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Based on 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:

1. Review of the EP plan, policies, and procedures on 5/14/24, reflected the facility's emergency plan lacked policies and procedures for subsistence needs for staff and residents, particularly specific policies describing alternate sources of energy to maintain proper temperatures, emergency lighting, and for the sprinkler and alarm systems, as well as sewage and waste disposal in a time of loss of power and/or water.

Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3, 7.2.1.5.10, and 7.2.1.6. Facilities can only lock doors and gates in the case of clinical need such as a special care unit.

Findings include:

1. During an observation on 5/14/24 at 9:35 a.m., the horizontal sliding doors leaving the ER area were found to be magnetically locked, with an electronic "push to exit" button inside the door. Entry to the ER from the outside was with an electronic device using a card to unlock the doors and enter. The system is set up as an "access-controlled" egress special locking arrangement. The motion detector was not a part of the system on the egress side of the door.

Whatever type of special locking arrangement they want to utilize throughout the facility, either delayed egress, or access-controlled egress, the facility must then apply all the features the code requires in NFPA 101-2012 Section 7.2.1.6. The locked doors in the lighted path of egress must also unlock and be open to occupants in the event the sprinkler or fire detection systems are activated.

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

Findings include:

1. Review of the facility records for testing of the emergency lighting documentation on 5/14/24 showed the facility had only performed a 30 second test on the emergency lighting, but failed to do the required 90 minute test annually, in a way that the battery was being tested.

The last 90 minute test of the emergency lights was in February of 2023.

Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.1.10.2.1, and Section 7.10.1.2.2.

Findings include:

1. During an observation on 5/14/24 at 10:36 a.m., the corridor from the swing-bed wing to the hospital was inspected for egress and signage. It was found to be missing an internally lit exit sign to guide occupants out of the swing-bed corridor and into the hospital.

Based on observation, the facility failed to ensure 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 and 19.3.2.1.3.

Findings include:

1. During an observation on 5/14/24 at 10:01 a.m., patient room 117 was being used a storage room. The corridor door would not close and latch under the power of a self-closer.

2. During an observation on 5/14/24 at 10:03 a.m., the med-surge inventory room was a storage room over 50 square feet in size. The corridor door was lacking the necessary self-closing device.

3. During an observation on 5/14/24 at 10:33 a.m., the swing bed clothing storage room was inspected. The room is over 50 square feet and was lacking the necessary self-closing device on the corridor door.

Based on observation, the facility failed to ensure the laboratory 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 19.3.2.2 and 8.7.1.3.

Findings include:

1. During an observation on 5/14/24 at 9:15 a.m., the laboratory was inspected. The corridor door to the lab was found to be wedged open. The corridor door is on a self-closer, as the lab must be protected as a hazardous area.

Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8).

Findings include:

1. During an observation on 5/14/24 at 9:20 a.m., the trauma room was inspected. There was an ABHR mounted on the wall above a light switch in the room.

2. During an observation 5/14/23 at 9:44 a.m., the soiled utility room in the ER was inspected. There was an ABHR station mounted over a light switch in the room.

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

a) complete an internal inspection every five years, in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Sections 13.2.7.1 and 13.2.7.2,

b) maintain the monthly gauge readings on the sprinkler riser per NFPA 25-2011, Section 5.2.4.2.

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) maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5.

e) inspect and maintain the sprinkler system in accordance with NFPA 13, 2010 Edition, Section 6.2.7.2.

f) ensure the inspector's test orifice was installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.17.4.2.1.

Findings include:

1. Review of the facility's sprinkler reports and through observation on 5/14/24 at 9:00 a.m., revealed the facility had not completed a 5-year internal inspection of the control valve and piping. The vendor kept stating it was due on the quarterly inspections, but the facility did not ensure it was completed.

2. During a review of facility sprinkler records and an interview on 5/14/24 at 8:00 a.m., staff member A, stated the facility was not actively documenting the sprinkler pressures at the standpipe.

3. During an observation on 5/14/24 at 9:20 a.m., the ER was inspected. There was a sprinkler head in the room that was choked with debris to the point you could not see the fusible bulb.

4. During an observation on 5/14/24 at 9:40 a.m., the sprinkler system standpipe was inspected. The box of spare sprinkler heads was found to be lacking the sidewall or directional type sprinkler heads. The facility had many sidewall heads in use.

5. During an observation on 5/14/24 at 9:42 a.m., the private exam room was inspected, an escutcheon ring was missing from a sprinkler head in the room.

6. During an observation on 5/14/24 at 10:25 a.m., the inspector's test valve and orifice in the boiler room were inspected. The valve was a 1" valve on a 1" pipe. This is too large to be a legitimate test. The testing orifice cannot be larger than the smallest orifice on the system.

Based on record review, the facility failed to ensure the fire safety plan and subsequent drills documented all requirements listed in the the code for responding to a fire drill per NFPA 101. 2012 Edition, section 19.7.1.2.

Findings include:

1. Review of the facility fire drills going back a year reflected the facility lacked documentation in regards to all the elements required by code for the fire safety plan. Some of the fire drill sheets were also not filled out in regards to what the scenario of the drill was, whether the hallway was cleared, and the smoke compartments evacuated or not, or whether there was a simulated call to the fire department as to whether the fire was real or not, and where it was located per the fire panel.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report).

Findings include:

1. Review of the fire safety maintenance records on 5/14/24, reflected the facility had not completed inspections of the fire doors on an annual basis. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers as related to NFPA 80. The facility copied the requirements listed in NFPA 80 chapter 5.

Based on observation the facility failed to maintain gas cylinders per NFPA 99-2012, Section 11.6.2.3.

Findings Include:

1. During an observation on 5/14/24 at 10:24 a.m., the oxygen storage room was inspected. There was a free-standing E-sized tank in the room with the other tanks. There were other slots in the rack which were open for the tank to have been placed.