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Based on record review and staff interview, the facility failed to have the diesel fuel tested annually for quality for 3 of 3 emergency generators. This deficient practice increased the potential that emergency power would not be supplied to the facility. The facility has the capacity for 13 beds with a census of 1 on the day of survey.


Findings are:
Record review on 4-4-23 at 2:48 pm revealed documentation was not provided to verify the diesel fuel for the generator tanks were tested annually for quality.

In an interview on 4-4-23 at 2:48 pm, Maintenance A confirmed the testing was not conducted.

NFPA 99, 2012, 8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

Based on observation and staff interview, the facility failed to provide smoke resistant partitions to separate hazardous areas from the rest of the building. This condition would allow smoke to migrate into the exit corridor. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:

Observation on 4-4-23 at 11:36 am revealed the door to Room 113, that was being used for storage, was not equipped with a self-closing device.

During an interview on 4-4-23 at 11:36 am, Maintenance Staff A confirmed the findings.

Based on record review and staff interview, the facility failed to have the kitchen range hood exhaust ductwork inspected every six months. This condition did not ensure the cleanliness of the system and increased the potential of a fire in the ductwork. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:
Record review on 4-4-23 at 11:20 am revealed, the facility had no documentation that the semi-annual inspection for grease build up had been completed.

In an interview on 4-4-23 at 11:20 am, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility failed to provide interior finishes that would provide a fire-retardant surface. This deficient practice increases the spread of fire, gases, and smoke. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:
Observations on 4-4-23 at 10:56 revealed, exposed wood (Plywood and 2x4's) around two windows on the west exterior wall of the boiler room.

During an interview on 4-4-23 at 10:56 am, Maintenance Staff confirmed the findings.

NFPA Standard:
18.3.3.2*
Interior Wall and Ceiling Finish. Interior wall and ceiling finish materials complying with Section 10.2 shall be permitted throughout if Class A, except as indicated in 18.3.3.2.1 or 18.3.3.2.2.

Based on observation and interview, the facility failed to ensure that the fire alarm system's circuit breakers were equipped with a lock out device. This deficient practice could allow the fire alarm panel to be inadvertently disconnected from its power supply, which would delay the response time to a fire affecting all occupants. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:
Observation on 4-4-23 at 10:59 am revealed, circuit breaker in the ELS electrical panel in the Electrical/Boiler room for the fire alarm was not equipped with a lock out device.

During an interview on 4-4-23 At 10:59 am, Maintenance Staff A confirmed the lack of lock out on the circuit breaker.

NFPA Standard:
2010 NFPA 72, 10.5.5.2
10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."
10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

Based on observation and interview, the facility allowed items to provide the required clearance to fire sprinklers and failed to maintain the fire sprinkler system to be clean and free of dust and dirt to accumulate. These deficient practices increased the potential of delayed sprinkler activation and obstructed spray pattern resulting in a larger fire that could spread outside of the room of origin. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:
Observation on 4-4-23 between 10:44 am and 11:04 am revealed:
1. Exam Room 1 had dust accumulated on the fire sprinkler deflector.
2. Exam Room 2 had dust accumulated on the fire sprinkler deflector.
3. Room 117 (Janitors Room), items on the top shelf encroached into the 18-inch required clear space for the sprinkler creating an obstruction.

During an interview on 4-4-23 between 10:44 am and 11:04 am, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility did not ensure that fire rated corridor separation doors would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke between smoke compartments. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:
Observation on 4-4-23 at 10:53 am revealed, the double 1½ hour fire rated smoke doors next to Room 115 were equipped with a latching device failed to latch within the doorframe.

During an interview on 4-4-23 at 10:53, Maintenance Staff A confirmed fire rated smoke doors were equipped with latching devices and failed to engage the frame.

