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Based on observation and interview, the facility failed to maintain the emergency egress lighting system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 7.9.2.1 and 19.2.9.1, by not ensuring emergency illumination be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. This deficient practice involves three light fixture in the facility and affects the staff and patients that occupy these areas. The facility has a capacity of 25 and a census of 2.

Findings include:

1. Observation and interview on 09/30/2021 at 12:30 p.m., revealed the battery backup emergency light located on the south side of the P.T.O.T. Conference Room failed to illuminate when tested. The Maintenance Supervisor verified this observation at the time of the survey process.

2. Observation and interview on 09/30/2021 at 12:35 p.m., revealed the battery backup emergency light located on the west wall of the P.T.O.T. East Waiting Room failed to illuminate when tested. The Maintenance Supervisor verified this observation at the time of the survey process.

3. Observation and interview on 09/30/2021 at 12:37 p.m., revealed the battery backup emergency light located in the P.T.O.T. Cardiac Rehabilitation Room failed to illuminate when tested. The Maintenance Supervisor verified this observation at the time of the survey process.

Based on record review and interview, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the fire alarm system is out of service for more than four hours in any 24-hour period in accordance with National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 edition, 9.6.1.6. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 25 and a census of 2 residents at the time of the survey.

Findings include:

1. Record review and interview on 09/30/2021 at 10:15 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Interim Life Safety Management Policy, revealed the intervals at which security personnel were directed to perform fire watches, or make rounds in the facility to check every area for fire, were stated to be every hour. Approved fire watches require every space in the facility to be checked for fire at least every 30 minutes. The Maintenance Supervisor verified the documentation at the time of the survey process.

2. Record review and interview on 09/30/2021 at 10:16 a.m. of the fire watch procedures for a fire alarm system outage in the facility's Fire Alarm System Shutdown policy, revealed the policy did not state that the fire watch designee is dedicated and the firewatch is continuous, as required. The Maintenance Supervisor verified the documentation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) Standard 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.2.1.1, by ensuring that sprinkler heads are free of corrosion, foreign materials, paint, and physical damage and shall be installed in the correct orientation. These items could affect the operation of the heads by obstructing spray patterns, delaying the response time, and causing the heads or the entire sprinkler system to be inoperable. This deficient practice affects all residents, staff, and visitors who may be in this hallway. The facility had a capacity of 25 and a census of 2 at the time of the survey.

Findings include:

Observation and interview on 09/30/2021 at approximately 11:39 a.m., revealed the facility failed to maintain the sprinkler system in the 400 Hallway. Two sprinkler heads in this hallway contained cobwebs, lint and dust throughout. The Maintenance Supervisor verified this observation during the survey process.

Based on record review, the facility did not assure that an adequate, complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects all occupants of the building, including residents, staff, and visitors. The facility had a capacity of 25 and a census of 2 residents at the time of the survey.

Findings include:

Record review on 09/30/2021 between 10:00 a.m. and 10:05 a.m. of the fire watch procedures for a sprinkler system outage in the facility's outage policy, revealed the policy was incomplete in that it did not address and was missing the following information:

1. Tagging an impaired system that has been removed from service at each fire department connection and the system control valve indicating which system, or part thereof, has been removed from service.

3. All preplanned impairments shall be authorized by the impairment coordinator, who shall verify the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(8) A tag impairment system has been implemented.
(9) All necessary tools and materials have been assembled on the impairment site.

4. Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.

5. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) The impairment tag has been removed.

The Maintenance Supervisor verified the documentation at the time of the survey process.

Based on observation and interview, the facility failed to install portable fire extinguishers in accordance with National Fire Protection Association (NFPA) Standard 10, Standard for Portable Fire Extinguishers, 2010 edition, 6.1.3.4, by ensuring all portable, non-wheeled fire extinguishers are installed on a hanger, in a supplied or listed bracket, or in cabinets or wall recesses. This deficient practice affects one fire extinguisher in one of seven smoke compartments and could affect staff in the Rehabilitation Building Attic. This facility had a capacity of 25 and a census of 2 consumers at the time of the survey.

