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Based on record review and interview, the facility failed to plan and implement a provision of subsistence needs for the staff and the patients, whether they evacuated or sheltered in place. This affects all occupants in the facility.

Findings include:

Review of the EP plan, policies, and procedures on 8/5/24, showed the facility lacked a complete system for determining subsistence needs for staff and patients. Specific needs for pharmaceutical supplies, alternate sources of energy to maintain temperatures, and emergency lighting for the number of patients and staff who would be sheltering in place was not addressed.

During an interview on 8/5/24 at 4:00 p.m. staff member A stated the emergency preparedness plan did not have specific information regarding pharmaceutical supplies, or alternate sources of energy the facility would utilize in an emergency.

Based on observation, interview and record review the facility failed to:

a) maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2.,
b) failed to ensure sprinkler piping was fee from external loads in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2., and
c) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.

These deficiencies affected all smoke compartments in the facility.

Findings include:

1. Review of the facility's quarterly sprinkler inspections showed a sprinkler inspection was not completed for the first quarter of 2024 (January - March).

During an interview on 8/5/24 at 2:15 p.m., staff member B stated the sprinkler company did not complete an inspection for the first quarter of 2024. Staff member B stated they rescheduled.

2. During an observation on 8/5/24 at 1:16 p.m., the basement storage room was inspected. Multiple cords were observed resting on the sprinkler piping.

3. During an observation on 8/5/24 at 2:00 p.m., the PT storage closet was inspected. There was storage within 18 inches of the sprinkler head.

Based on an observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

This deficiency affected 1 of 1 basement smoke compartments in the facility.

Findings include:

During an observation at 8/5/24 at 1:29 p.m., the area in front of the purchasing basement was inspected. A portable fire extinguisher was observed, blocked by storage of various items.

Based on observation, the facility failed to maintain corridor door openings in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.10.

This deficiency affected 1 out of 1 basement smoke compartments in the facility.

Findings include:

1. During an observation on 8/5/24 at 1:25 p.m., the IT room door was inspected. The corridor door was held open by a wedge.

2. During an observation on 8/5/24 at 1:26 p.m., the conference room door was inspected. The corridor door was held open by a wedge.

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).

This deficiency affected 1 out of 1 basement smoke compartment in the facility.

Findings include:

During an observation on 8/5/24 at 1:30 p.m., the purchasing office was inspected. There was a cart stored in front of the electrical panel.