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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 occupants.

Findings include:

Based on record review with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager from 10:00 a.m. to 4:30 p.m. on 06/26/23, the following was noted for the facility's emergency and standby power systems:

a. thirty-six-month period emergency generator testing documentation for four continuous hours for the facility's emergency generators identified as Generator #1 (rated at 300 kW) and Generator #2 (rated at 500 kW) was not available for review. Based on interview at the time of record review, the Project Manager stated the facility has three diesel fuel fired emergency generators, Generator #3 is the only one of the three generators which had thirty-six-month period testing conducted on 03/09/23 and agreed supplemental load testing documentation for four hours within the most recent three-year period for Generator #1 and Generator #2 was not available for review.

b. the emergency generator identified as Generator #2 is diesel fuel fired and rated at 500 kW. Monthly emergency generator load testing documentation for the most recent twelve-month period indicated no monthly test achieved not less than 30% (150 kW) of the EPS nameplate kW rating. Based on interview at the time of record review, the Project Manager agreed monthly load testing for Generator #2 did not achieve at least 30% load and agreed annual supplemental load testing documentation for the most recent twelve-month period was not available for review.

c. documentation of an annual fuel quality test for the facility's three diesel fuel fired emergency generators was not available for review. Based on interview at the time of record review, the Project Manager stated the facility has three diesel fuel fired emergency generators. Based on interview at the time of record review, the Maintenance Director stated contractor reports may have been e-mailed to the previous Maintenance Director's e-mail account for which he did not have access to but agreed documentation of an annual fuel quality test for each of the three-diesel fuel fired emergency generators was not available for review at the time of the survey.

d. monthly load testing documentation for the facility's three diesel fuel fired emergency generators for the most recent twelve-month period was incomplete. The transfer time was not documented on "Emergency Generator-Monthly Test Log" documentation. Generator inspection and testing is also documented on "Preventive Maintenance Checklist" documentation where the run time duration was listed as "20 minutes" and where the "Transfer Time (Less than 10 seconds)" is checked "OK" but the day of each inspection or test on the "Preventive Maintenance Checklist" is not the same date as monthly load testing dates on "Emergency Generator-Monthly Test Log" documentation. Based on interview at the time of record review, the Maintenance Director and the Project Manager agreed the transfer time for monthly load testing documentation for each of the facility's three emergency generators was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

e. monthly load testing documentation for the facility's three diesel fuel fired emergency generators for the most recent twelve-month period was incomplete. The cool down time was not documented on "Emergency Generator-Monthly Test Log" documentation. Generator inspection and testing is also documented on "Preventive Maintenance Checklist" documentation where the run time duration was listed as "20 minutes" and where the "Cool Down Time - (20 Minutes)" is checked "OK" but the day of each inspection or test on the "Preventive Maintenance Checklist" is not the same date as monthly load testing dates on "Emergency Generator-Monthly Test Log" documentation. Based on interview at the time of record review, the Maintenance Director and the Project Manager agreed the cool down time for monthly load testing documentation for each of the facility's three emergency generators was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

Based on observation and interview, the facility failed to ensure in 1 of 2 interior exit enclosures were not used for storage. LSC 7.2.2.5.3 states Enclosed, usable spaces within exit enclosures shall be prohibited, including under stairs, unless otherwise permitted by 7.2.2.5.3.2. which states enclosed, usable space shall be permitted under stairs, provided that both of the following criteria are met:
(1) The space shall be separated from the stair enclosure by
the same fire resistance as the exit enclosure.
(2) Entrance to the enclosed, usable space shall not be from within the stair enclosure. This deficient practice could affect all residents, staff and visitors using the exit stairwell.

Findings include:

Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/27/23 between 9:20 a.m. and 11:50 a.m., the exit stairwell connecting the first floor (marked Not an Exit) and the second-floor surgery OR area (marked an Exit) contained an enclosed storage room under the stairs used as an "IT" storage room containing IT equipment, boxes and other material. The door to the aforementioned room opens into the exit enclosure. Based on interview at the time of observation, the Project Manager and VP of Cooperate Compliance confirmed the aforementioned exit enclosure was used for storage.

This finding was acknowledged at the time of discovery by the Project Manager and VP of Cooperate Compliance and again at the exit conference with the Project Manager, VP of Nursing and CNO, Maintenance Director and CEO present on 06/27/23.

Based on observation and interview; the facility failed to provide clear direction with exit signage in 1 of 3 exits in accordance with LSC 7.10. LSC 7.10.1.2.1 exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. LSC 7.10.1.2.2 states horizontal components of the egress path within an exit enclosure shall be marked by approved exit or directional exit signs where the continuation of the egress path is not obvious. This deficient practice could affect 9 staff and patients.

