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Based on record review and interview, the facility failed to review and update the emergency preparedness plan annually. Findings:

1. The facility records were reviewed 01/15/2025. The CEO provided an emergency preparedness policy binder. The policy had not been reviewed and updated in the last 12 months.

2. The CEO was interviewed on 01/15/2025 and he stated he had not updated the emergency preparedness book yet.

Based on observation and interview the facility failed to ensure egress doors could be opened with one action as required.

Findings:

On 01/15/2025 the surveyor observed a dead bolt lock on patient room #5 and #7. These dead bolt locks required a key to unlock the door from the inside of the room.

The CEO was present when the dead bolts were observed on the patient room doors. He stated he would have the dead bolts removed as soon as possible.

Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system quarterly. Findings:

1. The facility records were reviewed on 01/15/2025. The most recent annual sprinkler inspection document was dated 09/17/2024.

The quarterly sprinkler inspections should have been performed in the first, second and fourth quarter of 2024. There was no documentation for the missing quarterly sprinkler inspections.

2. The CEO was present during the record review on and stated he was not aware the quarterly sprinkler inspections had not been done.

Based on record review and staff interview, the facility failed to assure the minimum required number of fire drills were conducted within the past year. Findings:

1. Review of the facility fire drill reports was conducted on 01/15/2025. There was no documentation the facility had conducted a fire drill for the following shift:

a. the first and second shifts for the first quarter of 2024.

b. the first and second shifts for the second quarter of 2024.

2. The CEO was interviewed on 01/15/2025 and stated the facility missed the fire drill for those shifts.

Based on record review and interview, the facility failed to conduct the routine inspections of the corridor doors throughout the facility. Findings:

1. The facility records were reviewed on 01/15/2025 and no documentation was found to show the facility had conducted routine corridor door and smoke door inspections.

2. The CEO was interviewed during the record review and he stated he was not aware of the corridor door and smoke door inspections.


Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
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.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessments were not completed and do not exist.

On 01/15/2025 the surveyor asked the CEO for the EES and Medical Gas building system risk assessments. She stated they were not aware of the requirement but would ensure they will be completed.

Based on record review, observation, and staff interview, the facility failed to properly maintain and test the generator as required by NFPA 99 in the event of an electrical outage. Findings:

1. During the record review on 01/15/2025 there was no documentation the facility has been performing an weekly visual check and a monthly 30 minute generator test.

2. The CEO was interviewed on 01/15/2025, and stated he did not have documentation of the generator weekly and monthly test.