00 p.m. with the Director of Facilities and Safety (DFS), the four exit doors in the building were equipped with a deadbolt requiring more than one motion to open the door when in the locked position. This was acknowledged by the DFS at the time of observations discussed with the DFS during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 6 exit discharges was clear of all obstructions which could prevent travel to a public way. This deficient practice could affect staff only.

Findings include:

Based on observation on 04/20/21 at 1:38 p.m. with the Director of Facilities and Safety (DFS), the back exit out of the Boiler room led to a loading dock was blocked on the outside by a heavy loading cart and could not be opened. Based on interview concurrent with the observation with the DFS it was stated staff had been told not to store the loading cart in front of the back door of the Boiler room. This was discussed with the DFS and the Director of Compliance during the exit conference.

1. Based on observation and interview, the facility failed to ensure continuity of egress lighting for 1 of 6 exits. For the purposes of this requirement, exit access shall include only designated stairs, aisle, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways and exit passageways leading to a public way. This deficient practice could affect clients, staff and visitors.

Finding include:

Based on observation on 04/20/21 at 1:05 p.m. with the Director of Facilities and Safety (DFS), the exit discharge out of 100 hall did not have any outside lighting for illumination of the public way. Based on interview at the time of observation, the DFS confirmed there was no lighting devices illuminating the public way for 100 hall. This finding was reviewed with the DFS and the Director of Compliance during the exit conference.

2. Based on observation and interview, the facility failed to ensure the lighting for 1 of 6 exit means of egress was arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness. LSC 7.8.1.4 requires illumination shall be arranged so that that the failure of any single lighting unit does not result in an illumination level of less than 0.2 foot-candle in any designated area. This deficient practice could affect 9 residents who reside on the Old Hall.

Findings include:

Based on observation on 04/20/21 at 1:08 p.m. with the Director of Facilities and Safety (DFS), the exit discharge outside the IT exit there is only a one bulb fixture available to illuminate the outside path to a public way. Based on interview at the time of observation, the DFS confirmed there was only a single bulb fixture available for the IT exit discharge. This finding was reviewed with the DFS and the Director of Compliance during the exit conference.

Based on record review and interview, the facility failed to ensure 5 of 5 battery backup lights were tested monthly for 30 seconds over the past year to ensure the light 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 residents in the facility.

Findings include:

Based on record review on 04/20/21 at 11:30 a.m. with the Director of Facilities and Safety (DFS), the Battery Operated Emergency Light Test Log for 2021 indicated the facility did not document the time for each month the lights were tested. Based on an interview at the time of record review, the DFS indicated the facility has battery operated emergency exit lights tested throughout the facility, but the facility neglected to document the number of seconds the lights were tested each month. This was discussed with the DFS and the Director of Compliance during the exit conference.

1. Based on observation and interview, the facility failed to ensure 1 of 4 hazardous areas observed such as Storage rooms over 50 square feet, would latch in their frame and be provided with a self-closing device. This deficient practice could affect staff on first floor.

Findings include:

Based on observation on 04/20/21 at 1:10 p.m. with the Director of Facilities and Safety (DFS), there were twenty six cardboard boxes stored in the "Mancave" on first floor next to the front reception area and there was no self closing device on the corridor door. Based on interview at the time of observation with the DFS it was acknowledged the corridor door to the Mancave was not provided with a self closing device on the corridor door. It was further acknowledged the area was over 50 square feet. This was discussed with the DFS and the Director of Compliance during the exit conference.

2. Based on observation and interview, the facility failed to ensure 1 of 4 hazardous areas observed such as Elevator Machine rooms was provided with an entry/exit door which was 3/4 hour fire rated. This deficient practice could affect all occupants in the facility.

Findings include:

Based on observation on 04/20/21 at 1:32 p.m. with the Director of Facilities and Safety (DFS), the entry/exit door to the Elevator Machine room was missing a fire rated label and could not be identified as having the 3/4 hour fire rating. Based on interview at the time of observation with the DFS it was acknowledged the Elevator Machine room door did not have a label to indicate it's fire rating and had to be considered a non-rated door. This was discussed with the DFS and the Director of Compliance during the exit conference.

1. Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 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, 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 record review with the Director of Facilities and Safety (DFS) on 04/20/21, the fire alarm annual report dated 03/11/21 in the comments section regarding the elevator stated: "This device will shut down the elevator will reset when system is reset, does not recall the elevator, the elevator stops where it's at until its reset." Based on interview at the time of record review it was acknowledged by the DFS the statement on the fire alarm annual report must be valid. This was discussed with the DFS and the Director of Compliance during the exit conference.

2. Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 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, 2010 Edition, Section 14.4.5 requires testing shall be performed in accordance with Table 14.4.5 Testing Frequencies. Section 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation. Section 14.4.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. 14.4.5.3.5 states smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. Section 14.6.2.4 states a record of all inspections, testing and maintenance shall be provided that includes all applicable information requested in Figure 14.6.2.4. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on review of Brenneco's Fire Alarm Systems "Initiating & Supervisory Device Tests & Inspections" documentation dated 03/11/21 with the with the Director of Facilities and safety (DFS) during record review on 04/20/21 it was stated in the device specs: Johnson controls duct detector model # 760 sensitivity test was not available. Based on interview at the time of record review, the DFS acknowledged the statement made in the device specs section must be correct. This was discussed with the DFS and the Director of Compliance during the exit conference

3. 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 Section 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 clients and staff.

Findings include:

Based on record review on 04/20/21 at 12:00 p.m. with the Director of Facilities and Safety (DFS), no documentation could be provided regarding a visual semi-annual fire alarm system inspection during the past 12 months. Based on interview at the time of record review, the DFS acknowledged there was no documentation for a semi-annual visual fire alarm system test/inspection during the past 12 months available for review.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control panels (FACP) was maintained in accordance with 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, 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 record review on 04/21/21 at 2:35 p.m. with the Director of Facilities and Safety (DFS), the FACP has been disabled since at least 03/10/20. According to the last annual fire alarm test report done by Priority 1 dated 03/10/20 in the comments section it stated: "Fire panel needs replaced.". The report also noted in the comments section; "All smoke detectors failed functional tests". Based on interview at the time of record review with the DFS it was stated the FACP had been hit by lighting and she further acknowledged the facility was aware it needed to be replaced. This was discussed with the DFS during the exit conference.

1. Based on observation and interview, the facility failed to ensure a 1 of 1 complete automatic sprinkler system was installed in accordance with 19.3.5.1. NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, Section 9.1.1.7, Support of Non-System Components, requires sprinkler piping or hangers shall not be used to support non-system components. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on observation with the Director of Facilities and Safety (DFS) on 04/20/21 at 1:35 p.m., the Boiler room on the first floor had several low voltage communication lines attached to the metal sprinkler pipe. Based on interview at the time of observation, the DFS acknowledged there were wires attached to the sprinkler pipe and was unaware this condition existed.

2. Based on observation and interview, the facility failed to ensure an automatic sprinkler system provided complete coverage in 1 of 1 Housekeeping rooms on the second floor. This deficient practice could affect only staff.

Findings include:

Based on observation on 04/20/21 at 2:01 p.m. with the Director of Facilities and Safety (DFS), the Housekeeping room on the second floor was not provided with sprinkler protection. This was confirmed by the DFS at the time of observation. This was discussed with the DFS and the Director of compliance during the exit conference.

3. Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 Transportation office's in accordance with NFPA 13. NFPA 13, 2010 edition, Section 6.2.7 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 staff in the Transportation office.

Findings include:

Based on observation on 04/20/21 at 1:25 p.m. with the Director of Facilities and Safety (DFS), an escutcheon was missing around 1 of 2 sprinkler heads in the Transportation office. Based on interview at the time of observation, the DFS acknowledged and confirmed the missing escutcheon. This was discussed with the DFS and the Director of Compliance during the exit conference.

4. Based on observation and interview, the facility failed to ensure the spray pattern for sprinkler heads were not obstructed in 1 of 1 Housekeeping closets first floor in accordance with 19.3.5.1. 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 noncontinuous 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 affect 12 residents, visitors and staff.

Findings include:

Based on observation on 04/20/21 at 1:18 p.m. with the Director of Facilities and Safety (DFS), the Housekeeping closet on the first floor contained several cardboard boxes which were stored on shelves within two to three inches from the deflector on the sprinkler head. Based on interview at the time of observation, the DFS acknowledged the obstructions were less than eighteen inches from the sprinkler head and would convey this to Housekeeping. This was discussed with the DFS and the Director of Compliance during the exit conference.

Based on record review and interview, the facility failed to document monthly sprinkler system inspections for 1 of 1 sprinkler risers in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on dry pipe sprinkler systems shall be inspected weekly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.3.2.1.1 states valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. This deficient practice could affect all residents in the facility.

Findings include:

Based on record review on 04/20/21 at 11:42 a.m. with the Director of Facilities and Safety (DFS) there was no documentation provided to verify the facility did monthly sprinkler gauge and control valve inspections for the past year. Based on interview during record review and at the exit conference it was confirmed no documentation could be produced to verify monthly sprinkler gauge and control valves had been inspected for the past year.

