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Based on record review and interview, the facility failed to provide a policy for an 1135 waiver in accordance with the Code of Federal Regulations (CFR) at §483.73(b)(8). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 21 and a census of 11.

Findings include:

Record review and interview on 04/07/2025 at 12:17 p.m., revealed that the facility was unable to provide a written policy in its Emergency Preparedness Plan to address how to apply for an 1135 waiver and the role of the facility under an 1135 waiver in the provision of care and treatment at an alternate care site identified by emergency management officials.

The Emergency Preparedness Manager verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain emergency lighting fixtures in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.9), 2012 Edition. This deficient practice affects approximately patients, staff, and visitors in the affected smoke zones. This facility has a capacity of 21 and a census of 11.

Findings include:

1. Observation on 04/04/2025 at 10:58 a.m., revealed that Emergency Light fixture #8 located in the Hallway across from the kitchen entrance did not illuminate when the battery backup was tested.

2. Observation on 04/04/2025 at 11:10 a.m., revealed that Emergency Light fixture #6 did not illuminate when the battery back up was tested.

3. Observation on 04/04/2025 at 11:50 a.m., revealed that Emergency Light fixture #54 located in the 2nd Floor, Med Vac Mechanical Room did not illuminate when the battery backup was tested.

The Maintenance representative verified these observations at the time of the survey process.

Based on observation and interview, the facility failed to maintain exit signage in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.10.5.1), 2012 Edition. This deficient practice affects approximately 8 residents, staff, and visitors in 1 of 9 smoke zones. This facility has a capacity of 21 and a census of 11.

Findings include:

1. Observation on 04/04/2025 at 12:15 p.m., revealed that the Exit Sign fixture #76 located in the 2nd floor, Med Spa area did not illuminate when the battery backup was tested.

2. Observation on 04/04/2025 at 12:49 p.m., revealed exit signage needed to be installed to at the south end of the north/south Hallway to direct occupants to the southeast exit door of the Senior Life Solutions Building.

The Maintenance Representative verified these observations at the time of the survey process.

Based on observation, interview, and record review, the facility failed to inspect and test smoke dampers in accordance with National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives (Section-19.4.1.1 and Section 19.4.9), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 21 and a census of 11.
Findings include:
Observation, interview, and record review on 04/07/2025 at 11:25 a.m., revealed that the facility contained smoke dampers in the ductwork of the air-handling units. The facility was unable to provide documentation that the dampers had been exercised and inspected within the last 6 years. Documentation provided the dampers were last inspected on 09/12/2015.
The Maintenance Supervisor verified this observation at the time of the survey process.

Based on record review and interview, the facility failed to maintain portable fire extinguishers in accordance with National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers (Section-7.2.1.2), 2010 Edition. This deficient practice affects approximately all patients, staff, and visitors in the affected smoke zones. This facility has a capacity of 21 and a census of 11.

Findings include:

Record review and interview on 04/04/2025 at 11:40 a.m., revealed fire extinguisher #14 located in the IT Server Room was missed when February and March 2025 monthly visual inspections were conducted and documented.

The Maintenance Representative verified this observation at the time of this 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 affected approximately 3-4 staff members in the kitchen in one of five smoke zones, as the doors would not prevent the spread of fire and smoke. This facility had a capacity of 21 and a census of 11 residents at the time of the survey.

Findings include:

Observation on 04/04/2025, at 11:02 a.m., revealed a bungee cord was being used to secure the Food Pantry Room door in the open position. This door had an automatic closure device installed and the bungee cord was preventing this door to remain in the shut position when not in use.

The Maintenance Representative confirmed this finding at the time of this survey.

Based on observation and interview, the facility failed to maintain electrical junction boxes in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.1.2), 2012 Edition and National Fire Protection Association (NFPA) 70, National Electrical Code (Section-314.25) , 2011 Edition. This deficient practice affects approximately staff in the affected smoke zone. This facility has a capacity of 21 and a census of 11.

Findings include:

On 04/04/2025 at 11:16 a.m., revealed an missing face plate cover on an electrical junction box located in the Generator Transfer Switch Room.

The Maintenance Representative confirmed 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 21 and a census of 11 residents at the time of the survey.

Findings include:

Record review on 04/07/2025, at 12:02 p.m. revealed the fire plan did not address the following information:

The plan did not address all the types of fire extinguishers located in the facility. The plan did not include the presence of the Ansul hood suppression system located in the Kitchen. The fire plan policy should include the proper use of this system and that all kitchen personnel are trained on its purpose and how to activated its use.

The Emergency Preparedness Manager verified this finding at the time of the survey.

Based on record review and interview, the facility is not conducting drills on a random basis and varied times in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.4), 2012 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity 21 and a census of 11.

Findings include:

Record review and interview on 04/07/2025 at 11:50 a.m., revealed the facility conducted fire drills during the second shift (3:00 p.m.-11:00 p.m.) and third shift (11:00 p.m.-7:00 a.m.) at essentially the same time of day during the four quarters of 2024-2025 inspection period. During the second shift, fire drill were conducted on 04/10/2024 at 4:30 p.m., 07/24/2024 at 3:30 p.m., 10/29/2024 at 3:15 p.m. and 01/28/2025 at 3:15 p.m.. During the third shift, fire drills were conducted on 04/26/2024 at 11:30 p.m., 07/18/2024 at 11:00 p.m., 10:26/2024 at 9:08 p.m. and 03/06/2025 at 10:55 p.m..

The Emergency Preparedness Manager verified this documentation at the time of the survey process.