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Based on record review and staff interview, the facility failed to provide documentation of a tracking system as part of their emergency preparedness plan policies and procedures to include a system to identify the location of both residents and on duty staff as required by 42 CFR 483.73(b)(2). The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 10/14/20 at 12:53 p.m., revealed the facility failed to provide documentation of a tracking system as part of their emergency preparedness plan policies and procedures to include a system to identify the location of both residents and staff as required. The facility had language indicating tracking of residents but did not include a system to track on duty staff. Administrative and Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to provide policies and procedures for applying for an 1135 Waiver as required by 42 CFR 483.73(b)(8). The deficient practice affects all residents and staff. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 10/14/20 at 12:53 p.m., revealed the facility did not have policies and procedures in place for applying for an 1135 Waiver as required. Administrative Staff and Maintenance Staff verified record review for Emergency Preparedness during the survey process.

Based on observations and staff interview, the facility failed to maintain all 2 hour rated walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.5 and 8.2.1.3. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observations and staff interview on 10/14/20, between 9:00 a.m. and 3:00 p.m., revealed the following deficiencies:

1. There was a hole, (approximately 3 inches), extending through the 2 hour rated wall in the Basement by the Cafeteria.
2. There was a penetration, (approximately 1/4 inch), around an insulated pipe extending through the 2 hour rated wall in the Basement by the Cafeteria.
3. There was a penetration, (approximately 1/2 inch), around a conduit extending through the 2 hour rated wall in the Basement by the Cafeteria.
4. There was an open pipe, (approximately 1 inch), extending through the 2 hour rated wall in the Basement by the Cafeteria that was not properly sealed.
5. There was an open pipe with red wires running through it, (approximately 1 inch), extending through the 2 hour rated wall in the Basement by the Cafeteria that was not properly sealed.
6. There were 8 holes, (all approximately 3/16 inch), extending through the 2 hour wall separating the Emergency Department from the Ambulance Garage.
7. There were 4 holes, (all approximately 1/4 inch), extending through the 2 hour wall separating the Emergency Department from the Ambulance Garage.

Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to test and maintain the emergency lighting system in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 7.9 and 19.2.9.1. A yearly test of the system for 90 minutes shall be conducted. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 10/14/20 at 11:06 a.m., revealed no available documentation of annual 90 minute testing of the emergency lighting system since 2018. Maintenance Staff verified record review during the survey process.

Based on observations and staff interview, the facility is not properly separating hazardous areas from other compartments. Hazardous areas shall be separated from other compartments by fire rated construction and self-closing doors in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.2.1. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observations and staff interview on 10/14/20, between 9:00 a.m. to 3:00 p.m., revealed the following deficiencies:

1. The corridor door to the South Basement Mechanical Room failed to close and latch properly upon swing of the door.
2. The corridor door to the Laundry Room failed to close and latch properly upon swing of the door.
3. The automatic closure device was removed from the corridor door to the Basement North Materials Storage Room.

Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. The primary power supply for the fire alarm system shall be mechanically protected. The location of the power supply for the fire alarm system shall be labeled at the main fire alarm control panel. Smoke detectors shall be maintained in proper condition. A signal shall be sent to a fire alarm panel or annunciator in a location staffed 24 hours a day in the event of a phone line communications failure. The facility has a capacity of 25 with a census of 3 residents.

Findings include:

Observations and staff interview on 10/14/20 at 1:30 p.m., revealed the following deficiencies:

1. The location of the power supply for the fire alarm system was not labeled at the main fire alarm control panel.
2. The circuit breaker supplying power to the fire alarm system was not mechanically protected.
3. There was a smoke detector in Room 131 that was not properly secured to the ceiling tile grid.
4. There was a smoke detector in Room 139 that was not properly secured to the ceiling tile grid.
5. Upon testing of the fire alarm system, a signal was not sent to a fire alarm panel or fire alarm annunciator panel in a location that is staffed 24 hours a day in the event of a phone line communications failure.

Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 10/14/20 at 10:52 p.m., revealed the fire alarm outage policy did not contain all required language and information as follows:

"When the fire alarm system is out of service for more than 4 hours in a 24 hour period, the Impairment Coordinator shall arrange for one of the following:
a) Evacuation of the building or portion of the building affected by the outage.
b) An approved fire watch. The fire watch is continuous and all portions of the facility will be checked at least once every 30 minutes."

Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to inspect and maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. Smoke detectors shall be tested for sensitivity every 2 years. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 10/14/20 at 11:37 a.m., revealed no available documentation of smoke detector sensitivity testing. Maintenance Staff verified record review during the survey process.

Based on observations and staff interview, this facility is not maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observations and staff interview on 10/14/20, between 9:00 a.m. and 3:00 p.m., revealed the following deficiencies:

1. There was a missing escutcheon for a sprinkler head installed on the ceiling of the Lobby by the Main Entrance.
2. There was a dirty sprinkler head on the ceiling of the Kitchen above the steamer.

Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.7.6. and National Fire Protection Association, NFPA 25, 2011 edition. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 10/14/20 at 10:52 a.m., revealed the sprinkler system outage policy did not contain all required information as follows:

1. The policy did not contain language indicating that the extent and expected duration of the impairment has been determined.
2. The policy did not contain language indicating that the areas or buildings involved have been inspected and increased risks determined.
3. The policy did not contain language indicating that recommendations have been submitted to management or the property owner.
4. The policy did not contain notification of the insurance carrier.
5. The policy did not contain language indicating that a tag impairment system has been implemented.
6. The policy did not contain language indicating that all necessary tools and materials have been assembled on the impairment site.
7. The policy did not address all of the following conditions: System leakage. Interruption of water supply. Ruptured piping. Equipment failure.
8. The policy did not contain all of the following required language: "When the sprinkler system is out of service for more than 10 hours in a 24 hour period, the Impairment Coordinator shall arrange for one of the following:
a) Evacuation of the building or portion of the building affected by the outage.
b) An approved fire watch.
c) Establishment of a temporary water supply.
d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire."

Maintenance Staff verified record review during the survey process.

Based on observation and interview, the facility failed to properly mount all fire extinguishers as required by National Fire Protection Association, NFPA 10, 2010 edition. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Observation and staff interview on 10/14/20 at 1:24 p.m., revealed the fire extinguisher in the Laundry Room was not properly mounted. Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide emergency plans and procedures as required by National Fire Protection Association, NFPA 101, 2012 Edition, 19.7.2.2. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 10/14/20 at 9:58 a.m., revealed the fire emergency plan and procedures policy did not contain all required information as follows:

1. The policy did not contain the use of all types of fire extinguishers in the facility.
2. The policy did not contain the use of the Kitchen Hood and Duct Extinguishment System.

Maintenance Staff verified record review during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills and maintain proper documentation of fire drills under varied conditions at different times of the day for two of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 10/14/20 at 11:31 a.m., revealed the following deficiencies:
1. There was no available documentation of fire drills during all shifts in the 2nd Quarter of 2020.
2. There was no available documentation of a fire drill for the 3rd Shift during the 3rd Quarter of 2020.
Maintenance Staff verified record review during the survey process.

Based on record review and staff interview the facility is not conducting an annual inspection of fire door assemblies in accordance with National Fire Protection Association, NFPA 80, 2010 Edition, The Standard for Fire Doors and Other Opening Protectives. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 10/14/20 at 11:21 a.m., revealed no available documentation of an annual inspection of fire door assemblies as required. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to properly document monthly testing under load of the generator set and perform weekly inspections of the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. The facility has a capacity of 25 with a census of 3 patients.

Findings include:

Record review and staff interview on 10/14/20 at 10:59 a.m., revealed the following deficiencies:

1. There was no available documentation of weekly inspections of the generator set.
2. There was no available documentation of meter start and stop readings during monthly testing of the generator set under load.

Maintenance Staff verified record review during the survey process.