Findings include:

Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/26/23 between 9:45 a.m. and 1:50 p.m., the side door exit in the Professional Office Building was marked with an appropriate exit sign as an Exit. However, confusion was created with an additional sign located in front of the door which stated the door was "NO EXIT." At the time of observation, the Project Manager and VP of Cooperate Compliance acknowledged the condition and described why the additional NO EXIT sign had been placed in front of the door.

This finding was acknowledged at the time of discovery by the Project Manager and VP of Cooperate Compliance and again at the exit conference with the Project Manager, VP of Nursing and CNO, Maintenance Director and CEO present on 06/27/23.

Based on record review and interview, the facility failed to ensure 1 of 1 kitchen fire suppression systems was inspected semiannually. NFPA 96, 2011 Edition, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 11.2.1 states maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and the exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at lease every six months. This deficient practice could affect all kitchen staff.

Findings include:

Based on review of the kitchen fire suppression system inspection contractor's inspection documentation dated 10/13/22 with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director and the Project Manager during record review from 9:30 a.m. to 12:45 p.m. on 06/27/23, documentation of semiannual kitchen fire suppression system inspection six months after 10/13/22 was not available for review. Based on interview at the time of record review, the Maintenance Director stated inspection contractor reports may have been e-mailed to the previous Maintenance Director's e-mail account for which he did not have access to but agreed documentation of semiannual fire suppression system inspection six months after 10/13/22 was not available for review at the time of the survey.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director and the Project Manager during the exit conference.

Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with LSC 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, Section 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the fire alarm system inspection contractor's "Inspection Summary" documentation dated 01/04/23 for the 201 Conrad Harcourt location with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, deficiencies were noted for the facility's fire alarm system. The "Device Deficiencies" section of the 01/04/23 inspection report stated the fire panel failed testing due to "Failure Reason: Reported 1 time out of 3 attempts to the maintenance shop needs trouble shot". Based on interview at the time of record review, the Maintenance Director stated inspection contractor repair documentation may have been e-mailed to the previous Maintenance Director's e-mail account for which he did not have access to but agreed repair documentation on or after 01/04/23 was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director and the Project Manager during the exit conference.

Based on record review and interview, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with LSC 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, Section 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the fire alarm system inspection contractor's "Inspection Summary" documentation dated 01/04/23 for the 323 Conrad Harcourt location with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, deficiencies were noted for the facility's fire alarm system. The "Device Deficiencies" section of the 01/04/23 inspection report stated the fire panel failed testing due to "Failure Reason: Com fault 1 and 2 upon arrival". Review of "Proposal and Service Agreement" documentation dated 03/23/23 indicated the contractor provided a quote for fire alarm system repair. Based on interview at the time of record review, the Maintenance Director stated the facility approved the quote but the contractor is awaiting parts to arrive to complete the repair.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director and the Project Manager during the exit conference.

1. Based on record review and interview, the facility failed to maintain automatic sprinkler systems in accordance with NFPA 25. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test and maintenance required by this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, Section 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. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on review of the sprinkler system inspection contractor's "Sprinkler System Inspection" documentation dated 07/20/22 for the Medical Office Building location with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, deficiencies were noted for the facility's sprinkler systems. The "Deficiencies" section of the 07/20/22 inspection report stated, "Panel Condition Deficiency Found 2nd floor MON T 1:2-37 wrong device on panel upon arrival". Based on interview at the time of record review, the Maintenance Director stated inspection contractor repair or replace documentation may have been e-mailed to the previous Maintenance Director's e-mail account for which he did not have access to but agreed repair or replace documentation on or after 07/20/22 was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

2. 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. Section 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, Section 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. Section 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.

Findings include:

Based on review of the sprinkler system inspection contractor's "Sprinkler System Inspection" documentation with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, sprinkler system inspection and testing documentation for the first quarter (January, February, March) 2023 was not available for review. Based on interview at the time of record review, the Project Manager agreed sprinkler system inspection and testing documentation for the first quarter 2023 was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

1. 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. Section 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, Section 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. Section 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 sprinkler system inspection contractor's "Inspection Report" and "Sprinkler System Inspection" documentation with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, sprinkler system inspection and testing documentation for the fourth quarter (October, November, December) 2022 was not available for review. Based on interview at the time of record review, the Project Manager agreed sprinkler system inspection and testing documentation for the fourth quarter (October, November, December) 2022 was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

2. 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, preaction and deluge 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 patients, staff, and visitors.

