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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 CF 482.15 by failing to incorporate policies and procedures in its emergency plan describing the facility's role under a waiver in accordance with Social Security Act, Section 1135, in the provision of care and treatment at an alternate care site identified by emergency management officials. This deficient practice affects all occupants of the facility. The facility had a capacity of 25 and a census of 8 patients at the time of the survey.

Findings include:

Record review and interview on 11/04/20 at 12:45 p.m., revealed the facility's emergency preparedness policies and procedures did not specifically address the facility's role in emergencies where the Health and Human Services Secretary declares a public health emergency. The emergency preparedness plan failed to demonstrate the facility's general awareness of the 1135 process, including the following:

1) Knowledge of how to request a waiver and who to contact (contact information) in the event an 1135 waiver needs to be requested.

2) The circumstances when an 1135 waiver might be granted based on the risk analysis.

3) How they would operate under and outline the responsibilities during the duration of the waiver period.

4) How they would plan jointly on issues related to staffing, equipment, and supplies.

The Maintenance Supervisor and the Administrator verified this finding during the survey process.

Based on observations and interviews, the facility failed to provide a one hour enclosure for the Elevator Equipment Room in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2. The facility had a capacity of 25 rand a census of 8 at the time of the survey.

Findings include:

Observation and interview on 08/21/2015 at 10:04 a.m., revealed gaps (approximately 1/2 inch in size) around three pipe penetrations and one (one inch) hole in the Basement Elevator Room (Room LL20). The Maintenance Supervisor confirmed this observation at the time of 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 facility had a capacity of 25 and a census of 8 patients at the time of the survey.

Findings include:

Record review and interview on 11/04/20 at 9:50 a.m., revealed the facility could not provide documentation of inspection and testing of fire and/or smoke door assemblies within the facility. Fire doors required to be functionally tested annually by an individual with knowledge and understanding of the operating components of the type of door being subject to testing. Interview of Maintenance Staff A and the Administrator revealed the facility staff was unaware of the inspection requirement and verified this finding during the survey.


NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 edition, 5.2* Inspections.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.3 Functional Testing.

5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

5.2.4.2 As a minimum, the following items shall be verified:

(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so
equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in
working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions.

5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay.

5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.