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Based on record review, the facility failed to establish and maintain a comprehensive emergency preparedness plan that is reviewed and updated at least every two years. The deficiency affects all of the staff and the residents who work and/or reside in the facility.

Findings include:

1. Review of the facility EP plan on 8/23/2021, reflected the facility did not have an updated Emergency Preparedness Plan. The facility changed ownership over a year ago, and there was no evidence of the facility plan being updated in the past two years.

Based on record review, the facility failed to establish and maintain a comprehensive emergency preparedness (EP) program which identified all-hazard approach strategies for addressing the facility's vulnerability during emergency events. This deficient practice had the potential to affect all staff and patients receiving services from the facility. Findings include:

Review of the facility's EP program on 08/23/21, showed the facility failed to complete an updated HVA risk assessment which included internal and external vulnerabilities of which may occur during an emergency event from 7/2018 through 8/23/2021.

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. This affects all occupants in the facility.

Findings include:

1. Review of the EP program on 08/23/21 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. The facility EP plan had not been reviewed or updated since July 2018.

Based on record review, the facility failed to update, implement, and review emergency preparedness (EP) policies and procedures at least every two years. This deficiency has the potential to affect all patients/residents and staff of the facility. Findings include:

1. A review of the facility EP program on 08/23/21 showed, the facility's EP programs policies and procedures were incomplete and lacked reviews and updates since July 2018.

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. This affects all occupants in the facility. Findings include:

1. Review of the EP plan, policies, and procedures on 8/23/21, 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. The facility EP plan had not been reviewed or updated since July 2018.

Based on record review, the facility failed to develop a system to track the location and availability of on-duty staff, volunteers, and patients during an emergency. The deficiency affects all staff, patients, and volunteers in the facility. Findings Include:

1. Review of the facility EP program on 8/23/21., showed the facility EP plan lacked supporting documentation that the facility had established a system to track on-duty staff, volunteers, and patients during an emergency. The facility EP plan had not been reviewed or updated since July 2018.

Based on record review, the facility failed to develop a policy and procedure for a means to preserve, access, protect residents' confidentiality; and to maintain resident information availability. This affects all of the residents/patients of the facility.

Findings include:

1. Review of the EP plan policy and procedures on 8/23/21, showed a lack of a written policy for the retention of the medical documentation that preserved resident/patient information, explaining how the medical information is accessed and secured while its confidentiality is protected. The facility described their medical documentation as being both electronic and paper records. The facility failed to provide a policy and procedure for how medical documentation will be handled during and emergency. The EP plan had not been reviewed or updated since July 2018.

Based on record review, the facility failed to ensure the EP plan contained current agreements/arrangements with other facilities and/or other providers to receive resident/patientss in the event of an evacuation and/or cessation of operations. This affects all the occupants in the facility.

Findings include:

1. Review of the EP plan on 08/23/21, showed a lack of written agreements with other facilities and/or providers in the event of limitations to provide needed services to all the residents/patients under their care to maintain continuity of services. The facility EP plan had not been reviewed or updated since July 2018.

Based on record review, the facility failed to describe its role under an 1135 waiver during the provision of care and treatment at an alternate site during an evacuation. This deficiency affects the entire facility. Findings include:

1. Review of the facility EP program on 08/23/21, showed the facility's EP plan did not include a policy or procedure for caring of patienst/residents at an alternate care site, delineating their role under the 1135 waiver, and showing joint planning on issues related to staffing, equipment and supplies at alternate care sites. The facility EP plan had not been reviewed or updated since July 2018.

Based on record review, the facility failed to maintain, and review its emergency preparedness (EP) communications plan every two years. This deficiency has the potential to affect all residents/patients and staff of the facility.

Findings include:

1. A review of the facility EP plan on 8/23/21 showed, the facility had not reviewed or updated the facility communications plan since July of 2018. The communication plan reflected outdated and incomplete information.

Based on record review, the facility failed to update as needed, an emergency preparedness communication plan. This deficiency has the potential to affect the entire facility.

Findings include:

1. Review of the facility EP program on 8/23/21 showed the facility's communication plan lacked documentation of contact information for entities providing services under arrangement, patients, physicians, other CAH's, and facility volunteers. The facility EP plan had not been reviewed or updated since July 2018.

Based on record review, the facility failed to develop and maintain an EP training and testing program that is based on the facility's Emergency Preparedness plan. This deficiency has the potential to affect the entire facility.

Findings include:

1. Review of the facility EP plan on 8/23/21 showed, the facility EP plan lacked documentation of testing and staff training of the facility EP plan. Additionally, the facility EP plan had not been reviewed or updated since July 2018.

Based on record review and interview, the facility failed to implement training of the EP program to all staff members, including contractors, consistent with each team members' expected roles during an emergency or a disaster, within the last two years. This deficiency affects all staff andresidents/ patients in the facility.

Findings include:

1. Review of the facility EP plan on 8/23/21 showed, the facility lacked documentation of staff training on the facility EP plan. Additionally, the facility EP plan had not been reviewed or updated since July 2018.

