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Tag No.: E0015
Based on document review and inspection, the facility failed to comply with federal, state and local emergency preparedness requirements in relation to providing subsistence needs for staff and patients.
Findings Include:
On May 1, 2019 at 11:45 AM, the facility failed to provide updated policies and procedures containing amount of water supply in the facility. Documentation review revealed the EP policies and procedures stated the facility shall have 1500 gallons of reserve water, but observation revealed 110 gallons of reserve water in the facility on the day of survey. Observation also revealed the kitchen serves the nursing home facility along with the hospital.
Tag No.: K0916
Based on observations, the facility failed to properly protect all the generator's required components as directed by NFPA 110 5.6.6 and NFPA 99 section 6.4.1.1.17.
Findings Include:
On May 1, 2019 at 10:50 AM, observation revealed the generator lacked a continuous supervised remote annunciator panel. The generator annunciator panel was located in an Electrical Room of the facility.
Tag No.: K0918
Based on document review, the facility failed to properly test the emergency generator as per NFPA 110 8.4.2. This deficiency affected all 52 residents in the facility on the day or survey.
Findings include:
On May 1, 2019, the facility was unable to provide adequate documentation of monthly load tests for the generator. No documentation of a generator load test could be provided from June 2018 thru November 2018, and January 2019.