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Based on record review and interview, the facility did not develop and maintain a complete emergency preparedness plan in accordance with the Code of Federal Regulations, 42 CFR 483.475(a)(3) [ICF]/ 483.73(a)(3) [LTC], by failing to address all hazards. This deficient practice affects all occupants of the facility. The facility had a capacity of 25 and a census of eight patients at the time of the survey.

Record review and interview on 06/30/21 at 9:39 a.m., revealed the facility had not included "emerging infectious diseases" in their all hazard approach. Facilities Director verified this finding during the survey process.

Based on record review, observation, and interview, the facility failed to maintain the automatic sprinkler system within the facility in accordance with the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.7.5 and NFPA Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.4.1.6 and 14.2, by not providing an internal pipe inspection within the last five years. This deficient practice could affect all smoke compartments and occupants of the facility. The facility had a capacity of 25 and a census of 8 patients at the time of the survey.

Findings include:

Record review on 06/30/21 at 11:00 a.m., of the facility's sprinkler system inspection reports, revealed the facility failed to maintain the fire sprinkler system by assuring a five year internal pipe inspection has been performed within the last five years. Interview of the Maintenance Supervisor revealed that he could not locate any paperwork for this inspection, he later verified through Building Sprinkler that is had not been performed within the last five years but it is scheduled for 07/02/21.