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Based on interview, it was determined the facility failed to test the batteries of exit light fixtures for 30 seconds and annually for an hour and a half in accordance with NFPA 101 Section 7.10.9. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the exit light to illuminate to mark the emergency exit in the event of a loss of normal power was not assured. The facility had a census of 10 patients on 07/23/12. The findings follow:

In an interview on 07/24/12 at 1350, the Maintenance Director verified battery testing of exit lights was not conducted.

Based on fire drill documentation review and interview, it was determined the facility failed to ensure the fire alarm system was activated as part of 5 (02/24/11, 05/31/11, 12/12/11, 12/29/11, and 06/20/12) of 12 fire drills from January 2011 through June 2012 in accordance with NFPA 101 Section 19.7.1.2. The failed practice had the potential to affect all patients, staff, and visitors, because the reliability of the fire alarm system to automatically contact the fire department monitoring station and provide audible and visual alarms to building occupants was not evaluated and could not be assured. The facility had a census of 10 patients on 07/23/12. The findings follow:

A. Review of the fire drill documentation from January 2011 through June 2012 revealed the fire alarm system was not activated during the fire drills conducted on 02/24/11, 05/31/11, 12/12/11, 12/29/11, and 06/20/12.. The fire drill documentation included an evaluation form with an item to be checked "Yes" or "No" that read "Was the fire alarm pull box activated?" This item was marked no.
B. The Maintenance Director verified the dates of the fire drills when the fire alarm system was documented as not activated in an interview on 07/25/12 at 1045.

Based on sprinkler system inspection documentation review and interview it was determined he facility failed to repair a water flow alarm that failed the most recent inspection. The failed practice had the potential to affect all patients, staff, and visitors because building occupants would not be immediately notified of sprinkler system activation, which had the potential to delay fire plan implementation. The facility had a census of 10 patients on 07/23/12. The findings follow:

A. Review of the most recent inspection of the sprinkler system conducted on 05/31/12 revealed a comment by the sprinkler service inspector that read "6 inch sprinkler system does not activate water flow alarm."
B. In an interview on 07/25/12 at 0920, the Maintenance Director verified the water flow alarm had not been repaired.

Based on Generator Log review and interview, it was determined the facility failed to ensure two of two (#1 and #2) generators were tested under load for at least 30 minutes monthly for 11 of 18 months from January 2011 through June 2012 (April 2011, May 2011, June 2011 August 2011, September 2011, October 2011, November 2011, December 2011, January 2012, February 2012, December 2011, January 2012, and May 2012.) The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the generator to provide emergency power to the facility in the event of the loss of normal power was not evaluated and could not be assured. The facility had a census of 10 patients on 07/23/12. The findings follow:

A. Review of the Generator Logs on 07/24/12 at 0915 revealed the following:
1) For Generator #1, there was no documentation of the monthly load test for May 2011 and November 2011. In addition, the length of the load test run time was not recorded for August 2011, September 2011, October 2011, December 2011, January 2012, and February 2012)
2) For Generator #2, there was no documentation of a monthly load test for April 2011, May 2011, June 2011, October 2011, November 2011, December 2011, January 2012, and May 2012.
B. The Maintenance Director verified there were no further generator logs available for review on 07/25/12 at 0945.