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Based on record review and interview, the facility failed to provide a policy for an 1135 waiver in accordance with the Code of Federal Regulations (CFR) at §485.625(b)(8). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 5.

Findings include:

Record review and interview on 10/29/24 at 10:20 a.m., revealed the facility was unable to provide a written policy in its Emergency Preparedness Plan to address the role of the facility under an 1135 waiver in the provision of care and treatment at an alternate care site identified by emergency management officials. The CFO verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain a 2-hour fire separation in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.1.3.5), 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 5.

Findings include:

Observation and interview on 10/29/24 at 12:08 p.m., revealed a 2-hour fire separation with a 3/4-inch and a 1-inch open to the center conduit penetrations being used for communications wiring. Located above ceiling near the PT Entrance in the separation between the hospital and the attached VMH Clinic. The Facilities Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure that required self-closing doors are maintained in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.2.2.2.7), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 2 of 9 smoke zones. This facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 10/29/24 at 12:10 p.m., revealed the 1-1/2 hour fire rated cross corridor double doors located in the Center Hall near Admitting failed to fully self-close and positively latch within the door frame as required. The Facilities Director verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.2.1.3), 2012 Edition. This deficient practice affects approximately 5 staff in 1 of 8 smoke zones. This facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 10/29/24 at 12:26 p.m., revealed the corridor door to the 2nd Floor Medical Records Storage Room failed to fully self-close and positively latch within the door frame as required. This room was greater than 50 square feet and being used for the storage of combustible materials. The Facilities Director verified this observation at the time of the survey process.

Based on observation, interview, and record review, the facility failed to maintain their fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.6.1.3), 2012 Edition, National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.2.1.2.2), 2010 Edition, and National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-19.4.1.1 and Section 19.4.9), 2010 Edition. These deficient practices affect all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 5.

Findings include:

1. Observation and interview on 10/29/24 at 9:30 a.m., revealed the fire alarm system control panel (FACP) indicated the system was in trouble mode.

2. Record review and interview on 10/29/24 at 11:19 a.m., revealed the facility was unable to provide any documentation for 6-year inspection and testing of their installed fire and smoke dampers throughout the facility. The Facilities Director verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain electrical junction boxes 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-314.25) , 2011 Edition. This deficient practice affects approximately 1 staff in 1 of 8 smoke zones. This facility has a capacity of 25 and a census of 5.

Findings include:

Observation and interview on 10/29/24 at 11:47 a.m., revealed an open electrical junction box with exposed wires located along the east wall in the 1st Floor IT Storage Closet. The Facilities Director verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to provide a complete fire safety plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.2.2(9)), 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 5.

Findings include:

Record review and interview on 10/29/24 at 11:29 a.m., revealed the provided Fire Safety Plan did not address the use of the different types of portable fire extinguishers in the facility. Nor did the plan address the use of the kitchen hood suppression system. The Facilities Director verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect and test fire door assemblies in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-5.2.1 and Section-5.2.14.3), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 5.

Findings include:

Record review and interview on 10/29/24 at 11:15 a.m., revealed the facility was unable to provide current documentation for annual inspection and testing for any of the required fire rated door assemblies throughout the facility. To include the rated roll down fire doors located at X-Ray and the Kitchen. Documentation provided indicates inspection and testing was last conducted in 2019. The Facilities Director verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to inspect their emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.4.1), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 5.

Findings include:

Record review and interview on 10/29/24 at 10:43 a.m., revealed the facility is not consistently conducting weekly inspections of their diesel powered emergency generator. Review of their generator logs showed gaps in dates between 08/28/24-09/09/24, 09/26/24-10/07/24, and 10/12/24-10/21/24. The Facilities Director verified this observation at the time of the survey process.