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Based on review of the facility Emergency Plan, record review and staff interview, it was determined, the facility failed to develop a facility-based risk assessment with all the CMS required elements prior to developing the facility's emergency plan. Failure to develop emergency plans based on a facility-based risk assessment including all the required elements poses a potential risk and may cause harm to the patients and staff during an emergency, if specific needs of both the patient and staff are not identified as part of the EP plan.

Findings include:


Observations made during document review made on July 22, 2022, revealed the facility failed to include Emerging Infectious Diseases in the facility based risk assessment and use it to develop a facility based risk assessment prior to developing the facility's emergency plan

Employees #1 and #2 confirmed during the exit conference that the facility did not include EID in their facility-based risk assessment and use it to create the facilities Emergency Plan.

Based on review of the Emergency Plan (EP), record review, and staff interview, it was determined the facility failed to develop a means for sharing information on occupancy/needs, and it's ability to provide assistance to the authority having jurisdiction. Failure to develop a means to report occupancy levels and/or needs may result in patients not receiving care and services as needed.


Findings include:

Observations during EP review on July 22,2022, revealed the facility's Emergency Plan documentation related to requirements for a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center did not include a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

Employee #1 confirmed during the exit interview that the EP plan for the facility did not include a method for sharing occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

Based on review of the facility Emergency Preparedness Plan, and staff interview, it was determined the facility failed to develop a written facility-based emergency planning, training and testing program. Failure to provide facility-based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency if staff are not aware of what is required by them to do, during an emergency situation.

Finding include:

Observation while reviewing the facility's Emergency Plan (EP) documentation on July 22, 2022, revealed the documentation related specifically to the facility-based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan did not include facility-based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan.

Employee #1 confirmed during an interview the EP plan did not include facility-based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan.

Based on review of the facility's Emergency Preparedness Testing Requirements, record review and staff interview, it was determined the facility failed to participate in drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency.


Findings include:

During document review on July 22, 2022, it was revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based or based exercise or table top drills for the full last two cycles. The drills for 2020 were missing.

Employee #1 confirmed during the exit interview that the facility was not able to locate proof of participation in a full-scale exercise that was community-based or a facility based exercise for the year 2020.

Based on observation it was determined that the fire rated door seperating the hospital from the outpatient treatment center did not have plates indication that the door had the 2 hour required fire rating to not resist the passage of fire or smoke. Failing to protect resident sleeping rooms from heat or smoke could cause harm or death to the patients and staff.

18.1.3.4 Contiguous Non-Health Care Occupancies. 18.1.3.4.1 *
Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by construction having a minimum 2-hour fire resistance rating, and the facility is not intended to provide services simultaneously for four or more inpatients who are incapable of self preservation.

Findings include:

Observations while on tour on 21-22, 2022, revealed that the wall and door between the out patient treatment center in the southeast corner on the building and the hospital premise did not meet the two hour rated fire wall seperation. The wall did exist but had many holes in it and it was not shown to have the correct rating on the drawings. The door did not show any fire rating on the door or the frame.

Employee # 1 confirmed the lack of a two hour fire rating for the wall between the OTC and the hospital

Based on observation of the corridor doors for the Hospital it was determined the facility failed to maintain the corridor doors to be self or automatic closing due to door stops or door wedges mounted on or observed under the corridor doors holding the corridor doors in an open position. Failing to keep self-closing or automatic closing doors closed will allow smoke and heat, during a fire, to spread throughout the facility, which could cause harm to the patients.


NFPA 101 Life Safety Code, 2012, Chapter 7 Existing, Section 21.3.2 1 Doors to hazardous areas shall be self closing or automatic closing in accordance with 21.2.2.4. Section 21.2.2.4 Any door required to be self closing shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. Section 7.2.1.8.2
The required manual fire alarm system and the systems required by 7.2.1.8.2. shall be arranged to initiate the closing action of all such doors throughout the entire facility. Section 7.2.1.8 Self Closing Devices. Section 7.2.1.8.1* A door normally required to be kept closed shall not be secured in the open position at any time and shall be self closing or automatic closing in accordance with 7.2.1.8.2

7.2.1.8 Self-Closing Devices. 7.2.1.8.1 * A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3. 7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met: (1) Upon release of the hold-open mechanism, the leaf becomes self-closing. (2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed. (3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code. (4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door leaf becomes self-closing. (5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.



