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Based on record review the facility failed to plan and implement a provision of subsistence needs for the staff and the residents. This affects all occupants in the facility.

Findings include:

1. Review of the EP plan, policies, and procedures on 10/6/2021, reflected the facility lacked a complete system for determining subsistence needs for staff and residents, particularly specific policies describing alternate sources of energy to maintain proper temperatures, emergency lighting, sprinkler and alarm systems, and sewage and waste disposal.

Based on record review, the facility failed to develop policy and procedures related to the emergency and standby power systems for the EP plan. The record review showed insufficient information about the role of the emergency generator meeting care needs of the residents, the other occupants, as well as the building's needs based on the facility's safety and hazard vulnerability assessment. This deficiency affects all of the occupants in the facility.

Findings include:

1. Review of the EP plan on 10/6/21 reflected a lack of specific details about what kind of services could be supported by the onsite emergency generator, i.e., the building temperatures, daily kitchen functions, safe food storage, illumination of the exit halls and exit signs, the electrical systems necessary for selected Information Technologies in the building, mapped locations of electrical outlets supported by the generator, number of days of shelter that could be provided, given the fuel type of the generator.

Based on observation, the facility failed to maintain exit signs in accordance with NFPA 101, 2012 Edition, Section 19.2.5.4.

Findings include:

1. During an observation on 10/6/21 at 10:57 a.m., the exit signs in the corridor to the long term care were inspected. There was an exit sign with the right pointing chevron punched out so the sign was telling occupants to go right to exit. There was no exit to the right just beyond the exit sign. The sign was giving conflicting instructions for the area where it was posted.

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 10/6/21 at 10:00 a.m., the basement record storage room A was inspected. The room is considered a hazardous room. The self-closing device on the door was found to be detached from being able to close the door as required.

2. During an observation on 10/6/21 at 10:13 a.m., the laundry was inspected. The laundry corridor door would not close and latch under the power of the self-closer.

3. During an observation on 10/6/21 at 10:46 a.m., the diagnostic imaging storage room was inspected. The corridor door would not close and latch under the power of the self-closer.

4. During an observation on 10/6/21 at 10:46 a.m., the PPE storage room was inspected. The corridor door would not close and latch under the power of the self-closer.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 10/6/2021 at 10:39 a.m., the lab was inspected. There were two ABHR dispensers mounted over two different light switches in the lab.

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

a) continuously maintain automatic fire sprinklers in reliable operating condition including examination of the heads per NFPA 25-2011, Sections 5.2.1.1.2; and
b) maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5.

Findings include:

1. During an observation on 10/6/21 at 10:18 a.m., the boiler room was inspected. There was a sprinkler head in the room which was painted white.

2. During an observation on 10/6/21 at 10:28 a.m., the spare sprinkler box was inspected. There were no spare directional sprinkler heads in the spare box at the standpipe. There were several spare sprinkler heads in use in the building.

3. During an observation on 10/6/21 at 10:50 a.m., the ER north corridor was found to have two sprinkler heads missing the escutcheon rings.

4. During an observation on 10/6/21 at 10:52 a.m., bay number 2 in the ER was found to have a sprinkler head missing the escutcheon ring.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Sections 6.1.3.1, 6.1.3.8.1, and 6.1.3.3.1.

Findings include:

1. During an observation on 10/6/21 at 9:51 a.m., the staff break room was inspected. There was a portable fire extinguisher sitting on the counter in the room. Extinguishers must be mounted to the wall or in a cabinet.

2. During an observation on 10/6/21 at 10:02 a.m., the portable extinguisher in the basement hall was mounted about 65 inches high, five inches over the maximum 60 inches to the top of the handle.

3. During an observation on 10/6/21 at 10:11 a.m., the laundry room was inspected. The portable extinguisher in the room was found to be obstructed from instant use by a sink and a cabinet in front of it.

Based on record review and interview, 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. This deficiency affects the entire facility.

Findings include:

1. Review of facility documents regarding fire drills on 10/6/2021 reflected there were no drills performed in the third quarter of 2021, and there was no alternate trainings on fire drills during that time.

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 of the fire/smoke compartments.

Findings include:

1. Review of the fire safety maintenance records on 10/6/21, 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 the bulk oxygen storage area in accordance with NFPA 55 Compressed Gases and Cryogenic Fluid Code 2010 Edition, Section 9.4.4.
Findings include:

1. During an observation on 10/6/21 at 10:04 a.m., the bulk oxygen storage tank area was inspected. There was no required signage on the fence or gate in regards to the oxygen and no smoking.

Based on record review, the facility failed to maintain the receptacles in patient areas. The deficient practice affected the entire facility.

Findings include:

Record review on 10/6/2021 revealed non-hospital grade receptacles located in resident rooms throughout the facility did not have annual retention testing as required by sections 6.3.4.1.2 and 6.3.4.1.3 in NFPA 99, Health Care Facilities Code.

Actual NFPA Standard: NFPA 99 (2012), 6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).