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Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to develop and implement emergency preparedness policies and procedures, based on subsistence needs for staff and patients. Failure to develop subsistence needs for staff and patients during an emergency could cause harm to staff and patients if immediate needs like food, water, medical and pharmaceutical supplies and alternate sources of energy are not planned for and available.

Finding include:

During observations while on tour Jan 9, 2024, it was revealed that the facilities did not have the needed amounts of food needed to sustain the staff, patients and visitor the four days as described in their plan. The facility did have enough storage in big tanks but no way to assure it remained safe to drink.

Employees # 2, and #15 confirmed during the exit interview conducted on Jan 9, 2024, that the sustenance on hand was not nearly enough.

Based on review of the facility's Emergency Preparedness Testing Requirements, record review and staff interview, it was determined the facility failed to participate in drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency.

Findings include:

During document review on January 09, 2024, it was revealed the facility was missing documents proving participation in a full-scale exercisem (FSE) that was community-based or a facility based exercise or table top drills for the last two cycles.

Employee #2, and # 15 confirmed during the exit interview that the facility was not able to locate proof of participation in a full-scale exercise that was community-based or a facility based exercise in the last four years.

Based on observation, it was determined the facility failed to maintain the special locking exit door located on the 2nd floor of the East Campus pediatric unit. Failing to provide manual release of the exit doors can cause the door to prevent exit during a fire which likely would result in injury or death to staff or patients.

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2
"Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall
release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only." NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following:
1. Locks complying with 19.2.2.2.5 shall be permitted.
2. Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.
3. Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
4. Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted.
5. Approved existing door-locking installations shall be permitted. 19.2.2.2.5 Door-locking arrangements shall be permitted in accordance with either 19.2.2.2.5.1 or 19.2.2.2.5.2. 19.2.2.2.5.1 Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 19.2.2.2.6. 19.2.2.2.5.2 Door-locking arrangements shall be permitted where patients' special needs require specialized protective measures for their safety, provided that all of the following are met:
1. Staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
2. A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.
3. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7.
4. The locks are electrical locks that fail safely so as to release upon loss of power to the device.
5. The locks release by independent activation of each of the following:
a. Activation of the smoke detection system required by 19.2.2.2.5.2(2)
b. Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3) 19.2.2.2.6 Doors that are located in the means of egress and are permitted to be locked under other provisions of 19.2.2.2.5 shall comply with all of the following:
1. Provisions shall be made for the rapid removal of occupants by means of one of the following:
a. Remote control of locks
b. keying of all locks to keys carried by staff at all times
c. Other such reliable means available to the staff at all times
2. Only one locking device shall be permitted on each door.
3. More than one lock shall be permitted on each door, subject to approval of the authority having jurisdiction

Findings include:

Observations while on tour on January 8, 2024, , revealed that all outside exit doors were locked without an emergency release mechanism in addition only the RN and facility manager had keys to open these doors in the event of an emergency. Four out four staff members wer not able to open any exterior door with the keys they had in their possession. In addition staff did not have keys to the fire extinguishers cabinets that were locked. The staff was provided keys during the survey and all staff are now able to get all patients and staff out of the building in an emergency and access the fire extinguishers.

Employees #2 and #15 confirmed during the walk down and at the exit conference that staff did not have keys to all exit doors and the doors did not release upon activation of the fire alarm.

Based on record review and interview the facility failed to provide required sprinkler inspections. Failing to inspect test and maintain the sprinkler system could cause the system to be inoperable due to lack of maintenance during a fire and could cause harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.5.1. "Buildings containing health
care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition,
"5.4.2 * Dry Pipe Systems. Dry pipe systems shall be kept dry at all times.
5.4.2.1 During nonfreezing weather, a dry pipe system shall be permitted to be left wet if the only other option is to remove the system from service while waiting for parts or during repair activities.
5.4.2.2 Refrigerated spaces or other areas within the building interior where temperatures are maintained at or below 40°F (4.4°C) shall not be permitted to be left wet.
5.4.2.3 Air driers shall be maintained in accordance with the manufacturer's instructions.
5.4.2.4 Compressors used in conjunction with dry pipe sprinkler systems shall be maintained in accordance with the manufacturer's instructions.
5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection,
testing, and maintenance.
Table 5.1.1.2 Summary of Sprinkler System Inspection, Testing, and Maintenance Gauges (dry, preaction, and deluge systems)
Weekly 5.2.4.2, 5.2.4.3, 5.2.4.4"

Findings include:

Based on record review and interview on January 09, 2024, revealed the facility failed to provide inspections and monthly isolation valve inspections for the last three years.

Employees #2 and #15 confirmed during the exit conference that the facility failed to provide documentation for monthly sprinkler gauge inspections and monthly isolation valve inspections for the last three years.

Based on observation the facility allowed the use of an extension cords and did not use the wall outlet receptacles for appliances. The use of extension cords as permanent wire could cause an over load from appliances causing a fire which
could harm patients and/or staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99,
Chapter 6, Section 6.3.2.2.6.2, "All Patient Care Areas," Sections 6.3.2.2.6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. NFPA 101 2012 Edition. 9.1 Utilities. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NEC 70 2011 Edition. 400.8 Uses Not Permitted. Unless specifically permitted in 400.7 flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure

Findings include:

Observations made while on tour on January 08 -10, 2024, revealed the facility allowed the use of an extension cord in the facility as permanent wiring. The refridgerator in the employee break room was powered by an extension cord. the cord had been there for some time due to dust on the cord.

Employees # 2 and 15 confirmed during the exit conference that the refredgeratr in the employee break room was being powered by an extension cord.

Based on observation the facility failed to maintain oxygen cylinders in a code-compliant and safe manner. Failure to maintain oxygen in a safe environment could result in jury or death of
staff and patients

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
1. Minimum distance of 6.1 m (20 ft)
2. Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic
sprinkler system designed in accordance with NFPA 13
3. Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/ 2 hour
11.3.4 Signs.
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.
11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
1. Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
2. Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
3. Cylinders shall be protected from tampering by unauthorized individuals.
4. Cylinders or cylinder valves shall not be repaired, painted, or altered.
5. Safety relief devices in valves or cylinders shall not be tampered with.
6. Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
7. A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
8. Sparks and flame shall be kept away from cylinders.
9. Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
10. Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1
11. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
12. Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

Finding include:

Observations while on tour Jan 08-09, 2024, revealed the facility was storing oxygen cylinders in the intake storga room with out labels to indicate weather on not the cylinders were empty or full.

Employees #2 and #25confirmed during the exit conference that the oxygen was not being stored correctly.

Based on interview and document review the facility failed to provide programs for continuing education and periodic review of safety guidelines and usage requirements for medical gases and oxygen cylinders. Failing to provide training programs and periodic review of safety guidelines for oxygen cylinders or liquid oxygen could cause harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 21, Section 21.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."." NFPA 99 2012 Edition Chapter 11 Section 11.5.2.1" Gas Equipment - Qualifications and Training of Personnel: Personnel concerned with the application, maintenance and handling of medical
gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained
in the maintenance and operation of equipment.

Findings include:

Observations and document review on January 09,2024, revealed the facility failed to provide
continuing education training with a periodic review of safety guidelines and usage requirements for medical gases and oxygen cylinders.

Employees #2, and #15 confirmed during the exit interview that the facility failed to provide proof of continuing safety education for medical gases.