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Based on observation, interview and facility record review the facility failed to develop Emergency Preparedness policy and procedures based on the community risk assessments prior to developing the facility's emergency plan. Failure to develop Emergency Plans based on community risk assessments may cause harm to the patients and staff during an emergency.

Findings include:

On September 15, 2020, while reviewing the facility's Emergency Plan with the Director of Maintenance and the Director of Quality and Risk Management, the facility failed to provide a community based risk assessment as required by CRF 494.62.

During the exit conference on September 15, 2020, the above finding was again acknowledged by the Director of Maintenance and the Director of Quality and Risk Management.

Based on review of the facility Emergency Plan, record review and staff interview, it was determined, the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on community risk assessments may cause harm to the patients and staff during an emergency.

Findings include:

On September 15, 2020, while reviewing the facility Emergency Plan, with the Director of Quality and Risk Management, their plan only used the facility assessment and did not include a community based all hazards risk assessment. CRF 494.62 requires both facility and commmunity hazard assessments to develop the policy and procedures.

During the exit conference on September 15, 2020, the above finding was again acknowledged by the Director of Quality and Risk Management.

Based on review of the facility emergency plan, and staff interview, it was determined the facility failed to develop and implement a policy and procedure for sheltering in place during an emergency. Failure to adequately shelter in place during an emergency could potentially lead to harm to both patients and staff, if the facility does not have processes and supplies readily available to institute when patients and staff cannot leave the facility.

Findings include:

The facility's Emergency Plan related to a process for sheltering patients and staff during an emergency was reviewed on September 15, 2020. The Emergency Plan (EP) did not identify a process for sheltering patients and staff during an emergency.

The Director of Quality and Risk Management confirmed on September 15, 2020, the facility EP plan did not identify a process for sheltering patients and staff during an emergency.

Based on review of the facility Emergency Preparedness Plan, and staff interview, it was determined the facility failed to develop a facility based emergency planning, training and testing program. Failure to provide facility based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency if staff are not aware of what is required by them to do, during an emergency situation.

Finding include:

The facility's Emergency Plan (EP) documentation related specifically to the facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan was requested on September 15, 2020. The plan did not include facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan.

The Director of Quality and Risk Management confirmed during an interview on September 15, 2020, the EP plan did not include facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan.

Based on observation and interview with staff it was determined, the facility failed to provide a safe means of egress out of the emergency exit doors. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof."

During the facility inspection conducted on September 15, 2020, along with the Director of Maintenance and the Director of Quality and Risk Management it was observed that one exit door in the front of the building was obstructed by a patient scale and a patient lift unit.

During the exit conference on September 15, 2020, the Director of Quality and Risk Management acknowledged that the emergency exit door located in the front of the building was impeded.

Based on observation of the doors in the Hospital, it was determined the facility failed to maintain the self or automatic closing due to door stops or door wedges mounted on or observed under the doors holding the doors in an open position. Failing to keep self-closing or automatic closing doors closed will allow smoke and heat, during a fire, to spread throughout the facility, which could cause harm to the patients.

NFPA 101 Life Safety Code, 2012, Section 7.2.1.8.1 A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self or automatic closing in accordance with 7.2.1.8.2.

Findings include:

On September 15, 2020 accompanied by the Director of Quality and Risk Management and the Director of Maintenance, observed that the doors to the Physical Therapy area were being held open by door wedges which defeated that automatic door closing units.

During the exit conference conducted on September 15, 2020, the above findings were again acknowledged by the Director of Quality and Risk Management and the Director of Maintenance.

Based on record review and interview with staff, it was determined the facility did not have documented evidence that the kitchen hood system was inspected semi-annually in accordance with NFPA 96. Failing to inspect the kitchen hood entire fire extinguishing system semi-annually could allow a build-up of grease and provide fuel for a fire. A fire in the kitchen has potential to harm the patients and staff.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... "Chapter 11, Procedures for the use , Inspection, Testing, and Maintenance of Equipment. Section 11.2 "Maintenance of the fire extinguishing systems and listed exhaust hoods containing a constant or fire activated water system that is listed to extinguish a fire in the grease removal devices hood exhaust plenums and a exhaust ducts shall be made by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction at least 6 months."

