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Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 24 of 24 residents.

Findings:

1.) During the facility tour, between the hours of 9:00 am to 3:00 pm it was observed the main fire alarm had not been annually certified by a licensed fire alarm agent.

2.) During the facility tour, between the hours of 9:00 am to 3:00 pm it was observed the fire alarm was yellow tagged by a licensed agent on 4/2/2018 due to the smoke detector near room 1312 not activating properly.

NFPA 72: 10.3.2 states, "System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code".

NFPA 72:10.4.1.2 states, "State or local licensure regulations shall be followed to determine qualified personnel. Depending on state or local licensure regulations, qualified personnel shall include, but not be limited to, one or more of the following: (1) Personnel who are registered, licensed, or certified by a state or local authority".

LRS 40:1646 (A)(B)(C) states, "The fire marshal is authorized to cause the inspection and testing of all life safety systems and equipment in the state, whether in public or private buildings, during installation or immediately after installation to determine compliance with applicable standards. The owner of any building containing a life safety system and equipment shall cause at a minimum an annual inspection to be made of the life safety system and equipment in that building to assure compliance with applicable safety standards and to determine whether structural changes in the building or in the contents of the building mandate alteration of a system. Life safety systems and equipment includes but is not limited to fire sprinkler, fire alarm, fire suppression, special locking systems and equipment, and portable fire extinguishers."

Interview with the Administrator revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system and was acknowledged by the Administrator.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 24 of 24 residents.

Findings:

During the facility tour, between the hours of 9:00 am to 3:00 pm it was observed the first floor fire pump room interior one hour rated fire barrier walls at the base on both sides had large penetrations and lacked one hour fire stopping material between the underside of the one hour fire barrier and the top side of the concrete floor.

NFPA 20: 4.12.1.1.2 states, "Indoor fire pump rooms in non-high-rise buildings or in separate fire pump buildings shall be physically separated or protected by fire-rated construction in accordance with Table 4.12.1.1.2."

NFPA 20: Table 4.12.1.1.2 Equipment Protection
Pump Building(s) Exposing Required
Room/House Pump Room /House Separation

Not sprinklered Not sprinklered 2 hour fire-rated
Not sprinklered Fully sprinklered or
Fully sprinklered Not sprinklered 50 ft (15.3 m)


Fully sprinklered Fully sprinklered 1 hour fire-rated
or
50 ft (15.3 m)

Interview with the Administrator revealed the facility was not aware the one hour fire pump room fire barrier was not complete, which was acknowledged by the Administrator during the exit meeting.

Based on visual observation the facility failed to provide properly door frame latching corridor doors for the residents sleeping rooms as per NFPA 101:3.6.3.5. When the inpatient bedroom doors latch a smoke resistive seal is formed to protect the room's occupants. The deficient practice had the potential to affect 8 of 24 residents involving 1 of 1 corridors having sleeping room doors that were deficient.

Findings:

During the facility tour on 6/5/2018 between the hours of 9:00 am to 3:00 pm, observations noted resident sleeping rooms 3,4,5,6,14,15,16,17 were not fully latching properly.

NFPA 101:3.6.3.5 (1) states "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" (lbf / pound - force).

Interview with Administrator revealed the facility was not aware of the patient corridor doors not latching properly in the frame.

Based on visual observation this facility failed to assure that the smoke compartmentation of the membrane between the egress corridor walls and the sleeping room doors were not compromised. Repairs to assure the protection of the occupants and the integrity of the means of egress are essential in case of a fire or other smoke emergency. The deficient practice had the potential to affect 1of 24 residents. 1 of 1 smoke compartments were deficient.

Findings:

During the facility tour, between the hours of 9:00 am to 3:00 pm it was observed the patient sleeping room door, labeled number fourteen, had a louvered grill installed at the base of the door.

NFPA 101:19.3.6.4.1 states, "Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors."

Interview with the Administrator revealed the facility was not aware of the patient room sleeping room door transfer grill allowing the transfer of smoke from the corridor to the sleeping room.

Based on visual observation the facility failed to assure that the smoke barrier doors in the facility properly protected the smoke compartment. The smoke barrier doors restrict the movement of smoke from one compartment to another. The deficient practice had the potential to affect 24 of 24 residents.
1 of 1 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 9:00 am to 3:00 pm it was observed the cross corridor smoke barrier doors when fully closed were not providing a smoke resistive seal to prevent the transfer of smoke.

Interview with the Administrator revealed the facility was not aware of the cross corridor doors were not creating a smoke resistive seal when closed.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 22 of 22 residents.
of smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 8:45 am to 2:00 pm it was observed the cross corridor 90 minute double door vision window is lacking a proper fire rating identifyied by a stamped marking "W -120".

NFPA 101: 8.3.4.2* states, "The fire protection rating for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions shall be in accordance with Table 8.3.4.2".

Interview with the Program Director revealed the facility was not aware of the vision sindow lacking a proper rating.

Based on visual observation the facility failed to assure the construction of the smoke barriers walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 24 of 24 residents.
1 of 1 smoke barriers were deficient.

Findings:

During the facility tour on 6/5/2018 between the hours of 9:00 am to 3:00 pm, observations noted the interior cross corridor double door smoke barrier vision window is lacking fire glazed glass for both doors.

Interview with the Administrator revealed the facility was not aware of non fire glazed glass in the smoke barrier vision window.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 22 of 22 residents.
4 of 4 quarters in 2017-2018 were deficient.

Findings:

During the record review, between the hours of 8:45 am to 2:00 pm it was observed the fire drills from the previous four calendar quarters lacked documented completed fire drills for each shift of each quarter.

NFPA 101:19.7.1.6 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."

Interview with the Administrator revealed the facility was not aware the fire drills were required for each shift of each working quarter.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 24 of 24 residents.
4 of 4 quarters in 2017-2018 were deficient.

Findings:

During the record review, between the hours of 9:00 am to 3:00 pm it was observed each of the last four calendar year quarters one of the two shifts had conducted a fire drill for each quarter.

NFPA 101:19.7.1.6 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."

Interview with the Administrator revealed the facility was not aware fire drills were not being held for each work shift.

Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 24 of 24 residents.

Findings:

During the facility tour and record review, between the hours of 9:00 am to 3:00 pm it was observed that the generator was not provided with a remote manual stop and remote manual signage located outside the interior generator room.

NFPA 110:5.6.5.6 states, "All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

NFPA 110:5.6.5.6.1 states, "The remote manual stop station shall be labeled."

Interview with the Administrator revealed the facility was not aware that a remote manual stop for the emergency generator was not provided outside of the interior two hour rated room.