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Based on record review and interview, the facility failed to develop, at a minimum, policies and procedures that address; the provision of subsistence needs for staff and patients whether they evacuate or shelter in place, including, but not limited to: Food, water, medical and pharmaceutical supplies, alternate sources of energy to maintain temperatures to protect patient health and safety and for the safe and sanitary storage of provisions, emergency lighting, fire detection, extinguishing and alarm systems, and sewage and waste disposal. This deficient practice could affect all occupants in the event of an emergency.

Findings Include:

On June 3, 2024, at approximately 12:05 PM, during record review of the facility emergency preparedness plan, the facility failed to include a policy that addressed the provisions of food and water for staff and residents in the event of an emergency, as required by 82.15(b)(1). Interview with the Chief Executive Officer at this time confirmed this finding.

Based on record review and interview, the facility failed to ensure automatic emergency lighting of 1-1/2 hour duration is provided in accordance with 7.9, as required by 19.2.9.1. This deficient practice could affect all occupants in the event of a power failure.

Findings Include:

On June 3, 2024 at approximately 10:39 AM, record review revealed the facility failed to test their emergency lights monthly during the months of September, October, and November of 2023, as required by NFPA 101, 7.9.3.1.1 (1). This finding was confirmed by the Maintenance Director at the time of record review.

Based on observation and interview, the facility failed to separate Hazardous areas from other spaces by smoke resisting partitions and self-closing doors. This deficient practice could affect all occupants in the event of a fire emergency.

Findings Include:

1) On June 3, 2024 at approximately 9:00 AM, observation revealed the door from the Maintenance Directors office going into the garage failed to have a self-closing device installed as required by NFPA 19.3.2.1.3.

2) On June 3, 2024 at approximately 9:30 AM, observation revealed two 1/2 inch round penetrations in Mechanical room 1. The void area around the penetrations failed to have approved, properly rated material capable of restricting the transfer of smoke as required by National Fire Protection Association (NFPA) 8.5.6.2. The Maintenance Director confirmed this finding at the time of discovery.

3) On June 3, 2024 at approximately 9:35 AM, observation revealed the hallway mechanical room door failed to close and latch completely when tested as required by NFPA 19.3.2.1.3.

The Maintenance Director confirmed these findings at the time of discovery.

Based on record review and interview, the facility failed to ensure cooking facilities are protected in accordance with NFPA 96, unless meeting the requirements of 19.3.2.5.2, 19.3.2.5.3 or 19.3.2.4.4, as required by 19.3.2.5.1 through 19.3.2.5.5, 9.2.3 and TIA 12-2. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

1) On June 3, 2024 at approximately 11:30 AM, record review revealed the facility failed to produce documentation showing the required semi-annual inspection/cleaning of the installed kitchen hood ventilation system as required by NFPA 96, 11.4.

2) On June 3, 2024 at approximately 11:35 AM, record review revealed the facility failed to conduct and document the monthly owner's hood inspection as required by NFPA 17A, 7.2.1 and 7.2.2.

These findings were confirmed by the Maintenance Director at the time of discovery.

Based on record review and interview, the facility failed to ensure the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72, and records are readily available as required by 19.6.1.3, 9.6.1.5, NFPA 70 and NFPA 72. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

On June 3, 2024 at approximately 11:37 AM, no records were made available to review indicating they have completed annual fire alarm inspections as required. This finding was confirmed by the Maintnenac Director at the time of discovery.

Based on record review and interview, the facility failed to ensure all of the required elements were included in their approved fire watch policy. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

On June 3, 2024 at approximately 11:27 AM, record review revealed the facility failed to include the appropriate Authority Having Jurisdiction (AHJ) contact numbers were included in their established fire watch policy, as required by National Fire Protection Association 101, 9.6.1.6. This finding was confirmed by the Maintenance Director at the time of record review.

Based on observation and interview, the facility failed to ensure the automatic fire sprinkler system was maintained as designed and installed. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

1) On June 3, 2024 at approximately 9:35 AM, observation revealed a ceiling tile missing in the telephone closet, which violates National Fire Protection Association (NFPA) 19.3.5.

2) On June 3, 2024 at approximately 9: 37 AM, observation revealed a ceiling tile missing in the server room, which violates NFPA 19.3.5.

