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Based on record review and interview, the facility did not develop an emergency preparedness plan based on an all-hazards approach in accordance with the Code of Federal Regulations, 42 CFR §485.625(a)(1), by failing to include planning for infectious diseases within their emergency preparedness program. This deficient practice affects all occupants of the facility. The facility had a capacity of 25 and a census of 6 residents at the time of the survey.

Findings include:

Record review and interview on 10/22/2021 at 12:07 p.m., revealed the facility had not included emerging infectious diseases within its documented risk assessment. CMS determined it was critical for facilities to include planning for infectious diseases within their emergency preparedness program and to include consideration of preparedness and infection prevention within their all-hazards approach, which covers both natural and man-made disasters.

Administrative Staff member verified these findings during the survey process.

Based on record review and interview, the facility did not develop and implement complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR 483.475(b)(8) [ICF]/ 483.73(b)(8) [LTC], by failing to incorporate policies and procedures in its emergency plan describing the facility's role under a waiver in accordance with Social Security Act, Section 1135, in the provision of care and treatment at an alternate care site identified by emergency management officials. This deficient practice affects all occupants of the facility. The facility had a capacity of 25 and a census of 6 residents at the time of the survey.

Findings include:

Record review and interview on 10/22/2021 at 12:17 p.m., revealed the facility's emergency preparedness policies and procedures did not specifically address the facility's role in emergencies where the Health and Human Services Secretary declares a public health emergency. The emergency preparedness plan failed to demonstrate the facility's general awareness of the 1135 process, including the following:

1) Knowledge of how to request a waiver and who to contact (contact information) in the event an 1135 waiver needs to be requested;

2) The circumstances when an 1135 waiver might be granted based on the risk analysis;

3) How they would operate under and outline the responsibilities during the duration of the waiver period; and

4) How they would plan jointly on issues related to staffing, equipment, and supplies.

The Administration Staff member verified this finding during the survey process.

Based on observation and interview, it was determined the facility did not provide appropriate construction standards as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.1.6. The facility failed to assure minimum building construction requirements were maintained by ensuring that damaged and missing ceiling tiles providing smoke barriers are maintained with fire rated materials. This deficient practice affected two of eight smoke zones and all staff and visitors in these areas of the facility. The facility had a capacity of 25 with a census of 6 patients at the time of the survey.

Findings include:

1. Observation and interview on 10/22/2021 at 10:35 a.m., revealed the facility failed to maintain the ceiling tile in the First Floor Housekeeping Storage Room. This room contained missing ceiling tile that affected the smoke zone integrity.

2. Observation and interview on 10/22/2021 at 11:04 a.m., revealed the facility failed to maintain the ceiling tile in the First Floor Hallway near Radiology. This hallway contained ceiling tile that had an approximately a three inch opening adjacent to a sprinkler head. This affected the smoke zone integrity in this area.


The Facilities Manager and Assistant Maintenance staff member verified this observation during the survey process.

Based on record review and interview, this facility is not providing fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This deficient practice affects staff and visitors in one of eight smoke compartments. This facility had a capacity of 25 and a census of 6 residents at the time of the survey.

Findings include:

1. Record review and interview on 10/22/2021 at 10:06 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility. This fire doors are required to be functionally tested annually by an individual with knowledge and understanding of the operating components of the type of door being subject to testing. The facilities Manager stated he was unaware of the inspection requirement.

2. On-sight walk through of the facility on 10/22/2021 at 11:28 a.m., revealed the east fire door of the double corridor fire doors near the Gift Shop was partially blocked. A gift shop display cart, approximately 2 foot by 2 foot, was located approximately one foot away from the east fire door within the corridor hallway.




NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition, 5.2* Inspections.

"5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.3 Functional Testing.

5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.5 Horizontally Sliding, Vertically Sliding, and Rolling Doors.

5.2.5.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.7 Assembly shall be reset after a successful test.

5.2.8 Resetting of the release mechanism shall be done in accordance with manufacturer's instructions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.10 Tin-clad and kalamein doors shall be inspected for dry rot of the wood core.

