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Based on record review and interview the facility failed to conduct monthly and annual tests of the battery-powered emergency lighting units. This deficient practice has the potential to affect all occupants in the facility. The facility census was 13.

Findings included:

Review of the preventive maintenance documentation of the fire safety equipment, conducted on the afternoon of 09/11/14, showed there was no documentation of monthly and annual testing of the battery-powered emergency lighting units provided in the kitchen and the off-site therapy clinic.

During an interview on 02/12/14 at 10:45 AM, Staff EE, Facilities Manager, stated that monthly and annual testing of the battery-powered emergency lighting units was not being conducted.

Section 7.9.3 of 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 1/2 hours.

Based on record review and interview the facility failed to conduct fire drills on at least a quarterly basis for each shift. This deficient practice has the potential to effect all occupants in the facility during an emergency situation. The facility census was 13.

Findings included:

Review of the facility fire drill records for the previous twelve months, conducted on the afternoon of 02/11/14, showed there was no documentation showing the night shift staff participated in a fire drill between June 11, 2013 and December 21, 2013.

During an interview on 02/12/14 at 2:06 PM, Staff EE, Facilities Manager, stated there was no documentation of a 3rd quarter fire drill being conducted on the night shift.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

Based on record review and interview the facility failed to exercise the emergency generator under load for a minimum of 30 minutes at least monthly. This deficient practice has the potential to affect all occupants of the facility. The facility census was 13.

Findings included:

Review of the generator testing log, conducted on the afternoon of 02/11/14, showed there was no documentation to indicate the emergency generator had been tested under load for a minimum of 30 minutes for the months of March 2013, December 2013 and January 2014.

During an interview on 02/12/14 at 2:05 PM, Staff EE, Facilities Manager, stated that there was no documentation showing the emergency generator was tested under load during those months.

Section 3-4.1.1.1 of the National Fire Protection Association (NFPA 99) states: Generator sets shall be tested twelve times a year with testing intervals between not less than 20 days or exceeding 40 days.

Based on observation and interview the facility failed to install Alcohol Based Hand Rub (ABHR) dispensers in a location away from an ignition source. This deficient practice affects the operation of the facility. The facility census was 13.

Findings included:

Observation and concurrent interview during a tour of the facility conducted on the morning of 02/12/14 showed the following:
-Observation at 9:19 AM, showed an ABHR dispenser, containing 700 milliliters of 70% ethyl alcohol, mounted on a wall directly over a duplex electrical switch in patient room 120.
-Observation at 9:21 AM, showed an ABHR dispenser, containing 700 milliliters of 70% ethyl alcohol, mounted on a wall directly over a duplex electrical switch in patient room 122.
-Observation at 9:24 AM, showed an ABHR dispenser, containing 700 milliliters of 70% ethyl alcohol, mounted on a wall directly over a duplex electrical switch in patient room 124.
-Observation at 9:30 AM, showed an ABHR dispenser, containing 700 milliliters of 70% ethyl alcohol, mounted on a wall in the medication room adjacent to the nurses station.

At the time of each observation, Staff EE, Facilities Manager, confirmed the ABHRs were mounted directly over duplex electrical switches.

The 2000 Existing Edition of the Life Safety Code, published by the National Fire Protection Association, states that where alcohol based hand rub dispensers are installed they shall not be installed over or adjacent to an ignition source.

Based on record review and interview the facility failed to conduct monthly and annual tests of the battery-powered emergency lighting units. This deficient practice has the potential to affect all occupants in the facility. The facility census was 13.

Findings included:

Review of the preventive maintenance documentation of the fire safety equipment, conducted on the afternoon of 09/11/14, showed there was no documentation of monthly and annual testing of the battery-powered emergency lighting units provided in the kitchen and the off-site therapy clinic.

During an interview on 02/12/14 at 10:45 AM, Staff EE, Facilities Manager, stated that monthly and annual testing of the battery-powered emergency lighting units was not being conducted.

Section 7.9.3 of 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 1/2 hours.

Based on record review and interview the facility failed to conduct fire drills on at least a quarterly basis for each shift. This deficient practice has the potential to effect all occupants in the facility during an emergency situation. The facility census was 13.

Findings included:

Review of the facility fire drill records for the previous twelve months, conducted on the afternoon of 02/11/14, showed there was no documentation showing the night shift staff participated in a fire drill between June 11, 2013 and December 21, 2013.

During an interview on 02/12/14 at 2:06 PM, Staff EE, Facilities Manager, stated there was no documentation of a 3rd quarter fire drill being conducted on the night shift.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

Based on record review and interview the facility failed to exercise the emergency generator under load for a minimum of 30 minutes at least monthly. This deficient practice has the potential to affect all occupants of the facility. The facility census was 13.

Findings included:

Review of the generator testing log, conducted on the afternoon of 02/11/14, showed there was no documentation to indicate the emergency generator had been tested under load for a minimum of 30 minutes for the months of March 2013, December 2013 and January 2014.

During an interview on 02/12/14 at 2:05 PM, Staff EE, Facilities Manager, stated that there was no documentation showing the emergency generator was tested under load during those months.

Section 3-4.1.1.1 of the National Fire Protection Association (NFPA 99) states: Generator sets shall be tested twelve times a year with testing intervals between not less than 20 days or exceeding 40 days.