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Based on documentation review and interview, it was determined the facility failed to develop an emergency preparedness program, affecting the entire facility.

Finding include
1. Review of documentation on December 15, 2025, between 11:20 a.m., and 11:40 a.m., revealed the facility failed to establish and maintain a comprehensive emergency preparedness program in accordance with 42 CFR 485.625 condition of participation to include the following standards:

(a) Emergency Plan
(b) Policies and Procedures
(c) Communication Plan
(d) Training and Testing
(e) Emergency and Standby Power Systems

Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the emergency preparedness deficiencies.

Based on observation and interview, it was determined the facility failed to maintain building construction requirements in four locations, affecting one of one floor.

Findings include:

1. Observation on December 15, 2025, between 10:33 a.m., and 11:03 a.m., revealed the following:

a. 10:33 a.m., a residential-style air conditioning unit's exhaust discharged into interstitial spaces within the IT Room, and the fire damper was located approximately eighteen inches above the exhaust opening within the ceiling.
b. 10:40 a.m., the suspended ceiling portion of the rated ceiling assembly had been removed in Room 108.
c. 10:42 a.m., the suspended ceiling portion of the rated ceiling assembly had been removed is Room 110.
d. 11:01 a.m., the suspended ceiling portion of the rated ceiling assembly had been removed in Room 210.
e. 11:03 a.m., rated ceiling tiles were missing/dislodged within Room 208.

Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the building construction deficiencies.

Based on documentation review and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of one floor.

Findings include:

1. Observation on December 15, 2025, at 11:22 a.m., revealed the facility lacked documentation to support one of two required semi-annual, kitchen exhaust hood duct cleanings.

Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the cooking facilities deficiency.

Based on observation and interview, it was determined the facility failed to properly install automatic sprinkler heads in three locations, affecting one of one floor.

Findings include:

1. Observation on December 15, 2025, between 10:40 a.m., and 11:10 a.m., revealed the following rooms lacked upright sprinkler head assemblies (ceilings removed):

a. 10:40 a.m., Room 108.
b. 10:41 a.m., Room 110.
c. 11:08 a.m., Room 210

Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two locations, affecting one of one floor.

Findings include:

1. Observation on December 15, 2025, between 10:12 a.m., and 10:22 a.m., revealed the following:

a. 10:12 a.m., a missing escutcheon plate, located within the Break Room.
b. 10:22 a.m., storage items located within eighteen inches of an adjacent sprinkler head assembly, located within the Team Leader's Office.

Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the automatic sprinkler system deficiencies.

Based on observation and interview, it was determined the facility failed to maintain corridor openings in three locations, affecting one of one floor.

Findings include:

1. Observation on December 15, 2025, between 10:13 a.m., and 10:28 a.m., revealed the following:

a. 10:13 a.m., the Dietary door required adjustment to fully latch.
b. 10:15 a.m., the ER door required adjustment to fully latch.
c. 11:28 a.m., the Patient Room 108 door was not smoke-tight.

Exit interview with the Director of Nursing and the Facilities Manager on December 15, 2025, between 11:45 a.m., and 11:50 a.m., confirmed the corridor opening deficiencies.