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Based on record review and staff interview, the facility did not develop policies for hazards identified in the risk assessment as required by 42CFR 485.625(a)(1)-(2). The deficient practice affects the entire facility. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 7/31/19 at 12:01 p.m., revealed the facility did not develop policies and include them as part of the emergency preparedness program for all hazards identified in the risk assessment. Administrative and Maintenance Staff verified record review for emergency preparedness.

Based on record review and staff interview, the facility failed to have policies and procedures that include a tracking system used to identify the location of sheltered or relocated residents and on-duty staff in accordance with 42 CFR 483.73(b)(2). The deficient practice affects the entire facility. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 7/31/19 at 12:01 p.m., revealed the facility failed to have policies and procedures that include a tracking system to identify the location of residents and on-duty staff in an emergency as required. Administrative and Maintenance verified record review for Emergency Preparedness during the survey process.

Based on record review and staff interview, the facility did not develop sheltering in place policies and procedures as part of the emergency preparedness program as required by 42CFR 485.625(b)(4). The deficient practice affects the entire facility. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 7/31/19 at 12:01 p.m., revealed the facility did not develop sheltering in place policies and procedures as part of the emergency preparedness program as required. Administrative and Maintenance Staff verified record review for emergency preparedness.

Based on record review and staff interview, the facility failed to provide policies and procedures for applying for a 1135 Waiver as required by 42 CFR 483.73(b)(8). The deficient practice affects all residents and staff. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 7/31/19 at 12:01 p.m., revealed the facility did not have policies and procedures in place for applying for a 1135 Waiver as required. Administrative and Maintenance verified record review for emergency preparedness.

Based on observations and staff interview, the facility failed to maintain all 2 hour rated walls with doors at least 1-1/2 hour fire rated in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.5 and 8.2.1.3. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations and staff interview on 7/31/19, between 9:00 a.m. and 4:00 p.m., revealed the following deficiencies:

1. There was an excess gap between the fire doors in the 2 hour wall by the CEO Office. The gap was large enough to easily see to the other side of the doors.
2. There were two penetrations, (both approximately 1/4 inch), around conduit extending through the two hour fire wall by the Chapel.
3. There was a penetration, (approximately 1/2 inch), around a copper pipe extending through the two hour fire wall by the Chapel.
4. There was a penetration, (approximately 1/4 inch), around a copper pipe extending through the two hour fire wall by the Chapel.
5. There was a penetration, (approximately 2 inches), around communications lines extending through the 2 hour rated seperation wall between the Hospital and Medical Clinic, by the Laboratory Reception.
6. There were three open conduit, (approximately 1/4 inch), extending through the two hour wall separating the Emergency Department from the Ambulance Garage.

Based on observations and staff interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition and NFPA 72, 2010 edition. Automatic fire alarm system occupant notification shall be installed in the enclosed courtyard. The location of the circuit breaker for the fire alarm system shall be labeled at the fire alarm control panel. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations and staff interview on 7/31/19, between 9:00 a.m. and 4:00 p.m.,revealed the following deficiencies:

1. A fire alarm audio/visual notification device was not installed in the enclosed courtyard as required.
2. The location of the power supply for the fire alarms system was not labeled at the fire alarm control panel.

Maintenance Staff verified observations during the survey process.

Based on observations and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. An audible and visual trouble signal shall be indicated upon loss of a phone line. The deficient practice affects the entire facility. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations and staff interview on 7/31/19 at 3:28 p.m., revealed an audible trouble signal was not sent to a location monitored 24 hours a day during a test of the fire alarm system. A visual signal was sent to the fire alarm annunciator panels located in the Emergency Department and the Patient Wing Nurses Station, however an audible signal was not received. Staff at both annunciator panels were not aware of a trouble signal. Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the fire alarm system is out of service for more than four hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.6.1.6. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 7/31/19 at 10:28 a.m., revealed the following deficiency:

The outage policy for the fire alarm system did not contain all of the following required language:
" When the fire alarm system is out of service for more than 4 hours in a 24 hour period, the Impairment
Coordinator shall arrange for one of the following:
1. Evacuation of the building or portion of the building affected by the outage.
2. An approved fire watch."

Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, this facility is not providing and maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observation and staff interview on 7/31/19 at 2:35 p.m., revealed a hydraulic nameplate was not provided at sprinkler system risers. Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide a policy regarding the procedures to be taken in the event the sprinkler system is out of service for more than 10 hours in any twenty-four hour period in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 9.7.6. and NFPA 25, 2011 Edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 7/31/19 at 10:28 a.m., revealed the following deficiencies:

1. The sprinkler system outage policy did not contain language indicating the extent and expected duration of the impairment have been determined.
2. The sprinkler system outage policy did not contain language indicating that the areas or buildings involved have been inspected and increased risks determined.
3. The sprinkler system outage policy did not address all of the following conditions as required: system leakage, ruptured piping, interruption of water supply, equipment failure.
4. The sprinkler system outage policy did not contain language indicating that all necessary tools and materials have been assembled on the impairment site.
5. The sprinkler system outage policy did not contain all of the following required language:
" When the sprinkler system is out of service for more than 10 hours in a 24 hour period, the Impairment
Coordinator shall arrange for one of the following:
a) Evacuation of the building or portion of the building affected by the outage.
b) An approved fire watch.
c) Establishment of a temporary water supply.
d) Establishment and implementation of an approved program to eliminate potential ignition sources
and limit the amount of fuel available to the fire."

Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, this facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 25 with a census of 15 residents.

Findings include:

Observation and staff interview on 7/31/19 at 2:19 p.m., revealed a penetration, (approximately 1/4 inch), around communications cables, extending through the smoke barrier wall by the Comfort Suite. Maintenance Staff verified observations during the survey process.

Based on record review and staff interview, the facility failed to provide emergency plans and procedures as required by National Fire Protection Association, NFPA 101, 2012 Edition, 19.7.2.2. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 7/31/19 at 10:53 a.m., revealed the following deficiencies:

1. The fire emergency plan and procedures policy did not contain use of the different types of fire extinguishers in the facility.
2. The fire emergency plan and procedures policy did not contain use of the Kitchen Hood and Duct Extinguishment System.

Maintenance Staff verified record review during the survey process.

Based upon record review and staff interview, the facility failed to hold fire drills and maintain proper documentation of fire drills under varied conditions at different times of the day 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 has a capacity of 25 with a census of 15 residents.

Findings include:

Record review and staff interview on 7/31/19 at 11:09 a.m., revealed the following deficiencies:
1. The facility failed to hold fire drills at varied times on the 2nd Shift as follows: 2/28/18 at 2:15 p.m., 5/30/18 at 2:20 p.m., 8/23/18 at 2:05 p.m., 11/30/18 at 2:05 p.m., 5/28/19 at 2:11 p.m.
2. The facility failed to hold fire drills at varied times on the 3rd Shift as follows: 9/14/18 at 5:30 a.m., 12/20/18 at 5:47 a.m., 3/29/19 at 5:33 a.m., 6/28/19 at 5:57 a.m.
3. The facility is holding silent fire drills on the 3rd Shift. There was no documentation of testing of the fire alarm system within 24 hours of running a silent fire drill.
Maintenance Staff verified record review during the survey process.

Based on record review and staff interview the facility is not conducting and documenting annual testing of swinging fire door assemblies as required by National Fire Protection Association, NFPA 80, 2010 Edition. The deficient practice affects all occupants of the building. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Record review and staff interview on 7/31/19 at 10:17 a.m., revealed no available documentation of annual testing of swinging fire door assemblies as required. Maintenance Staff verified record review during the survey process.

Based on observations, record review and staff interview, the facility failed to maintain and test the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. A weekly inspection of the generator shall be conducted. A monthly test under load shall be conducted. A remote manual stop station shall be provided for each generator set. The deficient practice affects all occupants of the facility. The facility has a capacity of 25 with a census of 15 patients.

Findings include:

Observations, record review and staff interview on 7/31/19, between 9:00 a.m. and 4:00 p.m., revealed the following deficiencies:

1. There was no remote manual stop station installed for the generator set.
2. There were gaps in the weekly generator log as follows: 2/19/18 to 3/6/18. 4/1/19 to 4/15/19. During these time periods weekly generator inspections were not recorded.
3. Monthly generator tests under load were not documented for the following months in 2018: January, March, April, June, July, August, September, October, November, December. Monthly generator tests under load were not documented for the following months in 2019: January, February, March, April.
4. There was no documentation of actual run times during monthly tests under load.
5. There was no documentation of amperage readings recorded during monthly tests under load.
6. There was no documentation of an annual fuel quality test for the generator set.
7. The generator annunciator panel was indicating a "common alarm." Maintenance Staff indicated they were aware of the alarm but did not know what the issue was.

Maintenance Staff verified observations and record review during the survey process.