5.2.11 Chains or cables employed shall be inspected for excessive wear and stretching."



The Facilities Manager and Assistant Maintenance Staff Member verified this finding during the survey.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2.1.3. This deficient practice affects one of eight smoke zones and could affect staff, and visitors within the affected zone. The facility had a capacity of 25 residents and a census of 6.

Findings include:

Observation and interview on 10/22/2021 at 10:50 a.m., revealed the Food Pantry Room the Kitchen exceeded 50 square feet in size and did not contain self-closure devices on the entrance door. This room measured approximately 10 feet by 20 feet in size.


The Facilities Manager and Assistant Maintenance staff member verified this observation during the survey process.

Based on observation and interview, the facility failed to ensure the fire alarm system is installed and maintained in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.6.1.3 and NFPA Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 10.5.5.3 by ensuring the fire alarm dedicated branch circuit(s) be mechanically protected. This deficient practice affects all occupants of the building, including patients, clients, staff, and visitors. This facility has a capacity of 25 with a census of 6.

Findings include:

Observation on 10/22/2021 at 10:45 a.m., revealed the fire alarm breaker, located in electrical Panel 1ALL Circuits #2A and #4A in the First Floor Electrical Room, were not secured with mechanical locks.

The Facilities Manager and Maintenance Assistant confirmed these observations during the survey process.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1, by ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage and shall be installed in the correct orientation. These items could affect the operation of the heads, delaying the response time, and causing the head to be inoperable. This deficient practice affects all staff and visitors who may be in the Hallway. The facility had a capacity of 25 and a census of 6 at the time of the survey.

Findings include:

1. Observation and interview on 10/22/2021 at approximately 10:40 a.m., revealed the facility failed to maintain the sprinkler system in the Hallway outside the First Floor Laundry Rooms. These two sprinkler heads heads had a large amount of accumulated foreign material deposited on them.

2. Observation and interview on 10/22/2021 at approximately 10:48 a.m., revealed the facility failed to maintain the sprinkler system in the Kitchen near the cooking ranges. These two sprinkler heads heads had a large amount of accumulated foreign material deposited on them.

3. Observation and interview on 10/22/2021 at approximately 10:52 a.m., revealed the facility failed to maintain the sprinkler system in the Cafeteria Room. These sprinkler heads heads had a large amount of accumulated foreign material deposited on them.

4. Observation and interview on 10/22/2021 at approximately 11:05 a.m., revealed the facility failed to maintain the sprinkler system in Hallway A. The sprinkler head in the Medical Surgery Area of this hallway was missing the escutcheon ring.



The Facilities Manager and Assistant Maintenance Staff member verified this observation during the survey process.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility had a capacity of 25 and a census of 6 residents at the time of survey.

Findings include:

Record review and interview on 10/22/2021 at 10:30 a.m. of the facility's fire drill documentation, revealed the third shift drills were conducted at approximately the same time of day. Third shift (2020-2021) fire drills were conducted on 12/18/2020 at 1:00 a.m., 02/26/2021 at 2:05 a.m., 06/30/2021 at 2:00 a.m., and 09/30/2021 at 2:40 a.m.


The Facilities Manager and Maintenance Assistant confirmed this observation during the survey process.

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Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility had a capacity of 25 and a census of 6 residents at the time of survey.

Findings include:

Record review and interview on 10/22/2021 at 10:30 a.m. of the facility's fire drill documentation, revealed the third shift drills were conducted at approximately the same time of day. Third shift (2020-2021) fire drills were conducted on 12/18/2020 at 1:00 a.m., 02/26/2021 at 2:05 a.m., 06/30/2021 at 2:00 a.m., and 09/30/2021 at 2:40 a.m.


The Facilities Manager and Maintenance Assistant confirmed this observation during the survey process.

Based on observation and interview, the facility is not ensuring fire door assemblies with defects that could interfere with operation are repaired or corrected without delay in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.6, 4.6.12, and 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.1.5. This deficient practice would not prevent the spread of smoke, affecting one of eight smoke compartments and could affect residents, staff, and visitors in the affected zone. This facility has a capacity of 25 with a census of 6.

Findings include:

1. Observation on 10/22/2021 at 10:55 a.m., revealed the north fire door located in the hallway outside the Dialysis Room did not close completely and latch when the two doors were allowed to close. The north door hung up on the door frame.

