HospitalInspections.org

Based on record review and interview, the facility did not document and identify, through risk assessment, an all hazards approach in their Emergency Preparedness Program (EPP) in accordance with the requirements of CFR 482.15(a)(1)(2). This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 08/14/2023 at 4:35 PM, review of the document titled "Emergency Preparedness and Response Plan" dated "REV 10/15/2019" revealed the all hazard's risk assessment completed by the facility at the time of the survey had not been updated within the past 24 months. The latest policy update occurred on 09/14/2019. No additional documentation was available at the time of the survey.

This deficient practice was confirmed at the time of discovery with Staff B.

Based on record review and staff interview, the facility did not participate and document two Emergency Preparedness exercises in the past 12 months to test the facility based emergency plan for evaluation and updating, if required, per 42 CFR section 482.15(d)(2). This deficient practice could affect all of the residents, as well as undetermined number of staff and visitors.

Findings include:

On 08/14/2023 at 6:21 PM, record review of the emergency preparedness plan revealed that the facility did not participate or conduct two exercises to test their emergency plan by participating in a facility based, tabletop or full-scale, community-based exercise or an actual event within the past 12 months. The last recorded exercises included a community event on Tornados on 12/02/2022. The facility did complete initial training of employees on the emergency preparedness policies. No additional After Action Reports or other documentation of an exercise was available at the time of the survey.

This deficient practice was confirmed at the time of discovery with Staff B.

Based on observation and staff interview, the facility did not ensure that egress corridors are continuously maintained free of materials that obstruct egress as required per NFPA 101, 2012 edition, Sections 19.2.1 and 7.1.10.2.1. The deficient practice could affect an undetermined number of staff and visitors.

Findings Include:

1. On 08/14/2023 at 12:56 PM, observation revealed that access to the exit from the Gym to the exterior was obstructed due to the storage of (5) wooden wedges on the vestibule floor. These items were identified at the time of survey and remained in place at the time of exit.

2. On 08/14/2023 at 12:58 PM, observation revealed that access to the exit from the Gym to the exterior was obstructed as one of the interior double doors was being held open by a wooden floor wedge. The door was equipped with a self-closer.

These deficient practices were confirmed at the time of discovery with Staff B.

Based on observation and interview, the facility did not protect a hazardous area in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.2.1, 19.3.2.1.2, 19.3.2.1.3, 19.3.2.1.5, 7.2.1.8, and 8.4.3. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

On 08/14/2023 at 12:22 PM, observation in the Basement Mechanical Room B-3, a room greater than 100 sqft in size, was protected with a sprinkler system but was not smoke tight. The furnace room door was not equipped with an automatic or self closing door closer. The furnace room had a fuel-fired heater and was considered a hazardous room.

This deficient practice was confirmed at the time of discovery with Staff B.

Based on observation and interview, the facility did not maintain smoke barriers in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.7.1, 19.3.7.3, 8.5.2, 8.5.3, 8.5.6, and 8.5.7. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 08/14/2023 at 2:27 PM, observation above the ceiling and above the double smoker barrier doors at the Acute Unit Corridor smoke barrier wall, separating smoke compartment from the Entry and Lobby smoke compartment, revealed (3) 3/4 inch diameter conduits that was not properly fire stopped according to an approved method.

This deficient practice was confirmed at the time of discovery with Staff B.

Based on observation and interview, the facility did not maintain the designated smoking area in accordance with NFPA 101, 2012 edition, Sections 19.7.4. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 08/14/2023 at 2:44 PM, observation in the Acute Unit Outdoor Smoking Cage, accessible through Storage Room 3, revealed the Resident's exterior smoking area did not include a butt collector of non-combustible material.

This deficient practice was confirmed at the time of discovery with Staff B.

Based on record review and interview, the facility did not complete maintenance and testing of the emergency generator and transfer switches accordance with the requirements of NFPA 101, 2012 edition, Sections 19.5.1 and 9.1.3; as well as NFPA 110, 2010 edition, Sections 8.3.4, 8.3.8, and 8.4.2.3. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

08/14/2023 at 4:48 PM, record review that no annual diesel fuel quality test was performed in the past 12 months, with documented results in accordance with the requirements of ASTM D975.

This deficient practice was confirmed at the time of discovery with Staff B.