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Based on record review and interview, the facility failed to inspect the emergency generator circuit breaker(s) annually, and exercise the circuit breakers periodically. This deficient practice increased the potential that emergency power would not be supplied to the facility during an emergency. The facility has the capacity for 23 beds with a census of 6 on the day of survey.

Findings are:
Record review on 3-5-19 at 11:14 am revealed a preventative maintenance plan was not adopted to inspect annually, and exercise periodically the emergency generator circuit breaker(s).

In an interview on 3-5-19 at 11:14 am, Maintenance A confirmed the inspection and testing was not implemented.

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

6.4.4.1.2.1*
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 interview, the facility failed to maintain a 2-hour fire separation between the Nursing Home and Hospital. This deficient practice would allow smoke and fire to migrate between the occupancies. The facility has the capacity for 23 beds with a census of 6 on the day of survey.

Findings are:
Observation on 3-5-19 at 2:06 pm revealed, the west 90-minute fire door between the Hospital and the Nursing Home failed to latch within the doorframe when closed.

During an interview on 3-5-19 at 2:06 pm, Maintenance Staff A confirmed the 90-minute fire door failed to latch.

Based on observation and interview, the facility failed to assure that the snow and ice was removed from the sidewalks, so that egress from the exit would not impede it to full instant use in the case of fire or other emergency. The facility has the capacity for 23 beds with a census of 6 on the day of survey.

Findings are:
Observations on 3-5-19 between 1:08 pm and 1:47 pm revealed:
1. The sidewalk outside the exit door 12 in the OR area was covered with snow.
2. The sidewalk outside the south exit in the OR area was covered with snow.
3. The sidewalk outside the South Center Wing exit next to room 211 was covered with snow.
4. The sidewalk outside the West Center Wing exit next to storage room was covered with snow.

During an interview on 3-5-19 between 1:08 pm and 1:47 pm, Maintenance Staff A confirmed the snow and covered sidewalks to public way.

NFPA Standard:
2012 NFPA 101, 7.1.10.1
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation and interview, the facility failed to assure that fire sprinklers were free of foreign materials. This deficient practice would affect the operation of the sprinklers and increased the potential that the sprinkler system would fail to activate as designed during a fire. The facility has the capacity for 23 beds with a census of 6 on the day of survey

Findings are:
Observations on 3-5-19 at 12:50 pm revealed, the sprinklers in the Kitchen near the hood and dish area were covered with corrosion.

During an interview on 3-5-19 at 12:50 pm, Maintenance Staff A confirmed the foreign materials on the sprinkler.

NFPA Standard:
NFPA 25, 2011, 5.2.1.1.1
Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer

Based on observation and interview, the facility allowed the obstruction of a corridor door and failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke within the exit corridors. The facility has the capacity for 23 beds with a census of 6 on the day of survey.

Findings are:
Observation on 3-5-19 between 12:32 pm and 2:48 pm revealed:
1. Dietician Office door was obstructed with a chair.
2. Exam Room 2 door failed to close and latch within the doorframe.
3. The double doors to the Telecommunication Room failed to be smoke-tight, one door failed to latch within the doorframe.

During an interview on 3-5-19 between 12:32 pm and 2:48 pm, Maintenance Staff A confirmed the findings.

NFPA Standard:
2012 NFPA 101, 19.3.6.3.10*
Doors shall not be held open by devices other than those that release when the door is pushed or pulled.
2012 NFPA 101, A.19.3.6.3.10 Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on documentation review and interview, the facility failed to conduct fire drills under varying conditions and failed to have staff participate in simulated drills, the facility only held discussions during third shift drills. These conditions would not provide simulated training for all staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response for residents. The deficient practice would affect all occupants.
The facility has the capacity for 23 beds with a census of 6 on the day of survey.

Findings are:
Record review on 3-5-19 at 12:07 pm revealed:
1. 2 of 3 first shift drills were conducted at 10:03 am and 10:37 am.
2. Facility failed to provide any documentation for fire drills for the 1st quarter in 2018.
3. Facility failed to provide documentation for the 3rd shift drill for the 2nd quarter in 2018.
4. Facility failed to provide documentation for the 3rd shift drill for the 3rd quarter in 2018.
5. Facility failed to provide documentation for the 2nd and 3rd shift drills for the 4th quarter in 2018.
6. Facility failed to provide documentation for any drills conducted in the 1st quarter in 2019.

During an interview on 2-19-19 at 1:57 pm, Maintenance Staff B confirmed the drills were not conducted under random conditions and that drill were not conducted.

Based on record review and interview, the facility failed to inspect the emergency generator circuit breaker(s) annually, and exercise the circuit breakers periodically. This deficient practice increased the potential that emergency power would not be supplied to the facility during an emergency. The facility has the capacity for 23 beds with a census of 6 on the day of survey.

Findings are:
Record review on 3-5-19 at 11:14 am revealed a preventative maintenance plan was not adopted to inspect annually, and exercise periodically the emergency generator circuit breaker(s).

In an interview on 3-5-19 at 11:14 am, Maintenance A confirmed the inspection and testing was not implemented.

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

6.4.4.1.2.1*
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 interview, the facility failed to assure that approved UL listed power strip and extension cords were not used within the facility. This deficient practice could increase the potential for an electrical fire. The facility has the capacity for 23 beds with a census of 6 on the day of survey.

Findings are:
Observations on 3-5-19 at 1:39 pm and 1:59 pm revealed:
1. An unapproved power strip at the nurse's station powering security television and security equipment.
2. An extension cord used to power a blow up snowman in the Fitness Center.

During an interview on 3-5-19 at 1:39 pm and 1:59 pm, Maintenance Staff confirmed the use of an unapproved power strip and extension cord.

Based on observation and interview, the facility failed to separate empty oxygen cylinders from full ones in storage. This deficient practice could cause confusion when choosing oxygen cylinders in an emergency resulting in an empty cylinder being chosen when a full one was required. The facility failed to post "Oxygen in Use, No Smoking" signs on rooms where oxygen was stored and failed to assure combustible were not stored with oxygen. The deficient practice would not alert persons entering the room to use extra caution with potential sources of ignition. The facility has the capacity for 23 beds with a census of 6 on the day of survey.

Findings are:
Observation on 3-5-19 at 1:13 pm and 1:55 pm revealed:
1. 2 empty oxygen cylinders was stored with full oxygen cylinders in the Oxygen Storage room.
2. No warning signage was posted on the Center Wing, Storage Room, which contained nine oxygen cylinders.
3. Combustible storage was placed adjacent to the oxygen cylinders in the Center Wing, Storage Room

During an interview on 3-5-19 at 1:13 pm and 1:55 pm, Maintenance Staff A confirmed the oxygen cylinders were intermixed and that no signage was posted.

NFPA Standard:
2012 NFPA 101, 19.1.1.3.1
All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants.

NFPA Standard:
2012 NFPA 99, 11.3.4.1
A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2
The sign shall include the following wording as a minimum:
CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING