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Based on document review and interview, the facility failed to maintain and update the emergency preparedness (EP) policies and procedures per requirements of 42 CFR §483.73(b) (1).
Findings Include:
On April 9, 2019 at 12:35 PM, the facility failed to provide updated policies and procedures containing amount of water supply in the facility. Documentation review revealed the EP policies and procedures stated the facility shall have120 gallons of reserve water, but observation revealed 1.5 gallons of reserve water in the facility on the day of survey.
The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on April 9, 2019.

Based on observation and testing, the facility failed to properly protect and maintain exit egress doors latching in accordance to NFPA 101 sections 19.2.2.2.4 & 7.2.2. This deficiency practice affected three (3) of nine (9) exits in the facility on the day of survey.
Findings Include:

On April 9, 2019, observation revealed the following exit doors lacked positive latching devices in the facility:

1) North Stairwell door on 2nd floor
2) North Stairwell door on 3rd floor
3) West Stairwell door on 3rd floor

The 2nd floor north, 3rd floor north and 3rd floor west stairwells were incapable of resisting the passage of smoke throughout the facility.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on April 9, 2019.

Based on observations the facility failed to provide the required fire resistance rating for the exit stairwell in accordance with NFPA 101 19.2.2.3, 7.2.2. This deficient practice has the potential of affecting one (1) of three (3) exits on the 2nd floor of the facility on the day of survey.

On April 9, 2019 at 10:50 AM, observations revealed open and unsealed holes in the North Stairwell door on the 2nd floor of the facility. The 2nd floor North Stairwell was incapable of resisting the passage of smoke throughout the facility.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on April 9, 2019.

Based on the review of documentations, the facility failed to properly inspect and do preventive maintenance of the generator as directed by NFPA 99 sections 6.4.4.1.1.3 and 6.4.4.2. This deficient practice has the potential of affecting entire facility on day of survey.
Findings include:
On April 9, 2019, at 12:20 PM, the facility could not produce documentation showing annual testing and certification of the generator over the last 12 months. The annual testing and certification shall be conducted by certified generator company.
The finding was acknowledged by the Facility Representative and Maintenance Supervisor verified this observation during the exit interview on April 9, 2019.