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Based on record review the facility failed to test properly the emergency surgical procedure lighting monthly and annually. This deficient practice affects one of five smoke compartments and all patents in the emergency room. This facility has a capacity of 47 and a census of 5 residents.

Findings include:

Record review of the facility's maintenance records on 12-5-19, revealed no documentation was provided regarding the testing of the emergency battery lighting system. The hospital emergency patient rooms were remodeled a short time ago. During the remodel of the procedure rooms, battery operated lights were installed with batteries in the ballasts. Maintenance Staff was unaware of these lights having battery back-up and failed to test the lights as required.

Maintenance Staff (A) verified this review of the records.

Based on observation and interview, the facility failed to maintain the staff training of the commercial cooking exhaust system in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 9.2.3 and NFPA Standard 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, 11.2. This deficient practice affects one of five smoke zones and could affect all residents, staff, and visitors in the Kitchen. The facility had a capacity of 47 and a census of 5 at the time of the survey.

Findings include:

1. Observation and interview on 12-5-19 at 11:00 a.m. of the facility's commercial exhaust system, revealed that one of the Kitchen Staff members working next to the commercial stove, failed to know how to activate the commercial hood suppression system in the event of a fire emergency.

2. Record review on 12-5-19 of the facility's cooking operations documentation, revealed the facility failed to maintain the Kitchen hood suppression system. The facility failed to have the fire-extinguishing system and listed exhaust hood inspected and serviced at least every six months by properly trained and qualified persons as required. The facility provided documentation of an inspection by Heiman dated 5-2019.


The Maintenance Supervisor verified these observations during the survey.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 2011 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 47 and a census of 5 at the time of the survey.

Findings Include:

1. Observation and interview on 12/5/19 at 10:32 a.m., revealed the facility failed to maintain the electrical system in the Dirty Linen Closet electrical panel. Electrical Panel CB4 breaker #35 and #37 were in the on position, charged and not labeled for their designations.

2. Observation and interview on 12/5/19 at 11:05 a.m., revealed the facility failed to maintain the electrical system in the Environmental Services Closet electrical panel. Electrical Panel CB2A breaker #36 was in the on position, charged and not labeled for its designation.

3. Observation and interview on 12/5/19 at 10:34 a.m., revealed the facility failed to maintain the electrical system in the Resident Wing Closet electrical panel. Electrical Panel NP7B contained breaker #28 that was in the on position, charged and not labeled for its designation.

4. Observation and interview on 12/5/19 at 10:46 a.m., revealed the facility failed to maintain the electrical system in the Same Day Surgery Public Restroom. The electrical outlet located on the south wall was not a G.F.C.I. outlet and with in six feet of the toilet.

Maintenance Staff (A) verified these observations.