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Based on record review and interview, the facility failed to inspect the emergency generator circuit breaker(s) annually, exercise the circuit breakers periodically and test the maintenance-free battery. This deficient practice increased the potential that emergency power would not be supplied to the facility during an emergency. The facility has the capacity for 21 beds with a census of 22 on the day of survey.

Findings are:
Record review on 2-11-20, at 1:24 pm revealed:
1. A preventative maintenance plan was not adopted to inspect annually, and exercise periodically the emergency generator circuit breaker(s).
2. Maintenance free-battery for the generator had not been tested.

During an interview on 2-11-20, at 1:24 pm, Facility Staff A confirmed the inspection and testing was not implemented.

NFPA Standard:
2012, NFPA 99, 6.6.4.1.2
Circuitry shall be maintained and tested in accordance with 6.4.4.1.2.

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 provide a second exit from PSU 2 and self-closing devices on the doors separating construction from an occupied area. This deficient practice would cause confusion and delay exiting during an emergency and would allow fire, gasses and smoke to migrate between the areas on the 2nd floor. The facility has the capacity for 21 beds with a census of 22 on the day of survey.

Findings are:
Observations on 2-11-20 at 11:47 am revealed:
1. Three doors separating the construction area on the 2nd floor failed to provide a self-closing devices.
2. Facility failed to provide a second means of egress from PSU 2.

During an interview on 2-11-20 at 11:47 am, Facility Staff A confirmed the lack of a second exit from the PSU 2 unit and the lack of a self-closing devices on doors into the construction area.

Based on observation and interview, the facility failed to maintain a 2-hour fire separation doors. This deficient practice would allow smoke and fire to migrate between the occupancies. The facility has the capacity for 21 beds with a census of 22 on the day of survey.

Findings are:
Observation on 2-11-20 between 1:30 pm and 1:35 pm revealed:
1. The 2-hour fire door on the 1st floor into Lasik failed to latch within the doorframe.
2. The 2-hour fire door on the 1st floor into ESA failed to latch within the doorframe.
3. The 2-hour west door into PSI failed to latch within the doorframe.

During an interview on 2-11-20 between 1:30 pm and 1:35 pm, Facility Staff A confirmed the findings.

Based on observation and staff interview, the facility failed to provide smoke resistant enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke and gases to migrate into the exit corridors. Facility census was 21 and licensed for 22 at the time of the survey.

Finding are:
Observation on 2-11-20 between 10:40 and 1:10 pm, revealed the following:
1. 2nd floor east Supply Room door equipped with a self-closing device, failed to latch into the doorframe.
2. The east Same Day storage room measured over 50 square feet, the door failed to provide a self-closing device.
3. The east Same Day storage room ceiling had an unsealed penetration.
4. "VAG" Laser room door, equipped with spring closure was held open with a trash can.
5. The east Electrical Room door in Same Day, failed to provide a self-closing device.
6. The Environmental Services door next to the stair and OR 10, equipped with a closure failed to close and latch within the doorframe.
7. Unsealed penetration in the ceiling in the IT Closet in the Cafeteria.

During interview on 2-11-20 between 10:40 am and 1:10 pm, Facility Staff A confirmed the findings.

Based on observation and interview, the facility failed to ensure that the fire alarm system's circuit breakers were identified with red marking. This deficient practice would delay the response time to a fire. The facility has the capacity for 21 beds with a census of 22 on the day of survey.

Findings are:
Observation on 2-11-20 at 11:25 am revealed, circuit breaker #27 in electrical panel E in the 2nd floor Environmental Services Closet, for the fire alarm was not locked and failed to provide a red marking.

During an interview on 2-11-20 at 11:25 am, Facility Staff A confirmed the lack of a lock and red marking on the circuit breaker.

Based on observation and interview, the facility failed to assure that smoke detectors were installed. This deficient practice would allow smoke, fire and gasses to spread, which would affect all occupants. The facility has the capacity for 21 beds with a census of 22 on the day of survey.

