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Based on record review and interview, the facility did not develop and implement complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR §483.73(b)(1), by failing to address subsistence needs including medical supplies and pharmaceutical needs in the event of an emergency. This deficient practice affects all occupants of the facility. The facility had a capacity of 25 and a census of 5 residents at the time of the survey.

Findings include:

Record review on 10/18/2021 at about 12:05 p.m., revealed the facility did not have a documented policy or procedure for the provisions of medical supplies and pharmaceutical needs in the event of an emergency.

The Facility Manager confirmed these findings during the survey process.

Based on record review and interview, the facility did not develop and implement complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR 483.475(b)(3). The facility failed to include the required information for all entities who provide services. The Emergency Preparedness plan failed to have contact information for patient's physicians, next of kin, guardian, or custodian & other facilities of similar provider or supplier type. This deficient practice affects all occupants of the facility. The facility had a capacity of 25 and a census of 5 residents at the time of the survey.

Findings include:

Record review and interview on 10/18/2021 at about 12:26 p.m., revealed the facility failed to include the required information and contact information for all entities who provide services such as patient's physicians, next of kin, guardian, or custodian & other facilities of similar provider or supplier type.

The Facility Manager confirmed these findings during the survey process.

Based on record review and interview, the facility did not develop and maintain a complete emergency preparedness communication plan in accordance with the Code of Federal Regulations, 42 CFR 483.475(c)(4), by not having updated contact information for Federal, State, & Regional Staff, the office of the State Long Term Care Ombudsman and the state Licensing Agency (DIA). This deficient practice affects all occupants of the facility. The facility had a capacity of 25 and a census of 5 residents at the time of the survey.

Findings include:

Record review and interview on 10/18/2021, at about 12:28 p.m., revealed the facility's communication plan did not include contact information for the Long Term Care Ombudsman, Federal, State and other EP Staff.

The Facility Manager verified this finding during the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas from other compartments. This deficient practice affects several compartments in the building. This could affect all residents, staff and visitors in the facility. The facility has a capacity of 25 and a census of 5.

Findings include:

1. Observation and interview on 10/18/2021 at about 11:54 a.m., revealed the facility failed to separate the Boiler Room from the Maintenance Shop. This room contained a 90 minute rated door that was well wore and in need of replacement. The doors edges were separating and the corners were falling apart.

2. Observation and interview on 10/18/2021 at about 1:01 p.m., revealed the Cardiac Rehab Room had its door closures removed.

3. Observation and interview on 10/18/2021 at about 1:18 p.m., revealed the Stress Test Waiting Room Room had its door closures removed.

4. Observation and interview on 10/18/2021 at about 1:48 p.m., revealed the Med Surge Utility Closet had a tile out of place. In the ceiling area a hole was also observed. This hole would allow for the flow of smoke through the building.


The Facility Manager verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1, by ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage and shall be installed in the correct orientation. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all residents, staff, and visitors who may be in the Kitchen or Boiler Room areas. The facility had a capacity of 25 and a census of 5 at the time of the survey.

Findings include:

1. Based on Observation and interview on 10/18/2021 at about 11:23 a.m., revealed the facility failed to maintain the sprinkler system in the Boiler Room. Several sprinkler heads contained lint and dust throughout.

2. Based on Observation and interview on 10/18/2021 at about 1:52 p.m., revealed the facility failed to maintain the sprinkler system in the Kitchen area. Several sprinkler heads contained lint and dust throughout.

The Facility Manager verified this finding during the survey process.

Based on record review and interview, this facility is not providing proper documentation of inspection and testing of fire and/or smoke door assemblies in openings required to have a fire protection rating in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives, 5.2. This deficient practice affects staff members who would use the basement doors. This facility had a capacity of 25 and a census of 5 residents at the time of the survey.

Findings include:

Record review and interview on 10/18/2021 at about 9:41 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies for the Basement doors. The facility has an attached assisted living facility, an attached Care Center and Basement areas separated by fire doors. Any of these fire doors are required to be functionally tested annually in accordance with NFPA 80 by an individual with knowledge and understanding of the operating components of the type of door being subject to testing.

The Facility Manager verified these documents during the survey process.

Based on observation and interview, the facility did not provide a proper storage of oxygen cylinders in accordance with National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 11.3.2.3 and 11.6.5 by failing to separate oxygen from combustibles or materials and segregate and label empty cylinders from full cylinders, respectively. This deficient practice affects staff in the Med Gas Storage area within the facility. The facility had a capacity of 25 with a census of 5 residents at the time of the survey.

Findings include:

Observation and interview on 10/18/2021 at about 1:36 p.m., revealed the Med Gas Storage Room contained a cardboard box that rested against an oxygen bottle also several combustible chairs were in this same area. During the survey the Facility Manager corrected the violation by removing the items.


The Facility Manager verified these observations during the survey.