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Based on interview and record review the facility failed to plan and implement a provision of subsistence needs for the staff and the residents. This affects all occupants in the facility.

Findings include:

During an interview on 3/6/24 at 12:20 p.m., staff member C stated the facility's emergency preparedness plan did not include information on how the facility will utilize alternate sources of energy to maintain temperatures and lighting in the facility, as well as how the facility will manage sewage and waste disposal.

Review of the EP plan, policies, and procedures on 3/6/24, reflected the facility's emergency plan lacked policies and procedures for subsistence needs for staff and residents, particularly specific policies describing how alternate sources of energy will maintain proper temperatures, emergency lighting, keep sprinkler and alarm systems online, as well as sewage and waste disposal in the event of a loss of water.

Based on interview and record review, the facility failed to complete a system to track the location and availability of on-duty staff and patients during an emergency. The deficiency affects all the occupants in the facility.

Findings Include:

Review of EP plan on 3/6/24, reflected a lack of documentation that the facility had established a system to track on-duty staff and the patients during an emergency. The system must be effective to track on-duty staff and the residents during evacuation or sheltering in place. If there is an evacuation, there must be a system to document the specific name and location of where they are evacuated to.

During an interview on 3/6/24 at 12:25 p.m., staff member C stated the facility did not have a method for tracking staff and patients during an emergency.

Based on interview and record review, the facility failed to develop and implement emergency preparedness (EP) policies and procedures, addressing the use of volunteers in an emergency.

This deficiency affects all staff and patients in the facility.

Findings include:

During an interview on 3/6/24 at 12:30 p.m, staff member C stated the facility's emergency preparedness plan did not include a policy for the use of volunteers in an emergency.

Review of the facility's Emergency Preparedness plan on 3/6/24 showed the facility did not include a policy and procedure for the use of volunteers in an emergency.

Based on record review, the facility failed to develop and implement an emergency preparedness (EP) communications plan which includes contact information for the Certification Agency as well as the Ombudsman.

This deficiency has the potential to affect all staff and patients at the facility.

Findings include:

1. Review of the facility emergency preparedness plan on 3/6/24 showed the facility's communications plan lacked contact information for the State Certification agency as well as the Ombusman.

Based on interview and record review the facility failed to maintain a emergency training and testing program based on the facility's Emergency Preparedness Plan. This deficiency affects all staff and patients at the facility.

Findings Include:

During an interview on 3/6/24 at 12:40 p.m., staff member C stated the facility's emergency preparedness training program was outdated and they are in the process of updating the program.

Review of facility's emergency preparedness plan on 3/6/24 showed the facility did not have a training and testing program for their Emergency Preparedness Plan.

Based on 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 of the occupants and staff in the facility.

Findings include:

1. Record review of the facility EP plan and training documents on 3/6/24 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.

Based on observation the facility failed to provide a hard packed all-weather travel surface from one exit discharges to the public way in accordance with NFPA 101, 2012 Edition, Sections 7.1.6.3 and 7.1.6.4.

These deficiencies affect 1 of 4 smoke compartments.

Findings Include:

During an observation on 3/6/24, the west exit discharge was identified as not having a hard packed all-weather travel surface to the public way the exit discharge did not have a hard packed all weather surface.

Based on observation, the facility failed to maintain the exit discharge to the public way with respect to keeping a level walking surface free of obstruction in accordance with NFPA 101, 2012 Edition, Section 7.1.6.2.and

These deficiencies affect 1 of 4 smoke compartments.

Findings Include:

During an observation on 3/6/24 at 12:27 p.m., the roof top exit egress path was inspected. The walkway was found to have multiple sections of the concrete chipped and broken. The hard-surface path to the public way cannot have more than a 1/4" variation in tread height.

Based on interview and record review, the facility failed to provide emergency lighting per NFPA 101-2012, Sections 19.2.9.1 and 7.9.3.1.1.

This deficiency affects the entire facility.

Findings include:

1. Review of the facility records for testing of the emergency lighting documentation on 3/6/24, showed the facility had not performed the required 30 second monthly lighting tests for the whole year.

During an interview on 3/6/24 at 12:15 p.m., staff member B stated he had completed the monthly tests from January 2023 - May of 2023 but had not completed them June 2023 - January 2024. He stated he started doing the 30 second monthly tests in February 2024.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.7.3.2

This deficiency affected 1 out of 4 smoke compartments in the facility.

Findings include:

1. During an observation on 3/6/24 at 1:17 p.m., the exit signage to the roof top exit was inspected. There were no exit signs located on the exit door to the public way. There were several doors which could be confused as a way out of the area. It would not be obvious in times of darkness, smoke, or panic.

Based on observation and review of previous surveys, the facility failed to enclose an exit stairway in the means of egress from the second to the first floor in accordance with NFPA 101, 2012 Edition, Sections 19.3.1., 19.3.1.1 and 8.6.2.

The deficiency affects 2 of 4 smoke compartments at the facility.

Findings include:

1. During an observation on 3/6/24 at 1:32 p.m., the stairway adjacent to the laboratory at the second floor level was open to the corridor. Required means of egress, including stairways, should be separated from other parts of the building with at least 1 hour construction.

Based on an observation, and interview the facility failed to assure hazardous rooms/areas 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, 19.3.2.1.3 and 19.3.2.1.5 (7).

This deficiency affects 1 of 4 smoke compartments.

Findings include:

During an observation on 3/6/24 at 1:04 p.m., room 211 was inspected. the room was being used as storage, was over 50 square feet and did not have a self-closure on the door.

