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Based on documentation review and interview, the facility failed to conduct all required weekly inspections of the emergency generator, failed to document the time to transfer to generator power and failed to have the diesel fuel tested annually for quality. These deficient practices increased the potential that the generator would fail to run during loss of power and would affect all occupants. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Documentation review on 6-26-19 at 1:20 pm of the provided emergency generator maintenance log revealed the documentation failed to exhibit all required information for weekly testing in accordance with National Fire Protection Association Pamphlet 110:
1. The engine system and all the components failed to be inspected and documented weekly.
2. The exhaust system and all the components failed to be inspected and documented weekly.
3. The cooling system and all the components failed to be inspected and documented weekly.
4. The fuel system and all the components failed to be inspected and documented weekly.
5. The electrical system and all the components failed to be inspected and documented weekly.
6. The time to transfer failed to be documented on the monthly test.
7. No documentation that the diesel fuel for the generator was tested for quality.

During an interview on 6-26-19 at 1:00 pm, Maintenance A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA Standard:
NFPA 110, 2010, 8.3.8
A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on observations and interview, the facility failed to assure a door in the means of egress was not locked against egress. This deficient practice would delay egress in the event of an emergency. The facility has the capacity of 18 beds with a census of 1 on the day of survey.

Findings are:
Observations on 6-26-19 at 1:34 pm revealed, the Kitchen door was equipped with a deadbolt lock and a knob hardware, which would require two motions to exit if the dead bolt was engaged.

During an interview on 6-26-19 at 1:34 pm, Maintenance Staff A confirmed that the door would require two motions to exit.

Based on observation, documentation review and interview, the facility failed to assure that the monthly and yearly emergency light testing was documented and failed to assure that battery backup emergency lights were provided in the new Operating Room. This deficient practice has the potential for emergency lights in the facility not operating during an emergency. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Observations on 6-26-19 at 2:12 pm revealed, the new Operating room failed to verify that battery operated emergency lights were provided.

During an interview on 6-26-19 at 2:12 pm, Maintenance Staff A failed to verify if battery operated emergency lights were provided in the Operating room.

NFPA Standard:
NFPA 99, 2012 6.3.2.2.11.1
One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.

Based on observation and interview, the facility failed to provide exit signs. This deficient practice had the potential for delay or to cause confusion during an emergency as occupants would be unable to locate exits. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Observations on 6-26-18 between 1:57 pm and 2:07 pm revealed:
1. While standing in the Employee corridor looking south, no exit sign was visible to direct occupants to the exit.
2. While standing next to the Employee Dining Room looking south, no exit sign was visible to direct occupants to the exit.
3. While standing in the Surgery corridor looking south, no exit sign was visible to direct occupants to the exit.
4. While standing outside the OR doors looking east, no exit sign was visible to direct occupants to the exit.

During an interview on 6-26-19 between 1:57 pm and 2:07 pm, Maintenance Staff A confirmed the lack of exit signage.

Based on observation and interview, the facility failed to assure that doors to hazardous areas would close and latch within the doorframe and hazard areas were smoke-tight. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Observation on 6-26-19 between 1:41 pm and 2:28 pm revealed:
1. The east Employee Dining room door equipped with a self-closing device failed to provide latching device.
2. The Sterile Storage room door equipped with self-closing device failed to latch within the doorframe.
3. An approximate 6 foot by 2 foot penetration above the door in the OR Electrical room.

During an interview on 6-26-19 between 1:41 pm and 2:28 pm, Maintenance Staff A confirmed findings.

Based on interview and record review, the facility failed to have the the kitchen exhaust hood and exhaust system inspected by a qualified and certified person on a semi-annual basis. This deficient practice would affect the efficiency of the fire-extinguishing system in the event of a fire. The facility has the capacity of 18 beds with a census of 1 on the day of survey.

Findings are:
Record review on 7-1-19 at 11:00 am revealed, the facility failed to provide documentation of semi-annual inspections of the kitchen exhaust hood and exhaust system.

During an interview on 7-1-19 at 11:00 am, Maintenance Staff A confirmed the lack of inspection for the exhaust hood system by a qualified and certified person and stated, "That the facility cleaned the exhaust system themselves."

NFPA Standard:
NFPA 96, 2011, 11.4
11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4.

Based on observation and interview, the facility failed to install fire sprinkler protection under ductwork, which was greater than 4 feet wide. This deficient practice would allow the fire to grow and potentially spread outside the room of origin.

Findings are:
Observations on 6-26-19 at 1:50 pm revealed, no fire sprinkler protection under ductwork in the Kitchen Pantry, which measured over four feet in width.

During an interview on 6-26-19 at 1:50 pm, Maintenance Staff A confirmed the ductwork measured over four feet and failed to provide sprinkler protection.

