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Based on record review and interview the facility failed to ensure their emergency preparedness plan was based on a all hazards risk assessment as required.

Findings:

Record review showed the facility did not complete a hazard vulnerability assessment (HVA) as required and therefore did not include it in the facility's emergency preparedness plan as required.

On 04/15/21 at 11:38am the surveyor asked staff A for the current HVA. Staff A stated they did not have a current or past HVA.

Based on record review and interview the facility failed to ensure the communication plan outlined the primary and alternative forms of emergency communication for use during an emergency event.

Findings:

Record review of the facility's emergency preparedness communication plan showed it did not contain the primary and alternative forms of emergency communication as required.

On 04/15/21 at 2:21pm the surveyor asked staff A to show where the primary and alternative forms of communication are outlined in the communication plan. Staff A stated they could not find where it was outlined but they will correct it to be in compliance.

Based on record review and interview the facility failed to ensure initial emergency preparedness (EP) training was provided to all staff and documentation kept as required.

Findings:

Record review showed there was no initial training documentation for EP that included the facility's emergency preparedness plan and EP policies as required.

On 04/15/21 at 1:47pm the surveyor asked staff A for the initial training documentation for EP a select sample of employees. Staff A stated they had no documentation for any staff which shows initial EP training that includes the facility EP plan.

Based on observation and interview the facility failed to ensure corridor doors had approved hold open devices complying with NFPA 101, Chapter 7.2.1.8.2 as required.

Findings:

On 04/14/21 at 10:58am the surveyor observed the two doors leading into the laboratory with self closers were being held open without approved hold open devices.

On 04/14/21 at 11:01am the surveyor asked staff A why the doors to the laboratory were being kept open without approved hold open devices. Staff A stated they did not know but will make sure they are either kept shut or will install compliant hold open devices as required.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 04/15/21 at 9:59am an ABC class fire extinguisher was observed in the kitchen with no placard posted next to it to indicate the hood fire protection system shall be activated prior to using the fire extinguisher.

On 04/15/21 at 10:00am the surveyor asked staff A why there was no placard posted near the ABC extinghisher. Staff A stated they were not aware of the requirement but will get it posted to be in compliance.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on record review and interview the facility failed to ensure fire drills conducted included the transmission of a fire alarm signal as required.

Findings:

Record review of the facility fire drill documentation for 2020 and 2019 showed each fire drill did not include verification of a transmission of a fire alarm signal.

On 04/14/21 at 10:47am staff A was asked to show the surveyor where they document how they verify the transmission of a fire alarm signal. Staff A stated they did use the pull stations to trip the alarm but did not each time but will for each one in the future.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessments were not completed.

On 04/14/21 at 1:23pm the surveyor asked Staff A for the EES and Medical Gas building system risk assessments and Staff A stated he was not aware of the requirement. Staff A stated they will get the medical gas and EES building system risk assessments started and completed.

Based on record review and interview the facility failed to ensure the emergency generator testing and inspection was completed as required.

Findings:

Record review showed generator two hour load bank was not completed for 2019 and 2018.

Record review showed emergency generator inspections were not completed for 2019 and 2018.

On 04/14/21 at 1:52pm Staff A was asked why the load banks and weekly inspections were not completed for 2019 and 2018. Staff A stated he is not sure as he was dietary manager and safety officer at those times. Staff A stated they will ensure load banks and weekly inspections are completed to be in compliance.