Deficiencies in Fire Safety Systems, Emergency Preparedness, and Grounds Maintenance
Penalty
Summary
The facility failed to maintain a safe environment by not correcting impairments related to the fire alarm system, not maintaining outside areas free of fire hazards, and not ensuring the Emergency Preparedness Plan was evaluated and updated annually. During inspection, the Emergency Preparedness Plan was found to have last been reviewed and signed in 2005, with no documentation of a more recent review. The Administrator, newly employed for one week, was unaware of the requirement for annual review and update of the Emergency Preparedness Plan and had not yet reviewed it. The facility housed 52 residents, including 17 who were dependent on ventilators for maintaining oxygen levels. Observations revealed the fire alarm annunciator near the Nurse Station displayed a trouble signal indicating a low battery, and the Maintenance Director confirmed ongoing issues with the fire alarm control panel, including a DC battery charge failure. Service tags on the panel indicated recent attempts to address the issue, but the trouble signal persisted. Additionally, the outside inspection showed overgrown vegetation, dead tree branches, dead brush, and leaves along the rear of the building, particularly near the smoking area, with multiple trees leaning against the roof. The Maintenance Director acknowledged responsibility for grounds maintenance and awareness of the overgrown vegetation but cited workload as a reason for the delay in addressing these hazards.