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Based on record review, the facility failed to include the resident/patient population, the type of services the facility has the ability to provide in an emergency, and the continuity of operations, including delegations of authority.

Findings include:

1. Review of the EP program on 09/21/21 reflected the facility lacked information about its resident population, persons at risk, how the persons were at risk, the type of services and staff availability with certain competencies that could be provided in an emergency; and equipment inventory and needs specific for the continuity of facility's operations.

Based on record review the facility failed to plan and implement a provision of subsistence needs for the staff and the residents/patients, whether they evacuated or sheltered in place.

Findings include:

1. Review of the EP plan, policies, and procedures on 09/21/21, showed the facility lacked a complete system for determining subsistence needs for staff and residents/patients, particularly specific needs for food, medical and pharmaceuticals, and sewage and waste disposal.

Based on observation, the facility failed to maintain egress doors with only one releasing operation in accordance with NFPA 101, 2012 Edition, Section 7.2.1.5.10.2.

Findings include:

1. During an observation on 09/21/21 at 9:51 a.m. room 215 was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room has the capacity to hold three or more people.

2. During an observation on 09/21/21 at 10:09 a.m. the social services office was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room has the capacity to hold three or more people.

3. During an observation on 09/21/21 at 10:35 a.m. room 101 was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room has the capacity to hold three or more people.

4. During an observation on 09/21/21 at 10:43 a.m. the CT bathroom was inspected. The door was found to be fitted with a lock which required more than one motion to open the door. The room has the capacity to hold three or more people.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7 and section 19.2.2.2.8.

Findings include:

1. During an observation on 09/21/21 at 9:47 a.m., the door leading to the activities storage was inspected. The door was fitted with a self-closure device and failed to close and positively latch when exercised.

2. During an observation on 09/21/21 at 10:01 a.m., the west hall closet was inspected. The door was fitted with a self-closure device and failed to close and positively latch when exercised.

3. During an observation on 09/21/21 at 10:49 a.m., the door leading to the old physical therapy room was inspected. The door was fitted with a self-closure device and failed to close and positively latch when exercised.

4. During an observation on 09/21/21 at 10:55 a.m., the door leading to the generator room was inspected. The door was fitted with a self-closure device and failed to close and positively latch when exercised.

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 09/21/21 at 10:39 a.m., the emergency disaster office was inspected. The room was being used as storage and is over 50 square feet. There was no self-closer on the door leading to the room from the corridor.

2. During an observation on 09/21/21 at 10:50 a.m., the old physical therapy room was inspected. The room was being used as storage and is over 50 square feet. There was no self-closer on the door leading to the room from the corridor.

3. During an observation on 09/21/21 at 11:05 a.m., the mechanical room was inspected. The room was being used as storage and is over 50 square feet. There was no self-closer on the door leading to the room from the corridor.

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 09/21/21 at 9:56 a.m., resident room 210 was inspected. There was an ABHR dispenser mounted over an electrical outlet.

2. During an observation on 09/21/21 at 10:37 a.m., treatment room #2 was inspected. There was an ABHR dispenser mounted over an electrical outlet.

3. During an observation on 09/21/21 at 10:37 a.m., the wall outside of treatment room #2 was inspected. There was an ABHR dispenser mounted over an electrical outlet.

Based on observation the facility failed to ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

Findings Include:

1. During an observation on 9/21/21 at 9:54 a.m., the salon bathroom was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

2. During an observation on 9/21/21 at 9:55 a.m., room 209 was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

3. During an observation on 9/21/21 at 10:06 a.m., room 304 was inspected. The ceiling mounted light in the bathroom was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

4. During an observation on 9/21/21 at 10:27 a.m., the kitchen janitor room was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

5. During an observation on 9/21/21 at 10:28 a.m., the kitchen dish room was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

6. During an observation on 9/21/21 at 10:30 a.m., the kitchen food storage room was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

7. During an observation on 9/21/21 at 10:40 a.m., the emergency disaster office was inspected. The ceiling mounted light in the room was blocking the sprinkler head next to it. The head was within 12 inches of the light, and the light was lower than the deflector on the sprinkler head.

Based on observation the facility failed to:

a) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.;
b) ensure sprinkler pipes were free of external loads in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2.;
c) ensure proper sprinkler maintenance in accordance with NFPA 101-2012 and NFPA 25-2011, Sections 5.1.1.1 and Table 5.1.1.2.

