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Based on observation, interview and facility record review the facility failed to develop Emergency Preparedness policy and procedures based on the community risk assessments prior to developing the facility's emergency plan.

Findings include:

On July 15, 2020 the surveyors, along with the Consultant, the Administrator and the Director of Maintenance we reviewed the facility's Emergency Plan. The plan did not include polices and procedures based on risk assessments for the community.

During the exit conference on July 15, 2020, the above finding was again acknowledged by the Consultant, the Administrator and the Director of Maintenance.

Failure to develop emergency plans based on community risk assessments may cause harm to the residents during an emergency.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined, the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan.

Findings include:

On July 15, 2020 the surveyors, along with the Administrator and the Director of Maintenance reviewed the facility's Emergency Plan. The plan which was developed, only used the facility assessment and did not include a community based all hazards risk assessment to develop their policy and procedures.

During the exit conference on July 15, 2020, the above finding was again acknowledged by the Administrator and the Director of Maintenance.

Failure to develop emergency plans based on community risk assessments may cause harm to the residents during an emergency.

Based on Observation with the Director of Facilities/Security it was observed that there was no emergency lighting in the emergency generator set.

NFPA 101, Life Safety Code, 2012 Edition, Chapter 18, Section 18.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.2.1 "Emergency illumination shall be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. NFPA 110, Emergency and Standby Power Systems, 2010 Edition, Chapter 7, Installation and Environmental Considerations, Section 7.3.1 "The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting.

Findings include:

On July 15, 2020 the surveyor accompanied by the Director of Facilities/Security observed there was no emergency lighting in or near the emergency generator set.

During the exit conference on July 15, 2020 the above finding was again acknowledged by the Director of Facilities/Security.

Failing to maintain emergency lighting units near the generator set in time of an emergency could cause harm to staff and/or first responders in an emergency power outage.

Based on observation and interview with the Director of Facilities/Security it was determined the facility failed to install a remote emergency stop button on the emergency generator.

NFPA 101 LIFE SAFETY CODE, 2012, Chapter 18, Section 18.5.1.2 "Utilities". (See Section 4.6.12.2) "Power for alarms, emergency communications systems, and illumination of the generator set locations shall be in accordance with the essential electrical system requirements of NFPA 99, Health Care Facilities Code." NFPA 99 "HEALTH CARE FACILITIES CODE". Chapter 6, Section 6.5.4.1.1.1 Maintenance of Alternate Power Source. "The generator set or other alternate power source and associated equipment, including all appurtenance parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 6.4.1.1.7 and 6.4.3.1. NFPA 110, Chapter 5, Section 5.6.5 Control Functions. 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.

Findings Include:

On July 15, 2020 the surveyor, accompanied by the Director of Facilities/Security observed there was no manual stop station located outside the generator set.

During the exit conference conducted on July 15, 2020 the above finding was again acknowledged by the Director of Facilities/Security.

Failure to have a manual stop station on the outside of the emergency generator could potentially put staff at risk of injury and or death during an emergency.

The facility failed to ensure there was no storage of flamable material within 5 feet of oxygen storage in a sprinklered storage room (room 119).

NFPA 101 LIFE SAFETY CODE, 2012 Edition, Chapter 18, Section 18.3.2.4 Medical Gas. "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, 2010 Edition, HEALTH CARE FACILITIES CODE". NFPA 99 HEALTH CARE FACILITIES CODE Chapter 11.3 Cylinder aand Container Storage Requirements. Section 11.3.2.3 (2). "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (2) Minimum distance of 1.5m (5ft) if the entire location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems".

On July 15, 2020 the surveyor along with the Director of Facilities/Security observed oxygen cylinder storage in Storage room #119 was 36 inches from a chair draped with plastic sheeting as well as shelving with cardboard boxes.

During the exit interview conducted on July 15, 2020 the above finding was again acknowledged by the Director of Facilities/Security.

Failure to maintain the minimum distance of medical gas cylinders from combustibles materials could result in harm to patients and staff during an emergency.