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Based on observation, documentation review and interview, the facility failed to have a program for exercising main and feeder circuit breakers connected to the Essential Electrical System, and failed to conduct all required inspections of the emergency generator. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility. The facility has the capacity for 17 beds with census of 5 on the day of survey.

Findings are:
Documentation review on 12-3-24 at 2:14 pm, of the emergency generator maintenance log revealed:
1. No current exercising the emergency breakers or main breaker was provided.
2. No time to transfer was provided on the monthly generator inspection report.
3. Not all parts/components of generator were listed for inspection on monthly generator inspection report.

During an interview on 12-3-24 at 2:14 pm, Staff A confirmed that the circuit breaker testing failed to be conducted and the lack of all components were listed on inspection report or the transfer time.

NFPA Standard:
2012 NFPA 99, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.
A.6.4.4.1.2.1
Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.

Based on observation and interview, the facility failed to provide an approved construction type for a building attached to the hospital. This deficient practice failed to ensure building integrity during fire conditions which would affect all occupants. The facility has the capacity for 17 beds with a census of 5 on the day of survey.

Findings are:
Observations on 12-3-24 at 11:50 am revealed, a non-sprinkled wooden garage/shed attached to the hospital.

During an interview on 12-3-24 at 11:50 am, Staff A confirmed the attached garage was constructed with wood.

Based on observation and interview, the facility failed to assure emergency lighting was not switchable. This deficient practice would cause confusion during an emergency. The facility has the capacity for 17 beds with a census of 5 on the day of survey.

Findings are:
Observations on 12-3-24 at 1:32 pm revealed, the Procedure room provided emergency lights that were switchable.

During an interview on 12-3-24 at 1:32 pm, Staff A confirmed the lights in the Procedure room were on emergency power but were switchable.

NFPA Standard:
2012 NFPA 99, 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 assure doors to hazardous areas provided self-closing device, were not held open, would close and latch within the doorframe. These deficient practices would allow fire, smoke and gasses to migrate into the exit corridor. The facility has the capacity for 17 beds with a census of 5 on the day of survey.

Findings are:
Observation on 12-3-24 between 11:00 am and 1:28 pm revealed:
1. Pool mechanical room located in the basement failed to provide a self-closing device on the door.
2. Chiller door in the basement was held open with a rubber door chock.
3. Unsealed penetrations in ceiling of the IT room.
4. Transfer switch room door was held open with a wooden block.
5. Fire rated door to the Director of Nutrition was held open with a rubber pig "Ron Jon".
6. The door to the positive pressure room in the Pharmacy, equipped with a self-closing device failed to close and latch within the doorframe.
7. OR was room door, equipped with a self-closing device was held open with a rubber door chock.

During an interview on 12-3-24 between 11:00 am and 1:28 pm, Staff A confirmed the findings.

Based on observation and interview, the facility failed to provide a cleaning schedule for the kitchen exhaust hood. This deficient practice would increase the potential for a fire, as a fire under the hood could possibly not be extinguished effectively.

Findings are:
Observation on 12-3-24 at 1:40 pm revealed:
1. No cleaning schedule was provided for the kitchen exhaust hood.

During an interview on 12-3-24 at 1:40 pm, Kitchen Staff A stated no written cleaning schedule was provided.

Based on observation and interview, the facility failed to assure a box containing spare fire sprinklers was provided, that sprinkler components were installed as designed, and that sprinklers were free of foreign matter. These deficient practices would not allow rapid replacement of a damaged sprinkler and a delay in sprinkler system response. The facility has the capacity for 17 beds with a census of 5 on the day of survey.

Findings are:
Observations on 12-3-24 between 11:16 am and 1:37 pm, revealed,
1. Facility did not provide a spare sprinkler box in the riser room.
2. Missing sprinkler escutcheon in the Pyxis Room.
3. Two of two sprinkler in the dish room in the kitchen were green with corrosion.

During an interview on 12-3-24 between 11:16 am and 1:37 pm, Staff A confirmed no spare sprinkler box was provided, missing escutcheon and corrosion.

NFPA Standard:
2010 NFPA 13
6.2.9.1* A supply of at least six spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced.
6.2.9.2 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property.
6.2.9.3 The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100°F (38°C). 6.2.9.4 Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

Based on observation and interview, the facility failed to assure fire extinguishers were inspected monthly. This deficient practice would delay access to the extinguisher during a fire. The facility has the capacity for 17 beds with census of 5 on the day of survey.

