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Based on record review and interview, the facility failed to establish a comprehensive Emergency Preparedness Program (EPP) in accordance with the Code of Federal Regulations (CFR) 42, Part 482.15, Condition of Participation for Hospitals.

Findings included:

On 03/19/2024 between 9:30 AM and 3:00 PM, during the record review with the Director of Plant Operations, the facility failed to provide evidence of an EPP. During the exit conference, the Chief of Operations and the Director of Risk Management concurred that the facility had no idea about their EPP or its requirements.

Based on record review and interview, the facility failed to develop and maintain an Emergency Preparedness Program (EPP) in accordance with the Code of Federal Regulations (CFR) 42, Part 482.15, Condition of Participation for Hospitals

Findings include:

On 03/19/2024 between 9:30 AM and 3:00 PM, during the record review with the Director of Plant Operations, the facility failed to provide evidence of an EPP development or maintenance of the program that meets the requirements of this section, utilizing an all-hazards approach. During the exit conference, the Chief of Operations and the Director of Risk Management concurred that the facility had no idea about their EPP or its requirements.

Based on record review and interviews, the facility failed to maintain battery back-up emergency lighting. Battery back-up emergency lighting is required to insure the safety of maintenance personnel in the event of a simultaneous failure of the public utility and the emergency generator.

Findings include:

On 03/19/2024 between 9:15 AM and 3:00 PM, during record review of the facility's emergency lighting records with the Director of Plant Operations (DOPO), it was revealed the emergency battery back-up lighting annual testing had not been completed with a 90 minute test interval. An interview was conducted with the maintenance staff concurrent with the observations and the staff member said that he just does a 30 second check for the annual testing.

Per NFPA 101 (2012 Edition) 19.2.9.1, 7.9.3, 7.9.3.1.1 (3)

Based on observations and interviews the facility failed to maintain exit signage in accordance with NFPA 101.

The findings include:

On 03/19/2024 between the hours of 9:30 a.m. and 11:30 a.m., during the tour of the dietary kitchen with maintenance staff and the Director of Risk Management, it was observed that the emergency exit sign above the dietary kitchen exit door was not illuminated. An interview was conducted with the maintenance staff concurrent with the observations and confirmed the findings.

Photographic evidence obtained.

per NFPA 101 (2012 Edition) 19.2.10.1, 7.9.2, 7.9.2.1, 7.10, 7.10.5, 7.10.5.1, 4.2.3, 4.6.12

Based on record review and interviews, the facility failed to maintain the Automatic Fire Alarm System (AFAS). This in the event of a fire could fail to activate the AFAS endangering the occupants in the event of an emergency.

Findings include:

On 03/19/2024 between 9:15 AM and 3:00 PM, during record review of the facility's AFAS inspection records with the Director of Plant Operations (DOPO), it was revealed the facility failed to provide documentation for a semi-annual testing and visual inspection report for the current AFAS inspection cycle. In an interview, the DOPO acknowledged concurrent with the findings.

Per NFPA 101 (2012 Edition) 19.3.4.4, 9.6.5, 9.6.5.1
Per NFPA 72 (2010 Edition) 14.3.1, (table 14.3.1), 14.4.5, (table 14.4.5)

Based on observations and interviews the facility failed to maintain the automatic fire sprinkler system (AFSS).

Findings include:

On 03/19/2024 between the hours of 9:30 a.m. and 11:30 a.m., during the tour of the facility with the maintenance staff and Director of Risk Management, it was observed that there was no inventory list of the sprinkler heads installed at the facility posted in the spare sprinkler head box. An interview was conducted with the maintenance staff concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 19.7.6, 4.6.12, 4.6.12.1, 9.7, 9.7.5
per NFPA 25 (2011 Edition) 5.2.1, 5.2.1.4 (1), 5.4.1.4, 5.4.1.4.1, 5.4.1.5

Based on observations and interviews the facility failed to maintain interior walls to be fire and smoke resistant in accordance with NFPA 101.

The findings include:

On 03/19/2024 between the hours of 9:30 a.m. and 11:30 a.m., during the tour of the Normal Electrical room with the maintenance staff and Director of Risk Management, observations were made of an improperly patched penetration in the 1-hour fire wall. An interview was conducted with the maintenance staff concurrent with the observations and confirmed the findings.

Photographic evidence obtained.

per NFPA 101 (2012 Edition) 19.3.7.3, 8.3.4, 8.3.4.1, 8.3.4.2, 4.6.12

Based on record review and interviews, the facility failed to conduct fire drills as required by NFPA 101 (2012 Edition). Fire drills are essential to the training of staff and residents in proper procedure in emergency situations. Untrained staff can allow confusion and possible delays in proper procedure in an emergency and jeopardize all within the facility.

Findings include:

On 03/19/2024 between 9:15 AM and 3:00 PM, during record review of the facility's fire drills with the Director of Plant Operations (DOPO),it was revealed that the facility had not performed a drill for the 4th Quarter -3rd shift in 2023. An interview was conducted with the DOPO concurrent with the observations and confirmed the findings.

per NFPA 101 (2012 Edition) 19.7.1.6

Based on record review and interviews, the facility failed to protect the fire barriers in accordance with NFPA 101 (2012 Edition) and NFPA 80 (2010 Edition). In the event of a fire, this condition could put occupants attempting shelter or evacuate in an unsafe environment.

Findings include:

On 03/19/2024 between 9:15 AM and 3:00 PM, during record review of the facility's Fire Door inspection records with the Director of Plant Operations (DOPO), it was revealed the facility could not provide documentation for an annual fire door inspection. An interview was conducted with the DOPO concurrent with the observations and confirmed the findings..

per NFPA 101 (2012 Edition) Chapter 8.3.3.1
per NFPA 80 (2010 Edition) Chapter 5.2, 5.2.1

Based on record review and interview, the facility failed to maintain the diesel fuel for the generator. Proper maintenance and inspection of the emergency power supply system helps to ensure proper functioning in an emergency situation.

Findings include:

On 03/19/2024 between 9:15 AM and 3:00 PM, during record review of the facility's generator maintenance program with the Director of Plant Operations (DOPO), it was reveal that the facility could not provide a current diesel fuel quality testing report. In an interview, the DOPO acknowledge concurrent with the findings.

per NFPA 99 (2012 Edition) 6.4.1.1, 6.4.1.1.16
per NFPA 110 (2010 Edition) 8.3.8