Findings include:

Based on review of the sprinkler system inspection contractor's "Inspection Report" and "Sprinkler System Inspection" documentation with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, sprinkler system gauges and valves were inspected by the contractor for two months of the most recent twelve-month period. Based on interview at the time of record review, the Project Manager stated facility maintenance staff do not perform additional sprinkler system gauge and valve inspections in addition to the contractor's quarterly inspections and agreed additional monthly sprinkler system gauge and valve inspection documentation for the most recent twelve-month period was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

Based on record review and interview, the facility failed to maintain automatic sprinkler systems in accordance with NFPA 25. LSC 9.7.5 requires all sprinkler systems shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test and maintenance required by this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, Section 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. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

Based on review of the sprinkler system inspection contractor's "Sprinkler System Inspection" documentation dated 07/20/22 for the 1339 North Cherry Street location with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, deficiencies were noted for the facility's 1 dry sprinkler system. The "Deficiencies" section of the 07/20/22 inspection report stated "Panel Condition Deficiency Found Trouble TELCO Line 1". Based on interview at the time of record review, the Maintenance Director stated inspection contractor repair or replace documentation may have been e-mailed to the previous Maintenance Director's e-mail account for which he did not have access to but agreed repair or replace documentation on or after 07/20/22 was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director and the Project Manager during the exit conference.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed for the protection of all patients in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25. NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Fire Watch" documentation dated June 2023 with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director and the Project Manager during record review from 9:30 a.m. to 12:45 p.m. on 06/27/23, the fire watch plan for sprinkler system impairment was incomplete. The fire watch policy for automatic sprinkler system impairment failed to also include notification of the alarm monitoring company, the building owner and the insurance carrier if the required automatic sprinkler system is out-of-service for 10 hours or more in a 24-hour period. Based on interview at the time of record review, the Vice President of Nursing agreed the fire watch plan for sprinkler system impairment was incomplete.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director and the Project Manager during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 3 portable fire extinguishers were 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 5 staff and visitors.

Findings include:

Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/26/23 between 9:45 a.m. and 1:50 p.m., the portable fire extinguisher located in the Walk-In Care Building, near the Mechanical Room was mounted on the wall with the top of the extinguisher more than 5 feet above the floor. Based on interview at the time of observation, the Project Manager agreed the fire extinguisher was mounted with the top of the extinguisher appearing to be greater than five feet above the floor.

This finding was acknowledged at the time of discovery by the Project Manager and VP of Cooperate Compliance and again at the exit conference with the Project Manager, VP of Nursing and CNO, Maintenance Director and CEO present on 06/27/23.

Based on observation and interview, the facility failed to ensure 1 of 1 corridor in the Medical Office Break Room would self-close, had no impediment to closing and latching into the door frame and would resist the passage of smoke. This deficient practice could affect 8 staff.

Findings include:

Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/26/23 between 9:45 a.m. and 1:50 p.m., the Break Room corridor door in the Medical Office Building adjacent to the stairwell entrance, equipped with a self-closing device, failed to self-close and latch positively into the door frame.

This finding was acknowledged at the time of discovery by the Project Manager and VP of Cooperate Compliance and again at the exit conference with the Project Manager, VP of Nursing and CNO, Maintenance Director and CEO present on 06/27/23.

Based on observation and interview, the facility failed to ensure 1 of over 8 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke. This deficient practice could affect 6 staff.

Findings include:

Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/26/23 between 9:45 a.m. and 1:50 p.m., the Lounge Area corridor door in the Pain Management Building failed to latch positively into the door frame.

This finding was acknowledged at the time of discovery by the Project Manager and VP of Cooperate Compliance and again at the exit conference with the Project Manager, VP of Nursing and CNO, Maintenance Director and CEO present on 06/27/23.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 3 of over 10 smoke barriers walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. LSC Section 8.5.2.1 requires smoke barriers to be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.6.2 requires penetrations for cables, cable trays, conduits, pipes, tubes, 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 smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the movement of smoke. This deficient practice could affect 12 staff.

Findings include:

Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/26/23 between 2:00 p.m. and 3:50 p.m., (1) a section of ceiling tile was missing in the smoke barrier drop ceiling in the basement Phone Room numbered A0060. And (2) fire barrier caulk had been knocked out in the ceiling and was missing in basement room #A00611. (3) Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/27/23 between 9:20 a.m. and 11:50 a.m., in the 2nd floor "IT" Hall Closet there was a gang of wires penetrating through the concrete floor which were not sealed.

