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Based on record review and interview with facility Administrator, the facility failed to develop and maintain an emergency preparedness plan that wa based on and included a documented facility-based and community-based risk assessment utilizing an all hazards approach. This in the event of a disaster or other emergency would leave the facility and its occupants vulnerable to the hazards of the event.

Findings include:

On 09/18/2018 while reviewing the facility's emergency preparedness plan, it was noted that the plan was not based on an all hazards approach and did not include the necessary risk assessment to ensure all hazards had been considered. The Administrator was unable to provide the documentation for an all hazard approach.

Based on record review and interview with facility Administrator, the facility's emergency preparedness plan failed to incorporate adequate policies and procedures for the provision of food and water during the event of an emergency, and failed to include provisions for sewage and waste disposal in the event of power loss.

Findings include:
On 09/18/2018, review of the facility's emergency preparedness plan was conducted and showed there to be no provisions in the plan related to sewage and waste disposal during the event of an emergency.
There was letter included with the plan from the food vendor used by the facility that stated the company would assist with food and water provisions up to three days prior to an impending emergency, but could not guarantee any food or water to the facility during or after the emergency.

Concurrent with the review, an interview was conducted with the facility Administrator who stated he was not aware the letter said that.

Based on record review and interview with facility Administrator, the facility failed to incorporate policies and procedures into their Emergency Preparedness plan that addressed the role of the facility in the provision and treatment at an alternate care site identified by emergency management officials.

Findings include:

On 09/18/2018 while reviewing the facility's emergency preparedness plan, there was no policy and procedure that specifically addressed the duties of caregivers, following the issuance of an 1135 waiver by the Secretary of Health and Human Services.

Concurrent with the review, the Administrator was unable to provide the documentation.

Based on observation and interview with the Maintenance Director, the facility failed to provide and maintain a 5-year internal inspection of the sprinkler system, in accordance with NFPA 101(2012 edition). Failure to inspect, maintain, and test system components could result in the system failing to perform as designed.

Findings include:

During the Fire & Life Safety document review of the facility with the Director of Maintenance on 09/18/2018 from 9am to 12pm, it was observed there had not been a 5-year internal inspection of the sprinkler system for the building the last inspection was done in 02/2013.

All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25 (2011 edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems). NFPA 101 Life Safety Code (2012 edition) 18.3.5 & 19.3.5 & 9.7.5.

Based on observations and interview with the Maintenance Director during the Fire & Life Safety tour, the facility failed to maintain proper maintenance of the Fire/Smoke doors. This condition could result in (2) Smoke Compartments to become involved in a Fire/Smoke situation. This could allow fire, smoke and fire gasses to enter the compartment, which would impede or deny the exiting of occupants in an emergency and result in harm to the occupants from the dangers of the emergency.

The findings include:

During the Fire & Life Safety tour of the facility with the Director of Maintenance on 09/18/2018 from 9am to 12pm, it was observed that several 1 hour rated Fire/Smoke doors were not closing properly
1. Basement, two records rooms, non- rated doors and no closures on doors to keep them closed, rooms # 7 & 9
2. Basement, room # 4, storage room, no closure on door, & non-rated door
3. Basement, storage room in laundry, no door closure & non-rated door
4. Kitchen, exit door in breeze way not closing
5. Kitchen, storage room, no door closure & non-rated door
6. Gym, entrance door from corridor, propped open with a wedge, this was a fire door
7. Corridor exit door next to gym, gap at top of door
8. Storage closet next to room # R142, no closure on door, packing boxes stored in room, hazard.
9. Room # 106, 114, 118, 122, & 126 , not closing properly
10. West hallway, linen room & bathroom doors not closing properly

An interview was conducted with the Director of Maintenance concurrent with the observations and he confirmed the findings.

NFPA 101, (2012 edition,) Chapter 19, 19.3.6.3.5, "Doors shall be provided with a means for keeping the door closed that is acceptable to the AHJ."

Based on observation and interview with the Maintenance Director, the facility failed to properly maintain the required Fire/Smoke barrier penetrations, which had not been fire stopped or smoke sealed per the requirements of NFPA 101(2012 edition). This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

Findings include:

During the Fire & Life Safety tour of the facility with the Director of Maintenance on 09/18/2018 from 9am to 12pm, it was found that penetrations through the wall above the ceiling had not been fire stopped or smoke sealed. The following locations were observed to have penetrations:
1. Penetrations in corridor walls from were lights were removed
2. Penetration in wall and door going into Social Services
3. Penetration in wall next to self-closing double doors on north hallway by the women's staff lockers
4. Penetration in wall above the ceiling at self -closing double doors next to the nurses station on the North Hallway
5. Penetration in wall above ceiling at the elevator
6. Penetration in wall above ceiling at self-closing double doors on South Hallway
7. Penetration above self-closing doors in Basement
8. Penetration in Basement, west unit storage room, around light
9. Penetration in Basement, room next to training support room, tile missing
10. Penetration, Kitchen, entrance from breezeway, ceiling tile missing
11. Kitchen, hallway, storage rooms, ceiling tiles missing

All locations were not properly protected with the required fire caulk. An interview was conducted with the Director of Maintenance concurrent with the observations and he confirmed the findings.

According to NFPA 101(2012 edition) 8.4.4 & 8.4.4.1 and 19.3.7.6

Based on observation and interview with the Maintenance Director, the facility failed to provide maintenance, inspection & testing of fire doors. This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.

Findings include:

During the Fire & Life Safety document review of the facility with the Director of Maintenance on 09/18/2018 from 9am to 12pm, it was observed that the facility failed to provide records of fire door Maintenance, Inspection & Testing.

Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review.

An interview was conducted with the Director of Maintenance concurrent with the observations and he confirmed the findings.

19.7.6, 8.3.3.1 (LSC), NFPA 80 (2010 edition) 5.2, 5.2.3