Based on observation, documentation review and interview, the facility failed to assure that the fire sprinkler in the Procedure Room was free of foreign material and that semi-annual sprinkler inspections were conducted. These deficient practices would affect the operating temperature of the sprinkler and increased the potential that the sprinkler system would fail to activate as designed during a fire, which would affect all occupants in all smoke compartments. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Observation on 6-26-19 at 2:21 pm revealed, the fire sprinkler in the Procedure Room was covered with paint.

Documentation review on 6-26-19 at 11:38 am revealed, the facility failed to have semiannual fire sprinkler inspections conducted and were only conducting an annual inspection.

During an interview on 6-26-19 at 11:38 am and 2:21 pm, Maintenance Staff A confirmed the foreign matter covering the sprinkler and the lack of semi-annual sprinkler inspection.

NFPA Standard:
2011 NFPA 25, Table 5.1.1.2
Vane and pressure switch type devices Semiannually 5.3.3.2
Valves supervisory alarm devices Table 13.1
Supervisory signal devices (except valve supervisory switches)

Based on record review and interview, the facility failed to assure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affected all occupants. The facility has the capacity for 18 beds with a census of 1on the day of survey.

Findings are:
Record review on 6-26-19 at 1:32 pm, of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than ten hours in a twenty-four hour period.
1. The policy failed to list emergency impairments would include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping and equipment failure.
2. The facility failed to have a list of contact information including property owner or designee, supervisors, authorities having jurisdiction (HHSS), fire alarm company and sprinkler company.

During an interview on 6-26-19 at 1:32 pm, Administration Staff A confirmed the lack of specific items in the fire watch policy.

NFPA Standard:
NFPA 26, 2011,15.5 Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that 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.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on observation and interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke within the exit corridors. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Observation on 6-26-19 at 1:56 pm and 2:38 pm revealed:
1. The door to the Employee Lounge failed to provide latching device.
2. The gap between the new OR doors was extreme.
3. The door to the Whirlpool Room failed to latch within the doorframe.
4. Patient Room #1 door failed to latch within the doorframe.
5. The door to the Procedure room failed to latch within the doorframe.

During an interview on 6-26-19 at 1:56 pm and 2:38 pm, Maintenance Staff A confirmed the findings.

Based on interview and record review, the facility failed to provide a complete fire safety plan. This deficient practice would delay evacuation and affected all smoke compartments and all occupants. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Record review on 6-26-19, at 1:36 pm revealed, the fire evacuation plan failed to include the evacuation of the smoke compartment, failed to assure that staff do not cross the room where the fire originates and did not include the evacuation of the fire triangle.

During an interview on 6-26-19 at 1:36 pm, Administration Staff A confirmed the lack of specific evacuation.

Based on documentation review and interview, the facility failed to conduct fire drills 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 patients. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Record review on 6-26-19 at 12:20 pm revealed:
1. 2 of 5 day shift drills were conducted at 1:03 pm, 1:09 pm.
2. 4 of 4 night shift drills were conducted at 6:15 am, 6:00 am, 5:00 am, 6:00 am
3. Night shift drills were only discussions and not actual drills.

During an interview on 6-26-19 at 12:20 pm, Maintenance Staff A confirmed the drills were not conducted under random conditions.

Based on record review and interview, the facility failed to have a preventative maintenance plan in place to inspect and test all fire rated doors annually throughout the facility. This deficient practice would allow the spread of fire through faulty doors that would otherwise contain a fire or smoke. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Record review on 6-26-19 at 12:08 pm revealed, the facility failed to provide written documentation of all 11 components for the annual inspection and testing of all fire rated doors throughout the facility.

During an interview on 6-21-19 at 12:08 pm, Maintenance Staff A confirmed fire doors were not tested and stated, "A past Fire Marshal, inspector instructed the facility that they were not required to do the door inspection because the facility was fully sprinkled."

Based on observation and interview, the facility failed to install ground fault protected outlet (GFCI) at the sink location in resident restrooms. This deficient practice would increase the probability of the electrical equipment to cause an electrical shock or fire, which has the potential to spread outside the room. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Observations on 6-28-19 between 2:33 pm and 2:48 pm revealed:
1. The light fixture above the sink in Laboratory bathroom provided an electrical outlet, which failed to be GFCI protected.
2. The light fixture above the sink in Business Office bathroom provided an electrical outlet, which failed to be GFCI protected.
3. The light fixture above the sink in DON bathroom provided an electrical outlet, which failed to be GFCI protected.
4. The light fixture above the sink in Patient bathroom #9 provided an electrical outlet, which failed to be GFCI protected.
5. The light fixture above the sink in Patient bathroom #7 provided an electrical outlet, which failed to be GFCI protected.
6. The light fixture above the sink in Patient bathroom #6 provided an electrical outlet, which failed to be GFCI protected.
7. The light fixture above the sink in Patient bathroom #5 provided an electrical outlet, which failed to be GFCI protected.

During an interview on 6-28-19 between 2:33 pm and 2:48 pm, Maintenance Staff A confirmed the outlet failed to be GFCI and tested the outlet to verify if it was functional.

