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Based on interview and facility document and policy review, the facility failed to provide evidence it conducted two exercises to test the emergency plan at least twice per year during the year of 2023. This deficient practice had the potential to affect all facility occupants

Findings included:

The facility's policy titled, "All Hazard Medical Surge Emergency Response Plan," last revised in 06/2011, specified, "7.8. All [Miners' Colfax Medical Center] staff will be trained in the All Hazard Emergency Response Plan and related policies and procedures. Staff will participate in a minimum of one "table top" exercise annually and participate in community/county drills as scheduled" and "13.1 Management Team members and available staff members will participate in at least one table-top exercise per year."

The facility's life safety code and emergency preparedness disaster books for the year of 2023 through October 2024 revealed there were no disaster drills available for review.

During an interview on 10/15/2024 at 2:40 PM, the Maintenance Supervisor revealed the Chief Executive Officer (CEO) and the Long-Term Care Administrator and Support Services (LTCA/SS) were responsible for conducting two drills annually to test the emergency plan. He stated he was not aware that the facility must conduct two disaster drills annually to test the emergency plan. He acknowledged he could not find any documentation where the facility had conducted two disaster drills to test the emergency plan for 2023 or 2024. He stated he expected the facility to conduct and document two disaster drills per year to test the emergency plan.

During an interview on 10/15/2024 at 3:33 PM, the Chief Nursing Officer (CNO) stated she was unsure if two disaster drills to test the emergency plan were completed for 2023. However, she noted she expected the facility to conduct and document two disaster drills per year to test the emergency plan.

During an interview on 10/15/2024 at 3:42 PM, the CEO revealed he was aware the facility must conduct two disaster drills annually to test the emergency plan. He acknowledged the facility lacked documentation to show disaster drills were completed for 2023, noting the drills to test the emergency plan were simply not done in 2023, but identifying they had been planning to complete the drills. He stated the LTCA/SS was responsible for conducting the drills, but noted the LTCA/SS just started in the role in June 2024, so it was the CEO's responsibility to conduct the drills in 2023. He stated he expected the facility to conduct and document two disaster drills per year to test the emergency plan.

During a telephone interview on 10/15/2024 at 4:22 PM, the LTCA/SS revealed he had just started in the role in June 2024 and did not know if the facility had conducted disaster drills to test the emergency plan in 2023. He stated he expected the facility to conduct and document two disaster drills per year to test the emergency plan.

Based on observation, interview, and facility policy review, the facility failed to provide and maintain a self-closing or automatic closing device on corridor doors to 1 of 13 hazardous storage room doors in accordance with National Fire Protection Association 19.3.2.1.

Findings included:

The facility's policy titled, "Door Closure Policy," dated 09/02/2009, revealed, "The purpose of this policy is to provide practical safeguards for persons and property from arising hazards." The policy contained no information regarding maintaining a self-closing device on corridor doors with combustible contents.

An observation on 10/15/2024 at 1:15 PM revealed a door to a storage room located across from the radiology department that contained combustible storage of Christmas decorations, cardboard boxes, office supplies, office chairs, medical records, and medical supplies. The storage room measured approximately 450 square feet and was not equipped with a self-closing device.

During an interview on 10/15/2024 at 2:43 PM, the Maintenance Supervisor revealed he was aware the radiology department had storage in the storage room in question, but was unaware of the contents in the room. He stated the room was appropriately 450 square feet and needed a self-closing device. He stated he made rounds of the facility daily but had missed inspecting the room in question. He stated he expected a storage room with combustible materials to contain a self-closing device installed on the corridor door. He stated the facility had no policy regarding maintaining a self-closing device on corridor doors with combustible contents.

During an interview on 10/15/2024 at 3:47 PM, the Chief Executive Officer revealed the Maintenance Supervisor was responsible for ensuring corridors that required self-closing devices were installed on the doors. He stated he was unaware the storage room across from radiology department had combustible contents. He stated he expected that storage rooms with combustible materials to have a self-closing device installed on the door.

During a telephone interview on 10/15/2024 at 4:24 PM, the Long-Term Care Administrator and Support Services revealed the Maintenance Supervisor had just called and told him about the storage room that contained combustible contents but lacked a self-closing device. He stated the Maintenance Supervisor was responsible for ensuring corridor doors with combustible contents contained a self-closing device and expected self-closing devices to be installed on corridor doors with combustible contents.

Based on interview and facility document and policy review, the facility failed to provide documentation of monthly load tests of the emergency power generator during 22 of 33 months reviewed. This deficient practice could result in a failure of the emergency power system, leaving the facility without egress and task lighting in the event of a power failure. This deficient practice had the potential to affect all facility occupants.

Findings included:

The facility's policy titled, "Emergency Generator," dated 08/26/2009, revealed, "6.2. The generator testing and maintenance shall occur daily, weekly, monthly, and on an annual basis."

The "Monthly Generator Load Test" for 01/2022 to 09/2024 indicated the generator was only tested under load on 01/2022, 02/2022, 03/2022, 04/2022, 03/2024, 04/2024, 05/2024, 06/2024, 07/2024, 08/2024, and 09/2024. There was no other documentation available for review for the timeframe in question.

During an interview on 10/15/2024 at 2:43 PM, the Maintenance Supervisor revealed he was not employed by the facility from May 2022 until August 2023. He stated when returned in August 2023, the generator would transfer and run under load for an hour and then cool down, but would never disengage from running under load. He stated they had to manually turn the transfer switch and breaker off to stop it from continuing to run under load. He stated the maintenance supervisor at the time told him to stop running it under load until the generator could be fixed. He stated it took the facility months to get the problem finally fixed in February 2024. He stated he was aware they had not tested the generator under load monthly as required. He stated he expected the generator to be tested under load monthly.

During an interview on 10/15/2024 at 3:46 PM, the Chief Executive Officer revealed he was aware the generator must be tested under load monthly. He stated he did not recall the actual concern with the generator and why it had not been tested under load monthly. He stated the individual in the maintenance supervisor role was responsible for ensuring the generator was tested under load monthly, noting they had some staff turnover during the past couple of years. He stated he expected the facility to conduct monthly generator load tests.

During a telephone interview on 10/15/2024 at 4:23 PM, the Long Term Care Administrator and Support Services revealed he started in his role in June 2024 and was just told the generator was not tested monthly under load during some months. He stated he was now responsible for ensuring the monthly load tests were completed and he expected the facility to monthly load test the generator.