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Based on record review and interview, the facility failed to test the specific gravity of the electrolyte in the starting batteries for the emergency generator. This deficient practice increased the probability that the generator would fail to run during an emergency loss of power. The facility has the capacity for 23 beds with a census of 4 on the day of survey.

Findings are:
Record review of on 01-28-2020 at 2:02 pm revealed that there was no documentation of monthly testing of the specific gravity of the electrolyte in the starting batteries for the emergency generator.

During an interview on 01-28-2020 at 2:02 pm, Maintenance Staff A and Maintenance Staff B confirmed the lack of electrolyte testing.

Based on observation, documentation review, and staff interview, the facility failed to properly maintain the fire sprinkler system. This deficient practice would cause failure of the fire sprinkler to operate as designed. The facility capacity was 23, with a census of 4 on the day of survey.

Findings are:

Observations on 01-28-2020, between 1:30 pm and 4:04 pm revealed the following:

1. The facility could not provide any documentation of a 5 year internal inspection of the fire sprinkler system.
2. A missing cover on the south concealed fire sprinkler in the dietary kitchen.
3. A missing cover on the south concealed fire sprinkler in the ER corridor.

During interviews on 01-28-2020 between 1:30 pm and 4:04 pm, Maintenance A and B confirmed the findings.

Based on documentation review and staff interview, the facility failed to hold fire drills under varied times and conditions for 1 of 2 shifts reviewed by not conducting the fire drills at least one hour apart from all other drills on the shift. This condition did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels. The facility capacity was 23 beds with a census of 4 on the day of survey.

Findings are:

Fire drill documentation review on 01-28-2020 at 1:19 pm revealed:
1. Second shift fire drills were conducted at 11:30 pm on 03-26-19, and at 11:20 pm on 12-10-19.

During an interview on 01-28-2020 at 1:19 pm, Maintenance Staff A and B confirmed the drills failed to be conducted during varied times and conditions.

Based on observation and staff interview, the facility failed to provide a metal container with a self-closing cover into which ashtrays could be emptied. This deficient practice could cause discarded smoking materials to smolder and ignite causing a fire. The facility has the capacity for 23 beds with a census of 4 on the day of survey.

Finding are:
Observation on 01-28-2020 at 2:35 pm revealed that the designated smoking areas failed to be provided with a proper ashtray and a metal container with a self-closing lid.

During an interview on 01-28-2020 at 2:35 pm, Maintenance Staff A and B confirmed the lack of the self-closing metal can or proper ashtray.

NFPA Standard:
2012 NFPA 101, 19.7.4*
Smoking regulations shall be adopted and shall include not less than the following provisions:
1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
3) Smoking by patients classified as not responsible shall be prohibited.
4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.
5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based on interview and documentation review, the facility failed to implement a testing and inspection program to document the integrity and operation of all fire rated doors throughout the facility. These deficient practices failed to ensure that the fire doors would operate as designed to prevent the spread of fire and smoke. The facility capacity was 23, with a census of 4 on the day of survey.

Findings are:

Documentation review on 01-28-2020 at 1:48 pm revealed that the facility failed to provide written documentation of annual inspections and testing of the all fire rated doors throughout the facility.

During an interview on 01-28-2020 at 1:48 pm, Maintenance Staff A and B confirmed the lack of complete fire rated door inspections.

Based on record review and interview, the facility failed to test the specific gravity of the electrolyte in the starting batteries for the emergency generator. This deficient practice increased the probability that the generator would fail to run during an emergency loss of power. The facility has the capacity for 23 beds with a census of 4 on the day of survey.

Findings are:
Record review of on 01-28-2020 at 2:02 pm revealed that there was no documentation of monthly testing of the specific gravity of the electrolyte in the starting batteries for the emergency generator.

During an interview on 01-28-2020 at 2:02 pm, Maintenance Staff A and Maintenance Staff B confirmed the lack of electrolyte testing.

Based on observation and interview, the facility allowed the use of electric extension cords as a substitute for permanent electrical wiring. This deficient practice could cause electrical injury and fires. The facility capacity was 23, with a census of 4 on day of survey.

Findings are:

Observation on 01-28-2020 at 3:11 pm revealed the use of an extension cord to power the lawn sprinkler system. This extension cord was run through the doorway from the laundry room to the tunnel.


During an interview on 01-28-2020 at 3:11 pm, Maintenance Staff A and B confirmed the findings.

Based on observation and interview, the facility failed to provide proper signage on the door of the Oxygen Storage room identifying the room as oxygen storage. This deficient practice did not alert persons entering the room of the oxidizing gas stored within, and to use extra caution with sources of ignition. The facility capacity is 23 beds, with a census of 4 on the day of survey.

Findings are:
Observation on 01-28-2020 at 3:52 pm revealed improper signage on the door to indicate that oxygen was stored within that room.

During an interview on 01-28-2020 at 3:52 pm, Maintenance A and B confirmed the findings.

NFPA Standard:
2012 ed., 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.

2012 ed., NFPA 99 11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING