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Based on record review and interview the facility failed to prepare an All Hazards Risk Assessment as part of their emergency preparedness plan in accordance with the requirements of CFR 403.748(a)(1)-(2). This deficient practice could affect all patients and an unknown number of staff and visitors.

Findings include:

On 09/19/2023 at 11:54am, review of the facility's emergency preparedness plan titled "Emergency Management 2023-2024" dated/reviewed 03/02/23 revealed that the plan's Hazard Value Analysis assessed the spread of infection as the number one hazard but failed to provide a policy to address the hazard in the EPP binder.

These deficient practices were confirmed by Staff S, T, U, V and W at the time of discovery.

Based on record review and interview, the facility failed to prepare and maintain an emergency preparedness plan in accordance with the requirements of CFR 483.73. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 09/19/2023 at 12:18 PM, review of the document titled " Emergency Management 2023-2024" dated/reviewed 03/02/23, revealed that the document did not include patient transfer agreements with other providers.

These deficient practices were confirmed by Staff S, T, U, V and W at the time of discovery.

Based on observation and interview, the facility did not maintain doors in stairway enclosures, smoke barriers, or hazardous area enclosures to be self-closing doors or automatic closing devices that released with the fire alarm or local smoke detectors complying with NFPA 101, 2012 edition, Sections 19.2.1, 19.2.2.2.7, 19.3.6.3.5, 19.3.7.8, 7.2.1.8.2, 8.3.3.3, 8.4.3, and 8.5.4.4; NFPA 72, 2010 Edition, Section 17.7.5.6.6.1; as well as NFPA 80, 2010 edition, Section 6.3.1.7.1. This deficient practice could affect 4 of 15 patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 09/19/2023 at 1:36 PM, observation revealed that room #103, a room greater than 50 sq. ft, of the sleep lab was being used for storage. Three additional beds and mattresses, a mattress standing against the wall and a chest of draws were stored there.
2. On 09/19/2023 at 1:37 PM, observation revealed that rooms #104, a room greater than 50 sq. ft, of the sleep lab was being used for storage.
3. On 09/19/2023 at 1:40 PM, observation revealed that the self-closing, 20-minute rated, smoke barrier door #1C290 adjacent near room 113 had one leaf which was stuck closed to the frame.

These deficient practices were confirmed by Staff S, T, U and V at the time of discovery.

Based on observation and interview, the facility did not maintain doors in rated wall enclosures to be self-closing doors or automatic closing devices complying with NFPA 101, 2012 edition, Sections 19.3.2.1, 19.3.2.1.5, 19.2.2.2.7, 19.3.6.3.5, 19.3.6.3.10, 8.3.4.2, 8.7.1.3, and 7.2.1.8. This deficient practice could affect an undetermined number of staff and visitors.

Findings include:

1. On 09/19/2023 at 2:31 PM, observation of the two 2-hour fire rated doors in the corridor leading to the ambulance bay revealed that when tested three times the doors would not completely close and would hang up on the doors' coordinator.

These deficient practices were confirmed by Staff S, T, U and V at the time of discovery.