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Based on document review and interview the facility failed to conduct monthly and annual tests of the battery-powered emergency lighting unit. This deficient practice affects all occupants of the building. The facility census was seven.

Findings included:

Review of the preventive maintenance documentation of fire safety equipment, conducted on the afternoon of 03/06/12, showed there was no documentation of monthly and annual testing of the battery-powered emergency lighting units in the facility.

During an interview on 03/06/12 at 2:15 PM, Staff Z, Plant Services Manager, stated that maintenance staff had not been testing the battery-powered emergency lighting units on a monthly and yearly basis.

Chapter 7.9.3 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ? hours.

Based on document review and interview the facility failed to conduct fire drills on at least a quarterly basis for each shift. This deficient practice affects all occupants of the building. The facility census was seven.

Findings included:

Document review of the facility ' s fire drill records for the previous year, conducted on the afternoon of 03/06/12, showed the following:

1. A facility fire drill was conducted at 5:00 AM on January 31, 2011.

2. A facility fire drill was conducted at 5:00 AM on February 28, 2011.

3. A facility fire drill was conducted at 8:00 AM on April 30, 2011.

4. A facility fire drill was conducted at 12:51 PM on September 9, 2011.

5. A facility fire drill was conducted at 2:41 PM on December 29, 2011.

6. During an interview on 03/06/12 at 12:45 PM, Staff Z, Plant Services Manager stated that there were only five fire drills conducted during 2011.

Chapter 18.7.1.2 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions and at unexpected times.

Based on observation the facility failed to install an Alcohol Based Hand Rub dispenser in a location away from an ignition source. The facility census was seven.

Findings included:

1. Observation on 03/06/12 at 8:59 AM showed an alcohol based hand rub dispenser mounted to the wall approximately 10 inches above an electrical light switch in the clinic office. This dispenser contained 9 ounces of 62% Ethyl Alcohol.

2. Observation on 03/06/12 at 9:27 AM showed an alcohol based hand rub dispenser mounted to the wall approximately 14 inches above an electrical light switch in the Director of Nurses office. This dispenser contained 9 ounces of 62% Ethyl Alcohol.

3. Observation on 03/06/12 at 9:59 AM showed an alcohol based hand rub dispenser mounted to the wall approximately 12 inches above an electrical switch in the Isolation Ante Room. This dispenser contained 9 ounces of 62% Ethyl Alcohol.

4. Observation on 03/06/12 at 10:11 AM showed an alcohol based hand rub dispenser mounted to the wall approximately 10 inches above an electrical switch in the X-ray room. This dispenser contained 9 ounces of 62% Ethyl Alcohol.

5. Staff Z, Plant Services Manager, confirmed at that time the dispensers were mounted above light switches in all four locations.

Record review of CMS Regulation shows: dispensers shall not be installed over or directly adjacent to an ignition source. Centers for Medicare & Medicaid Services, 42 CFR Parts 403, 416, 418, 460, 482, 483, and 485, [CMS-3145-IFC], RIN 1038-AN36, Medicare and Medicaid Programs; Fire Safety Requirements Federal Register, Vol. 70, No. 57, Friday, March 25, 2005 42 CFR 483.70 (a) (7)