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Based on record review and staff interview, the facility failed to provide a shelter in place policy as required by 42 CFR 483.73(b)(4). The deficient practice affects all occupants of the building. The facility has a capacity of 16 with a census of 4 patients.

Findings include:

Record review and staff interview on 3/4/20, between 9:30 a.m. and 2:30 p.m., revealed no available documentation of a shelter in place policy as required. Administrative and Maintenance Staff verified record review during the survey process.

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 16 with a census of 4 patients.

Findings include:

Record review and staff interview on 3/4/20, between 9:30 a.m. and 2:30 p.m., revealed the facility did not have policies and procedures in place for applying for a 1135 Waiver as required. Administrative Staff and Maintenance Staff verified record review for Emergency Preparedness during the survey process.

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 16 with a census of 4 patients

Findings include:

Observations and staff interview on 3/4/20, between 9:30 a.m. and 2:30 p.m., revealed the following deficiencies:

1. There was a hole, (approximately 1-1/2 inches), in the two hour rated fire wall by Rebab Services.
2. There was a hole, (approximately 4 inches), in the two hour rated fire wall by the IT Director Office.
3. There was a penetration, (approximately 1/4 inch), around a pipe extending through the two hour rated fire wall by the IT Director Office.
4. There was a penetration, (approximately 1/4 inch), around a flexible conduit extending through the two hour rated fire wall by Respiratory Therapy.

Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility is not properly separating hazardous areas from other compartments. Hazardous areas shall be separated from other compartments by fire rated construction and self-closing doors in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.2.1. The facility has a capacity of 16 with a census of 4 patients.

Findings include:

Observation and staff interview on 3/4/20 at 1:00 p.m., revealed two penetrations, (both approximately 1/4 inch), extending through the walls of the Medical Gas Room, D162. Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, the facility failed to install components of the the fire alarm system in accordance with National Fire Protection Association, NFPA 72, 2010 edition. Smoke detectors shall not be installed near air supply or return ventilation ducts. The facility has a capacity of 16 with a census of 4 patients.

Findings include:

Observation and staff interview on 3/4/20 at 1:25 p.m., revealed a smoke detector installed within 3 feet of an air supply or return ventilation duct in the Emergency Department by the Nurses' Station. 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 16 with a census of 4 residents.

Findings include:

Record review and staff interview on 3/4/20 at 11:16 a.m., revealed the facility's outage policy for the fire alarm system did not contain the following required information:

"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:

a) Evacuation of the building or portion of the building affected by the outage.
b) An approved fire watch. The fire watch is continuous and all portions of the facility will be checked
at least once every 30 minutes."

Maintenance Staff verified record review 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 National Fire Protection Association, NFPA 25, 2011 Edition. The deficient practice affects all occupants of the building. The facility has a capacity of 16 with a census of 4 residents.

Findings include:

Record review and staff interview on 3/4/20 at 11:16 a.m., revealed the facility's sprinkler system outage policy did not contain all of the following information as follows:

1. The policy did not contain language indicating that the extent and expected duration of the impairment
have been determined.
2. The policy did not contain language indicating that the areas or buildings involved have been inspected
and increased risks determined.
3. The policy did not contain language indicating that recommendations have been submitted to
management or the property owner.
4. The policy did not contain language indicating that the supervisors in the areas to be affected have been
notified.
5. The policy did not contain language indicating that a tag impairment system has been implemented.
6. The policy did not contain language indicating that all necessary tools and equipment have been
assembled on the impairment site.
7. The policy did not contain notification of the facility insurance carrier.
8. The policy did not name an Impairment Coordinator.
9. The 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 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 16 with a census of 4 patients.

Findings include:

Record review and staff interview on 3/4/20 at 11:07 a.m., revealed the following deficiencies:

1. The facility fire emergency plan and procedures policy did not contain identification of a safe/evacuation area.
2. The facility fire emergency plan and procedures policy did not contain language on use of the Kitchen hood and duct extinguishment system.
3. The facility fire emergency plan and procedures policy did not contain language on use of the K-rated fire extinguisher in the Kitchen.

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 16 with a capacity of 4 residents.

Findings include:

Record review and staff interview on 3/4/20 at 10:03 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 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 monthly test under load shall be conducted. The facility has a capacity of 16 with a census of 4 patients.

Findings include:

Record review and staff interview on 3/4/20 at 10:17 a.m., revealed the following deficiencies:

1. There was no available documentation indicating the generator set is being exercised at 30 percent of the nameplate value during monthly tests under load. The last annual load bank testing was documented in 2017.
2. There was no available documentation of amperage readings recorded for the generator set during monthly tests under load.
3. There was no available documentation of operation of the transfer switch as required during monthly tests under load.
4. There was no available documentation of run times as required during monthly tests under load.
5. There was no available documentation of meter start and stop readings as required during monthly tests under load.

Maintenance staff verified record review during the survey process.