Based on record review, the facility failed to maintain the kitchen hood extinguishing system in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition, Section 11.2.1.

This deficiency affects all residents in the facility.

Findings include:

1. Record review of the kitchen hood system inspection records reflected a lack of documentation to show the contractor had performed services on a semi-annual basis for the last year. The kitchen hood inspection documents were not located at the facility during the time of the survey.

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

This deficiency affects all smoke compartments at the facility.

Findings include:

1. During a review of the most recent facility fire alarm inspection on 3/6/24, the fire alarm report was inspected. 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.

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

a) to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2;

b) document weekly sandpipe gauge readings weekly in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 6.2.2.2. and monthly standpipe gauge readings for the wet system per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1.

c) maintain sprinkler heads free of foreign materials per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1,

d) failed to ensure sprinkler piping was fee from 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;

e) Failed to maintain sprinkler heads free of foreign materials in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1.

This deficiency affects all smoke compartments at the facility.

Findings include:

1. Review of the facility's quarterly sprinkler inspections showed the first quarter of 2023 (January - March 2023) and the last quarter of 2023 (October - December 2023) were missing.

During an interview on 3/6/24 at 11:17 a.m., staff member B stated he would need to call the sprinkler inspection company to have them send over the missing inspections.

2. Review of the facility's documentation on 3/6/24 showed the sprinkler pressure guage documentation for the wet system and the dry system was not being completed.

During an interview on 3/6/24 at 11:56 a.m., staff member B stated weeky dry sprinkler system and monthly wet sprinkler system documenttion was not being completed.

3. During an observation on 3/6/24 at 12:56 p.m., the laundry room was inspected. There was a waterline ziptied to the sprinkler piping.

4. During an observation on 3/6/24 at 12:58 p.m., the bio room was inspected. There were cords hanging off the sprinkler piping.

5. During an observation on 3/6/24 at 12:58 p.m., the medical records room was inspected. The sprinkler head was loaded with dust.

6. During an observation on 3/6/24 at 1:08 p.m., the HR office was inspected. There was a cord hanging off the sprinkler piping.

7. During an observation on 3/6/24 at 1:12 p.m., the boiler room was inspected. There was a cord hanging off the sprinkler piping.

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

a) to maintain the sprinkler system in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Table 5.1.1.2;

b) document weekly sandpipe gauge readings weekly in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 6.2.2.2. and monthly standpipe gauge readings for the wet system per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 13.2.7.1.

c) maintain sprinkler heads free of foreign materials in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1.,

d) 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),

e) ensure sprinkler head deflectors have enough clearance from the ceiling to not obstruct the spray pattern in accordance with NFPA 13, 2010 Edition, Section 8.5.5.1. and escutcheon plates shall be used to cover the annular space around the sprinkler in accordance with NFPA 13, 2010 Edition, Section 6.2.7.1.

These deficiencies affected all smoke compartments in the facility.

Findings include:

1. Review of the facility's quarterly sprinkler inspections showed the first quarter of 2023 (January - March 2023) and the last quarter of 2023 (October - December 2023) were missing.

During an interview on 3/6/24 at 11:17 a.m., staff member B stated he would need to call the sprinkler inspection company to have them send over the missing inspections.

2. Review of the facility's documentation on 3/6/24 showed the sprinkler pressure gauge documentation for the wet system and the dry system was not being completed.

During an interview on 3/6/24 at 11:56 a.m., staff member B stated weekly dry sprinkler system and monthly wet sprinkler system documentation was not being completed.

3. During an observation on 3/6/24 at 1:22 pm., room 102 was inspected. A sprinkler head was loaded with dust.

4. During an observation on 3/6/24 at 1:28 p.m., the sump pump room was inspected. There were a few missing ceiling tiles in the room which can effect activation times for the fire suppression system.

5. During an observation on 3/6/24 at 1:29 p.m., room 112 was inspected. A sprinkler head was loaded with dust.

6. During an observation on 3/6/24 at 1:58 p.m., the business office was inspected. A sprinkler head was missing an escutcheon ring and the deflector was pushed up into the ceiling tile.

Based on observation, the facility failed to install portable fire extinguishers in accordance with NFPA 101 Life Safety Code 2012 Edition, Sections 19.3.5.12, and NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1.

This deficiency affects all smoke compartments.

Findings include:

1. During observations throughout the facility on 3/6/24 there were multiple fire extinguishers mounted above 5 feet from the floor.

During an interview on 3/6/24 at 1:30 p.m., staff member B stated almost all the extinguishers were mounted above 5 feet. He stated he would go around the facility and ensure they all get mounted at the correct height.

Based on an observation 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).

This deficiency affects 2 out of 4 smoke compartments in the facility.

Findings include:

1. During an observation on 3/6/24 at 1:00 p.m., the bio room was inspected. A housekeeping cart was being stored in front of an electrical panel.

2. During an observation on 3/6/24 at 1:20 p.m. the server room was inspected. there was storage in front of the electrical pannel.

Based on observation, the facility failed to maintain the proper signage for the storage room for oxygen cylinders in accordance with NFPA 99, 2012 Edition, Section 5.1.3.1.9.

This deficiency affects 1 out of 4 smoke compartments.

Findings include:

During an observation on 3/6/24 at 1:05 p.m., the oxygen storage closet was inspected. The signage on the door read, "NO SMOKING OXYGEN IN USE." This verbiage is not compliant with NFPA standards.