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Based on record review and interview, the facility failed to provide plans for all hazards in accordance with the Code of Federal Regulations (CFR) at §483.73(a)(2). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 49 and a census of 21.
Findings include:
1. Record review and interview on 09/16/25 at 10:00 a.m., revealed that the facility was unable to provide documentation in their Emergency Preparedness Plan for how to deal with all events identified in their risk assessment. The facility did not identified infectious diseases in their risk assessment of their Emergency Preparedness Plan. The CEO and Maintenance Supervisor verified this observation at the time of the survey process.
2. Record Review and interview on 09/16/25 at 10:00 a.m., revealed that the facility was unalbe to provide documentation in there Emergency Preparedness Plan for how to deal with all events identified in their risk assessment. The facility did not identified cyber attack in their risk assessment of their Emergency Preparedness Plan. The CEO and Maintenance Supervisor verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide illumination of means of egress in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.8.1.1 and Section-7.9.2.7), 2012 Edition. This deficient practice affects all residents, staff, and visitors in all smoke zones. This facility has a capacity of 49 and a census of 21.

Findings include:

Observation and interview on 09/17/25 at 11:15 a.m., revealed the diesel emergency generator was enclosed and did not have any emergency lights on the inside of the closer that were battery powered. The reasoning for the battery powered emergency light in the enclosed area to help in case of a power failure of the emergency generator. The area of the enclosed emergency generator should have at least two battery powered back up emergency lights.

The Maintenance Supervisor confirmed this finding during the process of the survey.

1. Based on record review and interview, the facility did not maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 Edition, 14.6.2.4, 14.3.1, and 14.4.5. The deficient practice of not conduction semi-annual inspections of the fire alarm system does not ensure proper operation and prompt repair, affecting all occupants. This facility had a capacity of 49 and a census of 21 residents at the time of the survey.

Findings include:

Record review on 09/17/25 at 9:48 a.m., of the fire alarm inspection and testing forms conducted by General Fire and Knight Protection revealed the fire alarm system was inspected and tested on 05/27/25 and 04/23/24, however, this inspection and testing of the fire alarm system was overdue and did not ensure proper operation of the system.

This deficient practice was confirmed by the Maintenance Supervisor at the time of the survey.

2. Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.6.1.3), 2012 Edition and National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.2.1.2.2), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 49 and a census of 21.

Findings include:

Observation and interview on 09/17/25 at 12:07 p.m., revealed the medical surgery floor kitchen area open to the corridor on the second floor was missing a required smoke detector.

This deficient practice was confirmed by the Maintenance Supervisor at the time of the survey.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.1.1.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 49 and a census of 21.

Findings include:

Record review and interview on 09/17/25 at 9:42 a.m., revealed the facility failed to conduct quarterly testing of the sprinkler system for the first quarter of 2024/2025. The Mainentance verified this observation at the time of the survey process.

Based on record review and interview, the facility was not properly documenting all elements of testing for the emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.4.2), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 49 and a census of 21.

Findings include:

Record review and interview on 06/17/25 at 11:11 a.m., revealed the facility was doing the monthly load testing of the facility ' s diesel powered Emergency Generator. The facility was not documenting an testing done for the months of February or May in 2025. The Maintenance Supervisor verified this observation at the time of the survey process.