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Based on documentation review and interview, the facility failed to ensure that the transfer time from normal power to emergency power was not more than 10 seconds. This deficient practice increased the potential that the generator would provide immediate emergency power during a loss of the normal power source. The facility has the capacity for 16 beds with a census of 2 on the day of survey.

Findings are:

Documentation review on 6-5-19 at 10:53 am revealed the facility failed to document emergency power transferred within 10 seconds during the monthly load test of the generator.

During an interview on 6-5-19 at 10:53 am, Maintenance Staff A and Maintenance Staff B confirmed the findings the lack of information of the generator to supply service within 10 seconds.

Based on observation and interview, the facility failed to maintain corridors free of obstructions. This deficient practice could delay evacuation of residents during an emergency. The facility has the capacity for 16 beds with a census of 2 on the day of survey.

Findings are:

Observations on 6-5-19 at 12:07 pm revealed, two empty soiled linen carts were stored in the exit corridor in Zone E outside of the soiled linen storage room.

During an interview on 6-5-19 at 12:07, Maintenance Staff B confirmed the soiled linen carts in the corridor were not in use and being stored.

Based on record review and interview the facility failed to test and document battery operated exit signs monthly. The absence of complete, verifiable documented maintenance and repair history of the exit signs would result in a lack of visible exit signs in an emergency. The facility has the capacity for 16 beds with a census of 2 on the day of survey.

Findings are:

Record review on 6-5-19 at 11:09 am, revealed the documentation regarding the testing of the exit signage failed to include a monthly 30 second test.

During an interview on 6-5-19 at 11:09 am, Maintenance Staff A and Maintenance Staff B confirmed the lack of monthly testing of the exit signs.

NFPA Standard:
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2012 NFPA 101, 7.9.3 and 7.10.9

Based on observation and interview, the facility failed to maintain the 1-hour separation of hazardous areas of the second floor of the Bed Tower. This deficient practice would allow smoke and fire to migrate out of the hazardous area. The facility has the capacity for 16 beds with a census of 2 on the day of survey.

Findings are:

Observation on 6-5-19 between 12:11 pm and 1:00 pm revealed:
1. Unsealed penetrations around a 3/4" conduit, around a 1" conduit, and a 2" X 1 1/2" opening around a bar Joyce in the 1 hour rated wall in the paint storage room.
2. Unsealed penetration around a 1" conduit going thru a 1 hour rated fire wall above the double doors in Central Supply.

During an interview on 6-5-19 between 12:11 pm and 1:00 pm, Maintenance Staff A and Maintenance Staff B confirmed the findings of the unseal penetrations.

Based on documentation review and staff interview, the facility failed to provide all required documentation for the semi-annual fire alarm system inspection. This deficient practice did not ensure that all fire alarm devices were inspected and increased the potential that the fire alarm would fail to operate during a fire. The facility has the capacity for 16 beds with a census of 2 on the day of survey.

Findings are:

Record review on 6-5-19 at 4:00 pm revealed the facility had no documentation that the semi-annual fire alarm tests had been completed.

During an interview on 6-5-19 at 4:00 pm, the findings of documentation review were acknowledged and verified by Maintenance Staff A and Maintenance Staff B.

Based on observation and staff interview, the facility failed to provide complete fire sprinkler coverage. This deficient practice had the potential to allow a fire to potentially grow beyond the capabilities of the fire sprinkler system. The facility has the capacity for 16 beds with a census of 2 on the day of survey.

Findings are:

Observation on 6-5-19 at 2:20 pm revealed a clothes closet that measured over 6 square feet in area that was affixed to the building in the Sleep Study room, failed to have required fire sprinkler coverage.

During an interview on 6-5-19 at 2:20 pm, Maintenance Staff A and Maintenance Staff B confirmed the findings of no sprinkler protection in the closet.

Based on observation, documentation review, and staff interview, the facility failed to maintain the required minimum clearance around fire sprinkler deflectors and failed to provide documentation of the quarterly fire sprinkler system inspections. The deficient practice could prevent the fire sprinkler from activation in the case of fire and could obstruct the spray pattern of the sprinkler resulting in inefficient coverage and failure to extinguish a fire. The facility has the capacity for 16 beds with a census of 2 on the day of survey.

Findings are:

Observations on 6-5-19 between 12:15 pm and 2:00 pm revealed:

1. The facility failed to provide documentation of the quarterly inspections of the fire sprinkler system.
2. Clean Linen stored on the top shelf in the Clean Linen room in the hallway between the OR and ER were stored within 10 inches of the sprinkler deflector.
3. Boxes stored in the Clean Supply room in Imaging were stored within 14 inches of the sprinkler deflector.

During interviews on 6-5-19 between 12:15 pm and 2:00 pm, Maintenance Staff A and Maintenance Staff B confirmed the lack of documentation and findings.

Based on documentation review and interview, the facility failed to hold fire drills under varied conditions for 1 of 3 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, which would affect fire procedure response. The facility has the capacity for 16 beds with a census of 2 on the day of survey.

Findings are:

Fire drill documentation review on 6-5-19 at 10:45 am revealed, First shift fire drills were conducted at 2:15 pm on 5-22-19, 4:00 pm on 2-28-19, 3:20 pm on 11-29-18, and 2:15 pm on 8-31-18.

During an interview on 6-5-19 at 10:45 am, Maintenance Staff A and Maintenance Staff B confirmed the drills failed to be conducted during varied times.

Based on observation and interview, the facility allowed the use of portable electric space heaters and failed to provide documentation the heating element of the device did not exceed 212 degrees Fahrenheit. This deficient practice increased the potential of a fire. The facility has the capacity for 16 beds with a census of 2 on the day of survey.

Findings are:

Observations on 6-5-19 at 1:07 pm revealed a portable heating device in the Central Supply Office.

During an interview on 6-5-19 at 1:07 pm, Maintenance Staff A stated that the facility did not have the manufactures specification for the heaters and could not confirm the heating element of the device did not exceed 212 degrees Fahrenheit and that the heater was possibly brought into the facility by staff.

NFPA Standard:
2012 NFPA 101, 19.7.8
Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

Based on documentation review and interview, the facility failed to ensure that the transfer time from normal power to emergency power was not more than 10 seconds. This deficient practice increased the potential that the generator would fail to run during loss of power. The facility has the capacity for 16 beds with a census of 2 on the day of survey.

Findings are:

Documentation review on 6-5-19 at 10:53 am revealed the facility failed to document emergency power transferred within 10 seconds during the monthly load test of the generator.

During an interview on 6-5-19 at 10:53 am, Maintenance Staff A and Maintenance Staff B confirmed the findings the lack of information of the generator to supply service within 10 seconds.