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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 in the c-section room and the procedure room. This deficient practice has the potential to affect all occupants in these areas. The facility census was 22.

Findings included:

1. Review of the preventive maintenance documentation of the fire safety equipment, conducted on the afternoon of 10/22/13, showed there was no documentation of monthly and annual testing of the battery-powered emergency lighting units provided in the facility.

2. During an interview on 10/23/13 at 2:00 PM, Staff GG, Director of Plants and Grounds, 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 the facility failed to conduct fire drills at least quarterly for each shift. This deficient practice has the potential to affect all occupants in the facility. The facility census was 22.

Findings included:

1. Review of the fire drill records for the previous 12 months, conducted on the afternoon of 10/22/13, showed the following:
-The evening shift staff only participated in a fire drill three times during the previous 12 months which occurred in December of 2012, March of 2013 and August of 2013.
-The night shift staff only participated in a fire drill three time during the previous 12 months which occurred in January of 2013, April of 2013 and September of 2013.

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 observation and interview the facility failed to maintain the sprinkler system in a manner that would ensure the proper operation of the sprinklers during a fire. This deficient practice has the potential to affect all occupants in the facility. The facility census was 22.

Findings included:

1. Observation and concurrent interview during a tour of the facility, conducted on the afternoon of 10/23/13, showed the following:
-At 1:04 PM an escutcheon ring (a metallic or nonmetallic ring which is imbedded in the ceiling or wall around a sprinkler head to stabilize the water spray pattern if the sprinkler head is activated) was missing around a ceiling mounted sprinkler head in the Medical Records department.
-At 1:54 PM three escutcheon rings were missing around three ceiling mounted sprinkler heads in the post operative area in the surgery suite.
-At 1:57 PM five escutcheon rings were missing around five ceiling mounted sprinkler heads in the corridor outside the operating rooms in the surgery suite.

2. At the time of each observation, Staff GG, Director of Plants and Grounds, confirmed the escutcheon rings were missing.

Section 6.2.7.2 of the National Fire Protection Association (NFPA 13) states escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.

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 has the potential to affect all occupants in the facility. The facility census was 22.

Findings included:

1. Observation on 10/23/13 at 1:08 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.

2. Staff GG, Director of Plants and Grounds, confirmed at that time a battery-powered emergency lighting unit was not provided in 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 record review and interview the facility failed to conduct monthly and annual tests of the battery-powered emergency lighting units in the c-section room and the procedure room. This deficient practice has the potential to affect all occupants in these areas. The facility census was 22.

Findings included:

1. Review of the preventive maintenance documentation of the fire safety equipment, conducted on the afternoon of 10/22/13, showed there was no documentation of monthly and annual testing of the battery-powered emergency lighting units provided in the facility.

2. During an interview on 10/23/13 at 2:00 PM, Staff GG, Director of Plants and Grounds, 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 the facility failed to conduct fire drills at least quarterly for each shift. This deficient practice has the potential to affect all occupants in the facility. The facility census was 22.

Findings included:

1. Review of the fire drill records for the previous 12 months, conducted on the afternoon of 10/22/13, showed the following:
-The evening shift staff only participated in a fire drill three times during the previous 12 months which occurred in December of 2012, March of 2013 and August of 2013.
-The night shift staff only participated in a fire drill three time during the previous 12 months which occurred in January of 2013, April of 2013 and September of 2013.

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 observation and interview the facility failed to maintain the sprinkler system in a manner that would ensure the proper operation of the sprinklers during a fire. This deficient practice has the potential to affect all occupants in the facility. The facility census was 22.

Findings included:

1. Observation and concurrent interview during a tour of the facility, conducted on the afternoon of 10/23/13, showed the following:
-At 1:04 PM an escutcheon ring (a metallic or nonmetallic ring which is imbedded in the ceiling or wall around a sprinkler head to stabilize the water spray pattern if the sprinkler head is activated) was missing around a ceiling mounted sprinkler head in the Medical Records department.
-At 1:54 PM three escutcheon rings were missing around three ceiling mounted sprinkler heads in the post operative area in the surgery suite.
-At 1:57 PM five escutcheon rings were missing around five ceiling mounted sprinkler heads in the corridor outside the operating rooms in the surgery suite.

2. At the time of each observation, Staff GG, Director of Plants and Grounds, confirmed the escutcheon rings were missing.

Section 6.2.7.2 of the National Fire Protection Association (NFPA 13) states escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.

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 has the potential to affect all occupants in the facility. The facility census was 22.

Findings included:

1. Observation on 10/23/13 at 1:08 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.

2. Staff GG, Director of Plants and Grounds, confirmed at that time a battery-powered emergency lighting unit was not provided in 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.