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Based on interview and record review the facility failed to implement the initial and annual training of the EP program to all staff members, consistent with each team members' expected roles during an emergency or a disaster.

This deficiency affects all the occupants and staff in the facility.

Findings include:

1. Record review of the facility EP plan and training documents on 5/13/24 revealed, the facility did not have documentation that staff training for the EP plan was conducted initially for new staff and every other year for all current staff.

During an interview on 5/13/24 at 12:46 p.m., staff member C stated he did not have a specific training program for emergency preparedness and did not have documentation of staff who have completed emergency preparedness training upon hire and every two years after.

Based on record review and interview, the facility failed to ensure that load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 14.4.5 (6).

This deficiency affects all smoke compartments at the facility.

Findings include:

During a review of the most recent facility fire alarm inspection on 5/13/24, the fire alarm system was inspected on 10/24/23. There was no indication either written on the batteries or in the panel that the six-month voltage test had been completed by the facility semi-annually.

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

a) complete a 5-year internal inspection of the sprinkler piping in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 14.2.1.,

b) replace or test sprinkler gauges every 5 years in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.2,

c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3).

This deficiency affected all staff and patients at the facility.

Findings include:

1. Review of the facility's sprinkler inspections on 5/13/24 showed the facility had not had an internal inspection of the sprinkler piping or the gauges to the sprinkler system had been recalibrated or replaced in the last 5years. The last internal inspection was in 2018.

During an interview on 5/13/24 at 10:32 a.m., staff member B stated the sprinkler company was going to replace the sprinkler gauges at the same time the internal inspection was completed. Staff member B stated he knew it should have been done.

2. During an observation on 5/13/24 at 11:46 a.m., the gift storage room was inspected. The storage room had a missing ceiling tile.

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

a) complete a 5-year internal inspection of the sprinkler piping in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 14.2.1.,

b) replace or test sprinkler gauges every 5 years in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.2, and

c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3).

This deficiency affected all staff and patients at the facility.

Findings include:

1. Review of the facility's sprinkler inspections on 5/13/24 showed the facility had not had an internal inspection of the sprinkler piping or the gauges to the sprinkler system had been recalibrated or replaced in the last 5years. The last internal inspection was in 2018.

During an interview on 5/13/24 at 10:32 a.m., staff member B stated the sprinkler company was going to replace the sprinkler gauges at the same time the internal inspection was completed. Staff member B stated he knew it should have been done.

2. During an observation on 5/13/24 at 12:03 p.m., the charting room was inspected. There was a circular hole cut out of the ceiling tile.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter, as well as consistently documented the drill simulation under varied conditions in accordance with NFPA 101, 2012 Edition, section 18.7.1.6 and 18.7.2.2.

This deficiency affects all residents and staff at the facility.

Findings include:

During a review of facility fire drills on 5/13/24 it was determined the facility was missing the following fire drills:

a) First and second shift of the second quarter of 2023 (April - June 2023).
b) First and second shift of the fourth quarter of 2023 (October - December 2023).

Review of the facility's fire drills showed there was not a description of the simulation of the fire drill, therefore it could not be determined the fire drills were being simulated under varied conditions.

During an interview on 5/13/24 at 10:32 a.m., staff member B stated he did not usually write a summary of the drill and under what conditions the drill was being performed.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter, as well as consistently documented the drill simulation under varied conditions in accordance with NFPA 101, 2012 Edition, section 19.7.1.6 and 19.7.2.2.

This deficiency affects all residents and staff at the facility.

Findings include:

During a review of facility fire drills on 5/13/24 it was determined the facility was missing the following fire drills:

a) First and second shift of the second quarter of 2023 (April - June 2023).
b) First and second shift of the fourth quarter of 2023 (October - December 2023).

Review of the facility's fire drills showed there was not a description of the simulation of the fire drill, therefore it could not be determined the fire drills were being simulated under varied conditions.

During an interview on 5/13/24 at 10:32 a.m., staff member B stated he did not usually write a summary of the drill and under what conditions the drill was being performed.

Based on record review, the facility failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 101 2012 Edition, Section 9.1.3.1 and NFPA 110, Section 8.3.8.

This deficiency affects the entire facility.

Findings include:

Review of the emergency generator inspection records on 5/13/24, revealed there was no documentation showing the annual diesel fuel supply quality test was conducted within the last year.