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Based on documentation review and interview, the facility failed to conduct all required weekly inspections of the emergency generator 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. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Findings are:
Documentation review on 3-28-19 at 9:40 am 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 exhaust system and all the components failed to be inspected and documented weekly.
7. No documentation that the diesel fuel for the generator was tested for quality.

During an interview on 3-28-19 at 11:55 am, Maintenance Staff A confirmed that the generator testing documentation failed to be com and stated they were not aware of the fuel testing requirement

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 documentation review and interview, the facility failed to assure that the yearly emergency light testing was documented. This deficient practice has the potential for emergency lights in the facility not operating during an emergency. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Documentation review on 3-28-19 at 11:29 am revealed, the facility failed to provide documentation for the annual 1 ½ hour battery test for the emergency lights throughout the facility.

During an interview on 3-28-19 at 11:29 am, Maintenance Staff A confirmed the lack of testing documentation.

Based on observation and interview, the facility failed to assure the doors to hazardous areas would close and latch within the doorframe and were not held open. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Findings are:
Observation on 3-28-19 between 10:17 am and 10:48 am revealed:
1. The basement Storage Room equipped with a self-closing device was held open with a wire attached to shelving.
2. The south Server Room door failed to provide latching device, only a dead bolt lock was provided.
3. The Housekeeping door next to the Kitchen failed to latch within the doorframe.

During an interview on 3-28-19 between 10:17 am and 10:48 am, Maintenance Staff A confirmed findings.

Based on observation and interview, the facility failed to ensure that the fire alarm system's circuit breakers were equipped with a lock out device or a red marking. This deficient practice could allow the fire alarm panel to be inadvertently disconnected from its power supply, which would delay the response time to a fire. The facility has the capacity for 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 3-28-19 at 11:13 am revealed, circuit breaker in the electrical panel H in the basement mechanical room for the fire alarm was not equipped with a lock out device or a red marking.

During an interview on 3-28-19 at 11:13 am, Maintenance Staff A confirmed the lack of lock out and red marking on the circuit breaker.

NFPA Standard:
2010 NFPA 72, 10.5.5.2
10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."
10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

Based on interview and record review, the facility failed assure that a policy is in place regarding the procedures to be taken in the event that the fire alarm is out of service for more than four hours in any twenty-four hour period. The lack of written policies and procedures could result in staff failing to implement interim measures in the event of an emergency. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Findings are:
Record review on 3-28-19 at 11:35 am revealed, the facility did not have a policy regarding the procedures to be taken in the event that the fire alarm was out of service for more than four hours in a twenty-four hour period.

During an interview on 3-28-19 at 11:35 am, Maintenance Staff A confirmed the lack of a fire watch policy.

NFPA Standard:
When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8

Based on observation and interview, the facility allowed items to be attached to the fire sprinkler piping. 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 129 beds with a census of 60 on the day of survey.

Findings are:
Observation on 3-28-19 at 10:24 am revealed, several wires attached to the sprinkler pipe with black tape in the DON closet.

During an interview on 3-28-19 at 10:24 am, Maintenance Staff A confirmed the wire attached to the sprinkler pipe.

Based on record review and interview, the facility failed to provide 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. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Findings are:
Record review on 3-28-19 at 11:42 am, revealed the facility failed to provide any type of a fire watch policy.

During an interview on 3-28-19 at 11:42 am, Maintenance Staff A confirmed the lack of a fire watch policy.

NFPA Standard:
NFPA 25, 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 11 beds with a census of 4 on the day of survey.

Findings are:
Observation on 3-28-19 at 10:02 am and 11:08 am revealed:
1. The door to IT failed to provide latching device, only a dead bolt lock.
2. The door to the Charting Room only provided a roller latch.
3. The door to the Lounge failed to latch within the doorframe.

During an interview on 3-28-19 at 10:02 am and 11:08 am, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility did not ensure that fire rated 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. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Findings are:
Observation on 3-28-19 at 10:20 am revealed, the gap between the smoke doors next to the Lobby was greater than ½ inches.

During an interview on 3-28-19 at 10:20 am, Maintenance Staff A confirmed the findings.

Based on record review and staff interview, the facility failed to have a preventative maintenance plan in place to inspect and test all fire doors annually throughout the facility. This deficient practice would allow the spread of fire through faulty fire doors that would otherwise contain a fire. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Findings are:
Record review on 3-28-19 at 11:33 am revealed, the facility failed to inspect all fire rated doors throughout the facility.

During an interview on 3-28-19 at 11:33 am, Maintenance Staff A confirmed that the facility was unaware of the door inspection requirements.

NFPA Standard:
NFPA 80, 2010, 5.2*
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

Based on observation and interview, the facility failed to provide task illumination at the nurse's station. This deficient practice would not allow staff to continue operations in the event of power loss. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Findings are:
Observations on 3-28-19 at 10:43 am, when light switches at the nurse's station were turned to the off position, no lights remained on and the corridor lights also were switchable.

During an interview on 3-28-19 at 10:43 am, Maintenance Staff A confirmed the lights at the nurses station were switchable and in the off position no illumination was provided.

NFPA Standard:
1999, NFPA 99, 3-4.2.2.2
The critical branch shall supply power for task illumination, fixed equipment, select receptacles, and select power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases, task illumination, select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected
acute nursing areas, psychiatric bed areas (omit receptacles), and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)*Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits for the following areas:
(a) General care beds with at least one duplex receptacle per patient bedroom, and task illumination as required by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power circuits needed for effective facility operation, including single-phase fractional horsepower motors, which are permitted to be connected to the critical branch

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 11 beds with a census of 4 on the day of survey.

Findings are:
Observations on 3-28-19 at 10:33 am revealed, the light fixture above the sink in DON Office bathroom provided an electrical outlet, which failed to be GFCI protected.

During an interview on 3-28-19 at 10:33 am, Maintenance Staff B 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 125-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 documentation review and interview, the facility failed to conduct all required weekly inspections of the emergency generator 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. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Findings are:
Documentation review on 3-28-19 at 9:40 am 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 exhaust system and all the components failed to be inspected and documented weekly.
7. No documentation that the diesel fuel for the generator was tested for quality.

During an interview on 3-28-19 at 11:55 am, Maintenance Staff A confirmed that the generator testing documentation failed to be com and stated they were not aware of the fuel testing requirement

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 adaptors as a substitute for adequate wiring. This deficient practice would create electrical injury and increase a fire hazard. The facility has the capacity for 11 beds with a census of 4 on the day of survey.

Findings are:
Observation on 3-28-19 at 10:23 am and 10:39 am revealed:
1. Six-plex electrical adaptor plugged into an outlet next to the desk in the CEO office.
2. A non-hospital grade six-plex electrical adaptor plugged into an outlet within 6 foot of the patient care area in Patient Room 104.

During an interview on 3-28-19 at 10:23 am and 10:39 am, and Maintenance Staff A confirmed the use of the six-plex electrical adaptors.

Based on observation and interview, the facility failed to separate empty oxygen cylinders from full ones in storage. 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 11 beds with a census of 4 on the day of survey.

Findings are:
Observation on 3-28-19 at 10:56 am revealed, 2 empty oxygen cylinders was stored with 9 full oxygen cylinders in the Oxygen Storage room.

During an interview on 3-28-19 at 10:56 am, Maintenance Staff A confirmed the empty oxygen cylinders intermixed with full cylinders.