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Based on document review and interview, the facility failed to address all components of an emergency plan. This was evidenced by no records in the emergency plan provided that addresses the client population, the type of services the facilit was able to provide in an emergency, and the continuity of operations. This could potentially affect 2 of 2 patients and could result in facility being unprepared to provide services and continued care to the facility's clients in the event of an emergency.

Findings:

During document review and interview with staff on 7/1/19, the emergency plan was requested.

1. At 2:09 p.m., the emergency plan provided did not specifically address this facility's client population, including persons at-risk. The plans did not include the type of services that this particular facility was able to provide in an emergency, and nothing that addresses continuity of operations. Upon interview, the Maintenance Supervisor/Ambulance Director confirmed this finding.

Based on document review and interview, the facility failed to participate in a full-scale exercise that was community-based. This was evidenced by the failure to provide documentation that indicated they had participate in a full-scale community-based exercise or demonstrate the efforts made to identify the availability of a full-scale community-based exercise. This could potentially affect 2 of 2 patients and could result in a delayed response to a full-scale community wide emergency.

Findings:

During document review and interview with staff on 7/1/19, records of emergency preparedness training drills were requested.

1. At 1:01 p.m., documents provided indicated that the facility completed the following two facility-based disaster drills: a broken water line on 6/20/19 and cell-phone and land-lines down on 9/3/18. There were no records provided that indicated there was a community-based drill or that community entities were contacted to attempt a full-scale community-based emergency exercise drill within the last 12 months.

Upon interview, the Maintenance Supervisor/Ambulance Director confirmed this finding and stated that they did participate in the California Shakeout full-scale community-based disaster drill, but that they did not complete an after action report.

Based on document review, observation, and interview, the facility failed to maintain the emergency preparedness plan to include policy and procedure for the emergency power system. This was evidenced by no policy and procedure that addressed how the fuel supply will be obtained to keep the emergency power system operational for the minimum required time. This could potentially affect 2 of 2 patients and could results in the generator being non-operational during an emergency.

Findings:

During document review, a tour of the facility, and interview with staff on 7/1/19, the emergency power system was observed and the emergency preparedness plan policy and procedures for the system were requested.

During a tour of the facility, a 150 kilowatt propane fueled generator and two 1000 gallon propane fuel tanks were observed in the back outside area of the facility.

The document titled, "Emergency Procedure-Shelter-in-Place" indicated that the facility had enough water and food for 72 hours.

At 12:54 p.m., a document titled, "Conducting Weekly Tests of Emergency Generator" was provided. The document indicated the weekly maintenance and testing requirements for the generator. A second document titled, "Emergency Generator Failure" was provided and indicated a procedure for transfer switch failure and fuel contamination. There was no policy and procedure provided that indicated how much fuel the facility will store or how and where they will get the fuel supply to maintain the emergency power system running during an emergency.

Upon interview, the Maintenance Supervisor/Ambulance Director confirmed this finding.

Based on document review, observation, and interview, the facility failed to maintain the fire alarm system. This was evidenced by the absence of an annual charger test, an annual 30 minute discharge test, and one of two semi-annual load voltage tests for two of two sealed lead-acid back-up batteries on the fire alarm control unit (FACU). This affected two of two smoke compartments and could result in system impairment during an emergency situation.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
Table 14.4.5 Testing Frequencies.

6. Batteries - fire alarm systems
(d) Sealed lead-acid type
(1) Charger test: Initial/Reacceptance and Annually
(2) Discharge test (30 minutes): Initial/Reacceptance and Annually
(3) Load voltage test: Initial/Reacceptance and Semiannually

Findings:

During document review, observation, and interview with staff on 7/1/19, the FACU back-up batteries were observed and records were requested.

At 10:40 a.m., the FACU was observed with two sealed lead acid back-up batteries labeled with an installation date of 9/5/18.

1. At 11:44 a.m., records provided indicated that the the two batteries were tested for load voltage during the annual fire alarm system test/inspection completed on 9/5/18. There was no documentation provided that indicated a second semi-annual load voltage test was completed in the past 12 months. There were also no records provided that indicated an annual charger test or an annual 30 minute discharge test was completed in the past 12 months. Upon interview, the Maintenance Supervisor/Ambulance Director and the Maintenance Assistant confirmed this finding.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by one extinguisher that was obstructed from access. This affected one of two smoke compartments and could result in the inability to obtain the extinguisher in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.12 Portable fire extinguishers shall be provided in all
health care occupancies in accordance with 9.7.4.1.

9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Extinguishers, 2010 Edition.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During a tour of the facility and interview with staff on 7/1/19, the portable fire extinguishers were observed.

1. At 1:35 p.m., the K-type portable fire extinguisher located in the Dietary Kitchen was observed. The extinguisher was obstructed from access by two garbage bags that were hanging over the extinguisher. Upon interview, Maintenance Assistant confirmed finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by three corridor doors that were obstructed from closing. This affected two of two smoke compartments and could result in the inability to contain smoke and/or fire to a room.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.6.3.10* Doors shall not be held open be devices other then those that release when the door is pushed or pulled.

Findings:

During a tour of the facility and interview with staff on 7/1/19, the corridor doors were observed.

1. At 1:08 p.m., the corridor door to the Infection Control Office was equipped with a metal kick down door holder device on the lower part of the door that was used to hold the door open. Upon interview, the Maintenance Assistant confirmed this finding.

2. At 1:13 p.m., the corridor door to the Resident Room 10 on the Skilled Nursing side of the building was obstructed from closing by a bedside curtain of Bed A. Upon interview, the Maintenance Assistant confirmed this finding.

3. At 1:16 p.m., the corridor door to the Dining Room was being held open by a door stop device that was placed under the door. The door was equipped with a self closing device that was interfaced with the fire alarm system. Upon interview, the Maintenance Assistant confirmed this finding.

Based on document review, observation, and interview, the facility failed to maintain the door openings. This was evidenced by the absence of an annual inspection for fire door assemblies. This affected two of two smoke compartments and could result in the malfunction of the egress doors during an emergency situation.

NFPA 101. Life Safety Code, 2012 Edition
19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.)

8.3.3 Fire Doors and Windows.
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition
5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.
5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.
5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Findings:

During document review, a tour of the facility, and interview with staff on 7/1/19, the annual inspection and testing for fire doors were requested.

1. During a tour of the facility, a set of 3 hour fire rated doors were observed in the corridor near Patient Room 4 and Patient Room 5.

At 11:41 a.m., records provided indicated that the fire doors in the facility were tested by Fire Alarm System Vendor during an annual fire alarm system test/inspection on 9/5/18. There were no records provided that indicated an annual fire door assemblies were visually inspected from both sides to assess the overall condition of door assembly. Upon interview, the Maintenance Supervisor/Ambulance Director and Maintenance Assistant confirmed this finding.