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Based on record review and interview, the facility failed to provide complete emergency preparedness exercise documentation. The Hospital must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
a. When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
b. If the Hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the Hospital is exempt from engaging its next required full-scale in a community-based or individual, facility-based full-scale functional exercise for 1 year following the onset of the actual event.
(ii) Conduct an additional exercise that may include, but is not limited to the following:
a. A second full-scale exercise that is community-based or an individual, facility-based functional exercise.
b. A mock disaster drill; or
c. A tabletop exercise or workshop that is led by a facilitator that includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the Hospital response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the Hospital emergency plan, as needed in accordance with 42 CFR 482.15(d)(2).
This deficient practice could affect all occupants.

Findings include:

Based on record review on 11/06/24 between 9:30 a.m. and 2:30 p.m. with the Director of Operations and Chief of Quality and Compliance present, there was no documentation of Emergency Preparedness Exercises available for review. Based on interview at the time of record review, the Chief of Quality and Compliance stated there were no Emergency Preparedness exercises documentation available for review at the time of the survey.

This finding was reviewed with the Director of Operations at the exit conference.

Based on record review and interview, the facility failed to implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code in accordance with 42 CFR 482.15(e)(2). This deficient practice could affect all occupants.

Findings include:

Based on record review on 11/06/24 at 10:19 a.m. of the generator load testing and maintenance documentation for the last twelve months with the Director of Operations, the following was noted:
a) the transfer time for the diesel powered generator was not documented.
b) weekly inspections were not available for seven of the last 52 weeks.
c) fuel quality sample on 02/09/24 showed iron corrosion is highly elevated and sulfur level is slightly above range. Suggest to polish fuel to restore quality and resample in 3 months to monitor.
Based on interview at the time of record review, the Director of Operations confirmed the transfer time was not documented on the monthly load testing, and the weekly inspections were not available. Additionally, the Director of Operations could not locate documents to show any action taken on the diesel fuel quality and that it was resampled three months to monitor.

These findings were reviewed with the Director of Operations at the exit conference.

1. Based on observation and interview, the facility failed to ensure 1 of 1 battery powered emergency lights at the generator was maintained in accordance with LSC 7.9. LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. LSC 7.9.2.7 states the emergency lighting system shall be either be continuously in operation or shall be capable of repeated automatic operation without manual intervention. This deficient practice could affect all residents, staff and visitors in the facility.

Findings include:

Based on observation with the Director of Operations at 3:25 p.m. on 11/06/24, the battery operated emergency light at the diesel generator failed to function when its respective test button was pushed five times. Based on interview at the time of the observation, the Director of Operations stated battery operated lights in the facility are tested monthly and confirmed the aforementioned battery operated emergency light failed to function when its respective test button was pushed.

2. Based on observation and interview, the facility failed to ensure monthly testing documentation of battery backup lights in the facility were complete and accurate. Section 7.9.3.1.1 (1) requires functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered and (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all residents in the facility.

Findings include:

Based on record review on 11/06/24 at 1:10 p.m. with the Director of Operatons, the Battery Operated Emergency Light monthly testing was incomplete. The monthly 30 second testing was documented as being complete, but were not identified and itemized by location in the facility. Based on an interview at the time of record review, the Director of Plant Operations indicated the facility has battery operated emergency exit lights throughout the facility that are tested monthly by the Security staff, but the testing documentation is not itemized by location.

These findings were reviewed with the Director of Operations at the exit conference.

Based on record review and interview, the facility failed to ensure the automatic sprinkler piping systems was examined for internal obstructions where conditions exist that could cause obstructed piping as required by NFPA 25, 2011 Edition, the Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 14.2.1. Section 14.2.1 states, "except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficient practice affects all residents, staff and visitors.

Findings include:

Based on record review with the Director of Operations on 11/06/24 at 11:30 a.m., the annual sprinkler system inspection dated 08/21/24 indicated a 5 year internal pipe inspection was conducted 2023. Based on an interview with the Director of Operations at the time of record review, he stated inspection documentation for the most recent 5 year internal obstruction investigation was not available for review at the time of the survey.

This finding was reviewed with the Director of Operations at the exit conference.

Based on record review, observation and interview, the facility failed to inspect 1 of 30 portable fire extinguishers in the facility each month. NFPA 10, Standard for Portable Fire Extinguishers, Section 7.2.1.2 states fire extinguishers shall be inspected either manually or by means of an electronic device / system at a minimum of 30-day intervals. Section 7.2.2 states periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for nonrechargeable extinguishers using push-to-test pressure indicators.
Section 7.2.4.1 states personnel making manual inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action. Section 7.2.4.3 requires where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded. Section 7.2.4.4 requires where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method. Section 7.2.4.5 requires records shall be kept to demonstrate that at least the last 12 monthly inspections have been performed. This deficient practice could affect up to 16 residents, as well as staff.

Findings include:

Based on record review on 11/06/24 with the Director of Operations, the annual fire extinguisher inspections occurred 09/27/24. Based on observations with the Director of Operations 11/06/24 during a tour of the facility at 2:50 p.m., the monthly inspection tag on 1 of 2 fire extinguishers located in the second floor Mechanical room lacked documentation of monthly inspections for October 2024. This was confirmed by the Director of Operations at the time of observation.

This finding was reviewed with the Director of Operations at the exit conference.

1. Based on record review and interview, the facility failed to provide quarterly fire drill documentation for 1 of 3 shifts during 1 of 4 quarters. This deficient practice could affect all consumers in the facility.

