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Based on observation and a staff interview, a required exit discharge in the means of egress was not illuminated in accordance with NFPA 101 (2000), Chapter 19, Section 19.2.8. and Chapter 7, Section 7.8. In an emergency evacuation situation, this deficient practice could adversely affect all building occupants within the smoke compartment.

FINDINGS INCLUDE:

On 06/26/2014 at 12:25 PM, observation revealed the exterior exit discharge from the North Visitor's Entrance was not equipped with a two-bulb light fixture(s), to provide illumination of the means of egress from the building to the public way. This arrangement was not in accordance with the requirements at NFPA 101 (00) Chapter 7, Section 7.8.

This finding was verified with the chief building engineer at the time of discovery.

Based on observation and a staff interview, it was confirmed the facility failed to conduct one or more fire drills on each shift, during each quarter of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 18, Section 18.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect 31 of 31 patients, staff and visitors.

FINDINGS INCLUDE:

On 06/26/2014 at 9:30 AM, while reviewing fire drill reports for the previous year, no documentation could be provided verifying that fire drills were conducted during January, February, March, April or May of 2014.

This deficient practice was confirmed with the chief building engineer.

Based on observation and a staff interview, it was confirmed the facility failed to conduct one or more fire drills on each shift, during each quarter of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect 31 of 31 patients, staff and visitors.

FINDINGS INCLUDE:

On 06/26/2014 at 9:30 AM, while reviewing fire drill reports for the previous year, no documentation could be provided verifying that fire drills were conducted during January, February, March, April or May of 2014.

This deficient practice was confirmed with the chief building engineer.

Based on observation and a staff interview, a required exit discharge in the means of egress was not illuminated in accordance with NFPA 101 (2000), Chapter 19, Section 19.2.8. and Chapter 7, Section 7.8. In an emergency evacuation situation, this deficient practice could adversely affect all building occupants within the smoke compartment.

FINDINGS INCLUDE:

On 06/26/2014 at 12:25 PM, observation revealed the exterior exit discharge from the North Visitor's Entrance was not equipped with a two-bulb light fixture(s), to provide illumination of the means of egress from the building to the public way. This arrangement was not in accordance with the requirements at NFPA 101 (00) Chapter 7, Section 7.8.

This finding was verified with the chief building engineer at the time of discovery.

Based on observation and a staff interview, it was confirmed the facility failed to conduct one or more fire drills on each shift, during each quarter of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 18, Section 18.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect 31 of 31 patients, staff and visitors.

FINDINGS INCLUDE:

On 06/26/2014 at 9:30 AM, while reviewing fire drill reports for the previous year, no documentation could be provided verifying that fire drills were conducted during January, February, March, April or May of 2014.

This deficient practice was confirmed with the chief building engineer.

Based on observation and a staff interview, it was confirmed the facility failed to conduct one or more fire drills on each shift, during each quarter of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect 31 of 31 patients, staff and visitors.

FINDINGS INCLUDE:

On 06/26/2014 at 9:30 AM, while reviewing fire drill reports for the previous year, no documentation could be provided verifying that fire drills were conducted during January, February, March, April or May of 2014.

This deficient practice was confirmed with the chief building engineer.

Based on observation and a staff interview, testing of the digital alarm communicator transmitter (DACT) had not been conducted during each month of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 9, Section 9.6.1.4, and NFPA 70 (1999) and NFPA 72 (1999) and CMS policy. In a fire emergency, this deficient practice could adversely affect 31 of 31 patients, staff and visitors.

FINDINGS INCLUDE:

On 06/26/2014 10:05 AM, during a review of available records, no documentation could be provided verifying the digital alarm communicator transmitter (DACT) was tested during the months of January, February, March, April, and May of 2014.

This finding was confirmed with the chief building engineer.

Based on observation and a staff interview, the facility failed to maintain the emergency generator in accordance with the requirements at NFPA 101 (2000) Chapter 9, Section 9.1.3 and NFPA 110 (1999) Chapter 6, Section 6-4. In a fire or other emergency, this deficient practice could adversely affect 31 of 31 patients, staff and visitors.

FINDINGS INCLUDE:

On 06/26/2014 at 10:50 AM, during a review of the emergency generator monthly inspection and testing logs for the previous year, the percent of load (KW) had not been recorded. As such, it could not be documented that the emergency generator had been either:
1). Exercised at not less than 30% of the EPS nameplate rating, or;
2). Loaded to maintain the minimum exhaust gas temperature as recommended by the manufacturer, or;
3). Had a 2-hour load bank test performed within the previous year.

This finding was confirmed with the chief building engineer.