"Protection from Hazards" Chapter 39 Section 39.2.2.2 Doors Section 39.2.2.2.1 Doors complying with 7.2.1 shall be permitted. Chapter 39, Section 39.3.2.1, General "Hazardous areas including, but not limited to, areas used for general storage... shall be protected in accordance with Section 8.7." Chapter 8, Section 8.7.1.3 Doors in barriers required to have a fire resistance rating shall have a minimum 3/4 hour fire protecting rating and shall be self or automatic closing in accordance with 7.2.1.8. Section 7.2.1.8.1 A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self or automatic closing in accordance with 7.2.1.8.2.

Findings include:

Observations while on tour July 21-22, 2022, revealed the facility was not preventing the staff from utilizing door stops throughout the facility. Door stops were found in the following locations:

1. Door held open by a chair in the childrens seclusion area
2. Door stop applied in the patient advocate area
3. Door stop holding doors open in the dining room area on two different days
4. A supply room held open by a door stop

During the exit conference employees #1 confirmed the usage of doors stops throughout the facility.

Based on Observation it was determined the facility failed to assure that all parts of the facility were provided sprinkler system coverage. Failing to provide sprinkler coverage in all areas of the facility by blocking the sprinkler heads could result in the sprinkler not controlling the fire which could cause harm to the patients.


NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.5.1,"Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5." ." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems."

NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition8.10.6.3 * Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard - Chapter 8 Installation Requirements.
8.10.6.3.2
Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as stairs and landings.

Findings include:

Observations while on tour July 21-22 2022, revealed the sprinkler heads were missing from the first floor under stairwell in all four stairwells. The building was built utilizing the 2018 UBC which did not require the area under the stairs to be sprinkled. CMS states in an S&C letter where there is a discrepancy the more stringent code shall apply.
Employee # 1 confirmed during the exit interview conducted on July 22,2022, that the area under the first floor stairwells are not covered by sprinkler heads in all four stairwells.

Based on observation it was determined the facility failed to fill penetrations in the electrical room walls where conduits passed through. Failing to seal the penetrations, holes and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients during time of a fire.



NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations while on tour July 21-22, 2022, revealed the that facility had hole in the fire wall in the following locations:

1. Numerous pipes and conduits had missing or shrunken fire caulking in the main electrical room in the main hallway.

2. The fire door for the electrical room in the second floor area between the units was not a fire rated doors

Employee # 1 confirmed during the exit interview conducted July 22,2022 the separating wall between the elecrtical room second floor and the main exit and the wall in the electrical room first floor had unfilled holes in the barrier.

Based on record review and interview with staff, it was determined that the facility failed to conduct, maintain and document electrical receptacle testing in all patient care areas annually throughout the facility. Failing to test and document annually the receptacle testing of all patient care areas of the facility could lead to an ignition hazard in a patient care area potentially causing a fire and or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction." NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 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).

Findings include:

Observation during paperwork review on July 22,2022 revealed that there was no documentation to review for receptacle testing in patient care areas

Employee's #1 confirmed during the exit conference that there was no documentation to review for receptacle testing in patient care areas.

Based on observation and staff interview, it was determined the facility failed to ensure that the generator annunciator is located in a location being readily observed. Failing to have the annunciator observed has potential harm to patients and staff if the generator is not operating correctly and the need for emergency power is not available.

NFPA 99 2012 Edition Section 6.4.1.1.17 "A remote annunciator that is storage battery shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code).The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning (2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: (a) Low lubricating oil pressure (b) Low water temperature (below that required in 6.4.1.1.11) (c) Excessive water temperature (d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply (e) Over crank (failed to start) (f) Overspeed"

Findings Include:

Observation on tour conducted on July 21-22, 2022, revealed that the generator annunciator panel was located in the outside electrical room and not in a location that could be constantly monitored by staff.

Employee #1 acknowledged in a exit conference on July 22, 2022, that the generator annunciator was located in the outside electrical room and not in a location that can being constantly monitored by staff.