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Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect of residents.
4 of 4 quarters in 2021-2022 were deficient.

Findings:

During the record review on 9.21.2022, between the hours of 10:30 and 1:30p.m. the facility failed to maintain documentation for fire drills for each quarter on each shift.

NFPA 101:19.7.1.6 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.

Interview with the Administrator revealed the facility was not aware fire drills were not being held for each work shift of each quarter.

Based on visual observation the facility failed to assure records of weekly inspections on its emergency generator.
Findings:
During the record review on 9.21.2022 between the hours of 10:00a..m. and 1:30p.m. the facility failed to show the weekly generator log.
NFPA 110 8.4.1 Operational Inspection and Testing EPSS including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. Weekly inspection does not require running of the EPS. Running unloaded generators as part of this weekly inspection can result in long-term problems such as wet stacking. See Figure A.8.4.1(a) and Figure A.8.4.1(b). 8.3.4 a permanent record of the EPSS inspection, test exercises, operation , and repair shall be maintained and readily available.

Interview with the administrator revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the emergency generator.




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 14 of 14 residents.

Findings:

During the facility tour on 9.21.2022 between the hours of 10:00 am to 1:30 pm the following items were observed as deficient:

(1) The generator was not provided with a remote manual stop and remote manual signage located outside the weatherproof enclosure.

NFPA 110:5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

NFPA 110:5.6.5.6.1 The remote manual stop station shall be labeled.


Interview with the Maintenance Director revealed the facility was not aware that a remote manual stop for emergency generators was required.