Findings include:

Observation on 09/30/2021 at 12:33 p.m., revealed no fire extinguisher was present in the Rehabilitation Building Attic space where the HVAC system components are located.

Maintenance Staff verified this observation at the time of the survey process.

Based on observation and interview, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, 314.25, by not ensuring each box in completed installations shall have a cover. This deficient practice affects one staff in one of seven smoke zones. The facility has a capacity of 25 and a census of 2.

Findings Include:

Observation on 09/30/2021 at 12:09 p.m., revealed the facility failed to maintain the electrical system in the Pharmacy Storage Room. This room contained two ceiling light units hanging by electrical wires. The approximately four-inch by four-inch recessed junction boxes had exposed electrical wiring due to missing light mounting fixtures.

Maintenance Staff confirmed this observation at the time of the survey.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift and under varied conditions in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.7.1.6, for four of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. The facility had a capacity of 25 and a census of 2 residents at the time of survey.

Findings include:

Record review and interview on 09/30/2021 at 10:39 a.m. of the facility's fire drill documentation, revealed the facility failed to conduct any fire drills during this calendar year.

The Maintenance Director verified the documentation during the survey process.

Based on record review and interview, the facility failed to conduct/document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects all smoke compartments and all residents, staff, and visitors. The facility had a capacity of 25 and a census of 2 residents at the time of the survey.

Findings include:

1. Record review on 09/30/2021 at 09:30 a.m., revealed the facility was unable to provide the minimum required documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles.

The Maintenance Director confirmed this finding at the time of the survey.


NFPA 99 Health Care Facilities Code, 2012 edition, 6.3.4.2 Record Keeping.

6.3.4.2.1.2 At a minimum, the record shall contain the date,
the rooms or areas tested, and an indication of which items
have met, or have failed to meet, the performance requirements
of this chapter.

Based on record review and interview, the facility failed to maintain the emergency generator power supply as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.8, by not ensuring a fuel quality test was performed at least annually using tests approved by ASTM standards. This deficient practice affects all smoke compartments throughout the building and all occupants. The facility had a capacity of 25 and a census of 2 residents at the time of the survey.

Findings include:

Record review and interview on 09/30/2021 at 09:33 a.m., revealed the facility could not provide documentation of an annual fuel quality test for the generator diesel fuel.

Maintenance Director confirmed these findings at the time of the survey.

Based on observation and interview, the facility did not prohibit the use of extension cords beyond temporary installation or as a substitute for adequate wiring in accordance with National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 edition and NFPA 70, National Electrical Code, 2011 edition. This deficient practice may create electrical injury and fire hazards affecting staff in the Clean Linen Room of the facility. This facility had a capacity of 25 and a census of 2 residents at the time of the survey.

Findings include:

Observation on 09/30/2021 at 11:13 a.m., revealed one of the commercial washing machines lined up on the south wall in the Clean Linen Room was plugged into a white extension cord which was plugged into an electrical receptacle on the west wall.

This deficient practice was confirmed by the Maintenance Director this date of the inspection.

Based on observation and interview, the facility did not provide a proper storage of oxygen cylinders in accordance with National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 11.3.2.3 and 11.6.5 by failing to separate oxygen from combustibles or materials and segregate and label empty cylinders from full cylinders, respectively. This deficient practice affects one of seven smoke compartments and any residents, staff, and visitors in the south Nurses Station area of the facility. The facility had a capacity of 25 with a census of 2 residents at the time of the survey.

Findings include:

1. Observation and interview on 09/30/2021 at 11:41 a.m., revealed the 300 Closet Storage Room contained commingled oxygen cylinders that were not organized with any separation or provided labels designating empty or full. The Maintenance Director indicated the oxygen cylinders present were not normally stored in this room.

2. Observation and interview on 01/10/2018 at 12:00 p.m., revealed the 300 Closet Storage Room contained oxygen cylinders in close proximity to a cloth linen bed sheet used to cover a bath tub.

The Maintenance Director verified these observations during the survey.