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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 unit in the operating room. This deficient practice has the potential to affect all patients undergoing a surgical procedure in that room. The facility census was 15.

Findings included:

Review of the preventive maintenance documentation of the fire safety equipment, conducted on the morning of 01/29/14, showed there was no documentation of monthly and annual testing of the battery-powered emergency lighting unit provided in the operating room of the facility.

During an interview on 01/29/14 at 2:02 PM, Staff FF, Maintenance, stated that monthly and annual testing of the battery-powered emergency lighting unit 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 system for not less than 1 1/2 hours.

Based on document review and interview the facility failed to conduct all required inspections of the sprinkler system. This deficient practice affects all occupants in the facility. The facility census was 15.

Findings included:

Review of the facility sprinkler system inspection documents, conducted on the morning of 01/29/14, showed an outside contractor had last conducted an annual inspection of the sprinkler system on July 31, 2013. The July inspection report also showed that the sprinkler piping had not been inspected for obstructive materials within the required time frame. There was no documentation showing any type of inspection had been conducted on any portion of the sprinkler system since the annual inspection in July of 2013.

During an interview on 01/29/14 at 2:50 PM, Staff FF, Maintenance, stated an inspection of the sprinkler system was not being conducted on at least a quarterly basis and there was no documentation to show when the sprinkler piping was last inspected for obstructive materials.

Section 5.1 of the National Fire Protection Association (NFPA 25) states the minimum requirements for the routine inspection, testing and maintenance of sprinkler systems.

Based on observation and interview the facility failed to provide emergency task illumination for the emergency generator in case of powered failure and generator failure. This deficient practice has the potential to affect all occupants in the facility. The facility census was 15.

Findings included:

Observation on 01/29/14 at 2:42 PM during a tour of the facility showed the room where the emergency generator is located was not provided with a battery-powered emergency lighting unit of at least 1 and 1/2 hour duration to provide task illumination in the event of mechanical failure of the generator.

Staff FF, Maintenance, confirmed at that time a battery-powered emergency lighting unit was not provided for the generator room.

Section 3-4.2.2.2 of the National Fire Protection Association (NFPA 99) states emergency battery light for task illumination for emergency power at the generator set location shall be provided.

Based on observation and interview the facility failed to inspect the eye wash station (an apparatus used to physically wash the eyes in case the eyes become contaminated by foreign materials or substance) located in the laboratory. This deficient practice affects the operation of the laboratory. The facility census was 15.

Findings included:

Observation during a tour of the laboratory conducted on the afternoon of 01/29/14 showed no log or record to indicate when the eye wash station was last inspected.

During an interview on 01/29/14 at 1:51 PM, Staff GG, Laboratory Director, stated weekly inspections of the eye wash unit were not being conducted and documented.

Section 11.8.1.2.2 of the National Fire Protection Association (NFPA 99) states: Periodic safety inspection shall include the testing of all emergency showers, eye baths, and other emergency equipment.