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Based on observation and interview the facility failed to maintain all sets of smoke barrier doors in good working order. This deficient practice affects all patients in those two smoke compartments. The facility census was five patients.

Findings included:

1. Observation on 05/15/12 at 1:15 PM during a tour of the facility showed one of the two smoke barrier doors would not completely close and latch when released from the fire alarm system's automatic hold open device in the south corridor directly across from the nurses station.

2. Staff A, Emergency Operations Program Manager, confirmed at that time the smoke barrier door would not completely close and latch.

Section 18.3.7.6 of the National Fire Protection Association (NFPA 101) states: Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

Based on observation and interview the facility failed to provide an even, all-weather surface from each exit to a public way (an area of safety). This deficient practice affects all patients in the south corridor that might require the use of a flat, solid, clean surface to escape the building in an emergency. The facility census was five.

Findings included:

1. Observation on 05/15/12 at 12:53 PM during a tour of the facility showed a concrete pad approximately ten feet by twelve feet at the south exit of the obstetrical unit leaving approximately forty feet composed of grass and uneven ground to an area of safety, the paved parking lot to the east of the exit.

2. Staff A, Emergency Operations Program Manager, confirmed at that time an even, all-weather surface from the exit to an area of safety had not been provided.

Section 7.7.1 of the National Fire Protection Association (NFPA 101) states: Exits shall terminate directly at a public way or an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Based on document review and interview the facility failed to conduct monthly and annual tests of the battery-powered emergency lighting units in the operating rooms. This deficient practice affects all occupants in this area. The facility census was five.

Findings included:

1. Review of the preventive maintenance documentation of fire safety equipment, conducted on the morning of 05/15/12, showed there was no documentation of monthly and annual testing of the battery-powered emergency lighting units in the operating rooms.

2. During an interview on 05/15/12 at 2:05 PM, Staff A, Emergency Operations Program Manager, stated that an inspection of the battery-powered emergency lighting units was not being conducted on a monthly and annual basis.

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 ? hours.

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

Findings included:

1. Review of the facility sprinkler system inspection documents, conducted on the morning of 05/15/12, showed an outside contractor had last conducted an inspection of the sprinkler system on March 3, 2011. There was no documentation showing any type of inspection being conducted on any portion of the sprinkler system since the inspection in May of 2011.

2. During an interview on 05/15/12 at 2:25 PM, Staff A, Emergency Operations Program Manager, stated an inspection of the sprinkler system was not being conducted on at least a quarterly basis.

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 document review and interview the facility failed to conduct a semi-annual inspection of the range hood suppression system in the kitchen. This deficient practice affects all occupants in the facility. The facility census was five patients.

Findings included:

1. Review of the facility kitchen range hood suppression system inspection documents, conducted on the morning of 05/15/12, showed an outside contractor had last conducted an inspection of the range hood suppression system in February of 2011. There was no documentation showing any inspection of the suppression system being conducted since the inspection in February of 2011.

2. During an interview on 5/15/12 at 2:32 PM, Staff A Emergency Operations Program Manager, stated that an inspection of the range hood suppression system was not being conducted on a semi-annual basis.

Section 8-2 of the National Fire Protection Association (NFPA 96) states: An inspection and servicing of the fire-extinguishing system and listed exhaust hoods shall be made at least every 6 months by properly trained and qualified persons.

Based on observation and interview the facility failed to provide emergency task illumination for the emergency generator in case of power failure and generator failure. This deficient practice affects all occupants in the facility. The facility census was five patients.

Findings included:

1. Observation on 05/15/12 at 2:20 PM during a tour of the facility showed the area where the emergency generator is located was not provided with a battery emergency light of at least 1 and ? hour duration to provide task illumination in the event of mechanical failure of the generator.

2. Staff A, Emergency Operations Program Manager, confirmed at that time a battery emergency lighting unit was not provided for the generator.

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.