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Based on record review and 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)(8) [ICF]/ 483.73(b)(8) [LTC], by failing to incorporate policies and procedures in its emergency plan describing the facility's role under a waiver in accordance with Social Security Act, Section 1135, in the provision of care and treatment at an alternate care site identified by emergency management officials. This deficient practice affects all occupants of the facility. The facility had a capacity of 15 and a census of 3 patients at the time of the survey.

Findings include:

Record review and interview on 03/28/2022 at 11:45 a.m., revealed the facility's emergency preparedness policies and procedures did not specifically address the facility's role in emergencies where the Health and Human Services Secretary declares a public health emergency. The emergency preparedness plan failed to demonstrate the facility's general awareness of the 1135 process, including the following:

1) Knowledge of how to request a waiver and who to contact (contact information) in the event an 1135 waiver needs to be requested;

2) The circumstances when an 1135 waiver might be granted based on the risk analysis;

3) How they would operate under and outline the responsibilities during the duration of the waiver period; and

4) How they would plan jointly on issues related to staffing, equipment, and supplies.

The Administrator verified this finding during the survey process.

Based on record review and interview, the facility failed to document periodic testing of emergency lighting equipment in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.2.9.1 and 7.9.3. This deficient practice affects emergency lighting within the facility all patients, staff and visitors. The facility had a capacity of 25 and a census of 3 patients at the time of the survey.

Findings include:

Record review on 03/28/2022 at 10:19 a.m., revealed the facility was unable to provide documentation of annual functional testing for any battery backup emergency light fixture throughout the building. Interview of the Maintenance Supervisor revealed the facility had conducted monthly thirty second testing of emergency lighting fixtures but had not maintained any records annual ninety minute testing.

The Maintenance Supervisor and the Administrator confirmed this finding during the survey process.

Based on observation, record review and interview, the facility did not ensure corridor doors were not held open with a door stop or other impediments, are smoke resisting and are positive latching as required by National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.3.6.3/19.3.6.3. This deficient practice affected one of fifteen smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 15 and a census of 3 patients at the time of the survey.

Findings include:

Observation on 03/28/2022, at 10:00 a.m., revealed the door to the Kitchen Pantry was being held open with a wood door wedge.

A member of the Maintenance Department verified this observation at the time of this survey.

Based on interview and record review, the facility failed to provide a complete fire plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 18.7.1/19.7.1 and 18.7.2/19.7.2. The deficient practice affected all smoke zones and all occupants. This facility had a capacity of 25 and a census of 3 patients at the time of the survey.

Findings include:

Record review on 03/28/2022, at 10:54 a.m. revealed the fire plan did not address the following information:

The plan did not address all the types of fire extinguishers (ABC, K-type and Ansul) and how to use them or information about the range hood suppression system.

Administrative staff member verified this finding at the time of the survey.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all patients, staff and visitors in the event of a fire. The facility had a capacity of 25 and a census of 3 patients at the time of survey.

Findings include:

Record review and interview on 03/28/2022 at 9:50 a.m. of the facility's fire drill documentation, revealed second shift (3 p.m.-12 a.m.) drills for the first quarter 2022, third quarter 2021 and fourth quarter 2021 were conducted at approximately the same time of day. The first quarter drill was conducted on 02/21/2022 at 3:10 p.m., the third quarter drill was conducted on 08/25/2021 at 3:30 p.m. and the fourth quarter drill was conducted on 11/24/2021 at 3:05 p.m.

The Maintenance Director verified the documentation during the survey process.

Based on record review and interview, the facility failed to conduct/document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects four of seven smoke compartments and all residents, staff, and visitors. The facility had a capacity of 25 and a census of 3 patients at the time of the survey.

Findings include:

Record review on 03/28/2022 at 10:27 a.m., revealed the facility was unable to provide the minimum required documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles. Documentation provided by the facility revealed electrical receptacle testing had been conducted for the facility on 11/04/2021. However, this documentation did not contain retention testing values for each receptacles tested.

Interview of Maintenance Supervisor supporting documentation verified this at the time of this survey.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, by failing to use general precautions with power strips and surge protectors and allowing the use of non-approved electrical devices or adapters within the facility. These deficient practices affect staff in two of fifteen smoke compartments. The facility had a capacity of 25 and a census of 3 residents at the time of the survey.

Findings include:

1. Observation and interview on 03/28/2022 at 10:30 a.m., revealed a surge protector providing power to a fan in the Environmental Services Office.

2. Observation and interview on 03/28/2022 at 10:45 a.m., revealed a surge protector providing power to a coffee maker, fan and microwave oven in Room #261.

3. Observation on 03/28/2022 at 10:45 a.m., revealed a lamp in Room #261 was plugged into an extension cord which was plugged into an electrical receptacle in the wall.

Maintenance Staff verified these observations at the time of the survey process.