This finding was acknowledged at the time of discovery by the Project Manager and VP of Cooperate Compliance and again at the exit conference with the Project Manager, VP of Nursing and CNO, Maintenance Director and CEO present on 06/27/23.

1. Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times under varying conditions on the first shift for 4 of 4 quarters. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on review of "Fire Drill Observer Checklist" documentation with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, first shift fire drills conducted within the most recent twelve-month period on 07/28/22, 10/12/22, 01/11/23 and on 04/26/23 were conducted at, respectively, 1:45 p.m., 1:00 p.m., 2:00 p.m. and 1:00 p.m. Based on interview at the time of record review, the Vice President of Corporate Compliance stated the facility operates three shifts per day and agreed the aforementioned first shift fire drills were not conducted at unexpected times under varying conditions.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

2. Based on record review and interview, the facility failed to document all staff who participated in quarterly fire drills on the first, second and third shifts for four of four quarters. LSC Section 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions. LSC Section 19.7.1.8 states employees of health care occupancies shall be instructed in life safety procedures and devices. This deficient practice affects all patients, staff, and visitors.

Findings include:

Based on review of "Fire Drill Observer Checklist" documentation with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, documentation for first, second and third shift fire drills conducted within the most recent twelve-month period did not include all staff who participated in the fire drill. Based on interview at the time of record review, the Vice President of Corporate Compliance stated the facility operates three shifts per day. Based on interview at the time of record review, the Project Manager stated each fire drill documents the name of the maintenance staff who conducted the drill but agreed documentation for all fire drills conducted within the most recent twelve-month period did not include all staff who participated in the fire drill.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

1. Based on record review and interview, the facility failed to document 36-month period emergency generator testing for 2 of 3 emergency generators in accordance with NFPA 99 and NFPA 110. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.4.1.1.6.1 states Type 1 and Type 2 essential electrical system power sources (EPSS) shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110. NFPA 110, the Standard for Emergency and Standby Powers Systems, 2010 Edition, Section 8.4.9 states Level 1 EPSS shall be tested at least once within every 36 months. Section 8.4.9.1 states Level 1 EPSS shall be tested continuously for the duration of its assigned class (See Section 4.2). Section 8.4.9.2 states where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours. Section 8.4.9.5 states the minimum load for this test shall be specified in 8.4.9.5.1, 8.4.9.5.2, or 8.4.9.5.3. Section 8.4.9.5.3 states for spark-ignited EPS's, loading shall be the available EPSS load. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on record review with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager from 10:00 a.m. to 4:30 p.m. on 06/26/23, thirty-six month period emergency generator testing documentation for four continuous hours for the facility's emergency generators identified as Generator #1 (rated at 300 kW) and Generator #2 (rated at 500 kW) was not available for review. Based on interview at the time of record review, the Project Manager stated the facility has three diesel fuel fired emergency generators, Generator #3 is the only one of the three generators which had thirty-six month period testing conducted on 03/09/23 and agreed supplemental load testing documentation for four hours within the most recent three-year period for Generator #1 and Generator #2 was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

2. Based on record review and interview, the facility failed to exercise 1 of 3 emergency generators annually to meet the requirements of NFPA 110, 2010 Edition, the Standard for Emergency and Standby Powers Systems, Chapter 8.4.2. Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS (Emergency Power Supply) nameplate kW rating.
Section 8.4.2.3 states diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS (Emergency Power Supply System) load and shall be exercised annually with supplemental loads (Load Bank Test) at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on review of "Emergency Generator-Monthly Test Log" documentation with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, the emergency generator identified as Generator #2 is diesel fuel fired and rated at 500 kW. Monthly emergency generator load testing documentation for the most recent twelve-month period indicated no monthly test achieved not less than 30% (150 kW) of the EPS nameplate kW rating. Based on interview at the time of record review, the Project Manager agreed monthly load testing for Generator #2 did not achieve at least 30% load and agreed annual supplemental load testing documentation for the most recent twelve-month period was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

3. Based on record review and interview, the facility failed to ensure an annual fuel quality test was performed for the facility's three diesel fuel fired emergency generators. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.5.4.1.1.2 states Type 2 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, staff, and visitors.

