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Based on record review and interview, the facility failed to ensure the emergency preparedness plan addressed patient population, including, but not limited to, persons at-risk; the type of services the Hospital has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans in accordance with 42 CFR 485.625(a)(3). This deficient practice could affect all occupants.

Findings include:

During record review with the Facility's Director and Facility's Admin at 2:30 p.m. on 08/05/19, documentation could not be found ensuring the emergency preparedness plan addressed patient population, including, but not limited to, persons at-risk; the type of services the Hospital facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. Based on interview at the time of record review, the Facility's Director stated the policies regarding the type of services the Hospital has the ability to provide in an emergency; and continuity of operations could not be located.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness (EPP) training and testing program that is based on the emergency plan accordance with 42 CFR 485.625(d). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility's Director Facility's Admin at 2:20 p.m. on 08/05/19, the provided EPP did not include a training and testing program. Based on interview at the time of record review, the Facility's Director stated the facility has a training program but the program is not written into the EPP.

Based on observation and interview, the facility failed to ensure 2 of 3 separation fire doors would limit the spread of fire and restrict the movement of smoke. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.3.4.1 states every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. This deficient practice could affect 10 patients on the first floor and staff in the basement.

Findings include:

Based on observation with the Facility's Director on 08/05/19 at 11:15 a.m. to 2:00 p.m., the set of separation fire doors in the basement and on the first floor had a gap greater than 1/4 of an inch where the doors came together. This condition would not limit the spared of smoke from one side of the fire barrier to the other. Based on interview at the time of observation, the Facility's Director agreed there was a gap where the doors come together and would not restrict the movement of smoke.

Based on observation and interview, the facility failed to ensure 19 of 19 battery backup lights were tested monthly. Section 7.9.3.1.1 (1) requires functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all building occupants.

Findings include:

During record review with the Facility's Admin on 08/05/19 at 11:34 a.m., the Light Test Log for 2019 indicated the monthly 30 second testing was missing for January and March through July. Based on an interview at the time of record review, the Facility's Admin stated the aforementioned months were missing the 30 second checks.

Based on observation and interview, the facility failed to ensure 1 of 1 hazardous storage rooms in pool room was separated from other spaces by smoke resistant partitions. This deficient practice could affect 2 patients in the therapy pool.

Findings include:

Based on observation with the Facility's Director on 08/05/19 1:10 p.m., the pool mechanical and chemical storage room had four unsealed one inch penetrations around pipes in the ceiling. Based on interview at the time of the observation, the Facility's Director agreed there were unsealed penetrations in the pool mechanical and chemical storage room ceiling and provided the measurements of the unsealed penetrations.

Based on record review and interview, the facility failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices
This deficient practice could affect all building occupants.

Findings include:

During record review with the Facility's Admin on 08/05/19 at 11:34 a.m., documentation could not be provided regarding a visual semi-annual fire alarm system inspection. Based on interview at the time of record review, the Facility's Admin agreed that visual semi-annually inspection of the fire-alarm system was not completed on a semi-annual basis.

Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. NFPA 25, 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly and gauges on dry systems (5.2.4.2) shall be inspected weekly to ensure normal water or air pressure is being maintained. NFPA 25 13.3.2.1 states valves should be inspected weekly or valves secured locks or supervised (13.3.2.1.1) shall be permitted to be inspected monthly. This deficient practice could affect all occupants.

Findings include:

During record review with the Facility's Admin on 08/05/19 at 1:19 p.m., monthly inspection of the wet pipe nor a weekly inspection of the dry pipe sprinkler system's gauges and valves were not available for review. During an interview at the time of record review, the Facility's Admin stated the inspection of gauges and valves were not recorded.

Based on observation and interview, the facility failed to ensure 14 of 14 flexible cords power strips in patient care locations met the required UL rating of 1363A or 60601-1. This deficient practice could affect all patients.

Findings include:

Based on observation with the Facility's Director on 08/05/19 between 11:00 a.m. to 3:00 p.m., throughout the building there were crash carts in patient care areas. Each cart had a power-strip laying in a basket. Upon inspection of the power-strips, there was not a UL listing on the power strip and no documentation was provide to show the UL rating of the power strip. Based on interview at the time of observation, the Facility's Director agreed the power-strips were used in patient cares area and did not meet 1363A or 60601-1.