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Based on record review and staff interview, the facility failed to provide documentation that the emergency generator was inspected weekly and exercised under a load 12 times a year for the past 12 months reviewed. These deficient practices did not ensure the emergency generator would operate as designed in the event of a loss of power. This deficient practice would affect all occupants. The facility census was 6.

Findings are:

Record review on 3-2-2023 at 9:17 AM revealed the following:

1) Facility failed to provide documentation that the generator had been tested under a load of at least 30% of the rating of the generator 12 times for the past year.
2) Facility failed to provide 52 weekly inspection reports for the past year. The facility is equipped with two generators with a total of 104 weekly reports being needed. Only 45 total reports were provided for the past 12 months.

During an interview on 3-2-2023 at 9:17 AM, Maintenance Staff confirmed the findings.

Based on record review and staff interview, the facility failed to provide documentation for the fire alarm system smoke detector sensitivity testing. This deficient practice did not ensure that all fire alarm devices were inspected and increased the potential that the fire alarm would fail to operate during a fire. The deficient practice affected all occupants. The facility census was 6.

Findings are:

Record review on 3-2-2023 at 9:13 AM revealed the following:

1) The facility failed to provide documentation that the fire alarm system had sensitivity testing completed for the system smoke detectors for the past 24 months.

During an interview on 3-2-2023 at 9:13 AM, Maintenance Staff confirmed the finding.

Based on observation and staff interview, the facility failed to ensure the fire sprinkler system was installed for proper and complete building coverage and failed to provide a complete ceiling assembly by allowing multiple ceiling tiles to be missing. These deficient practices did not ensure smoke and heat would be kept below the ceiling to activate the fire sprinkler system or fire alarm system and did not provide proper sprinkler system coverage throughout the facility. The deficient practices would cause these systems to fail to operate as designed affecting all building occupants in 4 of 4 smoke compartments. The facility census was 6.

Findings are:

Observations on 3-2-2022 between 10:02 AM and 10:24 AM revealed the following:

1) Facility failed to maintain the drop-tile ceiling in the following locations:
a. Purchasing Room
b. Surgery Prep/Hold
c. North Entry by Lab
d. Furnace Room by Lab

2) Facility failed to provide proper facility fire sprinkler coverage by allowing fire sprinklers to be missing from the following locations:
a. Emergency Room (east side of corridor)
b. Hallway outside of X-Ray
c. X-Ray room
d. Entire Surgical Suite was not sprinklered

During interviews on 3-2-2023 between 10:02 AM and 10:24 AM, Maintenance Staff confirmed the findings.

Based on record review and staff interview, the facility failed to conduct fire drills or emergency orientation training quarterly on each shift at varied times under varying conditions and staffing levels. This deficient practice would not provide simulated training for staff response in the event of a fire. This deficient practice affected all occupants.

Findings are:

Record review on 3-2-2023 at 8:58 AM revealed the following:

1) Facility records review of fire drills for the past 12 months showed the following drills being conducted for the two nursing shifts:
a. 1st shift drills conducted on 6-24-2022 at 9:30 AM, and 12-30-2022 at 1:30 PM.
b. 2nd shift drill conducted on 3-8-2022 at 9:00 PM.

During an interview on 3-2-2023 at 8:58 AM, Maintenance Staff confirmed the findings.

Based on record review and interview, the facility failed to have a preventative maintenance plan in place to inspect and test all fire rated doors annually throughout the facility. This deficient practice would allow the spread of fire through faulty doors that would otherwise contain a fire or smoke. This would affect all occupants in 4 of 4 smoke compartments. The facility census was 6 residents.

Findings are:

Record review on 3-2-2023 at 9:20 AM revealed the following:

1) Facility failed to provide documentation that fire rated doors throughout the facility had been annually inspected and tested for proper operation and overall condition.

During an interview on 3-2-2023 at 9:20 AM, Maintenance Staff confirmed the finding.

Based on record review and staff interview, the facility failed to provide documentation that the emergency generator was inspected weekly and exercised under a load 12 times a year for the past 12 months reviewed. These deficient practices did not ensure the emergency generator would operate as designed in the event of a loss of power. This deficient practice would affect all occupants. The facility census was 6.

Findings are:

Record review on 3-2-2023 at 9:17 AM revealed the following:

1) Facility failed to provide documentation that the generator had been tested under a load of at least 30% of the rating of the generator 12 times for the past year.
2) Facility failed to provide 52 weekly inspection reports for the past year. The facility is equipped with two generators with a total of 104 weekly reports being needed. Only 45 total reports were provided for the past 12 months.

During an interview on 3-2-2023 at 9:17 AM, Maintenance Staff confirmed the findings.

Based on observation and staff interview, the facility failed to ensure electrical junction boxes were equipped with cover plates. This deficient practice could cause a fire or burn upon accidental contact. The deficient practice would affect approximately 2 occupants in 1 of 4 smoke compartments (Admin/Nurse Station). The facility census was 6.

Findings are:

Observation on 3-2-2023 at 10:06 AM revealed the following:

1) An electrical junction box in the ceiling above the ceiling tile near the Prep/Hold south door was missing a cover.

During an interview on 3-2-2023 at 10:06 AM, Maintenance Staff confirmed the finding.

Based on record review and staff interview, the facility failed to implement a testing and maintenance program for all portable patient-care related electrical equipment (PCREE), and for all non-PCREE equipment located within the patient care vicinity of all patient rooms. This practice increased the potential of electrical equipment within a patient room causing injury or a fire, which would affect all occupants. The facility has the capacity for 15 beds with a census of 6 on the day of survey.

Findings are:

Record review on 3-2-2023, at 9:20 AM revealed the facility did not document inspection/testing of PCREE equipment, and non-PCREE equipment within the patient care vicinity of resident rooms.

In an interview on 3-2-2023, at 9:20 AM, Maintenance Staff confirmed the testing was not conducted.