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Based on observations and interview during the survey, it was determined through on-going dialog with the Chief Executive Office and the Quality Manager that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(a)

Findings include

On 7/12/2023. during record review between 9:30 am and 10:30 am, the facility failed to provide the necessary annual program review needed to ensure compliance. The last documented review was conducted April 2021.

Surveyor was accompanied by the Chief Executive Office and the Quality Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Chief Executive Office and the Quality Manager that the facility failed to comply with Federal, State and local EP requirements to establish and maintain a comprehensive EP program (CFR 42 Part 483.625(b)(2)).

Findings include:

On 7/12/2023, during record review between 9:30 am and 10:30 am, the facility failed to provide a defined system to track the location of on-duty staff for evacuations or shelter- in-place during an emergency.

Surveyor was accompanied by the Chief Executive Office and the Quality Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to install proper maintain components, including fire rated doors within the sampled smoke compartments. This resulted in the potential for smoke and fire to spread to other areas of the facility (LSC 7.2.3, 19.2.2.2.3, 19.2.2.4).

Findings include:

1. On 07/11/2023, at 1:05 p.m., the rated door within the first floor corridor, when released, would not close and latch properly.

2. On 07/11/2023, at 1:45 p.m., the rated door leading from the Hopper room to the corridor, when released, would not close and latch properly.

3. On 07/11/2023, at 1:46 p.m., the labels on the 90 minute fire rated doors in the second floor corridor had been painted over and were no longer legible.

Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to install exit access and exit doors with an approved clear width of a minimum of 41.5" (hospitals and nursing homes) to accommodate the residents/patients served for the building. This resulted in the potential for panic and injury to residents/patients & staff during emergency evacuations and relocation (LSC 18.2.3.6, 18.2.3.7).

Findings include:

On 07/11/2023, during the facility tour there were (2) exterior egress glass doors at the end of the south corridor from the LTC Wing of the building that had been remodeled after March 2003 that did not meet the minimum 41.5" clear width measurement as required by Chapter 18 of NFPA 101.

* NOTE: This was a repeat deficiency from the survey completed on 10/27/2016 and the condition continues to exist.

Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.7.5, 9.7.7, 9.7.8, NFPA 70, NFPA 72 and NFPA 25).

Findings include:

1. On 07/12/2023, during record review between 8:00 a.m. and 10:00 a.m., there was no documentation provided by the facility showing the required annual Inspection, Testing and Maintenance (ITM) on the fire alarm system. The last annual fire alarm documented ITM was conducted 10/2021 and was past due since 10/2022.

2. On 07/11/2023, at 1:15 p.m., there was no mechanical set screw installed on the electrical breaker within the emergency panel to prevent accidental power loss to the Fire Alarm Control Panel.

Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to ensure the automatic sprinkler and standpipe systems were continuously maintained, inspected and tested in a reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 19.3.5, 9.7.5, 9.7.7, 9.7.8, NFPA 25, NFPA 2001).

Findings include:

1. On 07/12/2023, during record review between 8:00 a.m. and 10:00 a.m., the facility had no documentation of the required annual/semi-annual kitchen hood/suppression inspection. The suppression system was a water based suppression system and not a chemical based or UL300 approved suppression system.

2. On 07/11/2023, at 1:10 p.m., the gauges on the fire sprinkler riser were dated 2017 and were past due for recalibration or replacement since 2022.

Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to select, install, inspect and maintain fire extinguishers in accordance with adopted standards for extinguishers within the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.12, NFPA 10).

Findings include:

1. On 07/11/2023, at 2:01 p.m., there was a fire extinguisher within the x-ray department that was not properly installed and was sitting on a desk.

2. On 07/11/2023, at 2:03 p.m., there was a fire extinguisher within the triage area that was being blocked from being accessible by medical equipment stored in that area.

Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to maintain the facility elevator within the building. This resulted in the potential for entrapment of staff and residents. (LSC 19.5.4, 9.4, ASME A17.1).

Findings include:

On 07/11/2023, at 1:43 p.m., the emergency communication call button within the facility's elevator failed to work when tested by Surveyor.

Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of this findings.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.4 - 19.7.1.7).

Findings include:

On 07/12/2023, during record review between 8:00 a.m. and 10:00 a.m., facility fire drill documentation presented to the surveyor showed the facility failed to perform fire drills during the following shifts and quarters in years 2023, 2022 and 2021:

-night shifts in quarter 2, 2023 and 2022
-night and day shifts in quarters 3&4, 2022, 2021

Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Facility Administrator and Maintenance Director that the facility failed to provide safe storage for compressed gas. This resulted in the potential for damage of oxygen tanks in the compressed gas storage area . (LSC 19.3.2.4, NFPA 99 4.3.1.1.2).

Findings include:

1. On 07/11/2023, at 2:04 p.m., there were Carbon Dioxide tanks stored in the compressed gas storage area that were not properly secured to prevent damage to the tanks or surrounding tanks being stored.

2. On 07/11/2023, at 2:05 p.m., the compressed gas/oxygen tanks stored in the compressed gas storage area were not properly seperated full from empty and properly identified as being full or empty.

Surveyor was accompanied by the Facility Administrator and Maintenance Director who acknowledged the existence of these conditions.