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Based on observation and interview, the provider failed to maintain two separate hazardous areas (kitchen pantry and Gala/storage room) as required. Findings include:

1. Observation on 4/25/23 at 9:15 a.m. revealed the kitchen pantry was over 100 square feet in area and held copious amounts of combustible items (canned goods, plastic containers, and cardboard boxes). The corridor door was equipped with positive latching hardware but was not equipped with a closer.

2. Observation on 4/25/23 at 10:45 a.m. revealed the Gala/storage room in the lower level of the original building was over 100 square feet in area and held copious amounts of combustible storage (furniture and boxes) and was built as a one-hour fire-rated room. An unsealed penetration of the north wall existed at a four-inch electrical conduit installation through the fire-rated wall. The penetration must be sealed with an appropriate fire-stop material, such as intumescing red fire caulk.

3. Interview with the director of plant operations at the time of the observations confirmed those findings.

The deficiency affected two of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of the smoke compartment.

Based on observation, interview, and document review, the provider failed to ensure staff were familiar with the provider's fire drill procedures (closing corridor doors, announcement per procedures, and checking the door for the fire location). Findings include:

1. Observation on 4/25/23 at 12:58 p.m. revealed the fire alarm was initiated by placing the red fire simulation cloth flag in the director of nursing (DON) office. The DON went to the nurses station with the red flag without closing the door to that office (the source of the simulated fire). After a two-minute delay, an announcement was made of a "Fire Drill" in that wing of the building. The provider's fire policy indicated the announcement should be made as "Code Red". After the announcement, the fire alarm pull station was activated. Upon the arrival of six staff with fire extinguishers, one of the staff entered the room to extinguish the simulated fire (the door had never been shut to isolate the fire). One of the other staff members closed the remaining doors in that smoke compartment at that time. Upon closing the simulated fire source room door, testing of the procedure to check the corridor door for heat and smoke was checked. The wood door and metal handle were not safely checked by using the back of the hand to check for heat. Checking the fire policy for the provider revealed employees responding to a (simulated) fire was to follow the RACE (rescue, alarm, contain, extinguish). That portion of the building (which also contained patient rooms) was not equipped with automatic fire sprinklers.

Interview with the director of plant operations at the time of the observation confirmed those findings.

The deficiency had the potential to affect 100% of the occupants.

A. Based on observation and interview, the provider failed to install a remote stop button for the Kohler generator. Findings include:

1. Observation on 4/25/23 at 10:30 a.m. revealed there was not an emergency stop button installed for the Kohler generator at a remote location. There was a remote stop located in the housing for the generator, but it was behind closed access panels. Interview with the director of plant operations at the time of the observation confirmed that finding. He was unaware the existing remote stop location for the generator was not acceptable.

B. Based on record review and interview, the provider failed to document the generator battery conductivity monthly. Findings include:

1. Record review on 4/25/23 at 8:45 a.m. revealed there was not documentation of the battery conductivity in the monthly maintenance logs for the generator. Interview with the director of plant operations at the time of the record review confirmed that finding. He was unaware of the monthly battery conductivity documentation requirement for the generator.

The deficiency affected two of numerous requirements for generator maintenance.