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Based on record review and interview, the facility failed to provide a complete policy for subsistence needs in accordance with the Code of Federal Regulations (CFR) at §483.73(b)(1). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 1.

Findings include:

Record review and interview on 02/20/20 at 10:38 a.m., revealed the facility was unable to provide a written policy in its Emergency Preparedness Plan for arrangements and agreements for food, medical supplies, and pharmaceutical supplies in the event of an emergency. The Emergency Preparedness Coordinator verified this observation at the time of the survey process.

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 §483.73(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 1.

Findings include:

Record review and interview on 02/20/20 at 10:25 a.m., revealed 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 Emergency Preparedness Coordinator verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to test battery powered lights in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code (Section-6.3.2.2.11.5), 2012 Edition. This deficient practice affects all patients receiving deep sedation and general anesthesia. This facility has a capacity of 25 and a census of 1.
Findings include:
Record review and interview on 02/20/20 at 11:10 a.m., revealed the facility was unable to provide documentation for monthly and annual tests of the battery backup emergency lights in Operating Room #1 and Operating Room #2. The Plant Operations Coordinator 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. This deficient practice affects approximately 10 residents, staff, and visitors in 1 of 7 smoke zones. This facility has a capacity of 25 and a census of 1.

Findings include:

Observation and interview on 02/20/20 at 11:18 a.m., revealed the corridor door to Patient Room #212 did not contain a self-closing device. This patient room was greater than 50 square feet and was being used for the storage of combustible materials. The Plant Operations Coordinator verified this observation at the time of the survey process.

Based on observation, interview, and record review the facility failed to test and maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Sections-10.5.5.3, 14.4.5, 17.7.4.1, and 17.14.5), 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 1.

Findings include:

1. Observation and interview on 02/20/20 at 10:36 a.m., revealed the fire alarm breaker (#10) located in Panel LS-1 did not contain a mechanical breaker locking device which would prevent the breaker from inadvertently being turned off.

2. Record review and interview on 02/20/20 at 9:16 a.m., revealed the facility was unable to provide current documentation for testing of the magnetic door hold open/releasing devices that are tied to the fire alarm system. The 03/14/19 test report from the facility's fire alarm testing contractor stated that the door hold open devices were to be tested in the fall. However, the 09/12/19 test report did not contain any testing results for these devices.

3. Observation and interview on 02/20/20 at 11:56 a.m., revealed the smoke detector located in the corridor near the Radiology Restroom was installed with 3 feet of a HVAC air diffuser.

4. Observation and interview on 02/20/20 at 9:02 a.m., revealed that immediate and unobstructed access to the north manual fire alarm pull station at the Main Entrance was obstructed by a table and chairs. The Plant Operations Coordinator verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to provide a fire watch policy for the fire alarm system being out of service in accordance with National Fire Protection Association (NFPA 101), Life Safety Code (Section-9.6.1.6), 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 1.

Findings include:

Record review and interview on 02/20/20 at 10:53 a.m., revealed the facility was unable to provide a fire watch policy for the Fire Alarm System being out of service for 4 or more hours in a 24 hour period. The Plant Operations Coordinator 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 Protection Systems (Section-5.2.1.1.1), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 1.

Findings include:

Observation and interview on 02/20/20 at 9:30 a.m., revealed the 2nd level landing in Stairwell #2 contained 2 quick response sprinklers with paint on the bulbs, arms, and diffusers. The Plant Operations Coordinator verified this observation at the time of the survey process.

Based on record review and interview, the facility was unable to provide an impairment policy for the sprinkler system being out of service in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-15.1.1), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 25 and a census of 1.

Findings include:

Record review and interview on 02/20/20 at 10:50 a.m., revealed the facility was unable to provide an impairment policy for the Sprinkler System being out of service for 10 or more hours in a 24 hour period. To include pre-planned and emergency impairments. The Plant Operations Coordinator verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to ensure that smoke barriers are free of penetrations which would prevent the passage of smoke to an adjacent smoke compartment in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-8.5.6.2), 2012 Edition. This deficient practice affects approximately 10 residents, staff, and visitors in 2 of 7 smoke zones. This facility has a capacity of 25 and a census of 1.

Findings include:

Observation and interview on 02/20/20 at 12:03 p.m., revealed the smoke barrier separating the Emergency Department and Emergency Department Waiting Area contained 1/2 inch, 1-1/2 inch, and 4 inch open to the center conduits with blue communication wires that penetrated the barrier above the lay in ceiling tile at the Emergency Department double doors. The open to the center conduits would not prevent the passage of smoke from one smoke compartment to another. The Plant Operations Coordinator verified this observation at the time of the survey process.