Findings include:

Based on review of the facility's fire drill reports on 11/06/24 between 9:30 a.m. and 11:30 a.m. with the Director of Operations present, the facility lacked fire drill documentation for the first shift (day) of the second quarter (April, May, and June) of 2024. Based on interview at the time of record review, the Director of Operations said there was no other documentation available for missing fire drills during the previously mentioned shift and quarter of 2024.

2. Based on record review and interview, the facility failed to provide complete fire drill documentation for 11 of 12 fire drills performed during the past 12 month period. This deficient practice could affect all consumers in the facility.

Findings include:

Based on review of the facility's fire drill reports on 11/06/24 between 9:30 a.m. and 11:30 a.m. with the Director of Operations present, all 11 documented fire drills performed during the past 12 month period did not include the transmission of signal of the fire drills. Based on interview at the time of record review, the Director of Operations said there was no other documentation available to show the transmission of the fire alarm signal for each fire drill during the past 12 month period.

These findings were reviewed with the Director of Operations during the exit conference.

Based on observation, records review, and interview; the facility failed to ensure annual inspection and testing of all fire door assemblies were completed in accordance of LSC 19.1.1.4.1.1. Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) LSC 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. NFPA 80, 5.2.3.1 states functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. NFPA 80, 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

NFPA 80, 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
This deficient practice could affect all consumers and all other occupants in the facility.

Findings include:

Based on record review on 11/06/24 between 9:30 a.m. and 2:30 p.m. with the Director of Operations present, no annual inspection of the fire door assemblies were available for review. Based on observations during the tour of the facility between 2:30 p.m. and 3:35 p.m., there were labeled fire door assemblies noted throughout the building that were fire-rated and non-fire rated wall assemblies. Based on interview at the time of records review, the Director of Operations stated annual inspection documentation for the fire door assemblies during the past 12 month period was not available for review, and confirmed the doors in the facility were labeled 90-minute and 45-minute assemblies.

This finding was reviewed with the Director of Operations during the exit conference.

1. Based on record review and interview, the facility failed to document the transfer time to the alternate power source on the monthly load tests for 12 of the past 12 months to ensure the alternate power supply was capable of supplying service within 10 seconds. This deficient practice could affect all consumers, staff and visitors.

Findings include:

Based on record review on 11/06/24 at 1:55 p.m. with the Director of Operations, the Monthly Preventative Maintenance for Emergency Generator log sheets were reviewed over the past year and lacked the transfer time from normal power to emergency power. Based on interview at the time of record review, the Director of Operations confirmed the transfer time is not written on the Monthly Preventative Maintenance log sheets monthly when the load test is conducted.

2. Based on record review and interview, the facility failed to ensure corrective action was taken after an annual fuel quality test was performed for the facility's diesel powered generator. NFPA 99, Health Care Facilities Code, 2012 Edition Section 6.5.4.1.1.2 states Type 2 EES (Essential Electrical System) generator sets shall be inspected and tested in accordance with Section 6.4.4.1.1.3. Section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, 2010 Edition, Chapter 8. NFPA 110, Section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards. This deficient practice could affect all consumers and staff.

Findings include:

Based on record review with the Director of Operations on 11/06/24 at 12:20 p.m., documentation of an annual fuel quality test results for the diesel generator was dated 02/09/24. The result report stated 'Action Required' and that 'iron corrosion is highly elevated. Sulfur level of this fuel is slightly above the ultra low sulfur diesel range. We suggest to polish the fuel to restore the quality and reduce the existing particles. Resample in 3 months to monitor.' Based on interview at the time of records review, the Director of Operations stated the facility does have a diesel generator and that additional documentation to show the fuel quality issues were addressed was not available for review at the time of the survey.

3. Based on record review and interview, the facility failed to ensure a written record of weekly inspections for the generator was maintained for 7 of 52 weeks. NFPA 99, 6.4.4.1.3 requires onsite generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 8.4.1 requires an Emergency Power Supply System (EPSS) including all appurtenant components, shall be inspected weekly and exercised monthly. NFPA 99, 6.4.4.2 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all consumers and staff.

Findings include:

Based on record review with the Director of Operations on 11/06/24 from 9:30 a.m. to 2:30 p.m., documentation for seven weeks of weekly generator testing was not available for review. Those weeks are 01/14/24, 05/19/24, 05/26/24, 06/23/24, 08/11/24, 09/01/24 and 10/06/24. Based on an interview at the time of record review, the Director of Operations confirmed additional weekly generator testing documentation for the above mentioned weeks was not available for review at the time of the survey.

These findings were reviewed with the Director of Plant Operations at the exit conference.

Based on observation and interview, the facility failed to ensure 2 of 2 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used for (1) as a substitute for fixed wiring. This deficient practice could affect up to 2 staff.

Findings include:

Based on observations and interview during a tour of the facility with the Director of Plant Operations on 11/06/24 between 2:30 p.m. and 3:35 p.m., the following was noted:
a) at 2:53 p.m. in the second floor exam room, a power strip was being used to power a refrigerator (high power draw equipment). The Director of Operations plugged the refrigerator into the wall upon observation.
b) at 3:09 p.m. in the Recreational Therapist office on the second floor, a power strip was being used to power a refrigerator (high power draw equipment).

These finding were confirmed by the Director of Operations at the time of discovery and again at the exit conference with the Director of Operations present.