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Based on documentation review and interview, the facility failed to conduct monthly testing of electrolyte specific gravity of the batteries for the emergency generator. This deficient practice could cause the emergency generator to fail to start when needed and not supply emergency power to the facility. The facility has a capacity of 20 beds, with a census of 4 on the day of survey.

Findings are:
Record review on 3-13-19 at 10:30 am revealed the lack of documentation of the testing of the electrolyte specific gravity of the batteries for the emergency generator.

During an interview on 3-13-19 at 10:30 am, Maintenance Staff A confirmed the lack of documentation of the testing.

Based on observation and interview, the facility failed to assure all egress corridors had emergency lighting. This deficient practice could delay evacuation of residents during an emergency. The facility has the capacity for 20 beds with a census of 4 on the day of survey.

Findings are:
Observations on 3-13-19 at 11:55 am revealed there was no emergency lighting provided in the upper north corridor.

During an interview on 3-13-19 11:55 am, Maintenance Staff A confirmed the lack of emergency lighting.

Based on observation and staff interview, the facility failed to provide smoke resistant partitions to separate hazardous areas from the rest of the building. This deficient condition would allow smoke to migrate into the exit corridors, which would affect the evacuation of occupants. The facility has the capacity for 20 beds with a census of 4 on the day of survey.

Findings are:
Observation on 3-13-19 between 10:58 am and 12:39 pm revealed the following:
1. There was a 3 inch unsealed hole around a sprinkler pipe in the mechanical room ceiling.
2. There was a 2 inch by 5 inch unsealed hole around a water pipe hanger in the mechanical room.
3. The double doors to the ambulance unloading bay failed to properly close and be smoke tight.

In interviews on 3-13-19 between 10:58 am and 12:39 pm, Maintenance A acknowledged the ambulance bay doors did not properly close and the unsealed penetrations in the ceiling of the mechanical room

Based on observation and interview, the facility failed to secure the circuit breaker supplying the fire alarm system from being accidentally tuned off. This deficient practice would allow the fire alarm system to be non-functional in the case of a fire and fail to notify personnel of a fire hazard which would affect all occupants. The facility has a capacity of 20 beds with a census of 4 on the day of survey.

Findings are:
Observation on 3-13-19 at 10:44 am revealed there was no lock installed on the circuit breaker for the fire alarm panel.

In an interview on 3-13-19 at 10:44 am, Maintenance A confirmed the lack of a lock on the circuit breaker.

Based on document review, and staff interview the facility failed to properly maintain the fire alarm system by not having the annual fire alarm inspection performed. This deficient practice would cause failure of the fire alarm system to operate as designed and would affect all occupants. The facility capacity was 20, with a census of 4 on the day of survey.

Findings are:
Document review on 3-13-19 at 10:15 am revealed the facility had no documentation that an annual fire alarm inspection had been completed. The last inspection had been performed on 11-7-17

During an interview on 3-13-19 at 10:15 am, Maintenance Staff A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain doors to ensure smoke separation of the egress corridor in 1 of 7 smoke compartments. This condition would allow smoke and fire gases to migrate from patient rooms into the egress corridor. The facility capacity was 20, with a census of 4 on the date of survey.

Findings are:
Observation on 3-13-19 at 11:05 am revealed the door to the CT-scan room was dragging on the floor and failed to self-close.

During an interview on 3-13-19 at 11:05 am, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility did failed to ensure that fire rated corridor separation doors would resist the passage of smoke from one compartment to another. This deficient practice would not prevent the spread of fire and smoke between smoke zones. The facility has the capacity for 20 beds with a census of 4 on the day of survey.

Findings are:
Observation on 3-13-19 at 11:35 am, revealed the corridor doors in the north corridor failed close properly to be smoke tight.

During interview on 3-13-19 at 11:35 am, Maintenance Staff A confirmed the findings

Based on observation and interview, the facility failed to provide an approved cover for an open circuit breaker slot in electrical circuit breaker panel. The deficient practice increased the potential of an electrical shock or fire from unintended contact with live electrical wiring. The facility capacity is 20 with a census of 4 on the day of survey.

Findings are:
Observation on 3-13-19 at 11:32 am revealed an open circuit breaker slot in a circuit breaker panel in the housekeeping storage room.

During an interview on 3-13-19 at 11:32 am Maintenance A confirmed the findings.

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 20, with a census of 4 on the day of survey.

Findings are:
Documentation review on 3-13-19 at 10:36 am 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 3-13-19 at 10:36 am, Maintenance Staff A confirmed the lack of complete fire rated door inspections.

Based on documentation review and interview, the facility failed to conduct monthly testing of electrolyte specific gravity of the batteries for the emergency generator. This deficient practice could cause the emergency generator to fail to start when needed and not supply emergency power to the facility. The facility has a capacity of 20 beds, with a census of 4 on the day of survey.

Findings are:
Record review on 3-13-19 at 10:30 am revealed the lack of documentation of the testing of the electrolyte specific gravity of the batteries for the emergency generator.

During an interview on 3-13-19 at 10:30 am, Maintenance Staff A confirmed the lack of documentation of the testing.