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Based on records review and interview, the facility failed to develop procedures in accordance with section 1135 of the Act under the waiver. The deficient practice affected the entire facility. The facility had the capacity for 25 beds with a census of 14 on the day of survey.

The findings include:

Record review of the facilities' Emergency Preparedness Program on 05/07/19 at 8:31 am revealed the facility failed to develop procedures on how and when to request the 1135 waiver for the facilities role in providing care and treatment at an alternate care site identified by emergency management officials and how they would operate under the waiver.

Interview with the Director of Maintenance on 05/07/19 at 8:42 am revealed the facility did not have the proper documentation.

The census of 14 was verified by the CEO on 05/07/19. The findings were acknowledged by the CEO and verified by the Director of Maintenance at the exit interview on 05/07/19.

Based on observation, the facility failed to ensure the fire and smoke resistance rating of ceiling assemblies in a building of Type II (111) construction was maintained in accordance with NFPA 101-2012, Section 19.1.6.2. The deficiency affects the entire facility.

Findings include:

1. During an observation on 5/7/19 at 9:10 a.m., several ceiling tiles were removed from the ceiling in the Boiler room, revealing a large penetration in the construction between the main floor and the ceiling.

2. During an observation on 5/7/19 at 10:49 a.m., several ceiling tiles were removed from the ceiling in the Data/IT room, revealing a large penetration in the construction between the main floor and the ceiling.

Based on observation, the facility failed to ensure corridor doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7. This affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 5/7/19 at 10:38 a.m., the self-closure on the CT scan/imaging room failed to self-close and positively latch when exercised.

Based on observation and record review, the facility failed to ensure all of the battery powered emergency light fixtures were tested annually for 90 minutes in accordance with NFPA 101-2012, Section 7.9.3.1.1 (1)(3)(5), and failed to provide fully illuminated exit signage per NFPA 101-2012, Section 7.10.5.1. This deficiency affects the entire facility.

Findings include:

1. Review of facility's monthly maintenance documentation reflected there was no documentation of 90-minute testing records for the battery powered emergency lights.

2. During an observation on 5/7/19 at 10:09 a.m., the exit sign in the physical therapy main entrance had one of the bulbs burned out, it was not fully illuminated.

Based on observation, the facility failed to maintain hazardous areas in accordance with NFPA 101-2012, Sections 19.3.2.1 and 19.3.2.1.3. This deficiency affects the entire facility.

Findings include:

1. During an observation on 5/7/19 at 8:57 a.m., the door to the generator room was inspected. The door was fitted with a self-closer, but it failed to close and positively latch after being opened near full.

2. During an observation on 5/7/19 at 8:57 a.m., the door to the boiler room was inspected. The door was fitted with a self-closer, but it failed to close and positively latch after being opened near full.

Based on observation and record review, the facility failed to maintain protection of open areas from hazardous areas, in accordance with NFPA 101, 2012 Edition, Section 19.3.2.5. and failed to maintain the kitchen hood extinguishing system in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition, Section 11.2.1.

Findings include:

1. During an observation on 5/7/19 at 9:17 a.m., the kitchen was inspected. The door to the kitchen was exercised. It would not close and latch under the power of the self-closer.

2. Record review of the kitchen hood extinguishing system (wet chemical system) reflected lack of documentation to show the contractor had performed services on a semi-annual basis. All documentation provided by the facility reflected the hood was inspected in April of 2019, but was not inspected prior, in 2018. Further, no documentation was on file to show that the kitchen hood system had been cleaned in the last three years.

Based on record review and interview, the facility failed to:

a) ensure load voltage tests were conducted on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72-2010, Table 7-3.2.
b) ensure all test documents related to the fire alarm system was available for review in accordance with NFPA 72 National Fire Alarm and Signaling Code, 2010 Edition, Table 14.4.5.

These deficiencies affect all smoke compartments in the facility.

Findings include:

1. During a review on 5/7/19 at 8:23 a.m., there was no documentation that load voltage tests had been done on the FACP backup batteries on a semi-annual basis.

2. During record review on 5/7/19 at 8:24 a.m., records for the fire alarm and smoke detection systems were reviewed. The last annual inspection of the fire alarm and smoke detection systems was completed on 4/11/17.

During an interview on 5/7/19 at 11:30 a.m., staff A stated the facility had not had their fire alarm inspected since April of 2017.

3. During record review on 5/7/19 at 8:24 a.m., records for the fire alarm and smoke detection systems were reviewed. The smoke detector sensitivities were last completed in April of 2017. The documents lacked the smoke detector testing records for 2019.

