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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, 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 25 and a census of 4 residents at the time of the survey.

Findings include:

Record review on 04/12/2022 at 10:02 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 Maintenance Supervisor verified this finding during the survey process.

Based on observation and interview, the facility is not providing fire protection equipment related to commercial cooking in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2.5 and 9.2.3 and NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 10.2.2, by failing to provide a placard for the portable K type fire extinguisher in the Kitchen. This deficiency could affect staff response in extinguishing a fire that develops in the Kitchen and one of seven smoke compartments and approximately three staff. The facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Observation and interview on 04/12/2022 at 10:29 a.m., revealed there was no placard in place anywhere stating the fire protection system shall be activated prior to using the K type fire extinguisher, which was hung on a bracket in the dishwashing area of the Kitchen.

The Maintenance Supervisor confirmed this observation at the time of discovery.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1, by ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage and shall be installed in the correct orientation. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects four residents, staff, and visitors within two of seven smoke zones. The facility had a capacity of 25 and a census of 4 at the time of the survey.

Findings include:

1. Observation on 04/12/2022 at 12:04 p.m., revealed the facility failed to maintain the sprinkler system in the South Hall Med Surge corridor. The sprinkler head located above Resident Room 224 was missing its escutcheon ring.

2. Observation on 04/12/2022 at 12:29 p.m., revealed the facility failed to maintain the sprinkler system in the West Hall Med Surge corridor. The sprinkler head located above Resident Room 202 contained lint and foreign debris throughout.

3. Observation on 04/12/2022 at 12:41 p.m., revealed the facility failed to maintain the sprinkler system in the East Hall Med Surge Corridor. The sprinkler head located above Resident Room 209 contained lint and foreign debris throughout.

The Maintenance Director verified these findings at the time of the survey.

Based on record review, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Record review on 04/12/2022 at 9:18 a.m. of the fire watch procedures for a sprinkler system outage in the facility's outage policy, revealed the policy was incomplete in that it did not address and was missing the following information:

1. The insurance carrier has been notified and its phone number.

The Maintenance Director verified this finding at the time of the survey.

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 could affect approximately three staff in one of seven smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

Observation on 04/12/2022 at 10:47 a.m., revealed the door to the Facility Generator Room was being held open with a five gallon bucket. At the time of the survey, this door was installed with a self-closing device.

The Maintenance Director verified this finding at the time of the survey process.

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 one of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility had a capacity of 25 and a census of 4 residents at the time of survey.

Findings include:

Record review on 4/12/2022 at 9:42 a.m. of the facility's fire drill documentation, revealed the second shift drills were conducted at approximately the same time of day. All four quarters were conducted between the times of 3:03 p.m., and 3:39 p.m. On 1/27/21 at 3:39 p.m., on 4/30/21 at 3:03 p.m., on 7/15/21 at 3:03 p.m., and 10/27/21 at 3:05 p.m.

The Maintenance Director verified this finding at the time of the 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 one resident and staff in two of seven smoke compartments. The facility had a capacity of 25 and a census of 4 residents at the time of the survey.

Findings include:

1. Observation on 4/12/2022 at 11:18 a.m., revealed two surge protector's providing power to two separate lamps within the CIO Office.

2. Observation on 4/12/2022 at 11:51 a.m., revealed a surge protector providing power to a lamp within Resident Room 224 of the Med Surge South Hall.

The Maintenance Director verified these findings at the time of the survey.