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Based on record review and staff interview, the facility failed to provide policies and procedures for applying for a 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 11 patients.

Findings include:

Record review and staff interview on 6/26/19 at 12:14 p.m., revealed the facility did not have policies and procedures in place for applying for a 1135 Waiver as required. Administrative 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, 19.1.3.2 and 8.2.1.3. The facility has a capacity of 25 with a census of 11 patients.

Findings include:

Observations and staff interview on 6/26/19, between 9:00 a.m. and 4:00 p.m., revealed the following deficiencies:

1. There was a penetration, (approximately 1/4 inch), around two communications lines, extending through the 2 hour rated wall separating the Lobby from the Hospital.
2. There was a hole, (approximately 1 inch), extending through the 2 hour wall separating the Emergency Department from the Ambulance Garage.
3. There was a hole, (approximately 1/4 inch), extending through the 2 hour wall separating the Emergency Department from the Ambulance Garage.
4. There was a penetration, (approximately 1 inch), around an insulated pipe, extending through the 2 hour wall separating the Emergency Department from the Ambulance Garage.
5. There was a penetration, (approximately 1/2 inch), around an insulated pipe, 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 monthly test of the system for 30 seconds shall be conducted. A yearly test of the system for 90 minutes shall be conducted. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 11 patients.

Findings include:

Record review and staff interview on 6/26/19 at 10:04 a.m., revealed no available documentation of monthly testing of the battery backup emergency lighting system for August, 2018. Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, the facility failed to inspect, service and maintain the Kitchen Hood and Duct Extinguishment System in accordance with National Fire Protection Association, NFPA 96, 2011 edition. The facility has a capacity of 25 with a census of 11 patients.

Findings include:

Observation and staff interview on 6/26/19 at 2:04 p.m., revealed an excess buildup of grease on the filters of the Kitchen Hood and Duct Extinguishment System. Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to provide automatic fire alarm system occupant notification in the enclosed courtyard in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.4.3.1, 9.6.3.5, and NFPA 72, 2010 edition. The facility has a capacity of 25 with a census of 11 patients.

Findings include:

Observation and staff interview on 6/26/19 at 2:14 p.m., revealed a fire alarm audio/visual notification device was not installed in the enclosed courtyard as required. 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 deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 11 patients.

Findings include:

Record review and staff interview on 6/26/19 at 12:15 p.m., revealed the facility's fire alarm outage policy did not contain all required information as follows:

1. The fire alarm outage policy did not contain all of the following required language: " 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 shall be continuous and all portions of the building will be checked at least once every 30 minutes."

2. The fire alarm outage policy did not include notification of authorities having jurisdiction at both the beginning and conclusion of the outage.

Maintenance Staff verified record review 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 deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 11 patients.

Findings include:

Record review and staff interview on 6/26/19 at 12:15 p.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 have 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 language indicating that all necessary tools and materials have been assembled on the impairment site.
5. The policy did not contain notification of all authorities having jurisdiction at the beginning and end of the impairment.
6. The outage policy for the sprinkler system 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 an 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 staff interview, this facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 25 with a census of 11 patients.

Findings include:

Observation and staff interview on 6/26/19 at 2:37 p.m., revealed a penetration, (approximately 4 inches by 4 inches), around communications lines, extending through the smoke barrier wall by Nuclear Medicine. Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to provide and maintain smoke barrier doors with a minimum 20 minute fire rating, which close and latch properly, in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.6. The facility has a capacity of 25 with a census of 11 patients.

Findings include:

Observation and staff interview on 6/26/19 at 2:49 p.m., revealed one of the Surgery East Smoke Barrier Doors by the waiting room failed to close and latch properly when tested. Maintenance Staff verified observations during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills under varied conditions at different times of the day for four 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 11 patients.

Findings include:

Record review and staff interview on 6/26/19 at 10:53, revealed fire drills were conducted at very similar times of the day as follows: 1st Shift: 1/23/18 at 12:25 p.m., 4/30/18 at 12:30 p.m., 7/26/18 at 12:07 p.m., 10/30/19 at 12:40 p.m., 1/30/19 at 12:15 p.m. 2nd Shift: 2/22/18 at 3:05 p.m., 5/22/18 at 3:10 p.m., 8/15/18 at 3:07 p.m., 11/29/18 at 3:10 p.m., 2/27/19 at 3:10 p.m., 5/29/19 at 3:15 p.m. 3rd Shift: 3/26/18 at 6:35 a.m., 6/25/18 at 6:50 a.m., 9/20/18 at 6:48 a.m., 12/24/18 at 6:45 a.m., 3/29/19 at 6:30 a.m., 6/10/19 at 6:15 a.m. Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to maintain and test the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition, 8.3.8. An annual fuel quality test shall be provided. The facility has a capacity of 25 with a census of 11 patients.

Findings include:

Record review and staff interview on 6/26/19 at 1:42 p.m., revealed the facility did not provide documentation indicating that an annual fuel quality test approved by ASTM Standards was performed. Maintenance Staff verified record review during the survey process.