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Based on record review and interview, the facility failed to ensure the Emergency Preparedness Plan (EEP) include the role of the LTC facility 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 483.73(b) (8). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Assistant Director of Health Care on 06/02/21 at 11:45 a.m., a policy and procedure for the role of the LTC facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act was not available for review. Based on interview at the time of record review the Assistant Director of Health Care stated 1135 waiver policy could not be found.

The finding was reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on record review and interview, the facility failed to review and update the Emergency Preparedness Plan's (EPP) Training and Testing Plan at least annually in accordance with 42 CFR 483.73(a). This deficient practice could affect all occupants.

Findings include:

Based on records review with the Assistant Director of Health Care on 06/02/21 at 11:41 a.m., the EEP had a date of 2019 on the cover page, no other date could be found to show the EPP's Training and Testing Plan was reviewed and updated within the last year. Based on an interview during records review, the Assistant Director of Health Care stated the EEP's Training and Testing Plan has not been reviewed or updated within the last year.

The finding was reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on observation and interview, the facility failed to implement the emergency power system requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code in accordance with 42 CFR 482.15(e)(2). This deficient practice could affect all occupants.

Findings include:

Based on observation with the Facilities Director and the Inpatient Director on 06/02/21 at 10:02 a.m., the generator lacked a remote emergency stop and battery powered lighting required by LSC and NFPA 110. Based on interview at the time of record review, the maintenance Director stated the generator lacked a remote emergency stop and battery powered lighting.

The findings were reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on observation and interview, the facility failed to ensure the means of egress through 3 of 3 patient emergency exits with special locking arrangements for the clinical security needs of the patients would release upon activation of the smoke detection system or the fire sprinkler system. This deficient practice could affect all patients.

Findings include:

Based on observation with the Facilities Director and the Inpatient Director on 06/02/21 at 1:50 p.m., the inpatient area had special locking arrangements for patients with clinical security needs. The 300, 400, and 500 exit doors in the inpatient area were locked with a latch that hooked into the door frame and could be opened by a key carried by staff, but it could not determine if the doors would unlock from the door frame upon activation of the smoke detection system or sprinkler system. When the fire system was activated by a pull station the doors did not unlock. Based on interview at the time of observation, the Facilities Director stated it is unknown if the doors would unlock from the door frame if the smoke detection system or sprinkler system was activated.

The findings were reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on observation and interview, the facility failed to ensure 5 of 5 hazardous areas that contained fuel fire equipment were protected with a self-closing latching door. This deficient practice could affect all patients.

Findings include:

Based on observations with the Facilities Director and the Inpatient Director on 06/02/21 between 12:55 p.m. and 2:00 p.m., the corridor doors to the following hazardous areas that contained fuel fire equipment were not self-closing:
a) Housekeeping room 506.
b) Housekeeping room 303.
c) Mechanical room 302.
d) Mechanical room 401.
e) Mechanical room 404.
Based on interview at the time of observations, the Facilities Director agreed all five rooms contained fuel fired equipment and the corridor doors to the rooms were not self-closing.

The findings were reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control units, located in an area that was not continuously occupied, was provided with annunciation readily accessible to responding personnel to facilitate an efficient response to the fire situation. 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 and Signaling Code. NFPA 72, 2010 Edition, Section 10.16.3.1 states all required annunciation means shall be readily accessible to responding personnel. Section 10.16.3.2 states all required annunciation means shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation. Section 10.12.5 states the trouble signal(s) shall be located in an area where it is likely to be heard

Annex A is not a part of the requirements but is included for informational purposes only
Section A.10.16.3 states the primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation.
This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the Facilities Director and the Inpatient Director on 06/03/21 at 1:01 p.m., the main fire alarm control unit was in the I.T. room and a remote annunciator was in the font foyer. Both areas are only occupied during business hours and not continuously occupied. Based on interview at the time of the observations, the Inpatient Director agreed the main panel and remote panel were not in areas continuously occupied and stated there is no remote annunciator in the continuously occupied areas of the building.

The finding was reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on observation and interview, the facility failed to maintain the ceiling construction of 2 of 2 smoke compartments. 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 occupants.

Findings include:

Based on observation during a tour of the facility with the Facilities Director and the Inpatient Director on 06/02/21 between 12:00 p.m. and 1:30 p.m., in the suspended ceiling of the fount foyer, I.T. room, and housekeeping room 506, were missing ceiling tiles. This condition could delay the activation of the sprinklers installed on the suspended ceiling. Based on interview at the time of the observations, the Facilities Director agreed ceiling tiles were missing or not in place in the aforementioned locations.

The finding was reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on observation and interview, the facility failed to ensure 6 of 6 portable fire extinguishers were installed in accordance with NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition. Section 6.1.3.4 states portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means. (1) Securely on a hanger intended for the extinguishers. (2) In the bracket supplied by the extinguisher manufacture. (3) In a listed bracket approved for such purpose. (3) In a cabinet or wall recess. This deficient practice could affect all occupants.

