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Based on observation and interview, the facility failed to ensure the egress lighting for 1 of 8 exit means of egress was arranged so the failure of any single lighting fixture would not leave the area in darkness, failed to ensure 6 of over 20 exit signs were continuously illuminated, failed to ensure all electrical receptacles were tested in 15 of 15 patient care rooms. failed to ensure a written record of weekly inspections for the generator was maintained for 35 of 52 weeks, failed to maintain the ceiling construction in 4 of 4 areas in the facility and failed to conduct quarterly fire drills for 1 of 4 quarters.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to ensure the egress lighting for 1 of 8 exit means of egress was arranged so the failure of any single lighting fixture would not leave the area in darkness. LSC 7.8.1.4 requires illumination shall be arranged so that that the failure of any single lighting unit does not result in an illumination level of less than 0.2 foot-candle in any designated area, failed to ensure 6 of over 20 exit signs were continuously illuminated, failed to ensure all electrical receptacles were tested in 15 of 15 patient care rooms. NFPA 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.3 states receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. Additionally, Section 6.3.3.2, Receptacle Testing in patient care rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 gram (4 ounces) and failed to ensure a written record of weekly inspections for the generator was maintained for 35 of 52 weeks. NFPA 99, 6.4.4.1.3 requires onsite generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 8.4.1 requires an Emergency Power Supply System (EPSS) including all appurtenant components, shall be inspected weekly and exercised monthly. NFPA 99, 6.4.4.2 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.

Findings include;
Based on observations with the Facilities Technician (FT) on 02/13/24 at 09:35 a.m., the exit means of egress outside from the West Front exit only had one light fixture with only one light source. Based on interview at the time of observation, the FT agreed there was only one light source outside of the West Front exit.

Based on observations on 02/13/24 during a tour of the facility between 09:45 a.m. to 11:10 a.m. with the Facilities Technician (FT), the West exit sign, the North exit sign, Exit signs 15 and 17 by the receptionist, the East exit sign, the exit sign by room 216, and the exit sign by room 231 were not illuminated. Based on an interview with the FT at the time of observation, it was stated that he had recently replaced the exit sign light bulbs but the exit sign light bulbs are burned out again.

Based on record review with the Chief Compliance Officer / Vice-President of Facilities and Safety (CCO/VPoFS) on 02/13/24 at 11:12 a.m., documentation of a current receptacle retention test to test the physical integrity, continuity, or polarity of the patient care room receptacles available for review. Based on observations made during a tour of the facility, the facility's 15 patient rooms had roughly 6 electrical receptacles in each room, and they were not hospital grade outlets. Based on an interview at the time of the observations and records review, the Facilities Technician stated that he did not know about the necessity of an NFPA 99 requirement for the testing of the integrity of each receptacle in the patient care rooms.

Based on record review with the Chief Compliance Officer / Vice-President of Facilities and Safety (CCO/VPoFS) on 02/13/24 at 12:16 p.m., the facilities documentation entitled "Weekly Generator Test Log" lacked weekly generator inspection documentation from 06/02/23 to the present. Based on interview at the time of record review, the COO/VPoFS stated that the Maintenance Man quit that week, and it has taken a while for them to find a suitable replacement. They had recently hired a new person for this role, and he is getting his training this week on the generator functions and its documentation.

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 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 NFPA110, 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.

Based on record review with the Chief Compliance Officer / Vice-President of Facilities and Safety (CCO/VPoFS) on 02/13/24 at 12:16 p.m., documentation of an annual fuel quality test for the facilities 230 kW diesel-powered generator could not be located for review. Based on an interview at the time of record review, the CCO/VPoFS stated that she felt the annual fuel quality test for the facilities diesel-powered generator could not be located due to the lack of a person filling the Facilities Technician job until just recently adding that the new Technician was now hired and currently in training.

Based on observation and interview, the facility failed to maintain the ceiling construction in 4 of 4 areas in the facility. The ceiling traps hot air and gases around the sprinkler and causes the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.1.1 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 and failed to conduct quarterly fire drills for 1 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."

Findings include:

Based on observations with the Facilities Technician (FT) on 02/13/24 between 09:40 a.m. and 10:15 a.m.,
a) The entrance to the training room there was a 2" gap around a sprinkler head where the ceiling tile had dropped down,
b) In room 122 there was a 2' x 3' section of ceiling drywall cut out,
c) In the corridor by exit light H there was 2' x 2' ceiling tile missing,
d) and in the elevator room there was a 1' x 1' section of ceiling drywall cut out. These conditions could delay the activation of the sprinklers installed in ceilings. Based on interview at the time of observation, the FT agreed there were unsealed holes in the four ceilings mentioned.

Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler systems were provided with spare sprinklers, a spare sprinkler cabinet large enough to fit all spare sprinkler heads, and a sprinkler wrench on the premises. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.4 states a supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. The sprinklers shall correspond to the types and temperature ratings of the sprinklers on the property. The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100 degrees Fahrenheit. A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. This deficient practice could affect all patients and staff in the facility.

Based on observation with the Facilities Technician (FT) on 02/13/24 at 10:05 a.m., the spare sprinkler cabinet in the riser room was not large enough to contain all sprinkler heads and prevent damage to the sprinkler heads. When the spare sprinkler cabinet in the riser room was opened, the cabinet contained 3 sprinkler heads in protected slots, 13 sprinkler heads positioned on the 2 shelves not in protected slots and 5 sprinkler heads on top of the sprinkler cabinet. Based on interview at the time of the observations, the FT agreed the cabinet was not large enough to contain all spare sprinkler heads.

Based on record review with the Chief Compliance Officer / Vice-President of Facilities and Safety (CCO/VPoFS) on 02/13/24 at 11:39 a.m., documentation could not be provided regarding a fire drill for the third quarter (July, August, and September) on the night shift of 2023. Based on interview at the time of record review, the CCO/VPoFS acknowledged that there was no additional available fire drill documentation for review as of the time of this survey.