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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 patients and staff.

Findings include:

During record review with the Compliance Manager and the Facilities Manager on 12/03/19 at 1:49 p.m. the facility was unable to provided documentation of policies and procedures regarding 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. This was confirmed by the Compliance Manager at the time of record review.

Based on observation and interview, the facility failed to ensure 8 of 8 battery-operated emergency lights monthly testing was properly documented in accordance with LSC 19.2.9.1. Section 19.2.9.1 states that emergency lighting shall be provided in accordance with Section 7.9. 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:

During record review with the Facilities Manager on 12/03/19 at 12:57 p.m. the facility provided documentation for the testing of Battery Operated Emergency LIghts, however it was incomplete. The facility was unable to document the testing for November, 2019. Based on interview at the time of record review, the Facilities Manager agreed that 1 of 12 monthly tests for the most recent twelve month period was not available for review.

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

Findings include:

During record review with the Facilities Manager on 12/03/19 at 12:49 p.m., no documentation could be provided regarding a visual semi-annual fire alarm system inspection. The most recent annual test and inspection was completed on 05/19/19. Based on interview at the time of record review, the Facilities Manager agreed that visual semi-annually inspections of the fire-alarm system were not completed.

1) Based on observation and interview, the facility failed to protect 1 of 1 linen closets in accordance with LSC Section 19.3.5.3. Section 19.3.5.3 require healthcare facilities to be protected throughout by an approved, supervised automatic sprinkler system. This deficient practice could affect up to 12 patients and staff.

Findings include:

During a tour of the facility with the Facilites Manager on 12/03/19 at 2:31 p.m. the linen closet near the nurses station was found to not contain a sprinkler. The closet measured approximately 24 inches by 72 inches. Based on interview at the time of observation, the Facilities Manager agreed that the closet did not have a sprinkler and additionally stated that he thought the closet did contain a sprinkler.

2) Based on observation and interview, the facility failed to maintain the ceiling construction in one area throughout the facility. 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 could affect all patients, staff and visitors in the facility.

Findings include:

During a tour of the facility with the Facilities Manager on 12/03/19 at 2:40 p.m. 1 of 4 lay-in ceiling tiles was missing in the document closet. This was confirmed by the Facilities Manager at the time of observation.

Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 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. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on review of the quarterly sprinkler system inspection records on 12/03/19 at 12:24 p.m. with the Facilities Manager present, there was no quarterly sprinkler system inspection report available for the second quarter (April, May, June) of 2019. During an interview at the time of record review, the Facilities Manager acknowledged there was no written documentation available to show the sprinkler system had been inspected during the second quarter of 2019. Additionally, he stated that the sprinkler inspection vendor was delayed, and did not arrive until 07/12/19.

Based on record review and interview, the facility failed to ensure 1 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted between 6:00 a.m. and 9:00 p.m. 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:

During record review of titled "Oaklawn Fire Drill Observation Checklist" with the Facilities Manager on 12/03/19 at 12:13 p.m., the fire drill for 08/21/19 did not record the transmission of the alarm. This was confirmed by the Facilities Manager at the time of record review.

Based on observation, records review, and interview, the facility failed to ensure annual inspection and testing of 1 of 1 fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all occupants.

Findings include:

During record review with the Facilities Manager on 12/03/19 at 12:51 p.m. the facility was unable to provide an annual fire door inspection. During a subsequent tour of the facility on the same day from 2:25 p.m. to 3:00 p.m. a fire door was located in the Fire Wall that separates the Inpatient facility from the remaining building. Based on interview at the time of record review, the Facilities Manager agreed that the door was not inspected according to NFPA 80.

1) Based on record review and interview, the facility failed to ensure an annual fuel quality test was performed for the facility's diesel powered generator. NFPA 99, Health Care Facilities Code, 2012 Edition Section 6.5.4.1.1.2 states Type 3 EES (Essential Electrical System) generator sets shall be inspected and tested in accordance with Section 6.4.4.1.1.3. Section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition, Chapter 8. NFPA 110, Section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards. This deficient practice could affect all patients and staff.

Findings include:

Based on record review with the Facilities Manager on 12/03/19 at 3:00 p.m., no documentation of an annual fuel quality test for the diesel generator was available for review. Based on interview at the time of records review, the Facilities Manager stated the facility does have a diesel generator, however agreed he could not provide a diesel fuel test from the most recent twelve months.

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

Findings include:

Based on record review with the Facility Manager on 12/03/19 at 1:07 p.m., documentation for November, 2019 generator exercise was not available for review. Based on an interview at the time of record review, the Facility Manager agreed he was unable to provide documentation for the November, 2019 generator exercise.