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Based on record review and interview, the facility failed to provide a policy for an 1135 waiver in accordance with the Code of Federal Regulations (CFR) at §482.15(b)(8). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 6.

Findings include:

Record review and interview on 04/10/24 at 11:26 a.m., revealed that the facility was unable to provide a written policy in its Emergency Preparedness Plan to address the role of the facility under an 1135 waiver in the provision of care and treatment at an alternate care site identified by emergency management officials. The Plant Operations Lead verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide emergency task illumination in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.4.2.2.4.2 (3) (b)), 2012 Edition and National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.9.2.7), 2012 Edition. This deficient practice affects all patients who receive medication. This facility has a capacity of 25 and a census of 6.

Findings include:

Observation and interview on 04/10/24 at 12:32 p.m., revealed the 2nd Floor Medication Room did not contain automatic emergency task illumination. The lights in this room were controlled by a switch. In the event of a power outage this room could be left in darkness if the switch were in the off position even if the facility was under emergency generator power. The Plant Operations Lead verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to provide separation of hazardous areas in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.2.1.3), 2012 Edition. These deficient practices affect approximately 15 residents, staff, and visitors in 3 of 11 smoke zones. This facility has a capacity of 25 and a census of 6.

Findings include:

1. Observation and interview on 04/10/24 at 12:22 p.m., revealed that none of the 9 corridor doors for the decommissioned nursing facility resident rooms located in the East Wing of the 3rd Floor contained self-closing devices. These rooms were each greater than 50 square feet and being used for the storage of combustible materials.

2. Observation and interview on 04/10/24 at 12:38 p.m., revealed the corridor door to Room #211 on the 2nd Floor did not contain a self-closing device. This room was greater than 50 square feet and being used for the storage of combustible materials.

3. Observation and interview on 04/10/24 at 1:07 p.m., revealed the self-closing device for the corridor door to the ER Clean Supply Storage Room had been disconnected. This room was greater than 50 square feet and being used for the storage of combustible materials. The Plant Operations Lead verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to maintain their kitchen hood extinguishment system in accordance with National Fire Protection Association (NFPA) 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (Section-11.2.3), 2011 Edition. This deficient practice could affect all residents, staff, and visitors throughout the facility.

Findings include:

Record review and interview on 04/10/24 at 12:43 p.m., revealed the agent holding tank for the kitchen Ansul Extinguishment System was past due for 6-year hydrostatic testing. Documentation provided indicates the tank was last tested in December of 2015. The Plant Operations Lead verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain sprinklers in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protections Systems (Section-5.2.1.1.2(2)), 2011 Edition. This deficient practice could affect all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 6.
Findings include:
Observation and interview on 04/10/24 at 12:11 p.m., revealed the fusible link sprinkler located in the 4th Floor Dirty Utility Chute contained excessive green corrosion on the sprinkler arms, diffuser, and fusible link which requires the sprinkler to be replaced. The Plant Operations Lead verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure that corridor doors have a means of keeping the doors closed within the door frame in order to resist the passage of smoke in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.3.6.3.5), 2012 Edition. This deficient practice affects approximately 6 staff and visitors in 1 of 11 smoke zones. This facility has a capacity of 25 and a census of 6.

Findings include:

Observation and interview on 04/10/24 at 1:00 p.m., revealed the corridor door to the Lab located on the 1st Floor failed to positively latch within the door frame in order to keep the door closed. This was due to the door not containing any latching hardware. The Plant Operations Lead verified this observation at the time of the survey process.

Based on record review and interview, the facility is not conducting coded fire drills within the allowed timeframe in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.7), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 6.

Findings include:

Record review and interview on 04/10/24 at 10:13 a.m., revealed the 2nd shift fire drill for the 1st quarter of 2024 was a coded/silent drill that was conducted at 7:45 p.m. The timeframe for coded/silent drills is from 9:00 p.m.-6:00 a.m. The Plant Operations Lead verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain their emergency generators in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.3.8), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 6.

Findings include:

Record review and interview on 04/10/24 at 1:19 p.m., revealed the facility's alternate backup power was produced by two separate diesel powered emergency generators. The facility was not able to provide documentation for the annual testing of fuel for either of the generators. The Plant Operations Lead verified this observation at the time of the survey process.