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Based on a review of the facility records and interview with the staff, on 05/02/12 and 05/03/12, it was determined the facility failed to train all staff in disaster preparedness. The training consists of a table top in-service, an internal disaster scenario, and an external disaster scenario, at six month intervals. A lack of these training exercises could in the event of an internal or external disaster, cause confusion and/or panic from a lack of knowledge for staff and raise potential for negative outcomes to the residents and staff, and other building occupants.

The findings include:

During the tour of the facility on 05/02/12, it was observed that two kitchen staff were not caring a identification badge. One kitchen staff member, at 11:20 a.m., was asked to open the fire extinguisher cabinet in the dining room. The fire extinguishers are in locked cabinets and this staff member did not have a key to unlock the cabinet. It was noted that the fire extinguisher cabinets are equipped with a break away feature and do not require a key to open the cabinets. The kitchen staff member did not know about this feature.

During the tour of the facility on 05/03/12, at 12:30 p.m., on the third floor it was observed a staff member without an identification badge. When question about where the identification badge was the surveyor was told it was in his office.

NFPA 101 (2000 edition) 18.2 18.2.2.2.5

Based on an observation, staff interview, and record review conducted during the survey on 05/02/12, it was determined the fire sprinkler system failed to be completely maintained. The record review indicated the facility was not completing the quarterly inspection for the fire sprinkler system. This condition could place the lives of the occupants in danger should a fire occur and the fire sprinkler system failed to respond.

The findings include:

During the documentation review it revealed the fire sprinkler system had not been inspected as required. The facility occupied the building in January of 2012. NFPA, 25 requires the sprinkler system be inspected and tested quarterly.

NFPA 101 (2000 edition)
NFPA 25 (1998 edition)

Based on a review of the facility records and interview with the staff, on 05/02/12 and 05/03/12, it was determined the facility failed to train all staff in disaster preparedness. The training consists of a table top in-service, an internal disaster scenario, and an external disaster scenario, at six month intervals. A lack of these training exercises could in the event of an internal or external disaster, cause confusion and/or panic from a lack of knowledge for staff and raise potential for negative outcomes to the residents and staff, and other building occupants.

The findings include:

During the tour of the facility on 05/02/12, it was observed that two kitchen staff were not caring a identification badge. One kitchen staff member, at 11:20 a.m., was asked to open the fire extinguisher cabinet in the dining room. The fire extinguishers are in locked cabinets and this staff member did not have a key to unlock the cabinet. It was noted that the fire extinguisher cabinets are equipped with a break away feature and do not require a key to open the cabinets. The kitchen staff member did not know about this feature.

During the tour of the facility on 05/03/12, at 12:30 p.m., on the third floor it was observed a staff member without an identification badge. When question about where the identification badge was the surveyor was told it was in his office.

NFPA 101 (2000 edition) 18.2 18.2.2.2.5

Based on an observation, staff interview, and record review conducted during the survey on 05/02/12, it was determined the fire sprinkler system failed to be completely maintained. The record review indicated the facility was not completing the quarterly inspection for the fire sprinkler system. This condition could place the lives of the occupants in danger should a fire occur and the fire sprinkler system failed to respond.

The findings include:

During the documentation review it revealed the fire sprinkler system had not been inspected as required. The facility occupied the building in January of 2012. NFPA, 25 requires the sprinkler system be inspected and tested quarterly.

NFPA 101 (2000 edition)
NFPA 25 (1998 edition)