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Based on record review and staff interview, the facility did not develop and implement complete emergency preparedness policies and procedures in accordance with the Code of Federal Regulations, 42 CFR 483.475(b)(2) by failing to address a system of tracking the location of on-duty staff during and after an emergency. This deficient practice affects all occupants of the facility. The facility had a capacity of 11 and a census of 3 patients.

Findings include:

Record review and staff interview on 12/6/18 at 12:19 p.m., revealed the facility did not have available documentation of policies and procedures to address a system of tracking of on-duty staff and patients during and after an emergency as required. Administrative and Maintenance Staff verified record review during the survey process.

Based on observation and staff interview, the facility failed to maintain all 2 hour rated walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.1.3.2 and 8.2.1.3. The facility has a capacity of 11 with a census of 3 patients.

Findings include:

Observation and staff interview on 12/6/18 at 1:07 p.m., revealed a penetration, (3/16 inch), around an insulated pipe extending through the 2 hour wall separating the Emergency Department from the Ambulance Garage. Administrative and Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, this facility is not providing and maintaining the sprinkler system in accordance with National Fire Protection Association, NFPA 25, 2011 edition and National Fire Protection Association, NFPA 13, 2010 edition. The facility has a capacity of 11 with a census of 3 patients.

Findings include:

Observation and staff interview on 12/6/18 at 12:47 p.m., revealed a hydraulic nameplate was not provided at the sprinkler system riser. Administrative and 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 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 NFPA 25, 15.5.2, 2011 Edition. The deficient practice affects all occupants of the building. The facility has a capacity of 11 with a census of 3 patients.

Findings include:

Record review and staff interview on 12/6/18 at 10:29 a.m., revealed the following deficiencies:

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 affected areas 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 have been assembled at the impairment site.
7. The policy did not contain notification of the facility's insurance carrier.
8. The policy did not address the following conditions: System leakage. Interruption of water supply. Ruptured piping. Equipment failure.
9. The outage policy for the sprinkler system 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 an implementation of an approved program to eliminate potential ignition
sources and limit the amount of fuel available to the fire."

Administrative and Maintenance Staff verified record review during the survey process.

Based on observation and interview, the facility failed to properly mount all fire extinguishers as required by National Fire Protection Association, NFPA 10, 2010 edition. The facility has a capacity of 11 with a census of 3 patients.

Findings include:

Observation and staff interview on 12/6/18 at 12:54 p.m., revealed the top of a fire extinguisher installed in the Laboratory was in excess of five feet from the floor. Administrative and Maintenance Staff verified observations during the survey process.

Based on observation and staff interview, this facility is not assuring that all smoke barriers are free of penetrations that compromise the fire-resistance rating of the walls in accordance with National Fire Protection Association, 2012 Life Safety Code, existing edition, 19.3.7.3. The facility has a capacity of 11 with a census of 3 patients.

Findings include:

Observation and staff interview on 12/6/18 ay 1:00 p.m., revealed a penetration, (approximately 1/4 inch), around an insulated pipe extending through the smoke barrier wall labeled SD1-2, by the Laboratory Entrance. Administrative and Maintenance Staff verified observations 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 11 with a census of 3 patients.

Findings include:

Record review and staff interview on 12/6/18 at 10:37 a.m., revealed the following deficiencies:

1. The facility's fire emergency plan and procedures policy did not contain use of the Kitchen Hood and Duct Extinguishment system.
2. The facility's fire emergency plan and procedures policy did not contain use of the different types of fire extinguishers present in the facility.
3. The facility's fire emergency plan and procedures policy did not identify a safe area or an evacuation area as required.

Administrative and Maintenance Staff verified record review during the survey process.

Based on record review and staff interview, the facility failed to properly document monthly testing under load of the generator set in accordance with National Fire Protection Association, NFPA 110, 2010 Edition. The facility has a capacity of 11 with a census of 3 patients.

Findings include:

Record review and staff interview on 12/6/18 at 10:55 a.m., revealed the facility is not documenting the start and stop meter readings during monthly tests under load. Available documentation contained the starting meter reading without a meter reading at the end of monthly generator tests under load. Administrative and Maintenance Staff verified record review during the survey process.