Findings include:

Based on observations during a tour of the facility with the Facilities Director and the Assistant Director on 06/03/21 at 11:40 a.m., ABC portable fire extinguishers in the maintenance shop, I.T. room, break room, and pharmacy were sitting on the floor unsecured. Based on interview at the time of observation, the Facilities Director and the Assistant Director agreed there were fire extinguishers sitting on the floor in the aforementioned locations.

The finding was reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on record review and interview; the facility failed to ensure 1 of 1 fire damper systems were inspected and provided necessary maintenance after the first year after instillation and at least every six years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC) ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. Section 19.4.1.1 states the test and inspection frequency shall be every 4 years except for hospitals where the frequency is every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all occupants.

Findings include:

Based on records review with the Facilities Director and the Inpatient Director on 06/02/21 at 10:02 a.m., The facility was built and had smoke/fire dampers installed in 2015. No documentation of an inspection for the facility's smoke/fire dampers one year after installation was available for review. Based on interview at the time of records review, the Facilities Director stated the facility does have dampers in the HVAC system and the damper inspection one year after installation could not be found.

The finding was reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on observation, interview, and record review, the facility failed to provide a written plan that addressed all components in 1 of 1 written fire plans in accordance with 19.7.2.2. 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 the 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
This deficient practice could affect all occupants.

Findings include:

Based on records review with the Facilities Director and the Inpatient Director on 06/02/21 at 11:02 a.m., the provided fire emergency plan lacked information on partial or horizontal evacuation from one smoke compartment beyond a smoke or fire barrier to the next smoke compartment. Also, the plan did not identify the locations of smoke/fire door in the barriers. Based on interview during records review, the Facilities Director agreed the fire emergency plan did not contain complete instruction for evacuation of smoke compartment.

The finding was reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on record review and interview, the facility failed to conduct fire drills on each shift for 2 of 4 quarters. LSC 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. QSO-20-31 1135 temporary waiver states in lieu of a physical fire drill, a documented orientation training program related to the current fire plan, which considers current facility conditions, is acceptable. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area. This deficient practice affects all staff and patients.

Findings include:

Based on records review with the Facilities Director and the Inpatient Director on 06/02/21 at 10:02 a.m., the following shifts were missing documentation of a completed fire drill:
a) A third shift fire drill in the fourth quarter of 2020.
b) A third shift fire drill in the first quarter of 2021.
c) A second shift fire drill in the first quarter of 2021.
Furthermore, no documentation was provided to show staff reviewed fire safety procedures for the fourth quarter of 2020 and first quarter of 2021.
Based on interview at the time of record review, the Facilities Director agreed there were three missing fire drills and staff has not been trained in the fire safety procedures for the last two quarters.

The finding was reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on observation, records review, and interview, the facility failed to maintain proper testing of 1 of 1 rolling fire door/windows in accordance of NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition. LSC 4.5.8 requires any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance. NFPA 80 5.2.1 requires 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. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Facilities Director and the Inpatient Director on 06/02/21 at 12:07 p.m., there were non-rated wall length windows in the fire wall that were protected by a roiling fire door/window. Based on records review at 2:00 p.m., no documentation was provided to show if the roiling fire door/window has ever been inspected. Based on interview at the time of observation, the Facilities Director stated the roiling fire door/window has not been inspected since the building was built in 2015.

The finding was reviewed with the Facilities Director and the Inpatient Director during the exit conference.

#1. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a properly located remote stop in the event the generator caught fire. NFPA 110, Standard for Emergency and Standby Power Systems 2010 Edition, Section 5.6.5.6, requires 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.
Section 5.6.5.6.1, requires the remote manual stop station to be labeled.
Annex A is not a part of the requirements but is included for informational purposes only.
A.5.6.5.6 states for systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

Based on observation with the Facilities Director and the Inpatient Director on 06/02/21 at 10:02 a.m., a remote emergency stop button for the diesel power generator could not be located. Based on interview at the time of observation, the Facilities Director stated the generator was not equipped with a remote emergency stop button.

#2. Based on observation and interview, the facility failed to ensure 1 of 1 generators were provided with battery-powered emergency lighting. NFPA 110, 2010 Edition at section 7.3.1 requires the Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This deficient practice could affect all patients in the facility.

Findings include:

Based on observation with the Facilities Director and the Inpatient Director on 06/02/21 at 10:02 a.m., the emergency generator which was enclosed within privacy fencing did not contain battery-powered emergency lighting. Based on an interview at the time of observation, the Facilities Director stated the generator was not provided with battery-powered emergency lighting.

The findings were reviewed with the Facilities Director and the Inpatient Director during the exit conference.