HospitalInspections.org

Based on observation, record review and interview, the facility failed to provide documentation for the annual fuel test. This deficient practice increased the probability that the generator would fail to run during an emergency loss of power, which would affect the emergency systems in the facility. The facility has the capacity for 11 beds with a census of 2 on the day of survey.

Findings are:
During record review on 1-25-23 at 11:31 am, of the facility's generator inspection testing and maintenance records revealed, no fuel test was provided for the generator.

During an interview on 1-25-23 at 11:31 am, Maintenance Staff confirmed the lack of a current fuel test for the generator.

Based on observation, interview, the facility failed to provide emergency illumination that would operate automatically along the paths of egress. The lack of egress illumination along the path to safety would cause confusion and delay egress from the facility during an emergency. The facility has the capacity for 11 beds with a census of 2 on the day of survey.

Findings are:
Observation on 1-25-23 at 11:05 am revealed, when lights were turned off in the corridors, no lights remained on. No battery emergency lights were provided.

During an interview on 1-25-23 at 11:05 am, Maintenance Staff confirmed all lights in the corridors failed to stay illuminated when the switch was turned off.

Based on observation and interview, the facility failed to provide an exit sign on each side of a COVID barrier. The lack of exit signage would delay or cause confusion during an emergency. The facility has the capacity for 11 beds with a census of 2 on the day of survey.

Findings are:
Observation on 1-25-23 at 11:10 am revealed, the facility failed to provide an exit sign on one side of the COVID barrier.

During an interview on 1-25-23 at 11:10 am, Maintenance Staff confirmed the lack of an exit sign.

Based on observation and interview, the facility failed to assure acceptable fire sprinkler spacing. This deficient practice would not allow the sprinkler system to operate as designed. The facility has the capacity for 11 beds with a census of 2 on the day of survey.

Findings are:
Observation on 1-25-23 at 11:00 am and 11:10 am revealed:
1. Sprinklers in restroom 107 or 38 inches apart.
2. Sprinklers in restroom 109 or 35 inches apart.

During an interview on 1-25-23 at 11:00 am and 11:10 am, Maintenance Staff confirmed the sprinklers were installed too close together.

NFPA Standard:
2010, NFPA 13, 8.6.3.4
Minimum Distances Between Sprinklers. 8.6.3.4.1 Unless the requirements of 8.6.3.4.2, 8.6.3.4.3, or 8.6.3.4.4 are met, sprinklers shall be spaced not less than 6 ft (1.8 m) on center

Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire, smoke and gases within the exit corridors. The facility has the capacity for 11 beds with a census of 2 on the day of survey.

Findings are:
Observation on 1-25-23 at 10:32 am revealed, Nurse Administration door was obstructed by a trash can.

During an interview on 1-25-23 at 10:32 am, Maintenance Staff confirmed the door was obstructed by a trash can.

Based on observation, record review and interview, the facility failed to provide documentation for the annual fuel test. This deficient practice increased the probability that the generator would fail to run during an emergency loss of power, which would affect the emergency systems in the facility. The facility has the capacity for 11 beds with a census of 2 on the day of survey.

Findings are:
During record review on 1-25-23 at 11:31 am, of the facility's generator inspection testing and maintenance records revealed, no fuel test was provided for the generator.

During an interview on 1-25-23 at 11:31 am, Maintenance Staff confirmed the lack of a current fuel test for the generator.