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Based on documentation review and interview, the facility failed to have a program for exercising main and feeder circuit breakers serving the Essential Electrical System and failed to assure all required testing was conducted. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Documentation review on 9-6-23 at 12:08 pm of the emergency generator maintenance log revealed:
1. No program for exercising the emergency breakers or the main breaker was established.
2. Failed to assure a 30 minute monthly run time was completed every month.
3. Failed to include transfer time.
4. Failed to include cool down time.
5. Failed to test maintenance free batteries.
6. Failed to provide current fuel inspection.

During an interview on 9-6-23 at 12:08 pm, Staff A confirmed that the generator testing failed to be conducted.

NFPA Standard:
NFPA 99, 2012, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.
A.6.4.4.1.2.1
Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.

Based on observation and interview, the facility failed to provide self-closing doors at construction zones that would resist the passage of smoke or fire. This deficient practice would allow smoke or fire to spread from the construction zones into the occupied spaces of the facility. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Observation on 9-6-23 at 10:40 am revealed, Patient rooms 2 and 3 were under construction, the facility failed to provide self-closing devices on the doors.

During an interview on 9-6-23, at 10:40 am, Staff A confirmed the lack of self-closing devices.

Based on documentation review and interview, the facility failed to assure ground fault protected outlet (GFCI) were tested monthly. This deficient practice would increase the probability of the electrical equipment to cause an electrical shock or fire, which has the potential to spread outside the room in all smoke compartments. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Documentation review on 8-6-23 at 1:18 pm revealed, the facility failed to test the GFCI outlets.

During an interview on 8-6-23 at 1:18 pm, Staff A confirmed the GFCI breakers failed to be tested.

Based on documentation review and interview, the facility failed to have a program for exercising main and feeder circuit breakers serving the Essential Electrical System and failed to assure all required testing was conducted. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility. The facility has the capacity for 18 beds with a census of 3 on the day of survey.

Findings are:
Documentation review on 9-6-23 at 12:08 pm of the emergency generator maintenance log revealed:
1. No program for exercising the emergency breakers or the main breaker was established.
2. Failed to assure a 30 minute monthly run time was completed every month.
3. Failed to include transfer time.
4. Failed to include cool down time.
5. Failed to test maintenance free batteries.
6. Failed to provide current fuel inspection.

During an interview on 9-6-23 at 12:08 pm, Staff A confirmed that the generator testing failed to be conducted.

NFPA Standard:
NFPA 99, 2012, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.
A.6.4.4.1.2.1
Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.