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Based on record review and interview, the facility failed to test their emergency preparedness plan in accordance with the Code of Federal Regulations (CFR) at §483.73(d)(2). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 11.

Findings include:

Record review and interview on 02/04/25 at 10:45 a.m., revealed the facility failed to provide documentation for a second full scale community or facility based exercise or conduct a tabletop exercise that challenges the facility 's emergency preparedness plan.

The Maintenance Director verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to provide an adequate outage policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.5.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 11.

Findings include:

Record review and interview on 02/04/25 at 10:10 a.m., revealed the provided Sprinkler Outage Policy for the system being out of service for 10 or more hours in a 24 hour period did not address emergency impairments such as system leakage, interruption of water supply, ruptured piping, or other equipment failure.

The Maintenance Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain smoke barrier doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.7.8(1), 2012 Edition. This deficient practice affects approximately 10 residents, staff, and visitors in 2 of 11 smoke zones. This facility has a capacity of 25 and a census of 11.

Findings include:


Record review and interview on 02/04/25 at 11:10 a.m., revealed that the 1963 hallway east west doors failed to fully close when initiated.

The Maintenance Supervisor verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain access and working space around electrical panels in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code (Section-110.26), 2011 Edition. This deficient practice affects approximately 1 staff in 1 of 11 smoke zones. This facility has a capacity of 25 and a census of 11.

Findings include:

Observation and interview on 02/04/25 at 10:45 a.m., revealed numerous items being stored directly around and up to the electrical panels in the downstairs server room.

The Maintenance Director verified this observation at the time of the survey process.

Based on record review and interview, the facility is not conducting fire drills at unexpected times under varying conditions at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors as the lack of drills can affect the abilities of staff to respond in the event of an actual emergency. This facility has a capacity of 25 and a census of 11.

Findings include:

Record review and interview on 02/04/25 at 09:45 a.m., revealed that the facility was conducting fire drills quarterly on each shift however all drills were conducted within 60 minutes of all other drills in the past 12 months. First shift drills were commonly conducted at 1000 or 1030 while second shift drills were commonly conducted at 1500.

The Maintenance Supervisor verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect and exercise main and feeder circuit breakers for their emergency generator in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.4.4.1.2.1), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 11.
Findings include:
Record review and interview on 02/04/25 at 11:30 a.m., revealed that the facility was unable to provide documentation for annual inspection and exercising of the main and feeder circuit breakers for their emergency generator.
The Maintenance Supervisor verified this observation at the time of the survey process.