Based on observation, interview and record review, the facility failed to:

a) provide documentation of completion of all the required automatic sprinkler system tests and inspections.
b) ensure proper sprinkler maintenance in accordance with NFPA 101-2012 and NFPA 25-2011, Sections 5.1.1.1 and Table 5.1.1.2.
c) maintain the sprinkler system in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.5.6.1.
d) ensure sprinkler heads were installed clear of ceiling mounted fixtures in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.6.5.2 and Table 8.6.5.1.2.

These deficiencies affect the entire building.

Findings include:

1. A request for review of the facility's sprinkler testing and inspection reports on 5/7/19 at 8:01 a.m. revealed the facility was unable to provide documentation of a completed quarterly sprinkler system inspection for the second (2nd), third (3rd), and fourth (4th) quarters of 2018 and the first (1st) quarter of 2019. The facility was able to provide dates for inspections, as documented on the service tag located on the sprinkler riser in the sprinkler room.

Interview with the Maintenance Supervisor on 05/07/19 at 10:51 a.m. revealed the facility was aware of the missing quarterly sprinkler inspection paperwork.

Actual NFPA Standard: NFPA 25 (2011) Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
5.2.5 Waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.
5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.
5.3.3.3 Testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector's test connection.
13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place and operating properly.
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

2. Review of facility documentation for the automatic sprinkler system on 5/7/19 reflected a lack of monthly pressure gauge checks on the wet sprinkler system.

3. During an observation on 5/7/19 at 9:22 a.m., the walk-in cooler in the kitchen was inspected. The sprinkler head in the cooler was blocked by a large box that was sitting on a rack just beneath the sprinkler head.

4. During an observation on 5/7/19 at 9:43 a.m.., the escutcheon ring separated from the ceiling tile in the bathroom and the sink room of resident room #104b.

5. During an observation on 5/7/19 at 9:50 a.m., the Director of Nursing's office was found to have a sprinkler head obstructed by a light fixture.

6. During an observation on 5/7/19 at 9:52 a.m., the escutcheon ring separated from the ceiling tile in the janitor's closet located on north wing.

7. During an observation on 5/7/19 at 9:54 a.m., resident room 103 was found to have a sprinkler head obstructed by a light fixture.

8. During an observation on 5/7/19 at 9:58 a.m., the escutcheon ring was missing from the ceiling tile outside the nurse's station on the north wing hallway.

9. During an observation on 5/7/19 at 10:40 a.m., the hallway outside the X-ray room was found to have a sprinkler head obstructed by a light fixture.

10. During an observation on 5/7/19 at 10:47 a.m., the surgeon's locker room was found to have a sprinkler head obstructed by a light fixture.

Based on observation, interview and record review, the facility failed to:

a) install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.8.1 and NFPA 10-2010, Standard for Portable Fire Extinguishers, Section 7.3.1.1.1 and per Table 7.3.1.1.2
b) maintain access to portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Section 6.1.3.3.1.
c) ensure timely (every 5 years) hydrostatic testing for the K type extinguisher, located in the kitchen, in accordance with NFPA 101-2012, Section 9.7.4.1 and NFPA 10-2010, Section/Table 8.3.1 Hydrostatic Test Intervals for Extinguishers.

These deficiencies affect the entire building.

Findings include:

1. During an observation on 5/7/19 at 8:51 a.m., the portable extinguisher in the maintenance room was inspected. The extinguisher was observed sitting on the floor and unsecured. Staff member A, who accompanied the surveyor, stated the fire extinguisher was in-service and needed to be mounted to the wall.

2. During an observation on 5/7/19 at 8:59 a.m., the portable extinguisher outside the generator room was inspected. The extinguisher had not been serviced since August of 2017. Staff member A, who accompanied the surveyor, stated the fire extinguisher company who does the annual fire extinguisher maintenance and service must have forgot to check the extinguisher.

3. During an observation on 5/7/19 at 9:07 a.m., the portable extinguisher in the boiler room was inspected. The last documented six year or hydrostatic test completed was in August of 1988.

4. During an observation on 5/7/19 at 10:21 a.m., the K type fire extinguisher lacked the 5-year hydrostatic test tag. The unit was manufactured in 2012 and was due for the first hydrostatic testing in 2017.

5. During an observation on 5/7/19 at 9:26 a.m., the portable extinguisher in the hall outside of the kitchen was inspected. The last documented six year or hydrostatic test completed was in August of 2008.

6. During an observation on 5/7/19 at 10:30 a.m., the main entrance of the facility was inspected. The portable extinguisher in the room was found to be blocked from instant access by a large wooden chair.