Findings are:
Observation on 12-3-24 at 11:23 am and 1:08 pm revealed:
1. The fire extinguisher in the elevator equipment room had not been inspected.
2. The inspection tag for the fire extinguisher in the Lab was out of date.

During an interview on, 12-3-24 at 11:23 am and 1:08 pm Staff A confirmed extinguisher had not been inspected and needed to be replaced.

Based on observation and interview, the facility failed to ensure corridor doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire, smoke and gasses within the exit corridors. The facility has the capacity for 17 beds with census of 5 on the day of survey.

Findings are:
Observation on 12-3-24 at 11:46 am revealed, room 106 door failed to latch within the doorframe.

During an interview on 12-3-24 at 11:46 am, Staff A confirmed the door failed to close and latch within the doorframe.

Based on observation and interview, the facility failed to assure smoke barrier doors in the facility would be smoke tight. This deficient practice would increase the potential for fire, smoke and gases to spread. The facility has the capacity for 17 beds with census of 5 on the day of survey.

Findings are:
Observations on 12-3-24 between 12:12 pm and 1:20 pm revealed:
1. Excessive gap between the double smoke doors leading into Surgery from the Ambulance corridor.
2. Excessive gap between the double smoke doors next to Lab/Radiology check-in.
3. Excessive gap between the double smoke doors in Radiology next to DVA.
4. Smoke doors next to Hospitality failed to close and latch within the doorframe.

During an interview on 12-3-24 between 12:12 pm and 1:20 pm, Staff A confirmed the excessive gap and that the door failed to latch within the doorframe.

Based on observation and interview, the facility failed to provide unobstructed access to electrical panels. These deficient practices would cause a delay and injury when turning off the power during an electrical emergency. The facility has the capacity for 17 beds with census of 5 on the day of survey.

Findings are:
Observations on 12-3-24 at 11:38 am and 1:13 pm revealed:
1. Numerous bags of 40-pound salt in front of panel box ESA in the Mechanical Room next to the soft water equipment.
2. Chair in front of panel boxes in the electrical closet next to the DON office.

During an interview on 12-3-24 at 11:38 am and 1:13 pm, Staff A confirmed the items front of the panel boxes.

NFPA Standard:
2011 NFPA 70, 65.26
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

2011 NFPA 70, 65.32
Sufficient space shall be provided and maintained about electrical equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed,
the minimum clear work space shall be not less than 2.0 m (6 1/2 ft) high (measured vertically from the floor or platform) or not less than 914 mm (3 ft) wide (measured parallel to the equipment). The depth shall be as required in 65.34(A). In all cases, the work space shall permit at least a 90 degree opening of doors or hinged panels.

Based on observation, documentation review and interview, the facility failed to have a program for exercising main and feeder circuit breakers connected to the Essential Electrical System, and failed to conduct all required inspections of the emergency generator. These deficient practices increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility. The facility has the capacity for 17 beds with census of 5 on the day of survey.

Findings are:
Documentation review on 12-3-24 at 2:14 pm, of the emergency generator maintenance log revealed:
1. No current exercising the emergency breakers or main breaker was provided.
2. No time to transfer was provided on the monthly generator inspection report.
3. Not all parts/components of generator were listed for inspection on monthly generator inspection report.

During an interview on 12-3-24 at 2:14 pm, Staff A confirmed that the circuit breaker testing failed to be conducted and the lack of all components were listed on inspection report or the transfer time.

NFPA Standard:
2012 NFPA 99, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.
A.6.4.4.1.2.1
Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.

Based on documentation review and interview, the facility failed to implement the following:
testing and inspection as well as written procedures and policies for audits, testing and inspection of power strips throughout the facility. This deficient practice increased the potential of electrical equipment throughout the facility causing injury or a fire. The facility has the capacity for 17 beds with census of 5 on the day of survey.

Findings are:
Record review on 12-3-24 at 1:36 pm revealed:
1. Documentation of testing for power strips was not provided for review.

During an interview on 12-3-24 at 1:36 pm, Staff A confirmed the testing was not conducted.