NFPA Standard:
2011 NFPA 70, 210-8(b)
Ground-Fault Circuit-Interrupter Protection for Personnel Other than Dwelling Units
All 126-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified below shall have ground-fault circuit-interrupter protection for personnel.
1. Bathrooms
2. Rooftops
Exception: Receptacles that are not readily accessible and are supplied from a dedicated branch circuit for electric snow-melting or deicing equipment shall be permitted to be installed in accordance with the applicable provisions of Article 426.

Based on record review and interview, the facility failed to provide testing documentation for the line isolation monitor "LIM" in the Operating Room "OR". This deficient practice has the potential to affect how equipment operates which could result in an electrical fire and harm to the patient. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Documentation review on 6-26-19 at 2:18 pm revealed, the facility failed to provide documentation for testing of the LIM in the OR.

During an interview on 6-26-19 at 2:18 pm, Maintenance Staff A confirmed the lack of documentation for LIM testing.

2012 NFPA 99
6.3.3.3.2
The line isolation monitor (LIM) circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor whose value is 200 × V (ohms), where V equals measured line voltage. The visual and audible alarms (see 6.3.2.6.3.2) shall be activated.

6.3.4.1.4
The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.

6.3.4.1.5
After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2.

6.3.4.2.1.1
A record shall be maintained of the tests required by this chapter and associated repairs or modification.

6.3.2.6.3.6
A reliable test switch shall be mounted on the line isolation monitor to test its capability to operate (i.e., cause the alarms to operate and the meter to indicate in the "alarm on" zone). This switch shall transfer the grounding connection of the line isolation monitor from the reference grounding point to a test impedance arrangement connected across the isolated line; the test impedance(s) shall be of the appropriate magnitude to produce a meter reading corresponding to the rated total hazard current at the nominal line voltage, or to a lesser alarm hazard current if the line isolation monitor is so rated. The operation of this switch shall break the grounding connection of the line isolation monitor to the reference grounding point before transferring this grounding connector to the test impedance(s), so that making this test will not add to the hazard of a system in actual use; nor will the test include the effect of the line-to-ground stray impedance of the system. The test switch shall be of a self-restoring type.

Based on observation and interview, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. The facility failed to have panel boxes identified. These deficient practices have the potential to affect all occupants of the facility by affecting the egress lighting and emergency systems. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Observations on 7-1-19 between 11:00 am and 11:30 am revealed:
1. Electrical panel boxes throughout the facility failed to identify which transfer switch fed the panel.
2. Facility failed to confirm what electrical boxes provided life safety, critical and equipment circuits.
3. Electrical panel boxes throughout the facility have intermixed systems within the branches.

During an interview on 7-1-19 between 11:00 am and 11:30 am, Maintenance Staff A confirmed the findings.

Based on documentation review and interview, the facility failed to conduct all required weekly inspections of the emergency generator, failed to document the time to transfer to generator power and failed to have the diesel fuel tested annually for quality. These deficient practices increased the potential that the generator would fail to run during loss of power and would affect all occupants. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Documentation review on 6-26-19 at 1:20 pm of the provided emergency generator maintenance log revealed the documentation failed to exhibit all required information for weekly testing in accordance with National Fire Protection Association Pamphlet 110:
1. The engine system and all the components failed to be inspected and documented weekly.
2. The exhaust system and all the components failed to be inspected and documented weekly.
3. The cooling system and all the components failed to be inspected and documented weekly.
4. The fuel system and all the components failed to be inspected and documented weekly.
5. The electrical system and all the components failed to be inspected and documented weekly.
6. The time to transfer failed to be documented on the monthly test.
7. No documentation that the diesel fuel for the generator was tested for quality.

During an interview on 6-26-19 at 1:00 pm, Maintenance A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA Standard:
NFPA 110, 2010, 8.3.8
A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Based on observation and interview, the facility failed to prohibit the use of electrical extension cords as a substitute for adequate wiring. This deficient practice would create electrical injury and increase a fire hazard. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Findings are:
Observation on 6-26-19, at 2:46 pm revealed, a white extension cord in the Chief Financial Officer office used for an adding machine on the desk.

During an interview on 6-26-19 2:46 pm, Maintenance Staff A confirmed the use of the extension cord.

Based on documentation review and interview, the facility failed to assure that the dry time for the flammable surgical solution matched the manufactures instructions. This deficient practice failed to assure the safety of all occupants in the OR. The facility has the capacity for 18 beds with a census of 1 on the day of survey.

Documentation review on 7-1-19 at 10:25 am revealed, the facility policy of fire prevention in the operating room for DuraPrep stated, "DuraPrep will be allowed to dry 2-3 minutes or longer as needed, according to the manufacturer's recommendations.

Documentation review on 7-1-19 at 10:40 am revealed, the manufactures requirement for the dry time for DuraPrep stated, "do not drape or use ignition source until solution is completely dry (minimum of 3 minutes on hairless skin.

During an interview on 7-1-19 at 10:45 am, Staff B confirmed that the facility policy failed to match the requirement of the manufactures.