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Based on record review and interview, the facility failed to update their emergency plan in accordance with the Code of Federal Regulations (CFR) at §485.625(a)). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 20 and a census of 2.

Findings include:

Record review and interview on 04/20/21 at 10:30 a.m., revealed the facility failed to provide documentation that their emergency plan had been reviewed and updated at a minimum biennial basis. Documentation provided indicates the plan was last reviewed and updated in October-November of 2018. The Supervisor Plant Engineering verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to provide a policy for an 1135 waiver in accordance with the Code of Federal Regulations (CFR) at §483.73(b)(8). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 20 and a census of 2.

Findings include:

Record review and interview on 04/20/21 at 10:34 a.m., revealed the facility was unable to provide a written policy in its emergency preparedness plan to address the role of the facility under an 1135 waiver in the provision of care and treatment at an alternate care site identified by emergency management officials. The Supervisor Plant Engineering verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to update the communications plan as part of their emergency preparedness plan in accordance with the Code of Federal Regulations (CFR) at §485.625(c)). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 20 and a census of 2.

Findings include:

Record review and interview on 04/20/21 at 10:40 a.m., revealed the facility failed to provide documentation that the communications plan portion of their emergency preparedness plan had been reviewed and updated at a minimum biennial basis. Documentation provided indicates the plan was last reviewed and updated in October-November of 2018. The Supervisor Plant Engineering verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to update contact information as part of their emergency preparedness plan in accordance with the Code of Federal Regulations (CFR) at §485.625(c)(1)). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 20 and a census of 2.

Findings include:

Record review and interview on 04/20/21 at 10:43 a.m., revealed the facility failed to provide documentation that the contact information portion for their emergency preparedness plan had been reviewed and updated at a minimum biennial basis. Information to include contacts for staff, entities providing services under agreement, patient's physicians, and volunteers. Documentation provided indicates contact information was last reviewed and updated in October-November of 2018. The Supervisor Plant Engineering verified this observation at the time of the survey process.

Based on observation, interview, and record review, the facility failed to inspect and test smoke dampers in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-19.4.1.1 and Section 19.4.9), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 20 and a census of 2.
Findings include:
Observation, interview, and record review on 04/20/21 at 10:24 a.m., revealed the facility contained smoke dampers in the ductwork of the air-handling units. The facility was unable to provide documentation that the dampers had been exercised and inspected within the last 6 years. The Supervisor Plant Engineering and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that smoke barriers are free of gaps and penetrations that compromise the fire-resistance rating of the barriers and would allow the passage of smoke and fire to another smoke zone in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.7.3), 2012 Edition. This deficient practice affects all occupants throughout the facility. This facility has a capacity of 20 and a census of 2.

Findings include:

Observation and interview on 04/20/21 at 10:14 a.m., revealed the facility had a waiver for all duct work penetrations and gaps around the ducts above the hard lid ceilings for all smoke barriers. The duct work for the HVAC system does not contain smoke dampers at the barriers and not all gaps around the duct penetrations are sealed due to inaccessibility due to the hard lid construction of the ceilings. The Supervisor Plant Engineering and Maintenance Staff confirmed this previous waivered item had not been corrected at the time of the survey process.

Based on observation and interview, the facility failed to maintain electrical receptacles in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code, 2011 Edition. This deficient practice could affect approximately 3 residents, staff, and visitors in 1 of 6 smoke zones if the room were occupied. This facility has a capacity of 20 and a census of 2.

Findings include:

Observation and testing on 04/20/21 at 11:13 a.m., revealed that Patient Room #201 was unoccupied. However, the ground fault circuit interrupter (GFCI) electrical receptacle located near the bathroom sink failed to trip when tested. The Supervisor Plant Engineering and Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility is not assuring that power strips are being used in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-10.2.3.6), 2012 Edition. This deficient practice affects approximately 1 staff in 1 of 6 smoke zones. This facility has a capacity of 20 and a census of 2.

Findings include:

Observation and interview on 04/20/21 at 11:06 a.m., revealed the Overnight Doctor Room #406 contained a surge protector being used to supply power to a microwave. The Supervisor Plant Engineering and Maintenance Staff verified this observation at the time of the survey process.