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Based on observation and a staff interview, it was confirmed the facility failed to properly conduct one or more quarterly fire drills during the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 18, Section 18.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 04/29/2014 at 10:40 AM, while reviewing fire drill reports for calendar year 2013, it was confirmed that not all fire drills had been sufficiently varied. Specifically, fire drills conducted on the Night-shift during the 2nd, 3rd, and 4th Quarters of 2013 were commenced not greater than three (3) minutes apart.

This deficient practice was confirmed with the chief building engineer.

Based on observation and a staff interview, it was confirmed the facility failed to properly conduct one or more quarterly fire drills during the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 04/29/2014 at 10:40 AM, while reviewing fire drill reports for calendar year 2013, it was confirmed that not all fire drills had been sufficiently varied. Specifically, fire drills conducted on the Night-shift during the 2nd, 3rd, and 4th Quarters of 2013 were commenced not greater than three (3) minutes apart.

This deficient practice was confirmed with the chief building engineer.

Based on observation, not all control valves for the facility's automatic fire sprinkler system were equipped with required supervisory attachments, in accordance with the requirements at NFPA 101 (2000) Chapter 9, Section 9.7.2 and NFPA 72 (1999). In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 04/29/2014 at 1:50 PM, observation revealed a fire sprinkler post indicator valve (PIV) located on the West edge of the property. This PIV serves the fire sprinkler system in Building 01, and was not equipped with an electrically interconnected tamper switch.

This finding was confirmed with the chief building engineer at the time of discovery.

Based on observation and a staff interview, it was confirmed the facility failed to properly conduct one or more quarterly fire drills during the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 18, Section 18.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 04/29/2014 at 10:40 AM, while reviewing fire drill reports for calendar year 2013, it was confirmed that not all fire drills had been sufficiently varied. Specifically, fire drills conducted on the Night-shift during the 2nd, 3rd, and 4th Quarters of 2013 were commenced not greater than three (3) minutes apart.

This deficient practice was confirmed with the chief building engineer.

Based on observation and a staff interview, it was confirmed the facility failed to properly conduct one or more quarterly fire drills during the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 19, Section 19.7.1.2, and CMS policy. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 04/29/2014 at 10:40 AM, while reviewing fire drill reports for calendar year 2013, it was confirmed that not all fire drills had been sufficiently varied. Specifically, fire drills conducted on the Night-shift during the 2nd, 3rd, and 4th Quarters of 2013 were commenced not greater than three (3) minutes apart.

This deficient practice was confirmed with the chief building engineer.

Based on observation, not all control valves for the facility's automatic fire sprinkler system were equipped with required supervisory attachments, in accordance with the requirements at NFPA 101 (2000) Chapter 9, Section 9.7.2 and NFPA 72 (1999). In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.

FINDINGS INCLUDE:

On 04/29/2014 at 1:50 PM, observation revealed a fire sprinkler post indicator valve (PIV) located on the West edge of the property. This PIV serves the fire sprinkler system in Building 01, and was not equipped with an electrically interconnected tamper switch.

This finding was confirmed with the chief building engineer at the time of discovery.