| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 713026 | (X3) Date Survey Completed 04/27/2026 |
| Name of Provider or Supplier Bogalusa Rehabilitation Hospital | Street Address, City, State 621 Columbia Street, Bogalusa, LA | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| K0000 | This STANDARD is not met as evidenced by: Bogalusa Rehabilitation Hospital is not in compliance with the requirements of Title 42 Code of Federal Regulations, Part 482.41(b) (Life Safety Code). The findings that follow in this CMS 2567 demonstrate the non-compliance. The facility is sprinklered, licensed for eleven beds and a census of ten at time of survey. |
| K0345 | Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This STANDARD is not met as evidenced by: Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect ten of ten patients. Findings: During the facility tour on April 27, 2026 between the hours of 9:15 a.m. to 11:00 a.m. the fire alarm system sensitivity test documentation was lacking at time of survey. The interview with Administrator revealed the facility was not aware that the required inspections had not been conducted on the fire alarm system and was acknowledged by the Administrator. |
| K0353 | Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is not met as evidenced by: Based on visual observation the facility failed to assure that the sprinkler system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 25. The sprinkler system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect ten of ten patients. Findings: During the facility tour on April 27, 2026 between the hours of 9:15 a.m. to 11:00 a.m. the documented sprinkler quarterly inspections were lacking at time of survey. The interview with the Administrator revealed the facility was unaware the quarterly sprinkler inspections were lacking from the last year. |
| K0918 | Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This STANDARD is not met as evidenced by: Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect ten of ten patients. Findings: During the facility tour on April 27, 2026 between the hours of 9:15 a.m. to 11:00 a.m. the following items were in need of correction: the generator annunciator indicated the generator coolant was low, the weekly generator documentation was lacking for every week dating back a year and the yearly load bank documentation was lacking. The interview with the Administrator and Maintenance personnel revealed the facility was not aware the annunciator was indicating low coolant level and the weekly generator documentation was lacking for each week in the last year. The Maintenance personnel was aware the generator load bank yearly documentation was lacking. |