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Based on record review and staff interviews it was revealed the facility failed to test the emergency plan at least annually. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census is five (5).

Findings include:

During the facility emergency preparedness document review conducted on 08/27/19 between the hours of 3:00 p.m. and 4:00 p.m. the facility failed to complete the following emergency preparedness elements:

1. Annual emergency preparedness testing requirements were not met as the facility had not conducted a secondary full scale exercise or a tabletop exercise in the previous twelve months.

2. An interview on 08/27/19 at approximately 4:02 p.m. with the Emergency Preparedness Director verified this finding. The finding was also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.

Based on record review and staff interviews the facility failed to ensure that required emergency lighting systems were tested in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census is five (5).

Findings include:

1. Record review on 08/27/19 at approximately 9:13 a.m. revealed no documentation that battery powered exit lights located throughout the facility had received annual functional testing for a minimum of one and one half (1.5) hours for the previous twelve (12) months.

2. An interview on 08/27/19 at approximately 9:15 a.m. with the Maintenance Director verified this finding. The finding was also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.

Based on record review and staff interviews the facility failed to ensure that cooking equipment was protected in accordance with National Fire Protection Association (NFPA) 96. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census is five (5).

Findings include:

1. Record review on 08/27/19 at approximately 9:17 a.m. revealed no documentation that the kitchen range hood had been cleaned on a semi-annual basis as the most current cleaning was completed on 2/7/19.

2. An interview on 08/27/19 at approximately 9:18 a.m. with the Maintenance Director verified this finding. The finding was also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.

Based on observation and staff interviews the facility failed to ensure that the facility was protected throughout by an approved automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 13. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census is five (5).

Findings include:

1. An observation on 08/27/19 at approximately 2:06 p.m. revealed ceiling grid and conduit wire tied to the sprinkler system in the interstitial space above the Short Hall near Room 12.

2. An observation on 08/27/19 at approximately 2:16 p.m. revealed hard conduit and communication wiring laying on the sprinkler system and ceiling grid wire tied to the sprinkler system in the interstitial space above the Surgery Cardiopulmonary Corridor.

3. An observation on 08/27/19 at approximately 2:24 p.m. revealed communication wiring laying on the sprinkler system in the interstitial space above the Radiology Corridor near the Radiology Department entrance door.

4. An observation on 08/27/19 at approximately 2:31 p.m. revealed hard conduit wire tied and communication wiring laying on the sprinkler system in the interstitial space above the Emergency Room near Room 3.

5. An interview on 08/27/19 at approximately 2:33 p.m. with the Maintenance Director verified these findings. The findings were also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.

Based on record review and staff interviews the facility failed to ensure that air-conditioning, heating, ventilating ductwork and related equipment shall be in accordance with National Fire Protection Association (NFPA) 90 A. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census is five (5).

Findings include:

1. Record review on 08/27/19 at approximately 9:20 a.m. revealed no documentation of testing for six (6) fire dampers located in the two (2) hour fire rated separation wall near the Clinic and Medical Records was provided during survey.

2. An interview on 08/27/19 at approximately 9:21 a.m. with the Maintenance Director verified this finding. The finding was also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.

Based on record review and staff interviews the facility failed to maintain and test electrical receptacles at patient bed locations in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census is five (5).

Findings include:

1. Record review on 08/27/19 at approximately 9:27 a.m. revealed no documentation for testing of the physical integrity, continuity of the grounding circuit or correct polarity of the hot and neutral connections for each electrical receptacle at the patient bed locations in the facility.

2. An interview on 08/27/19 at approximately 9:29 a.m. with the Maintenance Director verified this finding. The finding was also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.

Based on record review and staff interviews the facility failed to ensure that maintenance and testing of the generator and transfer switches was performed in accordance with National Fire Protection Association (NFPA) 110. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census is five (5).

Findings include:

1. Record review on 08/27/19 at approximately 9:31 a.m. revealed no documentation of annual fuel quality testing for the emergency generator.

2. An interview on 08/27/19 at approximately 9:33 a.m. with the Maintenance Director verified this finding. The finding was also acknowledged by the Director of Nursing at the exit interview on 08/28/19 at approximately 11:30 a.m.