2. Observation on 10/22/2021 at 11:22 a.m., revealed by the Laboratory did not close completely and latch when tested. This was due to the excessive air flow through this area from the south entrance area.

3. Observation on 10/22/2021 at 11:28 a.m., revealed the two fire doors located near the Gift Shop did not close completely and latch when tested. This was due to the the doors rubbing on the top of the door frame and the west door having excessive resistance in the door track/release mechanism above the door.


The Facilities Manager and Maintenance Assistant confirmed these observations during the survey process.

Based on record review and interview, the facility failed to conduct/document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects all smoke compartments and all patients, staff, and visitors. The facility had a capacity of 25 and a census of 6 residents at the time of the survey.

Findings include:

1. Record review and interview on 10/22/2021 at 10:25 a.m., revealed the facility was unable to provide documentation of hospital-grade receptacle testing or documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles. Interview of Maintenance Staff revealed the facility was unaware they had to test upon install and maintain a written record of testing upon replacement or servicing of hospital-grade receptacles.

The Facilities Manager and Maintenance Assistant confirmed these observations during the survey process..


6.3.4.2.1.2 At a minimum, the record shall contain the date,
the rooms or areas tested, and an indication of which items
have met, or have failed to meet, the performance requirements
of this chapter.

Based on record review and interview, the facility failed to conduct/document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects all smoke compartments and all patients, staff, and visitors. The facility had a capacity of 25 and a census of 6 residents at the time of the survey.

Findings include:

Record review and interview on 10/22/2021 at 10:25 a.m., revealed the facility was unable to provide documentation of hospital-grade receptacle testing or documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles. Interview of Maintenance Staff revealed the facility was unaware they had to test upon install and maintain a written record of testing upon replacement or servicing of hospital-grade receptacles.

The Facilities Manager and Maintenance Assistant confirmed these observations during the survey process..


6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items
have met, or have failed to meet, the performance requirements of this chapter.

Based on record review, observations, and interview, the facility failed to maintain complete documentation of the inspections, tests, exercising, and operation of the emergency generator power supplies as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4; did not ensure the emergency generators for the building were properly equipped with a remote manual stop mechanism in accordance with NFPA Standard 110, 2010 edition, 5.6.5.6; could not provide documentation showing the emergency generator power supplies were exercised as required by NFPA Standard 110, 2010 edition, 8.4.2; and failed to maintain and test essential electrical system (EES) circuitry as required by NFPA Standard 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. These deficient practices affect all smoke compartments of the building and all occupants. The facility had a capacity of 25 and a census of 6 patients at the time of the survey.

Findings include:

1. Record review and interview on 10/22/2021 at 11:45 a.m., revealed the facility could not provide any documentation for the emergency generator weekly visual inspections. The Facilities Manager was not aware these weekly visual inspections were required to be conducted and documented.

2. Record review and interview on 10/22/2021 at 11:50 a.m., revealed the facility could not provide any documentation for fuel quality test-annual testing.


The Facilities Manager and Maintenance Assistant confirmed these observations during the survey process.

Based on record review, observations, and interview, the facility failed to maintain complete documentation of the inspections, tests, exercising, and operation of the emergency generator power supplies as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4; did not ensure the emergency generators for the building were properly equipped with a remote manual stop mechanism in accordance with NFPA Standard 110, 2010 edition, 5.6.5.6; could not provide documentation showing the emergency generator power supplies were exercised as required by NFPA Standard 110, 2010 edition, 8.4.2; and failed to maintain and test essential electrical system (EES) circuitry as required by NFPA Standard 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. These deficient practices affect all smoke compartments of the building and all occupants. The facility had a capacity of 25 and a census of 6 patients at the time of the survey.

Findings include:

1. Record review and interview on 10/22/2021 at 11:45 a.m., revealed the facility could not provide any documentation for the emergency generator weekly visual inspections. The Facilities Manager was not aware these weekly visual inspections were required to be conducted and documented.

2. Record review and interview on 10/22/2021 at 11:50 a.m., revealed the facility could not provide any documentation for fuel quality test-annual testing.


The Facilities Manager and Maintenance Assistant confirmed these observations during the survey process.