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Based on documentation review and interview, the facility failed to conduct all required weekly inspections of the emergency generator and failed to have the diesel fuel tested annually for quality. These deficient practices increased the potential that the generator would fail to run during loss of power. The facility has the capacity for 10 beds with a census of 5 on the day of survey.

Findings are:
Documentation review on 4-18-19 at 10:20 am of the provided emergency generator maintenance log revealed the documentation failed to exhibit all required information for weekly testing in accordance with National Fire Protection Association Pamphlet 110:
1. The engine system and all the components failed to be inspected and documented weekly.
2. The exhaust system and all the components failed to be inspected and documented weekly.
3. The cooling system and all the components failed to be inspected and documented weekly.
4. The fuel system and all the components failed to be inspected and documented weekly.
5. The electrical system and all the components failed to be inspected and documented weekly.
6. The exhaust system and all the components failed to be inspected and documented weekly.
7. No documentation that the diesel fuel for the generator was tested for quality.

During an interview on 4-18-19 at 10:20 am, Maintenance Staff A confirmed that the generator testing documentation failed to be complete and stated they were not aware of the fuel testing requirement

NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA Standard:
NFPA 110, 2010, 8.3.8
A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on observation and interview, the facility failed to provide exit doors that did not require an excess of 15 pounds of force to release the door hardware, this deficient practice would cause confusion and delay egress during an emergency. The facility has the capacity for 10 beds with a census of 5 on the day of survey.

Findings are:
Observations on 4-18-19, at 1:12 pm revealed, the east door in the Maintenance corridor leading to the dock failed to open with extreme pressure.

During an interview on 4-18-19, at 1:12 pm, Maintenance Staff A confirmed the door hardware was dragging on the threshold.

Based on observation and interview, the facility failed to assure the doors to hazardous areas would close and latch within the doorframe and were not held open. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor. The facility has the capacity for 10 beds with a census of 5 on the day of survey.

Findings are:
Observation on 4-18-19 between 12:17 pm and 1:08 pm revealed:
1. The Lactation Room door 374 equipped with a self-closing device failed to close and latch within the doorframe.
2. The Surgery Staff Lounge door equipped with a self-closing device failed to close and latch within the doorframe.
3. The Hood Room door 236 equipped with a self-closing device failed to close and latch within the doorframe.
4. The Storage Room door 245 equipped with a self-closing device failed to close and latch within the doorframe.
5. The Sleep Room 389, restroom door equipped with a self-closing device was obstructed with a brown rubber door wedge and clothes hanger on the self-closing device.

During an interview on 4-18-19 between 12:17 pm and 1:08 pm, Maintenance Staff A confirmed findings.

Based on documentation review and interview, the facility failed to conduct sprinkler inspection on a quarterly basis. This deficient practice could affect the operating of the sprinklers and increased the potential that the sprinkler system would fail to activate as designed during a fire and could delay the response of the fire sprinklers resulting in a larger fire that could spread outside the room of origin. The facility has the capacity for 10 beds with a census of 5 on the day of survey.

Findings are:
During documentation review on 4-18-19, at 10:30 am revealed, that the facility failed to conduct a quarterly inspection, the only documentation provided was the initial construction final dated 10-11-18.

During an interview on 4-18-19, at 3:40 am, Maintenance Staff confirmed only an initial construction inspection was provided.

Based on record review and interview, the facility failed to provide a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 10 beds with a census of 5 on the day of survey.

Findings are:
Record review on 4-18-19 at 11:20 am, revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in a twenty-four hour period. The policy provided failed to include that in a preplanned fire watch the facility would contact the fire department, property owner/or owners representative, alarm company, insurance company and the authorities having jurisdiction (HHSS, SFM).

During an interview on 4-18-19 at 11:20 am, Maintenance Staff A confirmed the lack of information on the fire watch policy.

NFPA Standard:
NFPA 25, 2011
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on record review and interview, the facility failed to have a preventative maintenance plan in place to inspect and test all fire doors annually throughout the facility. This deficient practice would allow the spread of fire through faulty fire doors that would otherwise contain a fire. The facility has the capacity for 10 beds with a census of 5 on the day of survey.

Findings are:
Record review on 4-18-19, at 10:13 am revealed, the facility failed to implement a maintenance plan to inspect all fire rated doors throughout the facility.

During an interview on 4-18-19, at 10:13 am, Maintenance Staff A confirmed the lack of maintenance plan.

NFPA Standard:
NFPA 80, 2010, 5.2*
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

Based on documentation review and interview, the facility failed to conduct all required weekly inspections of the emergency generator and failed to have the diesel fuel tested annually for quality. These deficient practices increased the potential that the generator would fail to run during loss of power. The facility has the capacity for 10 beds with a census of 5 on the day of survey.

Findings are:
Documentation review on 4-18-19 at 10:20 am of the provided emergency generator maintenance log revealed the documentation failed to exhibit all required information for weekly testing in accordance with National Fire Protection Association Pamphlet 110:
1. The engine system and all the components failed to be inspected and documented weekly.
2. The exhaust system and all the components failed to be inspected and documented weekly.
3. The cooling system and all the components failed to be inspected and documented weekly.
4. The fuel system and all the components failed to be inspected and documented weekly.
5. The electrical system and all the components failed to be inspected and documented weekly.
6. The exhaust system and all the components failed to be inspected and documented weekly.
7. No documentation that the diesel fuel for the generator was tested for quality.

During an interview on 4-18-19 at 10:20 am, Maintenance Staff A confirmed that the generator testing documentation failed to be complete and stated they were not aware of the fuel testing requirement

NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA Standard:
NFPA 110, 2010, 8.3.8
A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on observation and interview, the facility failed to prohibit the use of power strips as a substitute for adequate wiring. This deficient practice would create electrical injury and increase a fire. The facility has the capacity for 10 beds with a census of 5 on the day of survey.

Findings are:
Observation on 4-18-19, at 1:28 pm revealed, a refrigerator and commercial coffee maker was plugged into a power strip in the Dining Room at the AJ's coffee bar.

During an interview on 4-18-19, at 1:28 pm, Maintenance Staff A confirmed the power strip and stated, "that it was brought in from an outside vendor, and they were not aware of it's use," and could not confirm the items plugged in to the power strip do not pull more amperage than the power strip is rated for.

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 has the capacity for 10 beds with a census of 5 on the day of survey.

Findings are:
Observation on 4-18-19 at 1:20 pm revealed, 2 empty oxygen cylinders were stored with 3 full oxygen cylinders and 3 partially full oxygen cylinders in the Oxygen Storage room and no signage was provided.

During an interview on 4-18-19 at 1:20 pm, Maintenance Staff A confirmed the empty oxygen cylinders intermixed with full cylinders and the lack of signage