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Based on record review and interview, the facility failed to develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually.

The findings include;

Based on record review and interview with the maintenance staff, on 12/18/18 at 8:50 AM confirmed the facility failed to have a facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.

Facility management was present when the deficiency was identified and acknowledged by the administrative staff and administrator during the exit conference on 12/18/18.

Based on record review and interview, the facility failed to establish policy and protocols for the physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient care related equipment that indicates the tests, repairs, and modifications that are in accordance with service manuals, instructions, and procedures provided by the manufacturer. The deficient practice affected three of three smoke compartments, staff and 1 resident.

The findings include:

Record review and interview on 12/18/18 at 8:47 AM revealed no policy and protocol are established for testing intervals for the physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient care related equipment.
NFPA 101, 2012 Edition 19.7.6, 4.6.12
NFPA 99, 2012 Edition 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Facility management was present when the deficiency was identified and acknowledged by the administrative staff and administrator during the exit conference on 12/18/18.