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Based on record review and interview, the facility failed to maintain an emergency preparedness plan in accordance with the requirements of 42 CFR 403.748(a). This deficient practice could affect all 11 patients and an undetermined number of staff and visitors.

Findings include:

On09/09/2025 at 4:00 pm, review of the facility's Emergency Preparedness Plan revealed that the plan including the All Hazards Risk Assessment was not updated/reviewed within the past year. Most recent update was 02/13/2020.

This deficient practice was confirmed by Staff D and Staff S at the time of discovery.

Based on record review and staff interview, the facility did not have a communication plan as part of their emergency preparedness plan in accordance with the requirements of 42 CFR 485.625(c). This deficiency has the potential to affect all patients and an undetermined number of staff and visitors.

Findings include:

On 09/09/2025 at 3:55 pm, record review revealed that the facility did not have an updated written emergency communication plan. The plan's policy CL87024 Communication Plan was last updated on 02/13/2020. The plan had an origin date of 10/01/2017, a reviewed date of 02/13/2020 and a revision date of 00/00/00.

This deficient practice was confirmed by Staff D and Staff S.

Based on record review and staff interview, the facility did not participate and document two Emergency Preparedness exercises in the past 12 months to test the plan per 42 CFR section 483.73(d)(2). This deficient practice could affect all residents as well as undetermined number of staff and visitors.

Findings include:

On 09/09/2025 at 4:10 pm, record review of the emergency preparedness plan over the past 18 months revealed that the facility did not participate or conduct two exercises to test their emergency plan by participating in a facility based, tabletop or full-scale, community-based exercise or an actual event within the past year. The last recorded exercises included a Chemical Emergency Surge Table-Top which was an exercise held on 01/31/2024 and Medical Response surge on 02/29/2024. Both exercises were held beyond the required 12 month period.

This deficient practice was confirmed at the time of discovery with Staff D and Staff S.

Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101, 2012 edition, Sections 19.3.4.1, 9.6.1.3, and 9.6.1.5; as well as NFPA 72, 2010 edition, Sections 14.1, 14.1.4, 14.3.1, 14.3.3, 14.4.2.2, 14.4.5, and 14.6. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

1. On 09/09/2025 at 09:34 am, observation of the FACP at the entrance area of the facility revealed that there was a trouble alarm on the panel. When Staff was asked about the alarm Staff were unaware that there was a trouble alarm on the panel.

2. On 09/09/2025 at 12:00 pm, record review of fire alarm inspection and testing documents revealed that the semi-annual visual inspection of notification devices (horns, strobes, bells, chimes, or combination thereof), was not conducted by the facility or Action Fire and Alarm within the past 18 months. Staff W stated via phone that the facility does not do semi-annual inspections of the fire alarm system.

This deficient practice was confirmed by Staff U and Staff V at the time of discovery.

Based on observation and interview, the facility did not maintain an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems 2010 edition as required in NFPA 101: Life Safety Code, 2012 edition sections 9.7, 9.7.1.1(1), 19.3.5.1; NFPA 13 (2010 edition) Sections 6.2.9.1, 6.2.9.7 and 6.2.9.7.1. This deficient practice could affect all residents and an undetermined number of staff and visitors.

Findings include:

On 09/09/2025 at 3:14 pm, observation at the Sprinkler Riser revealed one spare sprinkler head box mounted on the wall near the sprinkler supply riser did not include a list of sprinkler heads installed with sprinkler identification number or the manufacturer model, orifice, deflector type, thermal sensitivity, pressure, type installed, sprinkler identification number and other required information consisting of general description, quantity of each type to be contained in the cabinet and the issue or revision date of the list.

This condition was confirmed at the time of discovery by Staff U and Staff V.

Based on observation and interview, the facility did not provide smoke barrier corridor wall separations as required in NFPA 101, 2012 edition, Sections 19.3.6.2.5, 19.3.6.2.6, 8.4.2, and 8.4.4. This deficient practice could affect an undetermined number of residents, staff and visitors.

Findings include:

On 09/09/2025 at 3:05 pm, observation above the lay in ceiling in the corridor outside of the CRC meeting room revealed a flexible metal BX cable pierced the 1-hour rated corridor wall and damaged the gypsum board around the opening and was not fire stopped according to an approved method.