Findings include:

Based on record review with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager from 10:00 a.m. to 4:30 p.m. on 06/26/23, documentation of an annual fuel quality test for the facility's three diesel fuel fired emergency generators was not available for review. Based on interview at the time of record review, the Project Manager stated the facility has three diesel fuel fired emergency generators. Based on interview at the time of record review, the Maintenance Director stated contractor reports may have been e-mailed to the previous Maintenance Director's e-mail account for which he did not have access to but agreed documentation of an annual fuel quality test for each of the three-diesel fuel fired emergency generators was not available for review at the time of the survey.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

4. Based on record review and interview, the facility failed to ensure documentation of the transfer time to the alternate power source was within 10 seconds for monthly load tests conducted for 3 of 3 emergency generators for the most recent 12-month period. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on review of "Emergency Generator-Monthly Test Log" documentation with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, monthly load testing documentation for the facility's three diesel fuel fired emergency generators for the most recent twelve-month period was incomplete. The transfer time was not documented on "Emergency Generator-Monthly Test Log" documentation. Generator inspection and testing is also documented on "Preventive Maintenance Checklist" documentation where the run time duration was listed as "20 minutes" and where the "Transfer Time (Less than 10 seconds)" is checked "OK" but the day of each inspection or test on the "Preventive Maintenance Checklist" is not the same date as monthly load testing dates on "Emergency Generator-Monthly Test Log" documentation. Based on interview at the time of record review, the Maintenance Director and the Project Manager agreed the transfer time for monthly load testing documentation for each of the facility's three emergency generators was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

5. Based on record review and interview, the facility failed to ensure 3 of 3 emergency generators was allowed a 5-minute cool down period after a load test for the most recent twelve-month period. NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition, Section 8.4.5(4) requires a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shut down. This delay provides additional engine cool down. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on review of "Emergency Generator-Monthly Test Log" documentation with the Vice President of Corporate Compliance, the Vice President of Nursing, the Maintenance Director, and the Project Manager during record review from 10:00 a.m. to 4:30 p.m. on 06/26/23, monthly load testing documentation for the facility's three diesel fuel fired emergency generators for the most recent twelve-month period was incomplete. The cool down time was not documented on "Emergency Generator-Monthly Test Log" documentation. Generator inspection and testing is also documented on "Preventive Maintenance Checklist" documentation where the run time duration was listed as "20 minutes" and where the "Cool Down Time - (20 Minutes)" is checked "OK" but the day of each inspection or test on the "Preventive Maintenance Checklist" is not the same date as monthly load testing dates on "Emergency Generator-Monthly Test Log" documentation. Based on interview at the time of record review, the Maintenance Director and the Project Manager agreed the cool down time for monthly load testing documentation for each of the facility's three emergency generators was not available for review.

These findings were reviewed with the Chief Executive Officer, the Vice President of Nursing, the Maintenance Director, and the Project Manager during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 1 power strips in the Private Office were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used as a substitute for fixed wiring. This deficient practice could affect up to 2 staff.

Findings include:

Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/26/23 between 9:45 a.m. and 1:50 p.m., in the Professional Office Building, Private Office, a power strip was being used to power both a dorm style refrigerator and a microwave oven (high power draw equipment).

This finding was acknowledged at the time of discovery by the Project Manager and VP of Cooperate Compliance and again at the exit conference with the Project Manager, VP of Nursing and CNO, Maintenance Director and CEO present on 06/27/23.

Based on observation and interview, the facility failed to ensure 1 of 1 power strips in the basement were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used as a substitute for fixed wiring. This deficient practice could affect up to 6 staff.

Findings include:

Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/26/23 between 2:00 p.m. and 3:50 p.m., (1) in the basement Lab Reference room #A00498 a power strip was being used to power a dorm style refrigerator (high power draw equipment). And (2) Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/27/23 between 9:20 a.m. and 11:50 a.m., in the Med Staff area on the 3rd floor a power strip was being used to power a coffee machine (high power draw equipment). And (3) in the "Lean Project Facilitator" office a power strip was being used to power a dorm style refrigerator (high power draw equipment).

This finding was acknowledged at the time of discovery by the Project Manager and VP of Cooperate Compliance and again at the exit conference with the Project Manager, VP of Nursing and CNO, Maintenance Director and CEO present on 06/27/23.

Based on observation and interview, the facility failed to ensure 2 of over 30 rooms did not use multi-plug adaptors as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. 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 affects 4 staff.

Findings include:

Based on observations and interview during a tour of the facility with the Project Manager and VP of Cooperate Compliance on 06/26/23 between 9:45 a.m. and 1:50 p.m., in the Medical Office Building (1) ENT's Physician's office and (2) Exam Room #7, multi-plug adaptors were in use powering equipment. Based on interview at the time of observation, the Project Manager and VP of Cooperate Compliance agreed multi-plug adaptors were being used.

This finding was acknowledged at the time of discovery by the Project Manager and VP of Cooperate Compliance and again at the exit conference with the Project Manager, VP of Nursing and CNO, Maintenance Director and CEO present on 06/27/23.