Based on observation and interview, the facility failed to ensure 1 of 1 portable fire extinguishers observed was installed in accordance with NFPA 10. NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1 states fire extinguishers having a gross weight not exceeding 40 lb. shall be installed so that the top of the fire extinguisher is not more than five feet above the floor. This deficient practice could affect staff only.

Findings include:

Based on observation on 04/20/21 at 1:30 p.m. with the Director of Facilities and Safety (DFS), the abc portable fire extinguisher mounted on the wall in the Elevator Machine room adjacent to the Boiler room was measured to be sixty nine inches from the floor to the top of the extinguisher. Based on interview at the time of observation, the DFS stated she was unaware of this requirement and would remount the fire extinguisher to within five feet from the floor. This finding was reviewed with the DFS and the Director of Compliance during the exit conference

Based on observation and interview, the facility failed to ensure 2 of 2 Central office corridor doors on the second floor would close completely and latch into their door frames. This deficient practice could affect 8 residents, visitors and staff on the second floor.

Findings include:

Based on observation on 04/20/21 at 1:43 p.m. with the Director of Facilities and Safety (DFS), the two Central office corridor doors on the second floor do not have latching equipment to latch into their respective door frames. Based on interview concurrent with the observation with the DFS it was stated no one has ever pointed this out before and she did not know the corridor doors must latch into their frame. This was discussed with the DFS and Director of Compliance during the exit conference.

1. Based on observation and interview, the facility failed to ensure 1 of 1 corridors with electrical panels were secured from non-authorized personnel per LSC 19.5.1.1. LSC 19.5.1.1 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. NFPA 70 Section 110.27(A) states live parts of electrical equipment over 50 volts or more shall be guarded against accidental contact by approved closures or by any of the following means: (1) by location in a room, vault, or similar enclosure that is accessible only to qualified persons. This deficient practice could affect all at least 9 residents, visitors and staff.

Findings include:

Based on observation on 04/20/21 at 1:16 p.m. with the Director of Facilities and Safety (DFS) there were two electrical panels installed in the corridor wall on Transportation hall which were not secured against non-authorized personnel. Based on interview during the observation, the DFS confirmed the electrical panels could be opened by anyone and was unaware they needed to be secured against unauthorized access. This was discussed with the DFS and the Director of Compliance during the exit conference.

2. Based on observation, the facility failed to ensure 1 of 1 electrical junction boxes observed were maintained in a safe operating condition. LSC 19.5.1.1 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, 2011 Edition, Article 314.28(3) (c) states junction boxes shall be provided with covers compatible with the box and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110. This deficient practice could affect over 9 residents, staff and visitors.

Findings include:

Based on observation on 04/20/21 at 12:36 p.m. with the Director of Facilities and Safety (DFS), one electrical junction box with exposed electrical wiring and no cover plate was noted in the Electrical Mechanical room in Activities attached to an air handling unit. Based on interview at the time of the observation, the DFS acknowledged the electrical junction box location was not provided with a cover. This finding was reviewed with the DFS and the Director of Compliance during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 4 power strips observed were not used as a substitute for fixed wiring according to 33.2.5.1. NFPA 70, 2011 Edition, 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 any staff, client or visitor.

Findings include:

Based on observation on 04/21/21 at 1:10 p.m. with the Director of Facilities and Safety (DFS), there was a power strip connected to an O2 concentrator in the second story Westside first client's bedroom. Based on interview at the time of observation, the DFS acknowledged the power strip was misused and informed staff this was not allowed. This was discussed with the DFS during the exit conference.

1. Based on observation, record review and interview, the facility failed to maintain testing of 1 of 1 elevators firefighter recall in accordance with 9.4.6, Elevator Testing. LSC 9.4.6.2 states that all elevators with fire fighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1/CSA B44, Safety Code for Elevators and Escalators. This deficient practice could affect all residents, visitors and staff.

Findings include:

Based on observation on 04/20/21 at 1:10 p.m. with the Director of Facilities and Safety (DFS), the elevator had a key access fire department recall feature. Based on record review with the DFS there was no documentation of a monthly firefighter recall test for the past year. Based on interview with the DFS, when asked during record review it was indicated there was no documentation for the monthly firefighter recall testing for the elevator in the facility. This was discussed with the DFS and the Director of Compliance during the exit conference.

2. Based on observation, interview, and record review; the facility failed to ensure the elevator equipment in 1 of 1 elevator equipment rooms was provided with a shunt trip. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main power supply to the affected elevator automatically upon, or prior to, the application of water from the sprinkler located in the elevator machine room. The elevator equipment room was located in the basement and could affect any resident using the elevator as well as visitors and staff.

