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Based on record review and staff interview the facility failed to develop and maintain a comprehensive emergency preparedness program that meets the requirements. This had potential to affect all 31 residents in the facility.

Findings include:

Record review on 01/09/18 between 10:00 A.M. to 1:30 P.M. noted the facility failed to complete three core elements of an Emergency Preparedness program. The facility had an Emergency Preparedness outline. The elements not completed include a comprehensive hazard vulnerability assessment, a training program and overall testing of the emergency preparedness program. The training program failed to include documentation for training of new staff and in-servicing of staff annually nor was a table top and/or full-scale exercise completed as concluded from an interview with staff #4 on 1/09/19 at approximately 2:30 PM. The Hazard Vulnerability Assessment (HVA) conducted by the facility addressed 34 types of hazards. Each hazard was rated with a high, medium or low risk, severity of impact and preparation level. The HVA provided failed to document a plan for each type of potential hazard identified.

Interview with Administrator #1 at time of discovery verified the facility had an incomplete Emergency Preparedness program.

Based on observation and staff interview the facility failed to provide the type of construction in accordance with NFPA 101 - 2012 Edition Section 19.1.6.1 through 19.1.6.7. This finding had the potential to affect all 31 residents in the facility. The facility census is 31.

Findings include:

Observation on 01/08/19 during facility tour between 9:00 A.M. and 1:00 P.M. and on 01/09/19 between 8:30 A.M. and 10:00 A.M. noted the building was a three-story building with a one-story addition. The original building was observed to be construction Type II (111). The one-story addition identified as the Office/Dining wing was observed to be Type III (200). These construction types were also confirmed with a copy of the facilities Certificate of Occupancy. The occupancy use group for the three-story original building was listed as I-2 (Healthcare). The occupancy use group for the one-story Office/Dining wing was listed as I-2 (Healthcare). There was not a two-hour fire rated separation between the two different construction types of the original building and wing addition. The type III (200) is not an acceptable construction type for a three-story Existing Healthcare Occupancy. Further observation revealed above the ceiling tile on the first floor of the building structure consisted of cinder block. The walls had a label painted on them that stated one-hour. There were two doors separating the original structure and Office/Dining Wing that were not fire rated. These doors had large windows. The windows had no fire rating. There were two doors separating the Dining Room and Kitchen. These two doors had different fire ratings. One door was 90 minutes and the other door was three-hour.

Interview with Director of Plant Operations (DPO) #2 and Corporate Director of Construction (CDC) #3 at the time of discovery during tour verified the findings. Further interview with CDC #3 revealed that the walls separating the original three-story structure and one-story addition were only one-hour fire rated. CDC #3 on 01/08/19 at 9:00 A.M. noted on the floor plans the fire separations and ratings which also revewal there was only a one-hour fire rated separation.

Based on record review and staff interview the facility failed to perform the monthly and/or annual inspections of emergency and Exit lighting in accordance with NFPA 101 - 2012 Edition 7.9.3.1.2. This finding has potential to affect 31 residents in the facility. The facility census is 31.

Findings include:

Record review on 01/07/19 from 9:00 A.M. to 3:30 P.M. and on 01/08/19 between 8:45 A.M. and 10:00 A.M. revealed no documentation of the annual or monthly inspections for Emergency and Exit lights for the last 12 months. These records were requested on 01/07/19, 01/08/19, and 01/09/19.

Interview with Director of Plant Operations (DPO) #2 confirmed the lack of records and shared their impression that because the entire facility was on generator back-up that the monthly and annual test were not required for any emergency lighting.

Based on record review, observation and staff interview the facility failed to ensure inspection and cleaning of kitchen hood system in accordance with NFPA 101 - 2012 Edition 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, and NFPA 96 - 2011 Edition Section 11.2. This finding had the potential to affect 31 residents. The facility census is 31.

Findings include:

Record review on 01/07/19 from 9:00 A.M. to 3:30 P.M. and on 01/08/19 between 8:45 A.M. and 10:00 A.M. revealed no documentation of kitchen hood system cleaning after 04/17/18.

Observation on 01/08/19 during tour of the facility between 9:00 A.M. and 1:00 P.M. noted a hood cleaning completion sticker posted on the Kitchen Hood. The date marked on this sticker was April 17, 2018.

Interview with Director of Plant Operations (DPO) #2 at time of discovery verified this finding. Further interview with DPO revealed there were no additional records available.

Based on record review and staff interview the facility failed to ensure fire dampers were maintained in accordance with NFPA 101 2012 Edition section 19.5.2, NFPA 90 A-2012 Edition, Section 5.4.8, and NFPA 80-2010 Edition, Section 19.4. This finding could potentially affect all 31 residents residing in the facility.

Findings include:

Record review on 01/07/19 from 9:00 A.M. to 3:30 P.M. and on 01/08/19 between 8:45 A.M. and 10:00 A.M. revealed no documentation of the last fire damper inspection and test performed. Certificate of Occupancy was 04/26/16. There was no report of the inspection and test of the fire dampers after installation.

Interview with Director of Plant Operations (DPO) #2 and Corporate Director of Construction (CDC) #3 at time of discovery verified this finding. Further interview with CDC#3 confirmed there were fire dampers throughout the facility and that the facility did not have record of the test and inspect after installation.

Based on observation, record review and staff interview the facility failed to ensure staff were properly trained in emergency procedures and fire plans in accordance with NFPA 101 - 2012 Edition 19.7.1 and 19.7.2.1. This finding had the potential to affect all 31 residents in the facility.

Findings include:

Interview with staff on 01/08/19 during tour of the facility between 10:00 A.M. and 1:00 P.M. noted staff did not know the location of the fire safety plan when requested. Observation during tour revealed the fire evacuation maps were not posted on the facility walls. A request to review the fire safety plan accessible to staff was made.

The Corporate Director of Construction (CDC) #3 stated the plan is located at the Nurse Station. The staff requested were not able to locate the plan. Other staff in the area were assisting in locating a plan. However, no staff were able to locate a copy of the fire safety plan.

Record review on 01/07/19 from 9:00 A.M. to 3:30 P.M. and on 01/08/19 between 8:45 A.M. and 10:00 A.M. noted the facility's Fire Safety Plan did not have all the required elements by NFPA 101 - 2012 Edition. The fire plan did not address preparation of floors and building for evacuation. The plan also did not address transmission of alarms to fire department.

Interview with the Director of Plant Operations (DPO) #2 and the Corporate Director of Construction (CDC) #3 at time of discovery during tour verified this finding.

Based on record review and staff interview the facility failed to ensure fire drills were conducted on each shift quarterly at varied times in accordance with NFPA 101 - 2012 Edition, Sections 19.3.4.3.2, 19.7, 9.6.1.3, 9.6.4, 10.18.3, NFPA 72 - 2010 Edition Sections 26.6.3.1.7. This deficient practice has the potential to affect 31 residents residing in the facility.

Findings include:

Record review on 01/07/19 from 9:00 A.M. to 3:30 P.M. and on 01/08/19 between 8:45 A.M. and 10:00 A.M. noted fire drills were not conducted under varied conditions. There were no records of fire drills conducted between the hours of 6:10 A.M. to 12:10 P.M. or between the hours of 6:15 P.M. and 4:25 A.M. during the last 12 months.

Per review there was no record of transmission of fire alarms to the monitoring company testing. For fhe months of May, June, September, and October 2018 there were no records of fire drills conducted. There was also no record of testing of transmission of fire alarms to the monitoring company.

Interview with Director of Plant Operations (DPO) #2 and Corporate Director of Construction (CDC) #3 at time of discovery during tour verified these findings.

Based on record review and staff interview the facility failed to ensure fire door assemblies were annually inspected and tested in accordance with NFPA 101 - 2012 edition Section 7.2.1.15, 8.5.4, and NFPA 80 5.2.4. This deficient practice had the potential to affect all 31 patients.

Findings include:

Record review on 01/07/19 from 9:00 A.M. to 3:30 P.M. and on 01/08/19 between 8:45 A.M. and 10:00 A.M. revealed no record of fire doors being inspected and tested according to applicable codes. In the facility were numerous doors with fire rated labels of 90 minutes and higher. The record provided revealed only a monthly check of corridor doors for open, close, latch, lock, and door closer speed.

Interview with Director of Plant Operations (DPO) #2 at the time of discovery during tour verified the findings. Further interview revealed the facility was unaware of any other inspections required for fire rated doors.

Based on record review and staff interview the facility failed to test and maintain electrical outlets in accordance with NFPA 99 - 2012 Edition, Section 6.3.3.2. This finding had the potential to affect all 31 residents.

Findings include:

Record review on 01/07/19 from 9:00 A.M. to 3:30 P.M. and on 01/08/19 between 8:45 A.M. and 10:00 A.M. revealed no evidence of receptacle outlet testing.

The record of electrical outlet inspections was requested at entrance and during the survey several times with the Director of Plant Operations and Corporate Director of Construction. There were no records made available for review during the survey.

Interview with Director of Plant Operations #2 and Corporate Director of Construction at time of discovery verified the findings.