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Based on documentation review and interview, the facility failed to conduct monthly testing of electrolyte specific gravity of the batteries, and annual testing of the diesel fuel for the emergency generator. This deficient practice could cause the emergency generator to fail to start and run when needed and not supply emergency power to the facility. The facility has a capacity of 25, with a census of 13 on the day of survey.

Findings are:
Record review on 01-16-20 at 10:52 am revealed:

1. The lack of documentation of the monthly testing of the electrolyte specific gravity of the batteries
2. Annual testing of the diesel fuel for the emergency generator.

During an interview on 01-16-20 at 10:52 am, Maintenance Staff A confirmed the lack of documentation of the testing.

Based on observation and interview, the facility failed to maintain the 1-hour separation, and to assure the doors to hazardous areas would close and latch within the doorframe. This deficient practice would allow fire, smoke and gasses to migrate into the exit corridors. The facility has the capacity for 25 beds with a census of 13 on the day of survey.
Findings are:
Observations on 01-16-20 between 1:35 pm and 2:37 pm revealed the following:

1. The door to the Medivator/scope cleaning room failed to fully close and latch within the door frame.
2. The door to the soiled/utility room on the nursing floor failed to fully close and latch within the door frame.
3. The door to the nursing storage room failed to fully close and latch within the door frame.
4. The door to the medical storage room failed to latch within the door frame.

During interviews on 01-16-20 between 1:35 pm and 2:37 pm, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility failed to provide and maintain all required equipment and appurtenances for the fire sprinkler system. This deficient practice could impact the response time and effectiveness of the sprinkler system. The facility has the capacity for 25 beds with a census of 13 patients on the day of survey.

Findings are:

Observation on 01-16-20 at 1:30 pm revealed 2 missing covers on the recessed sprinklers in the Endo room by surgery.

During an interview on 01-16-20 at 1:30 pm, Maintenance Staff A confirmed the findings.

Based on documentation review and interview, the facility failed to perform required fire drills. This deficient practice can lead to confusion and possible panic in the event of a real fire situation. The facility had a capacity of 25 with a census of 13 on the day of the survey.

Findings are:
Record review on 01-16-20 at 10:25 am revealed the following:
1. The first shift did no fire drill during the 2nd quarter of 2019.
2. The second shift did no fire drills during the 1st, 2nd, and 3rd quarters of 2019.
3. The third shift did no fire drills during the 1st, 2nd, and 3rd quarters of 2019.

During an interview on 01-16-20 at 10:25 am, Maintenance Staff A confirmed the findings.

Based on interview and documentation review, the facility failed to implement a testing and inspection program to document the integrity and operation of all fire rated doors throughout the facility. These deficient practices failed to ensure that the fire doors would operate as designed to prevent the spread of fire and smoke and affected all occupants in all smoke compartments. The facility capacity was 25, with a census of 13 on the day of survey.

Findings are:

Documentation review on 01-16-20 at 1:06 pm revealed that the facility failed to provide written documentation of annual inspections and testing of the all fire rated doors throughout the facility.

During an interview on 01-16-20 at 1:06 pm, Maintenance Staff A confirmed the lack of complete fire rated door inspections.

Based on documentation review and interview, the facility failed to conduct monthly testing of electrolyte specific gravity of the batteries, and annual testing of the diesel fuel for the emergency generator. This deficient practice could cause the emergency generator to fail to start and run when needed and not supply emergency power to the facility. The facility has a capacity of 25, with a census of 13 on the day of survey.

Findings are:
Record review on 01-16-20 at 10:52 am revealed:

1. The lack of documentation of the monthly testing of the electrolyte specific gravity of the batteries
2. Annual testing of the diesel fuel for the emergency generator.

During an interview on 01-16-20 at 10:52 am, Maintenance Staff A confirmed the lack of documentation of the testing.