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Based on document review and interview, the facility failed to maintain and update the emergency preparedness (EP) policies and procedures per requirements of 42 CFR §483.73(b) (1).


Findings Include:

On May 30, 2019 at 11:05 AM, the facility failed to provide updated policies and procedures containing amount of water supply in the facility. The facility only had one (1) gallon of emergency water of reserve water in the facility on the day of survey with the licensed for 29 patients.

The finding was acknowledged by the facility and Maintenance Supervisor verified this observation during the exit interview on March 30, 2019.

Based on observations, the facility failed to maintain a complete manual fire alarm system as directed by NFPA 72 code 1-5.4.6, and NFPA 101 19.3.4.1 and section 9.6. The deficient practice affected 3 (three) of 4 (four) smoke compartments and all patients in facility on the day of survey.
Findings Include:
On May 30, 2019 at 10:40 AM, observation and testing revealed two (2) of the four (4) manual pull stations did not initiate the fire alarm system. The fire alarm panel, smoke barrier doors, and horn strobes did not activate during the fire alarm testing.
The finding was acknowledged by the facility and verified by the Maintenance Director during the exit interview on 5-30-19.

Based on record review, the facility failed to properly perform fire drills as per NFPA 19 .7.1.2. The deficient practice affected all 4 (four) smoke compartments and all patients in facility on the day of survey.
Findings Include:
On May 30, 2019 at 12:10 PM, the facility was unable to provide documentation showing the performance of fire drills during the 2nd shift of the 1st, 2nd, 3rd, and 4th quarters for the annual year of 2018. It was also observed the fire drills were only being performed during the 1st shift for the last annual year of 2018.
The finding was acknowledged by the facility and verified by the Maintenance Director during the exit interview on 5-30-19.

Based on observation, testing and documentation review, the facility did not maintain the generator in accordance to NFPA 99 section 6.4.4, 6.4.4.2 and NFPA 110 section 8.4.2. This standard deficiency practice affected four (4) of four (4) compartments and all patients on the day of survey.
Findings include:
On May 30, 2019 at 11:15 AM, observation and testing revealed the Maintenance Director was incapable of performing a power transfer test for the generator in the facility. The Maintenance Director or any other facility staff were not knowledgeable on performing a transfer test on the generator. On May 30, 2019 at 11:30 AM, documentation review revealed the last generator annual test was performed in the year of 2017.

The finding was acknowledged by the facility and verified by the Maintenance Director during the exit interview on 5-30-19.