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Based on record review and staff interview, the facility did not conduct annual training of the emergency preparedness plan per 42 CFR section 403.748(d)(1). This deficient practice could affect all residents, as well as undetermined number of staff and visitors.

Findings include:

On 12/20/2022 at 10:13 am, record review of the emergency preparedness plan (EPP) revealed that the facility did not have documentation of the staff annual training in the EPP policies and procedures. Staff D stated that the person responsible for employee training and tracking had left the employ of the hospital.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on record review and staff interview, the facility did not participate in a community based full scale exercise to test the emergency preparedness plan per 42 CFR section 403.784(d)(2). This deficient practice could affect all residents, as well as undetermined number of staff and visitors.
Findings include:

On 12/19/2022 at 02:01 pm, record review of the emergency preparedness plan (EPP) revealed that the facility did not participate in a full-scale community-based exercise within the past twelve months. The facility did complete a tabletop training on burn surge on 01/01/2022.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on observation and interview, the facility failed to provide means of egress in accordance with the requirements of NFPA 101 (2012 edition) Sections 7.8 and 18.2.8. This deficient practice could affect 10 of 31 residents an undetermined number of staff and visitors.

On 12/19/2022 at 03:34 pm, observation in the Administration Suite revealed that there was no exterior emergency light to illuminate the exterior egress path present at the staff exit located next to finance room and clinical records room. This door has an illuminated exit sign above it.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on record review and staff interview, the facility did not ensure that functional tests of the battery powered emergency illumination equipment was provided in accordance with the requirements of NFPA 101 (2012 edition) Sections 18.2.9.1 and 7.9.3. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 12/20/2022 at 11:49 am, record review revealed that the battery-powered emergency light for the Automatic Transfer Switch (ATS) was not functionally tested for 90 minutes annually.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on observation and interview, the facility did not provide hazardous area self-closing doors as required in NFPA 101: Life Safety Code, 2012 edition sections 4.6.1.2, 19.3.2.1, 19.3.2.1.3 and NFPA (NEC) 70, 2011 s. 480.9.
This deficient practice could affect 5 of the 31 residents, as well as an undetermined number of staff and visitors.

Findings include:

On 12/19/2022 at 2:57 pm, observation of the rated door with closer between the Kitchen and Dry Storage revealed, that the self-closing door was obstructed by one plastic wedge.

These findings were confirmed at the time of discovery by a concurrent interview with Staff D.

Based on record review and interview, the facility did not inspect the kitchen range hood equipment in accordance with the requirements of NFPA 101 (2012 edition) Sections 18.3.2.5 & 9.2.3; and NFPA 96 (2011 edition) Sections 11.4, 11.6, 11.6.1 & 11.6.13. These deficient practices could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 12/20/2022 at 09:59 am, review of inspection records for the kitchen-hood exhaust and fire suppression system revealed that no semi-annual or annual inspection was conducted over the past 12 months. Last Hood inspection was held on 11/2021.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on record review and interview, the facility did not provide a complete policy addressing when the fire alarm system is out of service in accordance with the requirements of NFPA 101, 2012 Edition, Section 9.6.1.6 and Federal Register Vol. 81, No. 86, page 26886. This deficiency has the potential to affect all residents, and an undetermined number of staff and visitors.

Findings Include:

On 12/20/2022 at 01:59 pm, record review revealed the fire alarm outage policy did not state that rounds are to be continuous, did not contain a vendor list, and DHS email contact information to alert the Regional Fire Authority.

This finding was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on observation and staff interview, the facility did not provide a sprinkler system as required by the code; with all spaces sprinkler protected in accordance with NFPA 101 (2012 edition) sections 9.7.1.1, 9.7.2.1 & 18.3.5, and NFPA 13 (2010 edition) sections 6.7.1.3 & 6.7.1.3.2, NFPA 25 (2011 edition) section 13.3.1.3. This deficient practice could affect 31 of 31 residents, as well as an undetermined number of staff and visitors.

Findings include:

1. On 12/19/2022 at 10:02 am, observation in the pre-action sprinkler room units 1 and 2 revealed a toggle switch mounted on the wall in a 2" X 4" metal light switch box supplied power to the pre-action sprinkler system controller. Staff D did not know how opening the switch would affect the operation of pre-action system. No switch activation protection device or monitoring device was present that would indicate switch open/closed position no sign was displayed to describe its operation was present.

2. On 12/19/2022 at 02:49 pm, observation of the sprinkler riser revealed that the two main 12-inch water supply valves lacked valve position indicating devices with alarm nor were the valves secured in the open position with a chain & lock. Both valves had detents in the stem for a position indicator.

3. On 12/20/2022 at 10:50 am, observation in the 14 sq. ft. storage closet next to room 3069 had: one 2 foot X 2 foot, one 1 foot x 1 foot and one 3 inch x 2 foot ceiling tile missing. These missing tiles do not duplicate the tight conditions that were used in the sprinkler UL certification test.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on record review and interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 (2012 edition) Sections 4.7.1, 4.7.2, 4.7.6, 19.7.1, 19.7.1.4, 19.7.1.6, & 19.7.1.7. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 12/19/2022 at 1:41 pm, review of the facility fire drills for the last twelve months revealed that fire drills were not conducted at varied times. Fire drill was held on 5/6/22 at 08:23 am and at 10/19/22 at 0906 am, these drills were held within one hour of each other on the first shift.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on observation and interviews, the facility did not provide the correct identification or labeling of the receptacles in the kitchen per NAPA 99 (2012 edition), 6.4.2.2.6.2 (B) and NEC 70 (2011 edition) section 517.
FINDINGS INCLUDE:

On 12/19/2022 at 03:00 pm, observation in the kitchen revealed that the outlet serving the Robo Coupe food processor was not identified by a label on the cover plate.

This finding was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on record review and interview, the facility did not perform testing of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition) Sections 18.5.1 and 9.1.3; and NFPA 110 (2010 edition) Sections 8.3.7, 8.3.8, 8.4.1, 8.4.2, & 8.4.6. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

1. On 12/20/2022 at 12:09 pm, review of the monthly generator documentation revealed that neither specific gravity testing, nor conductance testing of the generator batteries was recorded for 12 of 12 prior months.
2. On 12/19/2022 at 11:51 am, record review of the weekly generator inspections revealed that the last weekly inspection was conducted on 12/02/22. No weekly generator inspection was held during the two weeks prior to the survey.
3. On 12/19/2022 at 12:15 pm, review of the generator records revealed that no record of a fuel oil test as having been performed in the past 12 months.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff D.

Based on observation and interview, the facility failed to maintain a clear working space in front of electrical disconnects in accordance with NFPA 101 (2012 edition) Section 9.1.2; NFPA 70 (2011 edition) Sections 110.26 & 110.34 (A). The deficient practice could affect 5 of 31 residents, as well as an undetermined number of staff and visitors

Findings include:

On 12/19/2022 at 3:05 pm, observation in the kitchen revealed that access to the electrical disconnect was less than the minimum required 3'-0" clearance. A large 50-gallon garbage can was stored in front of the electrical disconnects for the booster heater and dishwasher.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff D.