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Based on record review and interview the facility failed to ensure policy and procedures were established to address the use of volunteers in an emergency.

Findings:

Record review showed the facility failed to include a policy and procedure regarding the use of volunteers in the event of an emergency event when they activate their facility emergency plan.

On 12/16/21 at 11:38am the surveyor asked staff A to verify the volunteers roles at the facility for disasters. Staff A stated the facility did not have a policy in place, but the facility will revise and update their policies/procedures to address the volunteers roles and responsibilities in an emergency event.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 12/15/21 at 11:50 am an ABC class fire extinguisher was observed in the kitchen with no placard posted next to it to indicate the hood fire protection system shall be activated prior to using the fire extinguisher as required.

On 12/15/21 at 11:50 am Staff A stated they would get with their fire service vendor to get the appropriate placard for the fire extinguisher without the required placard in the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview the facility failed to ensure smoke partitions were maintained smoke tight as required.

Findings:

On 12/14/21 at 11:52am the surveyor observed approximately 14 ceiling tiles missing in an emergency egress corridor, three missing ceiling tiles missing in the cafeteria, and three ceiling tiles not properly in place in the group therapy room.

On 12/14/21 at 11:52am the surveyor asked staff A why the ceiling tiles were missing. Staff A stated the missing tiles in the corridor were missing was because they had some work being done on the HVAC unit but will get the ceiling tiles reinstalled to be in compliance.

Based on record review and interview the facility failed to ensure impedance testing/maintenance to hospital grade electrical receptacles in patient care areas were placed on a preventative maintenance program based on intervals defined by documented performance data per NFPA 99 2012 Edition standards as required.

Findings:

Record review showed the facility did not complete impedance testing for patient care related electrical receptacles for 2019, 2020 and 2021 as required per NFPA 99-2012 Edition standards.

On 12/14/21 at 11:27am the surveyor asked staff A why the impedance testing has not been completed per the NFPA 99 2012 Edition standard requirements. Staff A stated they did not know but will get with their electrical vendor and ensure NFPA 99 2012 Edition standard is adhered to for the impedance inspections.

Based on record review and interview the facility failed to ensure the emergency generator testing was completed.

Findings:

Record review showed the facility did not complete monthly generator load bank testing in 2021 from April to June.

On 12/15/21 at 1:52 pm the surveyor asked Staff A why the emergency generator was not load bank tested for three months. Staff A stated they did not know but will do retraining of the person who is responsible for conducting the monthly load bank testing of their emergency generator.