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Based on record review and interview, the facility failed to conduct required specific gravity testing of the electrolyte of the starting batteries for the emergency generator. This deficient practice would not ensure the emergency generator would operate upon loss of normal power. The facility had a census of 6 on the day of survey.

Findings are:

During record review on 5-21-25 at 2:39 pm, the facility failed to produce documentation to assure the specific testing of the electrolyte of the batteries for the emergency generator was conducted monthly.

During an interview on 5-21-25 at 2:39 pm, Maintenance Staff A and B confirmed the lack of testing.

Based on observation and interview, the facility failed to provide battery powered emergency lighting in the maintenance / electrical rooms where the controls and switches for the emergency generator are located. This deficient practice would cause confusion and delay repairs to the generator equipment in the event of a generator failure during an emergency. The facility had a census of 6 on the date of survey.

Findings are:
Observation on 5-21-25 at 5:08 pm revealed there was no emergency light fixture with back-up battery power provided in the rooms containing the controls and switches for the emergency generator.

During an interview on 5-21-25 at 5:08 pm, Maintenance Staff A and B confirmed the findings.

NFPA 110, 2010 ed. 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall
be provided with battery-powered emergency lighting. This
requirement shall not apply to units located outdoors in enclosures
that do not include walk-in access.

Based on record review and interview, the facility failed to conduct required specific gravity testing of the electrolyte of the starting batteries for the emergency generator. This deficient practice would not ensure the emergency generator would operate upon loss of normal power. The facility had a census of 6 on the day of survey.

Findings are:

During record review on 5-21-25 at 2:39 pm, the facility failed to produce documentation to assure the specific testing of the electrolyte of the batteries for the emergency generator was conducted monthly.

During an interview on 5-21-25 at 2:39 pm, Maintenance Staff A and B confirmed the lack of testing.

Based on observation and interview, the facility allowed the use of a light duty multi-plug surge protector as a substitute for permanent electrical wiring. This deficient practice could cause electrical injury and fires. The facility had a census of 6 on the day of survey.

Findings are:

Observation on 5-21-25 at 3:49 pm revealed the use of a light duty multi-plug surge protector, powering a small fan, a phone charger and a laptop computer in the corridor of the old specialty clinic.

During an interview on 5-21-25 at 3:49 pm, Maintenance Staff A and B confirmed the findings.