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Based on record review and staff interview, the facility failed to develop and maintain a comprehensive emergency preparedness program. This had potential to affect all residents in the facility and its offsite locations. The facility census was 23.

Findings include:

During record review on 09/23/19 and 09/24/19, the facility failed to complete the core elements of an Emergency Preparedness program. The facility had an Emergency Preparedness outline. The elements not completed include training plan, a facility-based hazard vulnerability assessment, and all applicable disaster plans. The training program did not address orientation of new staff, in-servicing staff annually, and table top and full-scale exercises. There was no testing of the emergency preparedness made available for review. The facility's offsite location was utilizing the hospital's emergency preparedness plan. There were no disaster plans or a hazard vulnerability assessment specific to the facility.

Interview with the Director of Plant Operations (DPO) #2 and Life Safety Consultant (LSC) # 5 at time of discovery verified the facility had an incomplete Emergency Preparedness program in place.

Based on record review, observation, and staff interview, the facility failed to perform the monthly and/or annual inspections of battery back-up emergency and exit lighting and or signage in accordance with NFPA 101 - 2012 Edition sections 19.2.9.1, 7.9.2 through 7.9.3.1.1 and 7.10.9.2. This has potential to affect 18 residents in the facility and staffs' ability to assist in an emergency. The facility census was 18.

Findings include:

During record review on 09/23/19, there was no record of the monthly inspections for the battery back-up Exit signs. The only record of monthly testing was a list of the devices. The report did not clarify what testing was conducted monthly. There were no records that indicated the facility conducted a 30 second monthly test monthly on all battery back-up emergency lights and exit signs.

Observation during facility tour on 09/24/19 between 8:00 A.M. and 10:00 A.M. it was noted battery operated exit signs and emergency lights in the facility. These signs were observed by the dietary manager's office and by room #17 over the fire doors.

Interview with the Director of Plant Operations (DPO) #2 and Life Safety Consultant (LSC) # 5 at time of discovery verified the deficient practices. When asked, DPO #2 and LSC #5 both stated that they hold the button for about ten seconds.

Based on observation and staff interview, the facility failed to ensure protection from hazardous areas in accordance with NFPA 101 - 2012 Edition 19.3.2 through 19.3.2.1.5, 6.2 through 6.2.2.4, 8.7.1.1, and NFPA 80 - 2010 Edition, Section 4.2 through 4.2.3. This deficient practice had the potential to affect 18 residents and staffs' ability to assist in an emergency. The Facility census was 18.

Findings include:

During observation during facility tour on 09/24/19 between 8:00 A.M. and 10:00 A.M., the boiler mechanical room had two gas fired boilers. The door from the corridor to this room was not a self-closing or automatic closing.

Interview with Life Safety Consultant (LSC) #5 at time of discovery during tour verified the deficient practice.

Based on observation and staff interview, the facility failed to ensure protection from hazardous areas in accordance with NFPA 101 - 2012 Edition 19.3.2 through 19.3.2.1.5, 6.2 through 6.2.2.4, 8.7.1.1, and NFPA 80 - 2010 Edition, Section 4.2 through 4.2.3. This deficient practice had the potential to affect five residents and staffs' ability to assist in an emergency. The facility census was five.

Findings include:

Observation during facility tour on 09/26/19 between 8:45 A.M. and 10:30 A.M. revealed the medical records room had a wall lined with open shelving lined with paper documents. The door from the corridor to this room was not a self-closing or automatic closing.

Interview with Director of Plant Operations (DPO) #2 at time of discovery during tour verified the deficient practice.

Based on observation and staff interview, the facility failed to ensure the dryers were maintained in accordance with the requirements of NFPA 101 - 2012 edition sections 19.5 through 19.5.1.2, 9.5.2, 4.6.9.2, 4.6.12.1, 4.6.12.4, 4.6.12.5 and 5.1.7. This had the potential to affect 18 residents and staffs' ability to assist in an emergency. The facility census was 18.

Findings include:

During observation on 09/24/19 between 8:00 A.M. and 10:00 A.M. the area behind the dryers had a large build-up of lint and debris. There was a dryer vent cleaning log on the wall behind the dryer. The last recorded dryer vent cleanout was 05/07/19.

Interview with the Director of Plant Operations (DPO) #2 and Life Safety Consultant (LSC) #5 on 09/23/19 at 4:00 P.M. verified the deficient findings.

Based on observation and staff interview, the facility failed to ensure electrical outlets were protected in accordance with NFPA 101 - 2012 Edition, Sections 6.3.2.2.8 through 6.3.2.2.8.6, 3.3.136, 3.3.139, and NFPA 70 - 2011 Edition Section 210.8 through 210.8(B)(8). This deficient practice had the potential to affect five residents in the facility and staffs' ability to assist residents in an emergency. The facility census was five.

Findings include:

During observation on 09/25/19 during tour of the facility between 8:45 A.M. and 10:30 A.M., two unprotected outlets were observed in the nurse station within six feet from the edge of the sink. The outlets were not ground fault circuit interrupter (GFCI) and they were not connected to a GFCI breaker.

Interview with the Director of Plant Operations (DPO) #2 and Life Safety Consultant (LSC) # 5 at time of discovery verified the deficient practice.

Based on observation, record review, and staff interview, the facility failed to ensure fire dampers were maintained in accordance with NFPA 101 2012 Edition section 19.5.2, 9.2.1, NFPA 90 A-2012 Edition, Section 5.4.8.1, NFPA 80-2010 Edition, Section 19.4.1 through 19.4.11, and NFPA 90 A 2012 Edition sections 5.4.5.2 through 5.4.6.2. This could potentially affect 18 residents residing in the facility. The facility census was 18.

Findings include:

During record review on 09/23/19, there was no record of fire, smoke, fire/smoke damper test, inspection, and/or maintenance on file. A request for fire, smoke, fire/smoke damper test and inspection report were made at the entrance conference with Director of Plant Operations (DPO) #2 at 11:15 A.M. There were no test and inspection report of fire, smoke, fire/smoke damper test and inspection made available for review. The facility's plan approval certificate was dated 01/26/16 and the certificate of occupancy was dated 06/21/16. No reports were provided for review by the exit conference on 09/25/19 at 1:29 P.M.

Observation during facility tour on 09/24/19 between 8:00 A.M. and 10:00 A.M. revealed fire/smoke dampers in the facility. Dampers were observed in areas such as the oxygen storage room, corridor smoke walls, and facility fire walls.

Interview with the Director of Plant Operations (DPO) #2 and Life Safety Consultant (LSC) #5 on 09/23/19 at 4:00 P.M. verified the deficient practices.

Based on record review and staff interview the facility failed to ensure the fire safety plan contained all components in accordance with NFPA 101 2012 Edition 19.7.2.1 through 19.7.2.3.3. This could potentially affect 18 residents and staffs' ability to assist in an emergency. The facility census was 18.

Findings include:

During record review on 09/23/19, the facility's fire safety plan did not include transmission of fire alarm to the monitoring company when the fire alarm system is activated.

Interview with the Director of Plant Operations (DPO) #2 and Life Safety Consultant (LSC) #5 on 09/23/19 at 4:00 P.M. verified the deficient practices.

Based on record review and staff interview, the facility failed to ensure the fire safety plan contained all components of a fire safety plan in accordance with NFPA 101 2012 Edition 19.7.2.1 through 19.7.2.3.3. This could potentially affect five residents and staffs' ability to assist in an emergency. The facility census was five.

Findings include:

During record review on 09/24/19, the facility's fire safety plan did not have all required elements required by NFPA 101 - 2012 Edition. The plan did not include transmission of fire alarm to the monitoring company when the fire alarm system is activated. The fire safety plan that the facility operated under at this facility was the plan from the hospital. The hospital plan stated that each department head would assign specific duties for staff in case of a fire. There was no specific plan for this location to direct staff their assigned fire plan response.

Interview with the Director of Plant Operations (DPO) #2 and Life Safety Consultant (LSC) #5 on 09/24/19 at 1:00 P.M. verified the deficient practices.

Based on record review and staff interview, the facility failed to test and maintain electrical outlets in accordance with NFPA 99 - 2012 Edition, Sections 6.3.3.2 through 6.3.3.2.4, 6.3.4.2, and 6.3.4.1 through 6.3.4.1.3. This deficient practice had the potential to affect 18 residents. The facility census was 18.

Findings include:

During record review on 09/23/19 between 11:45 A.M. to 4:00 P.M. it was noted no record of receptacle outlet testing for review when requested. The record of electrical outlet inspections was requested at the entrance conference with Director of Plant Operations (DPO) #2. The facility had hospital grade outlets. There was no record of electrical outlet testing within one year after installation.

Interview with the Director of Plant Operations (DPO) #2 and Life Safety Consultant (LSC) # 5 on 09/23/19 at 4:00 P.M. verified the deficient practices.

Based on record review and staff interview, the facility failed to test and maintain electrical outlets in accordance with NFPA 99 - 2012 Edition, Sections 6.3.3.2 through 6.3.3.2.4, 6.3.4.2, and 6.3.4.1 through 6.3.4.1.3. This deficient practice had the potential to affect five residents. The facility census was five.

Findings include:

During record review on 09/24/19, there was no record of receptacle outlet testing for review when requested. The record of electrical outlet inspections was requested at the entrance conference with Director of Plant Operations (DPO) #2. The facility had hospital grade outlets. There was no record of electrical outlet testing within one year after installation.

Interview with the Director of Plant Operations (DPO) #2 and Life Safety Consultant (LSC) #5 on 09/24/19 at 1:00 P.M. verified the deficient practice.