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Based on record review and staff interview, the facility failed to provide documentation of an annual facility-based exercise and an additional full-scale exercise or table-top exercise in accordance with 42 CFR 483.73. This deficient practice affects 11 patients in 12 of 12 zones. The facility has a capacity of 25 and a census of 11.

Findings include:

Record review and interview on 05/17/22 at 9:50 a.m. revealed the facility failed to conduct an annual full-scale exercise and an additional full-scale exercise or table top exercise within the previous 12 months.

Maintenance Staff A acknowledged this finding.

Based on surveyor observation and interview, the facility failed to maintain the battery-backup emergency lights in accordance with National Fire Protection Association (NFPA) 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 affects all occupants in 2 of 3 off-site clinics. The facility had a capacity of 25 and a census of 11 residents at the time of the survey.

Findings include:

Observation and interview on 05/17/22 revealed the following deficiencies:

1. At 12:43 p.m. the emergency light located in the Procedure Room of the Wesley Medical Clinic failed to function when tested.
2. At 1:23 p.m. the emergency light located in the Lab of the Kanawha Medical Clinic failed to function when tested.

Maintenance Staff A observed these findings.

Based on observation and interview, the facility failed to separate hazardous areas from other portions of the building in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.3.2.1 & 19.3.5.9. This deficient practice affects all occupants of 2 of 12 zones. This facility had a capacity of 25 and a census of 11 residents at the time of the survey.

Findings include:

Observation and interview on 05/17/22 revealed the following hazardous area deficiencies:

1. At 10:52 a.m. an approximately 4-inch by 3-inch hole through the ceiling of the Boiler Room.
2. At 11:18 a.m. five approximately 1-inch holes and an approximately 3-inch penetration around a pipe through the ceiling of the Sprinkler Room.

Maintenance Staff A confirmed the observations and findings at the time of discovery.

Based on interview and record review, the facility failed to provide a complete fire plan in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.7.1 and 19.7.2. This deficient practice affects 11 residents in 12 of 12 zones. This facility had a capacity of 25 and a census of 11 residents at the time of the survey.

Findings include:

Record review and interview on 05/17/22 at 10:00 a.m. revealed the following Fire Safety Plan deficiencies:

1. The Fire Safety Plan failed to state evacuation plans from each smoke zone in the building.

Maintenance Staff A acknowledged this finding.

Based on observation, record review, and interview, this facility did not maintain the diesel emergency generator in accordance with National Fire Protection Association (NFPA) 110 and failed to complete monthly documentation as required by National Fire Protection Association (NFPA) 99, 6.4.4, 6.5.4, & 6.6.4. The deficient practices of not properly maintaining the generator and not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator did not ensure proper operation and prompt repair affecting all occupants. This deficient practice affects 11 residents in 12 of 12 zones. The facility had a capacity of 25 and a census of 11 residents at the time of the survey.

Findings include:

Observation, record review, and interview conducted on 05/17/22 revealed the following deficiencies:

1.) At 10:28 a.m. the monthly load test log failed to state the start and stop times of the generator test.
2.) At 10:55 a.m. the generator emergency stops (2 generators) were located on the generators instead of at a remote location.
3.) At 1:57 p.m. no emergency stop was located on the generator serving the Britt Clinic.

Maintenance Staff A observed these findings.