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Based on observation and interview, the facility failed to ensure the means of egress through 1 of 3 exits with special locking arrangements for the clinical security needs of the patients were readily accessible by remote control of locks; keys carried by staff at all times; or other such reliable means available to the staff at all times. This deficient practice could affect 8 patients in the west hall

Findings include:

Based on observations with the Facilities Manager on 11/01/22 at 11:13 a.m., the west exit door was marked as a facility exit, was locked with a dead bolt, and could be opened using a key carried by staff, but when tested the dead bolt did not release. Based on interview at the time of observation, the Facilities Manager stated the lock was broken and did replace the lock and was functioning when tested a second time.


This finding was reviewed with the Facilities Manager during the exit conference.

Based on observation and interview, the facility failed to ensure the egress discharge for 2 of 5 exits was provided with illumination and were 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 all patients

Findings include:

Based on observations with the Facilities Manager on 11/01/22 at 11:20 a.m. and 11:45 a.m., the exit discharge outside the north exit did not have egress lighting. Also, there was only one light fixture with only one LED light outside the west exit. Based on interview at the time of observation, the Facilities Manager agreed there was only one light source outside of the west exit and no lighting out side of the north exit.

This finding was reviewed with the Facilities Manager during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm control panel was protected. NFPA 72, National Fire Alarm and Signaling Code Section 10.10.1 states a means for turning off activated alarm notification appliance(s) shall be permitted only if it complies with 10.10.3 through 10.10.7. Section 10.10.3 states the means shall be key-operated or located within a locked cabinet or arranged to provide equivalent protection against unauthorized use. This deficient practice could affect all occupants.

Findings include:

Based on observations with the Facilities Manager on 11/01/22 at 11:30 a.m., the fire control panel located at in the main lobby was in a cabinet but the door to the cabinet was unlocked when tested. This condition does not protect the fire alarm system against unauthorized use. Based on interview at the time of observations, the Facilities Manager agreed the cabinet door to the fire control panel was not properly secured.

This finding was reviewed with the Facilities Manager during the exit conference.

Based on observation and interview, the facility did not provide adequate signage for 1 of 1 fire department connection (FDC). NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, 13.7 Fire Department Connections. 13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place and operating properly.
This deficient practice could affect all occupants.

Findings include:

Based on observations with the Facilities Manager on 11/01/22 at 11:38 p.m., the FDC located by rear parking lot was not provided with a FDC identification sign. Based on interview at the time of observation, the Facilities Manager stated there was no identification sign on the FDC.

This finding was reviewed with the Facilities Manager during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of 2 receptacles within 6 feet from a sink were provided with ground fault circuit interrupter (GFCI) protection against electric shock. LSC 19.5.1.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code. NFPA 70, NEC 2011 Edition at 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, states, ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.
(B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms, (2) Kitchens, (3) Rooftops, (4) Outdoors,
(5) Sinks - where receptacles are installed within 1.8 m (6 ft.) of the outside edge of the sink.
(6) Indoor wet locations, (7) Locker rooms with associated showering facilities, (8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools.
NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect 2 patients in room 118.

Findings include:

Based on observations with the Facilities Manager on 11/01/22 at 12:35 p.m., there was an electric receptacle 29 inches from a sink in the restroom of room 118. The electric receptacle was not GFCI protected and did not trip when tested. Based on interview at the time of observation, the Facilities Manager agreed the electric receptacle was not GFCI protected when tested.

This finding was reviewed with the Facilities Manager 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. This deficient practice affects all occupants.

Findings include:

Based on records review with the Facilities Manager on 11/01/22 at 10:02 a.m., the following shifts were missing documentation of a completed fire drill:
a) A third shift fire drill in the second quarter of 2022.
b) A third shift fire drill in the third quarter of 2022.
c) A first shift fire drill in the third quarter of 2022.
Based on interview at the time of record review, the Facilities Manager stated the aforementioned drills were not conducted.

This finding was reviewed with the Facilities Manager during the exit conference.

Based on observation, record review and interview, the facility failed to ensure electrical receptacles in 8 of 8 patient sleeping rooms were tested at least annually for non-hospital receptacles and initially for hospital grade receptacles. 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 grams (4 ounces). This deficient practice could affect all patients.

Findings include:

Based on observations with the Facilities Manager on 11/01/22 between 11:00 a.m. and 12:00 p.m., the facility's patient sleeping rooms contained five to eight electrical receptacles with a mix of hospital and non-hospital grade receptacles. Based on records review at 10:30 a.m., there was no documentation available to show receptacle testing for the sleeping rooms. Based on interview at the time of the observation and records review, the Facilities Manager stated the receptacles will need to be tested.

This finding was reviewed with the Facilities Manager during the exit conference.

3.1-19(b)

Based on record review and interview, the facility failed to exercise 1 of 1 diesel 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 occupants.

Findings include:

Based on records review with the Facilities Manager on 11/01/22 at 10:07 a.m., the monthly load tests showed that load percentage for the diesel-powered generator for the months of October 2021 thru May 2022 were under 30%, and no annual load bank test was available for review. Based on interview at the time of record review, the Facilities Manager stated the generator load did not achieve 30 % of the generator's name plate rating for 8 of 12 months. Additionally, the Maintenance Director stated a load bank test for the generator was not conducted during the past year.

This finding was reviewed with the Facilities Manager during the exit conference.