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Based on record review and interview, the facility failed to incorporate into their Emergency Preparedness Program (EP) the policy and procedures for subsistence needs for staff and patients did not incorporate a program for maintaining temperatures to ensure the residents and occupants safety, welfare and comfort.

Findings included:

On 08/09/2022 between 9:00 AM and 3:00 PM. while reviewing the facility EP with the Risk Manager, the facility could not provide a policy or procedures for alternate sources of energy to maintain temperatures to protect patient health, safety, welfare and comfort in the event of a loss of the utility power system. Concurrent with the review the Administrator said that the facility was considering installing an alternate power source that would meet the needs to maintain temperatures to protect the residents and occupants safety, welfare and comfort.

Based on interviews, record review, and tour of the facility with the director of maintenance (DOM), the facility failed to failed to maintain the commercial cooking equipment which could endanger building occupants.

Findings included:

On 08/09/2022 between 9:00 AM and 3:00 PM during record review with the DOM, it was revealed that the facility failed to provide monthly kitchen quick check inspection reports. An interview with the kitchen manager during the kitchen tour, confirmed that monthly inspections were not being performed. In an interview, the DOM acknowledged the observations and the findings.

per NFPA 101 (2012 Edition) Chapter 19.3.2.5.1, 9.2.3
per NFPA 96 (2011 Edition) Chapter 10.2.6
per NFPA 17A (2010 Edition) Chapter 7.2, 7.2.1, 7.2.2 (1-8)

On 08/09/2022 between 9:00 AM and 3:00 PM during record review of the kitchen hood suppression system with the DOM, it was revealed that the facility could not provide a semi-annual inspection report after 01/17/2022. An interview was conducted with the DOM concurrent with the observations and confirmed the findings.

Per NFPA 101 (2012 Edition) 19.3.2.5, 19.3.2.5.1, 9.2.3
Per NFPA 96 (2011 Edition) 11.2.1

Based on a review of the facility records and interviews with the Director of Maintenance (DOM), the facility failed to maintain the fire protection sprinkler systems (FPSS) in accordance with NFPA 101 (2012 Edition). In the event of fire this could reduce the reliability of the system and jeopardize the safety of the occupants in the facility.

Findings included:

On 08/09/2022 between 9:00 AM and 3:00 PM during record review of the FPSS inspection documents, it was revealed that the facility failed to provide documentation for the 4th quarter of 2021 inspection and testing report. An interview was conducted with the DOM concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) Chapter 19.3, 19.3.5.1, 9.7, 9.7.5
per NFPA 25 (2011 Edition) Chapter 5.1.1.2, Table 5.1.1.2

Based on record review and interview with the director of maintenance (DOM), the facility failed to conduct fire drills as required by NFPA 101 (2012 Edition). Fire drills are essential to the training of staff and residents in proper procedure in emergency situations. Untrained staff can allow confusion and possible delays in proper procedure in an emergency and jeopardize all persons within the facility.

Findings included:

On 08/09/2022 between 9:00 AM and 3:00 PM during record review with the DOM, it was revealed that the facility had not performed the required fire drills for:
1) 1st Quarter - 1st shift for 2022
2) 2nd Quarter - 2nd shift for 2022
3) 4th Quarter -1st shift for 2021
An interview was conducted with the DOM concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 19.7.1.6

Based on record review and interview with the director of maintenance (DOM), the facility failed to protect the fire barriers in accordance with NFPA 101 (2012 edition) and NFPA 80 (2010 Edition). In the event of a fire, this condition could put occupants attempting shelter or evacuate in an unsafe environment.

Findings include:

On 08/09/2022 between 9:00 AM and 3:00 PM during record review of the annual fire door inspection records with the DOM, it was revealed that the facility provided documentation for an annual fire door inspection dated December 2018. The report detailed that 12 of 13 doors failed the inspection. In an interview with the DOM, they said that they could not provide evidence of any repairs and acknowledged the expired inspection concurrent with the observations and confirmed the findings..

per NFPA 101 (2012 Edition) Chapter 8.3.3.1
per NFPA 80 (2010 Edition) Chapter 5.2.1

Based on record review and interview with the director of maintenance (DOM), the facility failed to maintain the essential electrical system (EES) in accordance with NFPA 99 (2012 Edition) and NFPA 110 (2010 Edition).

Findings included:

On 08/09/2022 between 9:00 AM and 3:00 PM during record review of the EES maintenance with the DOM, it was revealed that the facility failed to provide evidence for both (50kW & 20kW) of the generators routine monthly load exercise from March 2022 through July 2022, where the operational test was initiated at an ATS and included testing of each Emergency Power Supply System (EPSS) component, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature or available load. An interview with the DOM revealed the facility did not have a written routine operational and testing program in place per NFPA 110 requirements.

per NFPA 99 (2012 Edition) 6.4.1.1, 6.4.1.1.15
per NFPA 110 (2010 Edition) 8.3.2.1