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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 LTC facility 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 483.73(b)(8). This deficient practice could affect all occupants.

Findings include:

Based on record review with the EOC Manager at 10:36 a.m. on 02/21/2018, the facility failed to ensure the emergency preparedness policies and procedures include the role of the LTC facility 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. Based on interview at the time of record review, the EOC Manager acknowledged the facility failed to ensure emergency preparedness policies and procedures include the role of the LTC facility 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.

Based on observation and interview, the facility failed to install the kitchen range hood system in accordance with the requirements of LSC 9.2.3. Section 9.2.3 states commercial cooking equipment shall be installed in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96, 2011 edition, Section 6.2.4.1 states kitchen range hood system filters shall be equipped with a drip tray beneath their lower edges. The tray shall be kept to the minimum size needed to collect grease and shall be pitched to drain into an enclosed metal container having a capacity not exceeding 1 gal (3.785 L). This deficient practice could affect up to 24 patients, as well as 4 staff and 2 visitors.

Findings include:

Based on observation with the EOC Manager during a tour of the facility at 11:40 a.m. on 02/21/18, one of one designated locations underneath the kitchen range hood system drip tray was missing an enclosed metal container for grease to drain into. The designated location for a grease container had a one inch in diameter hole in the drip tray beneath the system filters and had an affixed bracket for holding a container but no container was present. Based on interview at the time of observation, the EOC Manager acknowledged the designated location underneath the kitchen range hood system drip tray was missing an enclosed metal container for grease to drain into.

1) Based on observation and interview, the facility failed to ensure the spray pattern for sprinkler heads were not obstructed in 1 of 1 dining room in accordance with 19.3.5.1. NFPA 13, 2010 edition, Section 8.5.5.1 states sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2 and 8.5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Sections 8.5.5.2 and 8.5.5.3 do not permit continuous or noncontinuous obstructions less than or equal to 18 inches below the sprinkler deflector or in a horizontal plane more than 18 inches below the sprinkler deflector that prevent the spray pattern from fully developing. This deficient practice could affect all staff, visitors and patients in the dining room area.

Findings include:

Based on observation with the EOC Manager on 02/21/18 at 10:31 a.m., the Dining room area contained a cooler that met with a bulkhead. This bulkhead contained a sprinkler head that was approximately four inches from the top of the cooler. Based on interview at the time of observation, the EOC Manager acknowledged the aforementioned condition, and gave the listed measurement.

2) Based on observation and interview, the facility failed to provide sprinkler coverage for 2 of 2 areas outside and attached to the building and constructed of partially combustible material. NFPA 13, The Standard for the Installation of Sprinkler Systems at 8.15.7.1 requires sprinklers be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding four feet in width. This deficient practice could affect all patients in the facility using the patio areas.

Findings include:

Based on observation on 02/21/18 at 11:55 a.m. during a tour of the facility with the EOC Manager, there was a twenty seven by thirty foot overhang attached to the building outside both the Meadows and the Willows. This "patio" area contained four ceiling fans, and wood planking attached to the ceiling of the patio. The patio area was attached directly to the building. There was no sprinkler coverage provided under the overhang. Based on interview at the time of observation, the EOC Manager acknowledged there was no sprinkler coverage under the Meadows or the Willows patio overhang, or documentation that the wood planking was inherently flame retardant.

Based on record review, observation and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25 for 1 of 1 sprinkler system. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients and staff in the facility.

Findings include:

Based on review of Tyco / Simplex Grinnell's "Elements of Performance" documentation dated 03/13/17, 06/14/17, 09/18/2017, and 12/16/2017 on 02/21/18 at 11:30 a.m., there were no documented monthly sprinkler gauge inspections noted. In addition, weekly inspection documentation for all sprinkler system control valves was also not available for review. Based on interview at the time of record review, the EOC Manager acknowledged monthly sprinkler system gauge inspection documentation and weekly control valve inspection documentation, for the aforementioned periods was not available for review.

Based on record review and interview, the facility failed to ensure 12 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice affects all patients in the facility as well as staff and visitors.

Findings include:

Based on record review of the document titled "Fire Drill Critique" with the EOC Manager on 02/21/18 at 11:44 a.m., the documentation for the drills for the past twelve months lacked verification of the transmission of the signal for drills. Based on interview at the time of record review, the EOC Manager stated that he did ask the monitoring company for confirmation of the signal being received during his drills, but failed to document the verification of the transmission of the fire alarm signal in his records.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generator was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' stations. NFPA 99, 2012 Edition, Health Care Facilities Code, at 6.4.1.1.17 requires a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
(1) Individual visual signals shall indicate:
a. When the emergency or auxiliary power source is operating to supply power to load.
b. When the battery charger is malfunctioning.
(2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
a. Low lubricating oil pressure.
b. Low water temperature.
c. Excessive water temperature.
d. Low fuel when the main fuel storage tank contains less than a 4-hour operating supply.
e. Overcrank (failed to start).
f. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 6.4.1.1.17(1) and (2) occur but need not display these conditions individually. This deficient practice could affect all patients, as well as visitors and staff in the facility.

Findings include:

Based on interview during record review on 02/21/18 at 10:38 a.m., the EOC Manager said the facility has an emergency generator. When asked, the EOC Manager said there was a remote alarm annunciator panel for the generator at a 24 hour station in the Willows staff lounge. Based on observation during a tour of the facility, this was confirmed with the EOC Manager on 02/21/18 at 12:15 p.m. When tested, the alarm would sound and was said to be loud enough to alert the nurses at the nurse's station. Upon testing the alarm and asking nursing staff what the alarm was, they thought the alarm was coming from the bathroom assistance alarm. The remote alarm annunciator panel for the emergency generator not being at any nurses' station, or in a 24 hour supervised area was acknowledged by the EOC Manager at the time of the testing.

Based on observation and interview, the facility failed to ensure 1 of 2 recreation rooms were not using flexible cords as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects up to 22 patients and 4 staff.

Findings include:

Based on observation with the EOC Manager on 02/21/18 at 12:21 p.m., a fifteen foot extension cord was run from an electrical outlet to a flat-screen television mounted on the wall in the Meadows recreation room. Based on interview at the time of the observation, the EOC Manager acknowledged the use of an extension cord powering a flat-screen television in the Meadows recreation room.