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Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times in 1 of 4 smoke compartments. The findings were:

Observation on 11/19/15 at 10:50 AM revealed the kitchen door leading to the dining room was double locked. A second lock (dead bolt) was located approximately 42" above the floor. At the time of the observation the Facility Maintenance Manager acknowledged the second lock on the door.

Ref:
2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4

Based on document review and staff interview, the facility failed to provide fire drills held at unexpected times and at least quarterly on each shift. The findings were:

Document review on 11/19/15 from 12:00 PM to 12:35 PM revealed no record of fire drills were available for the first and third quarter of 2015. Interview with the Facility Maintenance Manger verified that no documentation was available.

Ref:
2000 NFPA 101, Section 19.7.1.2

Based on document review and staff interview, the facility failed to demonstrate an approved maintenance and testing program per NFPA 72. The findings were:

Document review on 11/19/15 from 12:00 PM to 12:35 PM revealed the semi-annual battery load voltage test had been completed only annually. The last two tests completed were 9/2014 and 9/2015. At the time of the document review the Facility Maintenance Manager stated they had only been testing the battery load voltage annually.

Ref:
2000 NFPA 101, Sections 19.3.4.2 and 9.6.1.4
1999 NFPA 72, Table 7-3.2,6,c,3

Based on observation and staff interview, the facility failed to ensure alcohol based hand rub (ABHR) dispensers were not installed over or adjacent to an ignition source. The findings were:

1. Observation on 11/19/15 at 10:33 AM revealed the ABHR dispenser in the infection prevention office was installed directly over a light switch. At the time of the observation the Facility Maintenance Manager acknowledged the location of the ABHR dispenser.
2.. Observation on 11/19/15 at 11:34 AM revealed the ABHR dispenser in room #15 was installed directly over an electrical outlet. At the time of the observation the Facility Maintenance Manager acknowledged the location of the ABHR dispenser.
Ref;
CFR 485.623 (7)(iv)

Based on observation and staff interview, the facility failed to arrange exit access so that exits are readily accessible at all times in 1 of 4 smoke compartments. The findings were:

Observation on 11/19/15 at 10:50 AM revealed the kitchen door leading to the dining room was double locked. A second lock (dead bolt) was located approximately 42" above the floor. At the time of the observation the Facility Maintenance Manager acknowledged the second lock on the door.

Ref:
2000 NFPA 101, Sections 19.2.2.2.1 and 7.2.1.5.4

Based on document review and staff interview, the facility failed to provide fire drills held at unexpected times and at least quarterly on each shift. The findings were:

Document review on 11/19/15 from 12:00 PM to 12:35 PM revealed no record of fire drills were available for the first and third quarter of 2015. Interview with the Facility Maintenance Manger verified that no documentation was available.

Ref:
2000 NFPA 101, Section 19.7.1.2

Based on document review and staff interview, the facility failed to demonstrate an approved maintenance and testing program per NFPA 72. The findings were:

Document review on 11/19/15 from 12:00 PM to 12:35 PM revealed the semi-annual battery load voltage test had been completed only annually. The last two tests completed were 9/2014 and 9/2015. At the time of the document review the Facility Maintenance Manager stated they had only been testing the battery load voltage annually.

Ref:
2000 NFPA 101, Sections 19.3.4.2 and 9.6.1.4
1999 NFPA 72, Table 7-3.2,6,c,3