Findings include:

Based on observation and interview on 04/20/21 at 1:32 p.m. with the Director of Facilities and Safety (DFS), the elevator equipment room located on the first floor was provided with a quick response sprinkler head and smoke detector protection, however a shunt trip could not be located. The DFS acknowledged she did not know what a shunt trip is and did not know where one may be located. Based on the Sprinkler Inspection and Test Report record review at 12:15 p.m. with the DFS, there was no mention of a shunt trip installation in the elevator machine room. This was discussed with the DFS and the Director of Compliance during 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 plan. 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
Section 18.2.3.4(4) states any required aisle or corridor shall not be less than 48 inches in clear width where serving as means of egress from patient sleeping rooms. Projections into the required width shall be permitted for wheeled equipment provided the relocation of wheeled equipment during a fire or similar emergency is addressed in the written fire safety plan and training program for the facility. The wheeled equipment is limited to:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
This deficient practice could affect all occupants.

Findings include:

Based on record review on 04/20/20 at 12:05 p.m. with the Director of Facilities and Safety (DFS), the Fire Safety plan did not address a. types of fire extinguishers throughout the facility, b. how to evacuate a smoke compartment to another smoke compartment behind a set of smoke/fire doors, c. extinguishment of fire or d. isolation of fire. Based on interview at the time of record review with the DFS and the Director of Compliance during the exit conference it was agreed the Fire Safety policy did not identify items a through d.

Based on record review and interview, facility staff failed to ensure that all personnel on all shifts are trained to perform assigned tasks and were familiar with the use of the facility's fire protection features during fire drills conducted for 2 of the last 4 quarters over the past year. This deficient practice could affect all clients.

Findings include:

Based on record review of Emergency Evacuation Drill Reports on 04/20/21 at 12:03 p.m. with the Director of Facilities and Safety (DFS) the fire drill reports indicated the following drills had not been done:
a. All shifts for the second quarter 2020.
b. All shifts for the third quarter 2020.
Based on an interview with the DFS at the time of record review, it was acknowledged previously mentioned shifts of the past year had not been done. In addition, the DFS could not produce documentation of staff participating in an orientation training program related to the current fire plan. The training will instruct all employees on their current duties, life safety procedures and the fire protection devices in their assigned area. This was discussed with the DFS during the exit conference.

Based on record review and interview, the facility failed to verify transmission of the fire alarm signal for 3 of 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 residents, staff and visitors.

Findings include:

Based on review of Monthly Fire Drill Reports on 04/20/21 at 12:13 p.m., with the Director of Facilities and Safety (DFS) there was no documentation for the transmission of the fire alarm signal the following quarter:
a. First quarter 2021, Night shift 1/28/21
b. Fourth quarter 2020, Night shift 12/17/20
c. Third quarter 2020, Night shift 09/28/20
Based on an interview with the DFS at the time of record review, it was stated the transmission signal of the fire alarm to the monitoring station had not been documented for the last 3 of 4 quarters. This was discussed with the DFS and the Director of Compliance during the exit conference.

Based on record review and interview, the facility failed to include in 1 of 1 smoking policies the designated location where smoking by clients and staff was permitted. This deficient practice could affect any client and staff.

Findings include:

Based on record review on 04/20/21 at 12:11 p.m. with the Director of Facilities and Safety (DFS), the smoking policy presented for review did not indicate where smoking by clients and staff was permitted. Based on interview concurrent with the record review the DFS stated this current smoking policy only stated that smoking was allowed at designated areas, but did not specify where. This was discussed with the DFS and the Director of Compliance during the exit conference.

Based on record review and interview, the facility failed to implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code in accordance with 42 CFR 483.73(e)(2). This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on review of generator Weekly and Monthly Load Test Log on 04/20/21 at 11:50 a.m., with the Director of Facilities and Safety (DFS) there was no documentation of monthly load testing done for the past twelve months. In addition, the last generator annual load bank test for diesel emergency power systems available for review was dated 05/06/19. Based on interview at the time of record review, the DFS acknowledged the load bank was past due and stated maintenance present before her did not keep records of weekly inspections or monthly load for the past year. This was discussed with the DFS and the Director of Compliance during the exit conference.

Based on observation and interview, the facility failed to ensure proper use of power strips in 3 of 3 rooms observed. This deficient practice could affect clients, visitors and staff.

Findings include:

Based on observations on 04/20/21 during the tour between 12:43 p.m. to 3:14 p.m. with the Director of Facilities and Safety (DFS), a power strip was used to power a lamp in the Front entrance lobby when the power cord from the lamp could easily reach the outlet. Next, a power strip was connected to another power strip in the IT room on the first floor. Lastly, a power strip was connected to another power strip in the Psychologist office on the second floor. Based on interview concurrent with the observations with the DFS, the misuse of the power strips described was confirmed. This finding was discussed with the DFS and the Director of Compliance during the exit conference