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Based upon a review of available reports and records, it was determined the facility had failed to conduct one or more fire drills, on a quarterly basis for each shift, in accordance with NFPA 101 (2000) Life Safety Code, Chapter 18, Section 18.7.1.2.. In a fire emergency, this deficient practice could adversely affect the safety of 17 of 17 patients.

FINDINGS INCLUDE:

On 6/8/10 at 11:30 AM, during a review of fire drill reports provided by the Director of Environmental Services [TW), it was verified that the facility failed to conduct required fire drills during the months of June and December of 2009. This deficient practice was not in conformance with NFPA 101 (00), Chapter 18, Section 18.7.1.2.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 18, Section 18.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On 6/8/10 at 2:02 PM, observation revealed that the electrical supply for the air compressor serving the dry pipe fire sprinkler system, was not permanently hard-wired into the building electrical system. Rather, the appliance was plugged into a wall outlet. This arrangement was not in conformance with NFPA 13 (99), Chapter 4, Section 4-2.6.2.

This deficiency was confirmed with the Maintenance Supervisor [JW] at the time of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Automatic fire sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically, in accordance with NFPA 101 (00), Chapter 18, Section 18.7.6, and Chapter 4, Section 4.6.12 and Chapter 9, Section 9.7.5 and NFPA 13 (1999) and NFPA 25 (1998).

FINDINGS INCLUDE:

On 6/8/10 between 9:30 AM and 3:30 PM, during a review of available documentation provided by the Maintenance Supervisor [JW), it was confirmed that the building fire sprinkler system had not been inspected and tested within the previous year. The most recent annual inspection report was dated 5/22/09, as completed by a contract vendor.

In a fire emergency, a non-compliant fire sprinkler system could adversely affect the safety of 17 of 17 patients.

Based upon a review of available reports and records, it was determined the facility had failed to conduct one or more fire drills, on a quarterly basis for each shift, in accordance with NFPA 101 (2000) Life Safety Code, Chapter 18, Section 18.7.1.2.. In a fire emergency, this deficient practice could adversely affect the safety of 17 of 17 patients.

FINDINGS INCLUDE:

On 6/8/10 at 11:30 AM, during a review of fire drill reports provided by the Director of Environmental Services [TW), it was verified that the facility failed to conduct required fire drills during the months of June and December of 2009. This deficient practice was not in conformance with NFPA 101 (00), Chapter 18, Section 18.7.1.2.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - There is an automatic sprinkler system, installed in accordance with NFPA 13 (1999), Standard for the Installation of Sprinkler Systems, with approved components, devices, and equipment, to provide complete coverage of all portions of the facility. The system is maintained in accordance with NFPA 25 (1998), Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. There is a reliable, adequate water supply for the system. The system is equipped with water flow and tamper switches which are connected to the fire alarm system, in accordance with NFPA 101 (2000), Chapter 18, Section 18.3.5. and Chapter 9, Section 9.7.

FINDINGS INCLUDE:

On 6/8/10 at 2:02 PM, observation revealed that the electrical supply for the air compressor serving the dry pipe fire sprinkler system, was not permanently hard-wired into the building electrical system. Rather, the appliance was plugged into a wall outlet. This arrangement was not in conformance with NFPA 13 (99), Chapter 4, Section 4-2.6.2.

This deficiency was confirmed with the Maintenance Supervisor [JW] at the time of discovery.

NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Automatic fire sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically, in accordance with NFPA 101 (00), Chapter 18, Section 18.7.6, and Chapter 4, Section 4.6.12 and Chapter 9, Section 9.7.5 and NFPA 13 (1999) and NFPA 25 (1998).

FINDINGS INCLUDE:

On 6/8/10 between 9:30 AM and 3:30 PM, during a review of available documentation provided by the Maintenance Supervisor [JW), it was confirmed that the building fire sprinkler system had not been inspected and tested within the previous year. The most recent annual inspection report was dated 5/22/09, as completed by a contract vendor.

In a fire emergency, a non-compliant fire sprinkler system could adversely affect the safety of 17 of 17 patients.