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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, 483.73(b)(8) [LTC], 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 25 residents at the time of the survey.

Findings include:

Record review on 12/9/2021 at 10:52 a.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; and

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

The Maintenance Supervisor verified this finding during the survey process.

Based on record review, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

Record review on 12/9/2021 at 9:33 a.m. of the fire watch procedures for a sprinkler system outage in the facility's outage policy, revealed the policy was incomplete in that it did not address and was missing the following information:

Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

The Maintenance Director verified the documentation at the time of the survey process.

Based on observation and interview, the facility failed to ensure the building's electrical system, wiring, and equipment are in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.1.2 and NFPA 70, National Electrical Code, 2011 edition, 110.26, by not providing or maintaining access and working space about electrical equipment. This facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

Observation on 12/9/2021 at 12:35 p.m., revealed the facility failed to maintain clearance around the electrical panel within the newest addition Electrical Room in the Basement. This electrical panel had a box of paper being stored in front of it.

The Maintenance Supervisor verified this observation at the time of the survey.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility had a capacity of 25 and a census of 25 residents at the time of survey.

Findings include:

Record review on 12/9/2021 at 10:19 a.m., of the facilities fire drill documentation, revealed the facility failed to conduct fire drills during the following shifts and quarters: The evening shift of the first quarter, the evening shift of the second quarter, the evening and night shifts of the third quarter, and all four shifts of the fourth quarter.

The Maintenance Director verified this finding at the time of the survey.

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 25 residents at the time of the survey.

Findings include:

Record review on 12/9/2021 at 10:06 a.m., revealed the facility could not provide annual documentation of inspection and testing of fire and/or smoke door assemblies within the facility. Annual documentation was provided, however, the inspection and testing was dated 4/9/2019.

The Maintenance Director verified this finding at the time of the survey.

Based on observation, the facility failed to maintain proper space heating appliances within the facility that have heating elements limited to 212 degrees Fahrenheit as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.8/19.7.8. The deficient practice would affect one zone. This facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

Observation on 12/9/2021, at 11:51 a.m., revealed one electric space heater was located in Office IB 107. When tested, this space heater did not shut off when tipped over.

The Maintenance Director verified this finding at the time of the survey.

Based on record review and interview, the facility failed to maintain and test essential electrical system (EES) circuitry, and failed to conduct an annual fuel quality test as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.4.4.1.2 and 6.4.4.2. The deficient practice affects all of the smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

1. Record review on 12/9/2021 at 10:44 a.m., revealed the facility was unable to provide documentation of inspection and exercising the components of the essential electrical system (EES) main and feeder circuit breakers. Interview of Maintenance Staff revealed the facility was unaware of this requirement.

2. Record review on 12/9/2021 at 10:52 a.m., revealed the facility could not provide documentation of an annual fuel quality test for the generator diesel fuel.

The Maintenance Director verified these findings at the time of the survey.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, by failing to use general precautions with power strips and surge protectors and allowing the use of non-approved electrical devices or adapters within the facility. The facility had a capacity of 25 and a census of 25 residents at the time of the survey.

Findings include:

1. Observation on 12/9/2021 at 12:15 p.m., revealed a surge protector providing power to a microwave in Room 166, the Doctor's Sleep Room.

2. Observation on 12/9/2021 at 12:47 p.m., revealed a surge protector providing power to a microwave and toaster within the Basement Storage Room by the Laundry Room.

The Maintenance Director verified these findings at the time of the survey.

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. The facility had a capacity of 25 with a census of 25 residents at the time of the survey.

Findings include:

Observation on 12/9/2021 at 11:28 a.m., revealed the Oxygen Storage Room within the Pulmonary Office contained oxygen cylinders that were not being labeled as "Full". Further inspection revealed there was a cart labeled as "empty" and contained several empty oxygen cylinders.

The Maintenance Director verified these observations during the survey.