Findings Include:

The fire suppression system for the kitchen hood system was requested on September 15, 2020. The facility was unable to provide documented evidence that the fire extinguishing system was inspected in accordance with NFPA 96 Edition semi-annually from May 2019 to May of 2020.

The exit conference conducted on September 15, 2020, the Director of Quality and Risk Management and the Director of Maintenance acknowledged that there was no documentation that the fire extinguishing system was inspected in accordance with NFPA 96, 2011 Edition, semi-annually from May 2019 to May of 2020.

Based on observation it was determined that the facility failed to maintain the sprinkler system in the facility. 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 residents.

NFPA 101 Life Safety Code, 2012 edition, Chapter 9, Section 9.7.1 "Each automatic sprinkler system required by another section of this Code shall be in accordance with on of the following." " NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 26, Section 26.1 "General." "A sprinkler system installed in accordance with standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25. NFPA 25, Section 5.2.1 "Sprinklers, Section 5.2.1.1.1 "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage." Failing to maintain sprinkler heads could cause harm to residents and staff by allowing a fire to spread before the temperature is reached to set of the sprinkler head.

Findings Include:

On September 15, 2020, the surveyor accompanied by the Director of Quality and Risk Management and the Director of Maintenance, observed sprinkler heads with dust/lint or paint on the sprinkler heads in the following locations:

a. Staff lounge, two sprinkler heads with dust/lint.
b. Dietary Office, two of two sprinkler heads with paint on them.
c. Kitchen Storage one of two sprinkler heads with dust/lint on them.

During the exit conference on June 1, 2017, the above findings were again acknowledged by the Director of Quality and Risk Management and the Director of Maintenance.

2. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "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, "Water Based Extinguishment Systems," Chapter 6, Section 6.3.4.1 states "Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge." Chapter 14, Section 14.2.1 states "Except as discussed in 14.2.1 and 14.2.1.4 an inspection of piping and branch lines conditions shall be conducted every 5 years by opening a flushing connection at the the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material."

Findings include:

On September 15, 2020 accompanied by the Director of Quality and Risk management and the Director of Maintenance reviewed an Annual sprinkler inspection and test report dated June 26, 2015. The facility did not have any other sprinkler reports to show that the 5 year internal inspection or the 5 year gauge test was performed.

During the exit conference on September 15, 2020, the above findings were again acknowledged by the Director of Quality and Risk management and the Director of Maintenance.

Based on interview with the Director of Quality and Risk Management and the Director of Maintenance it was determined that the facility failed to maintain and document electrical receptacle testing in patient care areas specifically to the patient care rooms throughout the facility. Failing to test the receptacles could lead to an ignition hazard in a patient care area resulting in fire and/or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction. NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

Findings include:

On September 15, 2020, accompanied by the Director of Quality and Risk Management and the Director of Maintenance reviewed the facility documentation on the receptacle testing and the documentation did not reflect that all of the patient care areas were tested in 2019.

During the exit conference conducted on September 15, 2020, the above finding was again acknowledged by the Director of Quality and Risk Management and the Director of Maintenance.

Based on Observation it was determined the facility allowed the use of a power strips and extension cords and did not use the wall outlet receptacles for appliances. The use of multiple power strips or extension cords could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

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. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On September 15, 2020 accompanied by the Director of Quality and Risk management and the Director of Maintenance, the following power strips and extension cords in the facility and appliances not directly plugged in to the receptacle wall outlets were observed..

1. A refrigerator plugged into a power strip in the Nursing Office.
2. Two refrigerators plugged into a power strip in the Intensive Care Unit.
3. Multiple power strips plugged into each other to form a chain in the Pharmacy.
4. Extension cord in use in the Pharmacy instead of permanent wiring.

During the exit conference conducted on September 15, 2020, the above findings were again acknowledged by the Director of Quality and Risk management and the Director of Maintenance.