HospitalInspections.org

Base on record review and interview, the facility failed to conduct fire drills with a frequency of one per shift per quarter. This deficient practice has the potential to affect the readiness of the staff in the case of fire emergency. This deficient practice has the potential to affect 2 patients in four of four smoke zones.
The facility has a capacity of 20 with a census of 2 on the day of the survey.

Findings are:
Record review on 5/16/2018 at 2:00 P.M. indicated that fire drills for the second shift had not been conducted for 6 of 6 quarters reviewed.

Interview conducted on 5/16/2018 at 2:00 PM of the Maintenance Personnel indicated that the facility ran two shifts, 7:00 AM to 7: PM and 7:00 PM to 7:00 AM, in a 24 hour period. They also indicated that they were unaware that drills for the second shift had not been completed.

Base on record review and interview, the facility failed to provide the proper testing and maintenance of the emergency generator. This deficient practice has the potential to result in generator failure due to lack of proper maintenance and testing. This deficient practice could affect all 2 residents in four of four smoke zones.
This facility has a capacity of 20 with a census of 2 at the time of the survey.

Findings are:
Record review on 5/16/2018 at 1:37 PM of the generator testing indicated that the load testing did not indicate that the required 30 % of the nameplate rating of the generator was achieved during the monthly load testing. Interview of Maintenance A on 5/16/2018 at 1:37 PM indicated that he was conducting load testing every month but the generator did not meet the 30% of the nameplate of the generator, nor was the optional load back test being conducted.