These deficient practices were confirmed by Staff U and Staff V at the time of discovery.

Based on observation and staff interview, the facility did not ensure the electrical wiring and equipment met the requirements of NFPA 101, 2012 Edition, Sections 19.5.1.1 and 9.1.2, as well as NFPA 70, edition 2011, Articles 110.8 and 110.27. This deficient practice could affect an undetermined number of staff and visitors.

Findings Include:

On 09/09/2025 at 2:45 pm, observation above the lay in ceiling in the corridor near smoke barrier wall and doors 1087A revealed that four, 4-inch by 4-inch metal electric junction boxes did not have cover plates leaving the raceway system open.

The deficient practice was confirmed by Staff U and Staff V at the time of discovery.

Based on observation and interview, the facility did not provide control of environmental ventilation per NFPA 101, 2012 edition, Sections 19.5.2.1, 19.7.6, 2.1, 4.5.8, 4.6.12, and 9.2; NFPA 99, 2012 edition, Sections 9.1.3 and 9.3.1.1; as well as ASHRAE Standard 170, 2008 edition, Section 7.1. These deficient practices could affect 2 of 11 residents, as well as an undetermined number of staff and visitors.

Findings Include:

On 09/09/2025 at 2:15 pm, observation in Resident Rooms 152 and Room 153 revealed that the return grills were not returning air to the HVAC system resulting in an odor present in the room. The return air grills were completely blocked with dust. The pressure relationship between the resident room and the corridor was not maintained.

The deficient practice was confirmed by Staff U and Staff V at the time of discovery.

Based on record review and interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 (2012 edition) Sections 4.7.1, 4.7.2, 4.7.4, 4.7.6, 19.7.1, 19.7.1.4 and 19.7.1.6. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

1. On 09/09/2025 at 11:20 am, review of the facility fire drills for the last twelve months revealed that fire drill record did not include the record of transmission of the alarm signal to the monitoring company.

2. On 09/09/2025 at 11:22 am, review of the fire drill records for the last twelve months revealed that the fire drills were not conducted at varied times. The facility performed fire drills during the 1st shift on 01/21/25 at 11:43 am, on 7/17/2025 at 11:30 am and on 12/16/24 at 10:43 am. The facility performed fire drills during the 2nd shift on 02/16/25 at 9:10 pm, on 05/19/25 at 9:41 pm, and on 08/25/24 at 9:25 pm. The facility performed fire drills during the third shift on 03/20/25 at 11:53 pm and on 06/24/24 at 12:15 am.

3. On 09/09/2025 at 11:23 am, review of the fire drill records for the last twelve months revealed that the time of the drill was not recorded for the drill held on 11/25/24.

This condition was confirmed at the time of discovery by a concurrent interview with Staff U and Staff V.

Based on record review and interview, the facility did not inspect smoke and fire rated door assemblies at least annually with a written record of inspection and testing in accordance with NFPA 101, 2012 edition, Sections 21.7.3, 21.7.6, 4.6.12, 7.2.1.15, 8.2.2.4, 8.3.3.3, and 8.3.3.4; as well as NFPA 80, 2010 edition, Sections 5.2 and 5.2.4. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

On 09/09/2025 at 12:29 pm, record review revealed that the facility had no record that fire rated door assemblies, including any corridor, combination smoke and fire barrier, or other doors, had been inspected or tested within the past 12 months.

This deficient practice was confirmed at the time of discovery with Staff U and Staff V.

Based on record review and interview, the facility did not perform testing of the emergency generator in accordance with the requirements of NFPA 101 (2012 edition) Sections 19.5.1 and 9.1.3 and NFPA 110 (2010 edition) Sections 8.3, 8.3.4, 8.3.7, 8.3.7.1, and 8.3.7.2. This deficient practice could affect all residents, as well as an undetermined number of staff and visitors.

Findings include:

On 09/09/2025 at 12:37 pm, record review of the monthly emergency generator inspection and testing documentation over the past 12 months revealed that conductance or specific gravity tests of the generator batteries was not performed.

This finding was confirmed at the time of discovery by a concurrent interview with Staff U and Staff V.