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Based on record review, the facility failed to develop and implement emergency preparedness (EP) policies and procedures, addressing the use of volunteers in an emergency or other emergency staffing strategies.

This affects all of the patients at the facility.

Findings Include:

1. Review of the facility EP program on 05/01/2023, showed the plan lacked information about the use of volunteers, whether the facility wants to utilize volunteers or not. It must address any and all training and the roles the volunteers would play in an emergency. Call lists must also have contact information for volunteers.

Based on record review, the facility failed to ensure the EP plan contained current agreements/arrangements with other facilities and/or other providers to receive resident/patients in the event of an evacuation and/or cessation of operations. This affects all the occupants in the facility.

Findings include:

1. Review of the EP plan on 05/01/2023, showed a lack of written agreements with other facilities and/or providers in the event of limitations to provide needed services to all the residents/patients under their care to maintain continuity of services.

Based on record review, the facility failed to describe its role under an 1135 waiver during the provision of care and treatment at an alternate site during an evacuation. This deficiency affects the entire facility. Findings include:

1. Review of the facility EP program on 05/01/2023, showed the facility's EP plan did not include a policy or procedure for caring of patients/residents at an alternate care site, delineating their role under the 1135 waiver, and showing joint planning on issues related to staffing, equipment and supplies at alternate care sites.

Based on observation and interview, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3 and 7.2.1.6.2, access-controlled egress door assemblies.

Findings include:

1. During an observation on 05/02/2023 at 8:28 a.m., the hospital main entrance was inspected. Two power-operated sliding doors were observed, marked as an emergency exits. Both sliding doors were found to have deadbolt locks. A key was required for the doors to unlock and allow egress from inside the hospital.

2. During an observation on 05/02/2023 at 8:30 a.m., the double corridor doors leading from the emergency department to the main lobby were inspected. The corridor was a marked exit. The doors were found to have badge controlled egress, and were able to lock with magnetic locks. There was no delayed egress set up on the magnetic locks.

During and interview on 05/02/2023 at 8:31 a.m., staff member B stated the doors locked every day at 6 p.m. and the use of a badge was required to unlock the doors.

Marked egress pathways cannot be locked, and if they are, they must be set up with special locking arrangements such as delayed-egress or access-controlled egress assemblies.

Based on observation, the facility failed to assure hazardous rooms had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3.

Findings include:

1. During an observation on 05/01/2023 at 8:58 a.m., room 2043 was inspected. The room was observed being used as a storage area, and it is over 50 square feet. There was no self-closing device on the corridor door as required for storage rooms.

Based on observation the facility failed to ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1(3).

Findings include:

1. During an observation on 05/01/2023 at 8:28 a.m., the main entrance was inspected. There was a a 1/2 inch opening observed in the ceiling, surrounding the escutcheon ring of the sprinkler head within the room.

Based on observation, the facility failed to inspect portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 7.2.1.2.

Findings include:

1. During an observation on 05/02/2023 at 8:20 a.m., the portable extinguisher outside of CT was inspected. It had not been initialed as having been inspected the month of April 2023.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6 and 19.7.2.2.

Findings include:

1. During a review of facility fire drills on 05/01/2023, it was determined the facility had not completed fire drills for:

a) the PM shift of the third quarter of 2022;
b) the PM shift of the fourth quarter of 2022;
c) the PM shift of the first quarter of 2023.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

This deficiency affects all smoke compartments.

Findings include:

1. Review of the fire safety maintenance records on 05/01/2023, reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers.

Based on observation, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 05/02/2023 at 8:40 a.m., the equiptment store room was inspected. An electrical panel was observed with a large cart being stored in front of it.

2. During an observation on 05/02/2023 at 8:50 a.m., the physical therapy area was inspected. An electrical panel was observed with a commode chair being stored in front of it.

Based on record review, the facility failed to ensure:

a) an annual diesel fuel supply quality test was conducted at least annually per NFPA 110, Section 8.3.8.; and
b) an emergency stop button for the generator was installed in accordance with NFPA 110, 2010 Edition, Section 5.6.5.6.

These deficiencies affect all occupants in the facility.

Findings include:

1. Review of the emergency generator inspection records on 05/01/2023, revealed there was no documentation of an annual diesel fuel supply quality test conducted within the last year.

1. During an observation on 05/02/2023 at 8:06 a.m., the generator was inspected. The generator providing power for emergency power did not have a remote manual stop outside of the housing of the prime mover or elsewhere on the premises.