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Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to develop and implement emergency preparedness policies and procedures, based on subsistence needs for staff and patients. Failure to develop subsistence needs for staff and patients during an emergency could cause harm to staff and patients if immediate needs like food, water, medical and pharmaceutical supplies and alternate sources of energy are not planned for and available.


Finding include

During observations while on tour Aug 15, 2024, it was revealed that the facilities did not have the needed amounts of water needed to sustain the staff patients and visitor the three days as described in their plan. The facilities plan involved off-site assistance for water sources.

Employees # 1,#2 confirmed during the exit interview conducted on Aug 15, 2024, that the sustenance on hand was not nearly enough.

Based on observation, the facility failed to provide a safe means of egress from multiple exit pathways to a public way. Failure to provide a clear and unimpeded means of egress could harm 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 there to egress there from or visibility thereof.

Observations made while on tour on August 14-15, 2024, revealed wheeled chairs, beds, and other medical equipment blocking the exit egress on the second and third floors of patient care areas. Some of these areas even had the floors marked as storage. Staff believed they were allowed to store items in the hallways as long as they were all on one side of the hallway.

During the exit conference on August 15, 2024, employees #1 and #2 confirmed the findings during the tour and exit conference.

Based on observation and records, the facility failed to maintain emergency plans and staff training for laboratory chemicals. Failure to create emergency plans and train the staff could have caused staff and patients to be overcome or injured by chemicals stored in the lab.

NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.3.2.2 * Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.
NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 9 Heating, Ventilation, and Air Conditioning (HVAC). 9.3.1.2 Laboratories shall comply with NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals.
NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 15 Features of Fire Protection
15.4 Laboratories. Laboratories using chemicals shall comply with NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, unless otherwise modified by other provisions of this code. [101:8.7.4.1]
NFPA 45: Standard on Fire Protection for Laboratories Using Chemicals, 2024 Edition - Chapter 8 Chemical Storage, Handling, and Waste Disposal. 8.3.4.2 * Incompatible materials shall be segregated to prevent accidental contact with one another. 8.3.4.4.1 * Proper management shall consist of the following elements:
(1) Defining those materials present that are time sensitive
(2) Defining each time-sensitive material's inspection frequency
(3) Defining proper or approved inspection methodologies to determine the relative hazard of the time-sensitive material
(4) Defining pass/fail criteria for inspection results
8.3.4.4.2 Time-sensitive materials that pass inspection shall be permitted to be redated and retained for an additional defined inspection period. 8.3.4.4.3 All other material shall be safely discarded.
NFPA 45: Standard on Fire Protection for Laboratories Using Chemicals, 2024 Edition - Chapter 12 Educational and Instructional Laboratory Operations. 12.2.1 * Where instructors are performing demonstrations or students are conducting experiments using hazardous materials, the instructor shall be required to perform a documented hazard risk assessment, provide a safety briefing to students, provide adequate personal protective equipment (PPE), and place a safety barrier (as required) between students and the demonstration or experiment to prevent personal injury. 12.2.2 * Instructors in teaching labs shall be trained and knowledgeable in fire safety procedures, emergency plans, the hazards present in the lab, the appropriate use of PPE, and how to properly conduct a hazard risk assessment.

Findings include:

Observations while on tour August 14-15, 2024, revealed that the chemicals being stored in the laboratory did not have any emergency plans or SDSs. In addition, there were no training documents confirming that the staff was trained in handling those chemicals during an emergency. The management stated that CAP (College of American Pathologists) inspectors had inspected the facility two weeks earlier, and the facility was cited, but no action had taken place to correct the problem.

Employees #1 and #2 confirmed during the exit that the lab was missing emergency plan documents for dealing with the stored chemicals and staff training.

Based on observations, the facility failed to add sprinklers in a room during a recent modification/room addition. Failure to have a sprinkler system throughout the facility could harm residents and/or staff during an emergency.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems."

Findings include:

Observations made while on tour August 14-15, 2024, revealed that a room was added in an outside mechanical room housing the UPS room. The room is fully enclosed and was built under an existing sprinkler system, but the system was not extended to it, resulting in it being without sprinkler heads.

Employees #1 and #2 confirmed the above findings during the tour on August 14, 2024, and the exit conference on August 15, 2024.

Based on observation, the facility failed to display a current hydraulic plate on the sprinkler riser. Failure to require a current date on the riser hydraulic plate could result in errors during modifications and failure of the sprinkler system.

NFPA 25 2011 Standard for the inspection, testing, and maintenance of water-based fire protection systems.
5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
A.5.2.6 The hydraulic design information sign should be secured to the riser with durable wire, chain, or equivalent. (See Figure A.5.2.6.)
Paragraph 5.2.6 requires that the hydraulic design information sign (also called a nameplate or placard) be inspected on a quarterly basis.
NFPA 13 requires a hydraulic design information sign on hydraulically designed systems so that the design criteria and system demand can be readily determined. The hydraulic design information sign can provide useful information to the owner. If the design information sign is missing, the owner should contact a design professional to determine the demand for the system, which can be written on a new design information sign. The details are also documented on the approved plans and hydraulic calculations, but these plans can be misplaced and may not be available when the property changes owners. A hydraulic design information sign that is securely fastened to the riser can provide the details when these other data are missing (see Exhibit 5.21). If the sign becomes loose or is difficult to read, it must be repaired or replaced.

Findings include:

Observation while on tour August 14-15, 2024, revealed the sprinkler riser in the south mechanical room was missing the required hydraulic plate. The quarterly inspections did not identify the missing plate.

Employees #1 and #2 confirmed during the tour that the sprinkler riser hydraulic plate in the south mechanical room was missing.

Based on observation and staff interviews, the facility failed to ensure that a remote stop or kill switch for the generator was installed. This affected the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop on the generator could cause a fire or harm the residents and staff.


Code reference: NFPA 110 2010 Edition; Standard for Emergency and Standby Power Systems 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation, located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. A.5.6.5.6 For systems located outdoors, the manual shut-down should be located external to the weatherproof enclosure and should be appropriately identified.

Findings include:

During observations during a tour conducted on August 14-15, it was revealed that the facility's generator did not have the required remote stop or kill switch. Per facility management, this switch is scheduled to be installed in a couple of months.

Employees #1 and #2 confirmed during the exit conference that the facility failed to install a remote stop switch for the emergency diesel generator.

Based on Observation, it was determined that the facility allowed the use of power strips but did not use the wall outlet receptacles for appliances. Failure to properly use power strips and outlets could lead to electrical overload or fire, which could harm the patients and staff.

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:

Observations made during the tour from August 14-15, 2024, revealed that the following locations had power strips plugged into equipment with heavy load-drawing appliances (refrigerators, microwaves, and large printers).
1. The case management office had a microwave in a power strip and two items plugged into an unprotected outlet splitter.
2. The refrigerator in the Biomed room was plugged into a power strip.

During the exit conference conducted on August 14-15, 2024, Employees # 1 and #2 confirmed the improper use of power strips and multi-plug adaptors without surge protection.