Findings are:
Observations on 2-11-20 at 1:48 pm revealed, a missing smoke detector from its base, near the warming kitchen.

During an interview on 2-11-20 at 1:48 pm, Facility Staff A confirmed the missing smoke detector.

Based on observation and interview, the facility failed to assure that fire sprinklers were free of foreign material and assure escutcheons were in place. This deficient practice would affect the operating temperature of the fire sprinklers and increased the potential that the sprinkler system would fail to activate as designed during a fire. The facility has the capacity for 21 beds with a census of 22 on the day of survey.
Findings are:
Observation on 2-11-20 between 11:28 am and 1:45 pm revealed:
1. Sprinkler in the Same Day IT closet was covered in foreign material.
2. Sprinkler in the south Same Day Mechanical Room was covered in foreign material.
3. Sprinkler was missing the escutcheon plate in the Basement Breakroom.

During an interview on 2-11-20 between 11:28 am and 1:45 pm, Facility Staff A confirmed the foreign matter covering the sprinklers and missing escutcheon.

Based on observation and interview, the facility failed to assure that patient doors were not obstructed. This deficient practice would allow fire, smoke and gasses to enter the exit corridor and would delay egress. The facility has the capacity for 21 beds with a census of 22 on the day of survey.

Findings are:
Observations on 2-11-20 at 11:00 am revealed, a trash can holding Patient Room 312 open.

During an interview on 2-11-20 at 11:00 am, Facility Staff A confirmed the trash can and removed it.

Based on observation and interview, the facility did not ensure that 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 compartments. The facility has the capacity for 21 beds with a census of 22 on the day of survey.

Findings are:
Observation on 2-11-20 at 10:24 am revealed:
1. The east smoke door at the Same Day Link equipped with latching hardware, failed to close and latch within the doorframe and was not smoke-tight.

During interview on 2-11-20 at 10:24 am, Facility Staff A confirmed the doors failed to be smoke tight.

Based on documentation review and interview, the facility failed to conduct fire drills once per shift per quarter under varying conditions. This deficient practice would not provide simulated training for all staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response for resident. The deficient practice would affect all occupant. The facility has the capacity for 21 beds with a census of 22 on the day of survey.

Findings are:
Record review on 2-11-20 at 2:20 pm revealed:
1. 10 of 13 drills reviewed were conducted at the end of the month.
2. Night shift drills were conducted at 10:00 pm, 9:00 pm, 9:55 pm, 9:52 pm.
3. Day shift drills were conducted at 4:40 pm, 3:00 pm, 3:45 pm.

During an interview on 2-11-20 at 2:20 pm, Facility Staff A confirmed the drills were not conducted at random conditions.

Based on record review and interview, the facility failed to inspect the emergency generator circuit breaker(s) annually, exercise the circuit breakers periodically and test maintenance free battery. This deficient practice increased the potential that emergency power would not be supplied to the facility during an emergency. The facility has the capacity for 21 beds with a census of 22 on the day of survey.

Findings are:
Record review on 2-11-20, at 1:24 pm revealed:
1. A preventative maintenance plan was not adopted to inspect annually, and exercise periodically the emergency generator circuit breaker(s).
2. Maintenance free battery for the generator had not been tested.

During an interview on 2-11-20, at 1:24 pm, Facility Staff A confirmed the inspection and testing was not implemented.

NFPA Standard:
2012, NFPA 99, 6.6.4.1.2
Circuitry shall be maintained and tested in accordance with 6.4.4.1.2.

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 identify full and empty oxygen cylinders. This deficient practice could cause confusion when choosing oxygen cylinders in an emergency resulting in an empty cylinder being chosen when a full one was required. The facility has the capacity for 21 beds with a census of 22 on the day of survey.

Findings are:
Observations on 2-11-20 at 11:10 am, revealed oxygen cylinders in the North Oxygen Storage which failed to be identified full or empty.

During an interview on 2-11-20 at 11:10 am, Facility Staff A confirmed the oxygen cylinders were not identified.