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Based on record review and staff interview, the facility failed to verify the transfer time from normal power to emergency power, and failed to conduct weekly inspections of the standby emergency generator. This practice increased the probability that the generator would fail to run during an emergency loss of power, which would affect the emergency systems in the facility. The deficient practice affected all staff and residents. .

Findings are:

Record review of emergency generator maintenance records on 5-15-2019 between 1:20 PM and 1:22 PM revealed the following:

1) The transfer time from normal to emergency power was not indicated in the documentation provided.
2) The facility failed to document weekly inspections of the emergency generator after December 2018.

During an interview on 5-15-2019 between 1:20 PM and 1:22 PM, Maintenance Staff confirmed the findings.

Based on observation and staff interview, the facility failed to separate hazardous areas by smoke resistive partitions, and failed to ensure all hazardous areas were separated by self-closing doors at all times in 1 of 16 smoke compartments (1st level northwest). This condition would allow smoke to migrate into the exit corridor, which would affect approximately 3 occupants.

Findings are:

Observations on 5-15-2019 at 2:05 PM revealed the following:

1) 1st level laundry room storage room door was not equipped with a self-closing device.
2) 1st level laundry room storage room had a 2-inch gap around pipe penetrations in the ceiling.
3) 1st floor laundry room storage room had a 2-inch gap around pipe and ductwork penetrations in the wall.

During an interview on 5-15-2019 at 2:05 PM, Maintenance Staff confirmed the findings.

Based on interview and record review, the facility failed to provide a complete policy regarding the procedures to be taken in the event that the fire alarm system was out of service for more than four hours in any twenty-four hour period. The lack of a complete written policy and procedure could result in staff failing to implement interim safety measures in the event of an emergency affecting all residents.

Findings are:

Record review on 5-15-2019 at 1:30 PM revealed the following:

1. The facility failed to provide the contact information for the State Fire Marshal and failed to state that the State Fire Marshal would be notified in the event of a fire watch.
2. The facility failed to provide a copy of the facility's Fire Watch Policy.

During an interview on 5-15-2019 at 1:30 PM, Maintenance Staff confirmed the findings.

Based on interview and record review, the facility failed to ensure that a complete policy was in place regarding the procedures to be taken in the event that the fire sprinkler system was out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure could result in staff failing to implement interim safety measures in the event of an emergency affecting all residents.

Findings are:

Record review on 5-15-2019 at 1:30 PM revealed the following:

1. The policy failed to provide the contact information for the State Fire Marshal and the Insurance Company.
2. The facility failed to provide a copy of the facility's Fire Watch Policy.

During an interview on 5-15-2019 at 1:30 PM, Maintenance Staff confirmed the findings.

Based on record review and staff interview, the facility failed to conduct fire drills quarterly on 1 of 3 shifts (1st shift), and failed to conduct fire drills at varied times under varied conditions on 2 of 3 shifts (2nd shift and 3rd shift). The deficient practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response. The deficient practice affected all staff and residents.

Findings are:

Record review and staff interview on 5-15-2019 at 3:21 PM revealed the following:

1) The facility failed to conduct a fire drill on 1st shift for the time period of May 2018 to June 2018.
2) The facility conducted 5 of 5 drills on 2nd shift at: 7:30 PM, 9:00 PM, 5:40 PM, 3:30 PM, and 3:30 PM.
3) The facility conducted 4 of 4 drills on 3rd shift at: 3:00 AM, 1:30 AM, 11:15 PM, and 1:10 AM.

During an interview on 5-15-2019 at 3:21 PM, Maintenance Staff confirmed the findings.

Based on record review and interview, the facility failed to have a preventative maintenance plan in place to inspect and test all fire rated doors annually throughout the facility. This deficient practice would allow the spread of fire through faulty doors that would otherwise contain a fire or smoke, which would affect all occupants.

Findings are:

Record review on 5-15-2019 at 1:52 PM revealed, the facility failed to provide written documentation of annual inspections and testing of all fire rated doors throughout the facility.

During an interview on 5-15-2019 at 1:52 PM, Maintenance Staff confirmed the finding.

Based on observation and interview the facility failed to provide approved cover plates for electrical junction boxes in 1 of 16 smoke compartments (1st level northwest). This deficient practice increased the potential of an electrocution injury or fire from unintended contact with live electrical equipment. The deficient practice affected approximately 2 occupants.

Findings are:

Observations on 5-15-2019 at 1:57 PM revealed the following:

1) There was an electrical junction box on the wall in the fire sprinkler riser room that was not equipped with an approved cover plate.

During an interview on 5-15-2019 at 1:57 PM, Maintenance Staff confirmed the finding.

Based on record review and staff interview, the facility failed to test all patient bed hospital-grade electrical receptacles annually. This deficient practice increased the risk of fire from a failed outlet, which would affect all occupants. The facility census was 4.

Findings are:

Record review on 5-15-2019 at 1:51 PM revealed documentation of annual patient bed location hospital-grade electrical receptacle testing was not provided for review.

During an interview on 5-15-2019 at 1:51 PM, Maintenance Staff confirmed the finding.

Based on record review and staff interview, the facility failed to verify the transfer time from normal power to emergency power, and failed to conduct weekly inspections of the standby emergency generator. This practice increased the probability that the generator would fail to run during an emergency loss of power, which would affect the emergency systems in the facility. The deficient practice affected all staff and residents. .

Findings are:

Record review of emergency generator maintenance records on 5-15-2019 between 1:20 PM and 1:22 PM revealed the following:

1) The transfer time from normal to emergency power was not indicated in the documentation provided.
2) The facility failed to document weekly inspections of the emergency generator after December 2018.

During an interview on 5-15-2019 between 1:20 PM and 1:22 PM, Maintenance Staff confirmed the findings.