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Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include the role of the Hospital 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 482.15(b) (8). This deficient practice could affect all occupants.

Findings include:

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., a policy and procedure for the role of the Hospital 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 CCO/VPoFS confirmed this item was not covered in the facilities Emergency Preparedness binder adding that she was unaware of the regulation and agreed that no policy and procedure was available for review as of the time of this survey.

This item was discussed with the CCO/VPoFS and the Facilities Technician at the exit conference on 02/13/24 at 1:25 p.m.

Based on record review and interview, the facility failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The Hospital must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
a. When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
b. If the Hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the Hospital is exempt from engaging its next required full-scale community-based or individual, facility-based full-scale functional exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
a. A second full-scale exercise that is community-based or an individual, facility-based functional exercise.
b. A mock disaster drill; or
c. A tabletop exercise or workshop that is led by a facilitator that includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the Hospitals response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the Hospitals emergency plan, as needed in accordance with 42 CFR 482.15(d)(2). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Compliance Officer / Vice-President of Facilities and Safety (CCO/VPoFS) on 02/13/24 at 12:51 p.m., the facility could not provide documentation of a full-scale exercise that is community-based or an individual, facility-based functional exercise, or a mock disaster drill. Based on an interview at the time of record review, the CCO/VP0FS stated that they had difficulty in deciding what type of drill to perform adding that they had some ideas but with the facility moving in the very near future, they have just not had time to plan and implement a drill as of the time of this survey.

This item was discussed with the CCO/VPoFS and the Facilities Technician at the exit conference on 02/13/24 at 1:25 p.m.

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 482.15(e)(2). This deficient practice could affect all occupants.

Findings include:

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 Load 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.

This item was discussed with the CCO/VPoFS and the Facilities Technician at the exit conference on 02/13/24 at 1:25 p.m.

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. This deficient practice could affect 5 patients and staff using the West Front exit.

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.

This finding was reviewed with the Chief Compliance Officer and FT during the exit conference.

Based on observation and interview, the facility failed to ensure 6 of over 20 exit signs were continuously illuminated. This deficient practice could affect 5 patients in the facility.

Findings include:

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.

These findings were reviewed with the Chief Compliance Officer and FT at the exit conference.

1. 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. This deficient practice could affect 5 patients in 4 areas of the facility.

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.

These findings were reviewed with the Chief Compliance Officer and FT during the exit conference.


2. 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.

Findings include:

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.

These findings were reviewed with the Chief Compliance Officer and FT during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 40 corridor doors resist the passage of smoke and are capable of resisting fire for 20 minutes. This deficient practice could affect 2 patients in one smoke compartment.

Findings include:

Based on observation with the Facilities Technician (FT) on 02/13/24 at 11:35 a.m., the corridor door to client room H, had 2 half inch holes that went through the door. Based on interview at the time of observation, the FT agreed there were 2 half inch holes in the H room door.

The finding was reviewed with the Chief Compliance Officer and FT during the exit interview

Based on observation and interview, the facility failed to ensure electrical wirings were protected. NFPA 70, 2011 Edition. Article 406.5 (F) Exposed Terminals, Receptacles shall be enclosed so that live wiring terminals are not exposed to contact. This deficient practice could affect staff and patients entering and exiting facility and in room 206, 207, and 208.

Findings include:

Based on observation during a tour of the facility with the Facilities Technician (FT) on 02/13/24 at 09:30 a.m. at the main entrance, there was a piece of flexible conduit on the wall above the main entrance door with exposed wires extending out. Each wire had a wire nut on it but there was not an electrical box to protect the wires from contact. Also in rooms 206, 207, and 208 there was one electrical receptacle with a broken cover in each room. Based on interview at the time of observation, the FT acknowledged the aforementioned conditions and confirmed that exposed wiring was visible.

This finding was reviewed with the Chief Compliance Officer and FT at the exit conference.

Based on record review and interview, the facility 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." This deficient practice could affect all occupants.

Findings include:

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.

This item was discussed with the CCO/VPoFS and the Facilities Technician at the exit conference on 02/13/24 at 1:25 p.m.

Based on observation, record review and interview, the facility 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). This deficient practice could affect all occupants.

Findings include:

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.

This item was discussed with the CCO/VPoFS and the Facilities Technician at the exit conference on 02/13/24 at 1:25 p.m.

a) Based on record review and interview, the facility 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. This deficient practice could affect all occupants.

Findings include:

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.

This item was discussed with the CCO/VPoFS and the Facilities Technician at the exit conference on 02/13/24 at 1:25 p.m.


b) 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. This deficient practice could affect all occupants.

Findings include:

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.

This item was discussed with the CCO/VPoFS and the Facilities Technician at the exit conference on 02/13/24 at 1:25 p.m.

Based on observation and interview, the facility failed to ensure 2 of 4 flexible cords were installed properly and used in a safe manor. NFPA 99, Section 10.2.4.2 states adapters and extension cords meeting the requirements of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted. Section 10.2.4.2.3 states the cabling shall comply with 10.2.3. Section 10.2.3.5.1 states cord strain relief shall be provided at the attachment of the power cord to the appliance so that mechanical stress, either pull, twist, or bend, is not transmitted to internal connections. This deficient practice could staff and one patient by the Information Technology (IT) room.

Findings include:

Based on observation with the Facilities Technician (FT) on 02/13/24 at 10:00 a.m., in the IT room, 2 power strips used to power equipment, were not secured, and were dangling from the outlet on the wall. This condition could put stress on the power cord causing damage to the power cord. Based on interview at the time of observations, the FT agreed the 2 power strips were dangling, not secured, and stated the power strips will need to be mounted or set on the floor.

These findings were reviewed with the Chief Compliance Officer and FT during the exit conference.