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Based on record review the facility failed to include within their EP program, the type of services the facility could provide in an emergency, and the facility continuity of operations plan. This deficency affects the entire facility. Findings include:

1. Review of the facility EP program on 8/2/19 at 11:00 a.m., showed, the facility Emergency Preparedness Program lacked information about the type of services that the facility could provide in an emergency, equipment inventory, information about the facility's patient population, and needs specific for the continuity of facility's operations.

Based on record review the facility failed to plan and implement a provision of subsistence needs for the staff and the patients, whether they evacuated or sheltered in place. This affects all occupants in the facility. Findings include:

1. Review of the EP plan, policies, and procedures on 8/2/19, at 11:00 a.m, showed the facility lacked a complete system for determining subsistence needs for staff and patients, particularly specific needs for food, medical and pharmaceuticals, and sewage and waste disposal.

Based on record review the facility failed to develop a policy and procedure for a means to preserve access, protect residents' confidentiality; and to maintain resident information availability. This affects all of the residents. Findings include:

1. Review of the EP plan policy and procedures on 8/2/19, at 11:00 a.m., showed a lack of a written policy for the retention of the medical documentation that preserved resident information, explaining how the medical information is accessed and secured while its confidentiality is protected. The facility failed to provide a policy and procedure for how medical documentation will be handled during an emergency.

Based on record review, the facility failed to describe its role under an 1135 waiver during the provision of care and treatment at an alternate site during an evacuation. This deficiency affects the entire facility. Findings include:

1. Review of the facility EP program on 8/2/19, at 11:00 a.m., showed the facility's EP plan did not include a policy or procedure for caring of patients at an alternate care site, delineating their role under the 1135 waiver, and showing joint planning on issues related to staffing, equipment and supplies at alternate care sites.

Based on record review, the facility failed to update as needed, an emergency preparedness communication plan. This deficiency has the potential to affect the entire facility. Findings include:

1. Review of the facility EP program on 8/2/19 at 11:00 a.m., showed the facility's communication plan lacked documentation of contact information for entities providing services including paitents physicians, and staff.

Based on record review, the facility failed to develop and implement emergency preparedness (EP) communications plan including contact information for The State Licensing and Certification Agency. Findings include:

1. Review of the facility EP plan on 8/2/19, at 11:00 a.m., showed the facility's emergency preparedness plan lacked contact information for The State Licensing and Certification Agency.

Based on observation, the facility failed to ensure the fire and smoke resistance rating of ceiling assemblies in a building of Type V (111) construction was maintained in accordance with NFPA 101-2012, Section 19.1.6.2 and failed to maintain the 2-hour fire rated barrier in the B-wing, in accordance with NFPA 101-2012, Sections 19.1.3.5 and 8.2.1.3. The deficiency the entire facility.

Findings include:

1. During an observation on 8/2/19 at 9:30 a.m., the maintenance hallway was inspected. A ceiling tile was observed with a portion cut out and wires were extending through the open area.

2. During an observation on 8/2/19 at 9:59 a.m., the basement storage room was inspected. A ceiling tile was missing from the dropped ceiling fixture.

3. During an observation on 8/2/19 at 10:28 a.m., the 2-hour fire rated doors leading to the assisted living facility were inspected. The doors failed to close and positively latch when exercised.

4. During an observation on 8/2/19 at 10:29 a.m., the 2-hour fire rated doors leading from the kitchen to the nursing station were inspected. The doors failed to close and positively latch when exercised.

5. During an observation on 8/2/19 at 10:34 a.m., the materials room was inspected. A ceiling tile was missing from the dropped ceiling fixture.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7.

Findings include:

1. During an observation on 8/2/19 at 9:26 a.m., the self-closure on the basement floor elevator door failed to self close and positively latch when exercised.

2. During an observation on 8/2/19 at 9:29 a.m., the self-closure on the door leading to the maintenance hallway failed to self close and positively latch when exercised.

3. During an observation on 8/2/19 at 9:39 a.m., the basement bathroom door was held open with a non-compliant door holder. The door also had a self-closure.

4. During an observation on 8/2/19 at 10:15 a.m., the CAT scan room door was held open with a non-compliant door holder. The door also had a self-closure.

5. During an observation on 8/2/19 at 10:18 a.m., theX-ray room door was held open with a non-compliant door holder. The door also had a self-closure.

6. During an observation on 8/2/19 at 10:19 a.m., the self-closure on the main floor elevator door failed to self close and positively latch when exercised. The door had an attached self-closure.