These findings were confirmed by the Maintenance Director at the time of discovery.

Based on record review and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested and maintained in accordance with NFPA 25, and records are readily available as required by 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

On June 3, 2024 at approximately 11:29 AM, record review revealed the facility failed to provide documentation of the required 5 year internal inspection of piping and branch line conditions as required by NFPA 25, 14.2.1. This finding was confirmed by the Maintenance Director at the time of record review.

Based on record review and interview, facility failed to ensure all of the required elements were included in their approved fire watch policy. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

On June 3, 2024 at approximately 11:27 AM, record review revealed the facility failed to include the appropriate Authority Having Jurisdiction (AHJ) contact numbers were included in their established fire watch policy, as required by National Fire Protection Association 25, 15.5.2. This finding was confirmed by the Maintenance Director at the time of record review.

Based on observation and interview, the facility failed to ensure rooms containing electrical equipment are free from the storage of combustible items. This deficient practice could affect 3 occupants in the event of a fire.

Findings Include:

On June 3, 2024 at approximately 9:35 AM, observation revealed multiple combustible items stored within three feet of electrical equipment inside of the transfer switch room, which violates National Fire Protection Association 70, 110.26. This finding was confirmed by the Maintenance Director at the time of observation.

Based on record review and interview, the facility failed to ensure fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions, are held at unexpected times under varying circumstances, conducted at least quarterly on each shift and responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership as required by 19.7.1.4 through 19.7.1.7. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

On June 3, 2024 at approximately 9:22 AM, record review revealed the facility failed to ensure their fire alarm signal was received by the monitoring company while conducting fire drills. This finding was confirmed by the Maintenance Director at the time of discovery.

Based on observation and interview, the facility failed to ensure combustible decorations were prohibited except as permitted by the requirements of 19.7.5.6. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

On June 3, 2024 at approximately 9:15 AM, observation revealed combustible crepe paper hung from the ceiling throughout the corridor heading to the dining area. This finding was confirmed by the Maintenance Director at the time of discovery.

Based on record review and interview, the facility failed to inspect and test annually in accordance with NFPA 101, 19.7.6, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives 5.2, 5.2.3. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. This deficient practice could affect all occupants in the event of a fire.

Findings Include:

On June 3, 2024 at approximately 9:32 AM, record review revealed the facility failed to conduct and document annual fire door inspections as required by NFPA 80, 5.2.1 for the installed fire doors at their facility. Of the records provided, the most recent inspection was conducted in March 2023. This finding was confirmed by the Maintenance Director at the time of record review.

Based on record review and interview, the facility failed to ensure the gas and vacuum systems are inspected and tests and records are maintained as required by 5.1.14.2.3, 5.2.13, 5.3.13 and 5.3.13.4 of NFPA 99. This deficient practice could affect all occupants requiring oxygen in the event of system failure.

Findings Include:

On June 3, 2024, at approximately 2:26 PM, record review revealed the facility failed to ensure their medical gas system (piped in oxygen system) was tested annually as required by NFPA 99, 5.1.14.4.4. No records were made available by the exit of this survey. The Maintenance Director confirmed this finding at the time of record review.

Based on record review and interview, the facility failed to ensure generators or other alternative power sources and associated equipment is capable of supplying service within 10 seconds, is maintained, inspected, tested and exercised in accordance with NFPA 110, and records are readily available as required by 6.4.4, 6.5.4 and 6.6.4 of NFPA 99, NFPA 110, NFPA 111 and 700.10 of NFPA 70. This deficient practice could affect all occupants in the event of a power failure.

Findings Include:

1) On June 3, 2024 at approximately 11:31 AM, record review revealed the facility failed to ensure the diesel fuel for their generator was tested annually as required by NFPA 110, 8.3.8.

2) On June 3, 2024 at approximately 11:32 AM, record review revealed the facility failed to conduct annual 90 minute load bank test as required by NFPA 110, 8.4.2.3.

3) On June 3, 2024 at approximately 11:33 AM, record review revealed the facility failed to conduct specific gravity testing or conductance testing of their generator batteries as required by NFPA 110, 8.3.7.1

These findings were confirmed by the Maintenance Director at the time of record review.