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Based on record review and staff interview, the facility failed to inspect the emergency electrical system (EES) main and feeder breakers annually, and failed to exercise these circuit breakers periodically for 2 of 2 emergency generators. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 4/18/24 at 11:48 am revealed documentation was not provided to verify emergency electrical system (EES) main and feeder circuit breakers were inspected annually and exercised periodically.

In an interview on 4/18/24 at 11:48 am, Maintenance A confirmed the testing was not conducted.

NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be
maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.

Based on observation and staff interview, the facility allowed a self-closing hazard room door to be held open by an unapproved method. This practice would allow smoke to migrate into the Kitchen.

Findings are:
Observation on 4/18/24, at 1:30 pm revealed the Kitchen Janitor A133 door was propped open by a door chock, which prevented the corridor door from self-closing.

In an interview on 4/18/24, at 1:30 pm, Administration A acknowledged the findings, and removed the door chock at the time of observation.

Based on record review and staff interview, the facility failed to conduct fire drills under varying times and conditions. This practice did not provide training for staff to respond to a fire emergency during various activities and staffing levels.

Findings are:

Record review on 4/18/24, at 11:06 am of fire drills revealed fire drill times were not varied by one hour for the 2nd shift in 2023: 2/27/23 at 9:30 pm and 11/27/23 at 10:00 pm.

In an interview on 4/18/24, at 11:06 am, Maintenance A acknowledged the findings.

Based on record review and staff interview, the facility failed to inspect the emergency electrical system (EES) main and feeder breakers annually, and failed to exercise these circuit breakers periodically for 2 of 2 emergency generators. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 4/18/24 at 11:48 am revealed documentation was not provided to verify emergency electrical system (EES) main and feeder circuit breakers were inspected annually and exercised periodically.

In an interview on 4/18/24 at 11:48 am, Maintenance A confirmed the testing was not conducted.

NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be
maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.