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Based on record review and interview, the facility failed to incorporate into their Emergency Preparedness Program (EPP) the policy and procedures to ensure adequate alternate energy sources necessary to maintain safe temperatures to protect patient health.

Findings:

While reviewing the facility EPP at 10 a.m. on 7/08/19, a request was made to the Maintenance Director to review the facility's policy and procedures to ensure adequate alternate energy sources necessary to maintain safe temperatures to protect patient health. The Maintenance Director said they were unable to produce required documents.

These findings were reconfirmed with the Administrator and Maintenance Director during the closing conference at 1:10 p.m. on 7/08/19.

Code: 42 CFR 483.73(b)(1)

Based on observation and interview, the facility failed to maintain fire door inspection reports as required by NFPA 80 (2010 ed.) 5.2.1 and 5.2.4.2.

Findings:

During record review of the building with the Maintenance Director on 7/08/019 at approximately 10 a.m., records for the fire door inspection report was requested. The report was incomplete. At that time, the Maintenance Director said he was unaware that it was incomplete.

These findings were re-confirmed with the Administator during the exit conference at 1:10 p.m. on 7/08/019.

Code: NFPA 80 (2010 ed.) 5.2.1 & 5.2.4.2

Based on observation and interview, the facility failed to ensure that portable fire extinguishers were inspected annually NFPA 101. Chapter 19.3.5.12 establishes that "Portable fire extinguishers shall be installed in all healthcare occupancies in accordance with 9.7.4.1" and per 9.7.4.1, "inspected and maintained in accordance with NFPA 10, Standard for portable fire extinguishers."

Findings:

During the review of record on 7/08/19 at approximately 9:45 a.m., fire extingusher testing records were reviewed. The latest fire extingusher test was conducted on 6/20/18 a period in excess of one year. Interview with the Maintenance Director at that time revealed that he was unaware the inspection report was not current.

These findings were re-confirmed with the Administrator and Maintenance Director during the exit conference at 1:10 p.m. on 7/08/019.

NFPA 101 19.3.5.12, Ch 9.7.4.1, NFPA 10