Based on record review and interview, the facility failed to conduct fire drills and failed to conduct them under varying conditions for 2 of 2 shifts reviewed. The facility also failed to provide documentation from the monitoring company that the fire alarm system had been activated during the drills. These deficient practices would not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:
Record review on 4-4-23 at 12:21 am revealed:
1. 1st shift fire drills were conducted on 8-16-22 at 2:30 pm, 10-19-22 at 1:03 pm, 3-31-23 at 2:15 pm. No drill was conducted during the 2nd quarter of 2022
2. 2nd shift fire drills were conducted on 12-8-22 at 8:30 pm, 2-3-23 at 7:35 pm. No drills were conducted during the 2nd and 3rd quarters of 2022.
3. No documentation was provided from the fire alarm monitoring company to verify that the fire alarm was activated during drills.

During an interview on 4-4-23 at 12:21 pm, 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 by a qualified person. This deficient practice failed to ensure that the fire doors would operate as designed to prevent the spread of fire and smoke and affected all residents. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:
Documentation review on 4-4-23 at 3:10 pm revealed, that the facility failed to provide written documentation of annual inspection and testing of the fire rated doors throughout the facility by a qualified person.

During an interview on 4-4-23 at 3:10 pm, Maintenance A confirmed the lack of documentation.

NPFA Standards
NFPA 80
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on record review and staff interview, the facility failed to test patient bed electrical receptacles annually throughout the facility. This practice increased the risk of fire from a failed outlet. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:
Record review on 4-4-23 at 1:38 pm revealed documentation of annual patient bed location receptacle testing was not provided for review.

In an interview on 4-4-23 at 1:38 pm, Maintenance Staff A confirmed the testing was not documented, but showed the necessary tools that were being used to test outlets.

NFPA 99, 2012, 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Based on record review and staff interview, the facility failed to have the diesel fuel tested annually for quality for 3 of 3 emergency generators. This deficient practice increased the potential that emergency power would not be supplied to the facility. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:
Record review on 4-4-23 at 2:48 pm revealed documentation was not provided to verify the diesel fuel for the generator tanks were tested annually for quality.

In an interview on 4-4-23 at 2:48 pm, Maintenance A confirmed the testing was not conducted.

NFPA 99, 2012, 8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.

Based on observation and staff interview, the facility failed to prohibit the use of extension cords and power strips as a substitute for permanent wiring. This deficient practice would increase the possibility of a fire. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:

Observations on 4-4-23 between 10:03 am and 1:46 pm revealed the following:

1. Office manager Room 106 had a power strip plugged into another power strip.
2. Supply Materials Directors office Room 108 had a fan and a refrigerator plugged into a power strip.
3. Back up ER Room 110 had medical equipment and a computer plugged into a non-hospital grade power strip within six feet of a patient care area.
4. In the Operating Room, medical equipment was plugged into a rated hospital power strip lying on the floor.
5. The two AC units in the basement were plugged into extension cords hanging from pipes.

During an interview on 4-4-23 between 10:03 am and 1:46 pm, Maintenance Staff A confirmed the use of power strips and extension cords.

Based on record review and staff interview, the facility failed to implement the following: documentation of inspection and testing as well as an inspection and testing program for all portable patient-care related electrical equipment (PCREE) used in the facility; documentation of inspection as well as an inspection program for all non-PCREE equipment located within the patient care vicinity of all resident rooms and; documentation of an audit, testing and inspection as well as written procedures and policies for audits, testing and inspection of power strips throughout the facility. This practice increased the potential of electrical equipment throughout the facility causing injury or a fire, which would affect all occupants. The facility has the capacity for 13 beds with a census of 1 on the day of survey.

Findings are:
Record review on 4-4-23 at 1:49 pm revealed:
1. Written policies and procedures for conducting audits and testing of power strips, PCREE and non-PCREE devices was not provided.
2. Documentation of initial testing for power strips, PCREE and non-PCREE devices was not provided for review.

In an interview on 4-4-23 at 1:49 pm, Maintenance Staff A confirmed the testing was not conducted and policies not provided.