Findings include:

1. Review of facility sprinkler inspection reports reflected the five-year internal inspection, and calibration/replacement of the standpipe gauges for the facility had not taken place every five years. The last five-year internal inspection and calibration/replacement of the sprinkler gauges for the facility were not documented.

During an interview on 09/21/21 at 8:30 a.m., staff member A stated he had been working for the facility for over four years and during that time an internal inspection had not occured.

2. During an observation on 09/21/21 at 9:44 a.m., the activities closet was inspected. The sprinkler head within the room was observed to be covered in a white substance.

3. During an observation on 09/21/21 at 10:17 a.m., the main entrance storage closet was inspected. Several ceiling tiles were observed to be missing from the ceiling within the room.

4. During an observation on 09/21/21 at 10:29 a.m., the kitchen freezer was inspected. A sprinkler head was observed, obstructed by various items that were placed within 18 inches of the sprinkler head.

5. During an observation on 09/21/21 at 10:41 a.m., the CT room was inspected. The sprinkler head in the room was observed to be missing its escutcheon ring.

6. During an observation on 09/21/21 at 10:51 a.m., the sprinkler standpipe room was inspected. The spare sprinkler head box was found to be missing representative replacement sprinkler heads for all of the sprinkler heads used throughout the facility.

7. During an observation on 09/21/21 at 10:53 a.m., the generator room was inspected. The sprinkler head within the room was observed to be covered in a white substance.

8. During an observation on 09/21/21 at 10:54 a.m., the elevator room was inspected. The sprinkler head within the room was observed to be covered in a white substance.

9. During an observation on 09/21/21 at 10:55 a.m., the laundry room was inspected. Three sprinkler heads within the room were observed to be covered in a white substance.

10. During an observation on 09/21/21 at 11:00 a.m., the laundry room bathroom was inspected. The sprinkler head within the room was observed to be covered in a white substance.

11. During an observation on 09/21/21 at 11:01 a.m., the server room was inspected. Several wires were observed attached to the sprinkler pipe within the room.

12. During an observation on 09/21/21 at 11:07 a.m., the mechanical room was inspected. Several wires were observed attached to the sprinkler pipe within the room.

13. During an observation on 09/21/21 at 11:08 a.m., the basement storage room was inspected. Several wires were observed attached to the sprinkler pipe within the room.

14. During an observation on 09/21/21 at 11:10 a.m., the purchasing hallway was inspected. Several wires were observed attached to the sprinkler pipe within the room.

15. During an observation on 09/21/21 at 11:11 a.m., the purchasing hallway was inspected. The sprinkler heads within the room were observed to be covered in a white substance.

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 09/21/21 reflected the facility failed to perform fire drills during:

a) the PM shift of the fourth quarter of 2020;
b) the PM shift of the second quarter of 2021.

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 09/21/21, 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 observations, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

Findings include:

1. During an observation on 09/21/21 at 10:03 a.m., the dirty utilities room was inspected. The electrical panel in the room was blocked from easy access by several items being stored in front of it.

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 09/21/21 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).

Based on record review and interview, the facility failed to:
a) ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 110, Section 8.3.8; and
b) ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1.

Findings include:

1. Review of the emergency generator inspection records on 09/21/21, showed the annual diesel fuel supply quality test was not conducted within the last year.

During an interview on 09/21/21 at 8:32 a.m., staff member A stated the facility had not completed an annual fuel quality test for the generator. He stated, "I cannot tell you the last time that was done, we do not have anyone that comes to inspect the generator annually."

2. During a review of facility generator records, and interviews on 09/21/21 at 10:54 a.m., staff member A stated the generator had no labeled manual stop button. The manual stop station needs to be in a remote location outside of the room housing the prime mover, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.

Based on observation, the facility failed to ensure power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4.

Findings include:

1. During an observation on 09/21/21 at 10:07 a.m., the director of nursing office was inspected. The power strip used in the room did not have a UL 1363 rating.

2. During an observation on 09/21/21 at 10:21 a.m., the bird room was inspected. The power strip used in the room did not have a UL 1363 rating.

3. During an observation on 09/21/21 at 11:03 a.m., the server room was inspected. The power strip used in the room did not have a UL 1363 rating.

Based on observation the facility failed to maintain oxygen cylinders per NFPA 99-2012, Section 11.6.2.3.

Findings include:

1. During an observation on 09/21/21 at 10:24 a.m., the oxygen storage room was inspected. There was one E-sized oxygen tank observed sitting on the floor of the room, unsecured by chains or by being placed in a rack.