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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 patients, 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 in accordance with 42 CFR 482.15(b)(1). This deficient practice could affect all occupants.

Findings include:

During record review with the Director of Facilities, Director of Acute Intensive Services, and Director of Accredidation and Quality Improvement on 02/26/19 at 2:03 p.m. no documentation could be provided regarding protection from extreme heat. Based on interview at the time of record review, the Director of Facilities stated the facility's air-conditioning units were not powered by the emergency generator. The Director of Acute Intensive Services and Director of Accredidation and Quality Improvement agreed that the emergency preparedness plan did not address excessive heat.

Based on record review and interview, the facility failed to develop policies and procedures of the role of the facility under a waiver declared by the Secretary of Health and Human Services, 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, as required by 42 CFR 482.15(b)(8). This deficient practice could affect all residents, staff, and visitors.

Findings include:

During record review with the Director of Facilities, Director of Acute Intensive Services, and Director of Accredidation and Quality Improvement on 02/26/19 at 2:03 p.m. no documentation of policies and procedures of the role of the facility under a waiver declared by the Secretary of Health and Human Services, 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 could be located. Based on interview at the time of record review, the Director of Acute Intensive Services and Director of Accredidation and Quality Improvement were unaware of the 1135 waiver, and confirmed that there was no policy in place.

Based on record review, observation and interview; the facility failed to ensure all fire alarm system initiating devices were tested in accordance with the schedules for testing frequency in NFPA 72. LSC Section 19.3.4.1 states a manual fire alarm system shall be provided in accordance with Section 9.6. LSC Section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electric Code and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, 2010 Edition, Table 14.3.1 states that certain fire alarm system components need to be visually inspected semiannually:
a. Control unit trouble signals - verify that they are readily visible
b. Remote annunciators - verify that they are in proper operating condition and free of damage
c. Initiating devices - verify that they are in place, unobstructed and free of damage.
d. Notification appliances - verify that they are unobstructed and free of damage
e. Magnetic hold-open devices - verify that they are free of damage and function properly
This deficient practice could affect all building occupants.

Findings include:

During record review with the General Services Supervisor on 02/26/19 at 11:59 a.m. no documentation could be provided indicating the fire alarm system was visually inspected semi-annually in the most recent twelve month period. Based on interview at the time of record review, the General Services Supervisor agreed that the fire alarm system was not visually inspected semi-annually.

Based on record review and interview, the facility failed to document sprinkler system inspections 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 wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.2.4.2 states gauges on dry pipe sprinkler systems shall be inspected weekly to ensure that normal air and water pressures are being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all residents, staff, and visitors.

Findings include:

During record review for the most recent twelve month period with the General Services Supervisor during record review on 02/25/19 at 11:49 a.m. weekly dry sprinkler system gauge inspection documentation for 48 weeks of the most recent 52 week period was not available for review. Monthly wet sprinkler system gauge inspection documentation for 8 months of the most recent 12 month period was also not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 8 months of the most recent 12 month period was not available for review. Based on interview at the time of record review, the General Services Supervisor acknowledged sprinkler system gauge and control valves were only inspected when the sprinkler vendor came to the facility on a quarterly basis and that inspection documentation for the aforementioned weekly and monthly periods was not available for review.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8.5. 8.5.6.3 states that where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5. 8.3.5.1 states that penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust 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 fire barrier shall be protected by a firestop system or device. The fire stop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops. This deficient practice could affect all building occupants.

Findings include:

During a facility tour with the General Services Supervisor and the Director of Facilities on 02/26/19 at 11:33 a.m. a 1 inch by 1 inch penetration was found in the smoke barrier wall above ceiling tile near Door 13B. Based on interview at the time of observation, the General Services Supervisor and the Director of Facilities acknowledged the penetrations in the smoke barrier and agreed to the measurement.