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Tag No.: K0025
Based on observation and interview, the facility failed to provide smoke barriers that would provide at least a one half hour fire resistance rating in accordance with LSC Sections 19.3.7.3 and 19.3.7.5. This deficient practice could potentially affect all 3 occupants of the facility, all of the staff and any visitors present at the time of a potential incident if smoke and fire were allowed to transfer from one smoke compartment to another. Findings include:
1. On 7/20/16 at 1:32 PM, an open penetration was observed above the smoke doors at the entrance to the Acute Care Wing. This penetration was caused by a bundle of wires.
In an interview on 7/20/16 at 1:33 PM, POD#1 acknowledged that there was a penetration above the smoke doors at the entrance to the Acute Care Wing.
Tag No.: K0046
Based on record review, observation and interview, the facility failed to provide and maintain emergency lighting in accordance with LSC Sections 19.2.9.1 and 7.9. This deficient practice could potentially affect all 3 occupants of the facility, all of the staff and any visitors present at the time of a potential incident if the emergency lighting failed to operate as designed during an emergency. Findings include:
1. On 7/20/16 at 12:10 PM during review of records it was noted the documentation for the monthly 30 second tests of the battery-operated emergency lights was missing for the months of December 2015 through June 2016.
In an interview on 7/20/16 at 12:11 PM, POD#1 acknowledged that the documentation for the monthly 30 second tests of the battery-operated emergency lights was missing for the months of December 2015 through June 2016.
2. On 7/20/16 at 12:12 PM during review of records it was observed that the documentation for the annual 90 minute tests of the battery-operated emergency lights was missing for 2016. The last documented 90 minute test was conducted in February of 2015.
In an interview on 7/20/16 at 12:13 PM, POD#1 acknowledged that the documentation for the annual 90 minute tests of the battery-operated emergency lights was missing for 2016.
3. On 7/20/16 at 1:09 PM it was observed that the battery-operated emergency light in the Operating Room failed to operate properly when tested.
In an interview on 7/20/16 at 1:10 PM, POD#1 acknowledged that the battery-operated emergency light in the Operating Room failed to operate properly when tested.
4. On 7/20/16 at 1:51 PM it was observed that the battery-operated emergency light above the Cafeteria Egress Door failed to operate properly when tested.
In an interview on 7/20/16 at 1:52 PM, POD#1 acknowledged that the battery-operated emergency light above the Cafeteria Egress Door failed to operate properly when tested.
5. On 7/20/16 at 1:58 PM it was observed that the battery-operated emergency light in Purchasing failed to operate properly when tested.
In an interview on 7/20/16 at 1:59 PM, POD#1 acknowledged that the battery-operated emergency light in Purchasing failed to operate properly when tested.
Tag No.: K0050
Based on review of records and interview, the facility failed to provide written documentation regarding fire drills in accordance with LSC Section 19.7.1.2. This deficient practice could potentially affect all 3 occupants of the facility, all of the staff and any visitors present at the time of a potential incident if staff are not properly trained in approved emergency procedures. Findings include:
1. On 7/20/16 at 11:19 AM during review of records it was observed that the facility failed to conduct and document any fire drill for the 2nd shift of the 1st quarter of 2016.
In an interview on 7/20/16 at 11:20 AM, POD#1 acknowledged that the facility failed to conduct and document any fire drill for the 2nd shift of the 1st quarter of 2016.
2. On 7/20/16 at 11:21 AM during review of records it was observed that the times that the drills are conducted for the 3rd shift need to vary. Observed drill times for the 3rd shift were 4:06 AM; 3:35 AM; 4:25 AM and 3:55 AM.
In an interview on 7/20/16 at 11:22 AM, POD#1 acknowledged that the 3rd shift fire drills were conducted at the times noted above.
Tag No.: K0062
Based on observation and interview the facility failed to ensure that the automatic sprinkler system is maintained and tested in accordance with LSC Sections 19.7.6, 4.6.12, and 9.7.5 and NFPA 13 and 25. This deficient practice could potentially affect 6 staff members of the facility if the automatic sprinkler system failed to operate as designed during a fire. Findings include:
1. On 7/20/16 at 1:47 PM it was observed that the storage in the Bread Pantry was within 18 inches of the sprinkler deflector.
In an interview on 7/20/16, POD#1 acknowledged that the storage in the Bread Pantry was within 18 inches of the sprinkler deflector.
Tag No.: K0064
Based upon review of records and interview, the facility failed to provide and maintain fire extinguishers in accordance with LSC Sections 19.3.5.6 and 9.7.4.1 and NFPA 10. This deficient practice could potentially affect all 3 occupants of the facility, all of the staff and any visitors present at the time of a potential incident if the fire extinguishers did not function as designed during a fire. Findings include:
1. On 7/20/16 at 11:55 AM during review of records it was noted there was no documentation of the monthly checks of the fire extinguishers.
In an interview on 7/20/16 at 11:56 AM, POD#1 acknowledged that there was no documentation of the monthly fire extinguisher checks due to the service provider taking the tags when the annual maintenance was performed.
Tag No.: K0069
Based on record review and interview, the facility failed to protect cooking facilities in accordance with LSC Section 19.3.2.6 and NFPA 96. This deficient practice could potentially affect all 3 occupants of the facility, all of the staff and any visitors present at the time of a potential incident if the hood suppression system failed to operate as designed. Findings include:
1. On 7/20/16 at 12:25 PM during review of records it was observed that the semi-annual maintenance, inspection and testing of the hood suppression system was late. Documentation was presented for 10/23/15 and 5/20/16.
In an interview on 7/20/16 at 12:26 PM, POD#1 acknowledged that the semi-annual maintenance of the hood suppression system was conducted beyond the 6 month interval.
Tag No.: K0144
Based on record review and interview, the facility failed to provide documentation that generators are maintained in accordance with LSC Section 19.5.1, NFPA 99 Section 3-4.4.1, and NFPA 110 Section 8.4.2. This deficient practice could potentially affect all 3 occupants of the facility, all of the staff and any visitors present at the time of a potential incident if the generator failed to operate as designed during an emergency. Findings include:
1. On 7/20/16 at 11:34 AM during review of records it was noted there was no documentation of a 30 minute load test of the Type II generator for December of 2015.
In an interview on 7/20/16 at 11:35 AM, POD#1 acknowledged that there was no documentation of a 30 minute load test of the Type II generator for December of 2015.