Based on record review, the facility failed to conduct a full-scale community-based (or a full-scale facility based) exercise. This deficiency affects all staff and patients in the facility. Findings include:

1. Review of the facility EP plan on 8/23/21 showed a lack of evidence that the facility had conducted a full-scale community-based and/or facility-based exercise in the past. No documentation was available for review showing the facility had conducted any of the following, at any time in the past:

a) full scale exercise that is community-based;
b) individual, facility-based functional exercise;
c) a mock or disaster drill; or
d )a tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

Additionally, the facility EP plan had not been reviewed or updated since July 2018.

Based on observation, the facility failed to ensure emergency exit doors were operational per NFPA 101, 2012 Edition.

Findings include:

1. During an observation on 08/23/21 at 11:55 a.m., the emergency exit door in the first floor stairwell area was inspected. The door would not open without an excessive amount of force applied to the door.

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 08/23/21 at 11:36 a.m., the door leading to the HIM office 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 08/23/21 at 11:57 a.m., the door leading to the phlebotomy office 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 08/23/21 at 12:11 p.m., the door leading to the provider office 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 08/23/21 at 12:16 p.m., the door leading to bath/shower room, next to the soiled utility 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 ensure the smokeproof rated stairway enclosure was maintained per NFPA 101-2012, Section 7.1.3.2.

Findings include:

1. During an observation on 08/23/21 at 11:53 a.m., the door leading to the stairwell enclosure, going from the second to the first floor was inspected. The door would not close and latch under the power of the self-closing device.

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 8/23/21 at 12:35 p.m., resident room 120 was inspected. The room was observed being used as storage. The door leading to the room was not fitted with a self-closure. The room is considered a hazardous area, it was over 50 square feet.

2. During an observation on 8/23/21 at 12:35 p.m., the resident day room was inspected. The room was observed being used as storage. The door leading to the room was not fitted with a self-closure. The room is considered a hazardous area, it was over 50 square feet.

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 08/23/21 at 12:01 p.m., the main entry was inspected. An alcohol-based hand sanitizer dispenser was observed, installed on the wall, directly above an electrical source.

2. During an observation on 08/23/21 at 12:43 p.m., room 105 was inspected. An alcohol-based hand sanitizer dispenser was observed, installed on the wall, directly above an electrical source.

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 8/23/21 at 12:20 p.m., the 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.

Based on observation, the facility failed to 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.

Findings include:

1. During an observation on 8/23/21 at 12:27 p.m., the IT room was inspected. Two ceiling tiles were observed missing from the drop-down ceiling.

Based on observation, the facility failed to:
a) 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.; and
b) 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.

Findings include:

1. During an observation on 8/23/21 at 11:31 a.m., the sprinkler pipe above the ceiling outside of the laundry room was inspected. Several cable television wires were observed, attached to the sprinkler pipe.

2. During an observation on 8/23/21 at 11:32 a.m., the custodian room was inspected. A ceiling tile was observed missing from the drop-down ceiling.

3. During an observation on 08/23/21 at 12:05 p.m., the CT hallway was inspected. Nine ceiling tiles were observed missing from the drop-down ceiling.

4. During an observation on 08/23/21 at 12:08 p.m., the sprinkler pipe in the CT hallway was inspected. A ceiling tile support mount was observed, attached to the sprinkler pipe.

5. During an observation on 8/23/21 at 12:10 p.m., the provider office was inspected. A ceiling tile was observed missing from the drop-down ceiling.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

Findings include:

1. During an observation on 08/23/21 at 12:29 p.m., the physical therapy reception area was inspected. The portable extinguisher in the room was found to have PT equipment being stored in front of it.

Based on observation, the facility failed to maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.

Findings include:

1. During an observation on 08/23/21 at 9:13 a.m., the emergency room entrance to the hospital was inspected. The portable extinguisher in the room was found to have a large cart with PPE supplies being stored in front of it.

2. During an observation on 08/23/21 at 11:25 a.m., the mechanical room was inspected. The portable extinguisher in the room was found to have a cabinet with a large printer being stored in front of it.

3. During an observation on 08/23/21 at 11:58 a.m., the lab was inspected. The portable extinguisher in the room was found to have a box being stored in front of it.

Based on observation, the facility failed to ensure fire/smoke barrier doors located in the fire/smoke partitions were maintained per NFPA 101-2012, Section 19.3.7.8.

Findings include:

1. During an observation on 8/23/21 at 12:25 p.m., the 3-hour fire/smoke doors separating Building 03 from Building 01 failed to close and latch when exercised.

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 8/23/21 reflected the facility failed to perform fire drills during:

a) the AM shift of the fourth quarter of 2020;
b) the PM shift of the first quarter of 2021;
c) 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 8/23/21, 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 record review, the facility failed to maintain the receptacles in patient areas. The deficient practice affected the entire facility.

Findings include:

Record review on 8/23/2021 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 observations, the facility failed to ensure power strips complied with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-Life Safety Code (LSC).

Findings include:

1. During an observation on 8/23/21 at 12:40 p.m., the Director of Nursing office was inspected. A power strip was observed, dangling off the wall against the desk. The power strip was not supported or mounted to the wall or floor within the room.