7. During an observation on 8/2/19 at 10:20 a.m., the kitchen door was held open with a non-compliant door holder. The door also had a self-closure.

8. During an observation on 8/2/19 at 10:31 a.m., the housekeeping closet by the nursing station was held open with a non-compliant door holder. The door also had a self-closure.

9. During an observation on 8/2/19 at 10:20 a.m., the kitchen door was held open with a non-compliant door holder. The door also had a self-closure.

10. During an observation on 8/2/19 at 10:36 a.m., the self-closure on the personal care closet door failed to self close and positively latch when exercised.

11. During an observation on 8/2/19 at 10:37 a.m., the self-closure on the dirty utility room door failed to self close and positively latch when exercised.

Based on observation, the facility failed to prevent the use of enclosed exit stairway for storage purposes per NFPA 101-2012, Sections 7.1.3.2.3 and 7.2.2.5.3. This deficiency affects 1 of 1 basement smoke compartments.
Findings include:

1. During an observation on 8/1/19 at 10:11 a.m., the basement exit enclosure near the emergency room entrance was inspected. The stairwell enclosure contained a large wooden shelf. Enclosures cannot be used as storage areas.

Based on observation and record review, the facility failed to maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.

These deficiencies affect the entire building.

Findings include:

1. During an observation on 8/2/19 at 9:31 a.m., the maintenance hallway was inspected. An electrical wire was observed lying across the sprinkler pipe.

2. During an observation on 8/2/19 at 9:32 a.m., the maintenance hallway was inspected. Television wires were observed lying across the sprinkler pipe.

3. During an observation on 8/2/19 at 9:36 a.m., the maintenance hall was inspected. A sprinkler head was observed covered with white paint.

4. During an observation on 8/2/19 at 9:37 a.m., the maintenance shop was inspected. A blue IT cord was observed lying across the sprinkler pipe.

Based on observation, the facility failed to maintain corridor doors and to ensure a means suitable for keeping the doors closed in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.5. These deficiencies affect the entire facility.

Findings include:

1. During an observation on 8/2/19 at 10:44 a.m., the corridor door to resident room 9 was inspected. The door would not close and positively latch with a nominal amount of force placed on it.

2. During an observation on 8/2/19 at 10:45 a.m., the corridor door to resident room 19A was inspected. The door would not close and positively latch with a nominal amount of force placed on it.

3. During an observation on 8/2/19 at .10:47 a.m., the corridor door to resident room 20A was inspected. The door would not close and positively latch with a nominal amount of force placed on it.

4. During an observation on 8/2/19 at 10:48 a.m., the corridor door to resident room 21 was inspected. The door would not close and positively latch with a nominal amount of force placed on it.

5. During an observation on 8/2/19 at 10:49 a.m., the corridor door to resident room 25 was inspected. The door would not close and positively latch with a nominal amount of force placed on it.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6. This deficiency affects the entire facility.

Findings include:

1. Review of facility documents regarding fire drills on 8/2/19, showed there was no documentation for completed fire drills for AM and NOC shifts for the second quarter of 2018, and NOC shift for the fourth quarter of 2018.

Based on record review and interview, the facility failed to ensure all dampers were mapped out, tested, documented under simulated fire conditions per NFPA 105-2010, Standard for Smoke Door Assemblies and Other Opening Protectives, Sections 6.5.5 (view full closure of fusible link dampers every 4 years) and 6.5.11 (location of dampers, dates of inspection, and any deficiencies). This deficiency affects all smoke compartments.

Findings include:

1. Review of fire safety inspection reports on 8/2/19 reflected a lack of inspections for the pneumatic and the fusible link dampers wihin the last four years.

During an interview on 8/2/19 at 8:30 a.m., staff member A stated that he did not have any documentation that the dampers had been tested within the last four years.

Based on record review, the facility failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 110, Section 8.3.8 and failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1. The deficiencies affect the entire building.

Findings include:

1. Review of the emergency generator inspection records on 8/2/19, showed the annual diesel fuel supply quality test was not conducted within the last year.

2. During an observation on 8/2/19 at 9:46 a.m., the generator was inspected. The generator lacked a labeled manual stop station at a remote location outside of the room housing the prime mover, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.

Based on observation, the facility failed to ensure extension cords were not used in the facility and that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4. This deficiency affects 1 smoke compartment.

Findings include:

1. During an observation on 8/2/19 at 10:43 a.m., the social services office was inspected. An extension cord was observed, which was in use and plugged into the outlet on the wall.