7. During an observation on 5/7/19 at 10:34 a.m., the business office area was inspected. The portable extinguisher in the room was found to be blocked from instant access by a table with multiple office equipment.

8. During the observations on 5/7/19, the fire extinguishers throughout the facility lacked inspections for March and April of 2019, indicated by the missing staff initials on the extinguishers' tags, and missing documentation on the monthly fire extinguisher maintenance logs.

Based on observation, the facility failed to maintain corridor doors and to ensure a means suitable for keeping the doors closed in accordance with NFPA 101, 2012 Edition, Section 19.3.6.3.1 and 19.3.6.3.5. These deficiencies effect 1 of 2 smoke compartments.

Findings include:

1. During an observation on 5/7/19 at 10:11 a.m., the corridor door to resident room 204 was exercised. The door would not close and positively latch with a nominal amount of force placed on it.

Based on observation, the facility failed to ensure smoke barriers were maintained to prevent the potential for smoke to spread in accordance with NFPA 101-2012, Section 19.3.7.3. These deficiencies affect the entire facility.

Findings include:

1. During an observation on 5/7/19 at 9:37 a.m., 3-hour rated fire barrier doors were exercised in the north wing. The doors failed to positively latch.

2. During an observation on 5/7/19 at 9:38 a.m., several unsealed pipes and cords were observed with penetrations extended through the 3-hour barrier in the north wing.

Based on record review, the facility failed to conduct fire drills for every shift in every quarter in accordance with NFPA 101, 2012 Edition, section 19.7.1.6. This deficiency affects all smoke compartments.

Findings include:

1. Review of facility documents regarding fire drills for the last year reflected there was no documentation for completed drills for any evening shift of the second, third, and fourth quarters of 2018, day shift of the third quarter of 2018, and day and evening shifts during the first quarter of 2019.

Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report). This deficiency affects all fire/smoke compartments.

Findings include:

1. Review of the fire safety maintenance records on 5/7/19 reflected the lack of the annual fire door assembly testing documentation. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangements in the building and show inspections of all components of the doors in those barriers.

Based on observation, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d). This deficiency affects 1 of 2 smoke compartments.

Findings include:

1. During an observation on 5/7/19 at 10:48 a.m., the electrical panel in the doctor's office was blocked from easy access by various items being placed in front of it.

Based on observations, the facility failed to maintain the electrical system in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-12(B). The deficiency affects the entire building.

Findings include:

1. During an observation on 5/7/19 at 9:35 a.m., the north wing corridor was examined. An electrical outlet receptacle was observed that was cracked/broken.

2. During an observation on 5/7/19 at 9:55 a.m., the north wing corridor was examined. There was a low voltage outlet missing its protective cover plate.

3. During an observation on 5/7/19 at 10:48 a.m., the doctor's office was inspected. An electrical outlet was observed to be missing its protective cover plate.

Based on observation, the facility failed to ensure a labeled remote manual stop station for the generator was installed in accordance with NFPA 110-2010, Section 5.6.5.6 and 5.6.5.6.1. The deficiency affects the entire building.

Findings include:

1. During an observation on 5/7/19 at 8:54 a.m., the generator was inspected. The generator lacked a labeled manual stop station at a remote location outside of the room housing the prime mover, of a type in order to prevent inadvertent or unintentional operation of the generator in an emergency.

Based on observation, the facility failed to ensure extension cords were not used in the facility and that power strips were used per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4. This deficiency affects the entire facility.

Findings include:

1. During an observation on 5/7/19 at 9:51 a.m., the power strip, used in the Director of Nursing's office, did not have a UL 1363 rating.

2. During an observation on 5/7/19 at 10:24 a.m., the activities office had an extension cord in use in the room.

3. During an observation on 5/7/19 at 10:25 a.m., the activity room had an orange extension cord in use in the room.

4. During an observation on 5/7/19 at 10:27 a.m., two power strips, used in the dining area, did not have UL 1363 ratings.

5. During an observation on 5/7/19 at 10:39 a.m., three power strips, used in the Emergency Room, did not have UL 1363 ratings.

6. During an observation on 5/7/19 at 10:50 a.m., two power strips, used in the Operating Room, did not have UL 1363 ratings.

Based on observation and interview, the facility failed to maintain oxygen cylinders per NFPA 99-2012, Section 11.6.2.3. The deficiency affects the entire facility

Findings include:

1. During an observation on 5/7/19 at 10:52 a.m., one E size oxygen cylinder was free standing in the oxygen room, and three E size oxygen cylinders were observed laying on their side stacked on the floor of the oxygen room.

During an interview on 5/7/19 at 10:53 a.m., staff member A stated the oxygen cylinders should be secured within the room.