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Based on observation, record review and interview, the facility failed to provide documentation for the program to exercise the main and feeder circuit breakers serving the Essential Electrical System. This deficient practice increased the probability that the generator would fail to run during an emergency loss of power. The facility has the capacity for 10 beds with a census of 8 on the day of survey.

Findings are:
During record review on 4-12-23 at 12:14 pm, of the facility's generator inspection testing revealed:
1. The facility failed to have documentation for the inspection and testing of the main and feeder circuit breakers.

During an interview on 4-12-23 at 12:14 am, Staff A confirmed the of the lack of testing.

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.

Based on observation and interview, the facility failed to maintain means of egress free of obstructions. This deficient practice could delay evacuation during an emergency. The facility has the capacity for 10 beds with a census of 8 on the day of survey.

Findings are:
Observations on 4-12-23 at 11:03 am revealed, table covered with PPE and numerous paper bags under the table in patient care corridor.

During an interview on 4-12-23 at 11:03 am, Staff A confirmed the table with combustibles on it, and stated that there was no active COVID in the building.

Based on observation and interview, the facility failed to assure hazard areas provided smoke-tight construction. This deficient practice would allow fire, smoke and gases to spread out of the room into the exit corridors. The facility has the capacity for 10 beds with a census of 8 on the day of survey.

Findings are:
Observations on 4-12-23 between 10:22 am and 10:43 am revealed:
1. Unsealed penetrations around water return pipes in the fire pump room.
2. Fire caulk pulling away from copper pipe in the Med. Gas room.
3. Gap along the top of door 413.

During an interview on 4-12-23 between 10:22 am and 10:43 am, Staff A confirmed the findings.

Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke. This deficient practice would allow smoke, fire, and gases to migrate into the egress corridors. The facility has the capacity for 10 beds with a census of 8 on the day of survey.

Findings are:
Observation on 4-12-23 at 11:43 am revealed, patient door 104 to failed to latch.

During an interview on 5-25-22 between 11:03 and 2:23 pm, Administration Staff A confirmed the findings

Based on observation, record review and interview, the facility failed to provide documentation for the program to exercise the main and feeder circuit breakers serving the Essential Electrical System. This deficient practice increased the probability that the generator would fail to run during an emergency loss of power. The facility has the capacity for 10 beds with a census of 8 on the day of survey.

Findings are:
During record review on 4-12-23 at 12:14 pm, of the facility's generator inspection testing revealed:
1. The facility failed to have documentation for the inspection and testing of the main and feeder circuit breakers.

During an interview on 4-12-23 at 12:14 am, Staff A confirmed the of the lack of testing.

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.

Based on observation and interview, the facility failed to assure that a cover was provided for an electrical junction box. This deficient practice would increase the potential for an electrical fire. The facility has the capacity for 10 beds with a census of 8 on the day of survey.

Findings are:
Observations on 4-12-23 at 10:29 am revealed, exposed wires for the heater in the med gas room.

During an interview on 4-12-23 at 10:29 am, Staff A confirmed the exposed wires.

Based on interview and documentation review, the facility failed to provide documentation of an audit, testing and inspection as well as written procedures and policies for audits, testing and inspection of power strips throughout the facility. This deficient practice increased the potential of electrical equipment throughout the facility causing injury or a fire, which would affect all occupants. The facility has the capacity for 10 beds with a census of 8 on the day of survey.

Findings are:
Record review on 4-12-23 at 1:00 pm revealed:
1. Written policies and procedures for conducting audits and testing of power strips.
2. Documentation of initial testing for power strips was not provided for review.

During an interview on 4-6-23 at 1:00 pm, Staff A confirmed the testing was not conducted and policies were not provided and stated they were unaware of the requirement.

Based on interview and documentation review, the facility failed to provide inspection and maintenance records for the bulk oxygen system. This deficient practice would not assure the system would function properly. The facility has the capacity for 10 beds with a census of 8 on the day of survey.

Findings are:
Documentation review on 4-12-23 at 12:40 pm revealed the lack of current inspection and maintenance records for the bulk oxygen system.

During an interview on 4-12-23 at 12:40 pm, Staff A provided the 2021 report and no other reports were given to review.


7.6.5.1
Maintenance of flammable gas system piping and components shall be performed annually by a qualified representative of the equipment owner.
7.6.5.2
This maintenance shall include inspection for physical damage, leak tightness, ground system integrity, vent system operation, equipment identification, warning signs, operator information and training records, scheduled maintenance and retest records, alarm operation, and other safety-related features.
7.6.5.3
Scheduled maintenance and retest activities shall be formally documented, and records shall be maintained a minimum of 3 years.