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Based on document review, the facility failed to maintain proper testing and proper documentation for the testing of smoke detector sensitivity. Testing of the smoke detectors helps to ensure proper function in emergency conditions. Failure of a smoke detector will delay or hinder the detection of fire or smoke, this may endanger all of the occupants within the facility.

The findings include:

During the document review with the Maintenance Director and the Safety Coordinator on 12/17/2012 at 11:30am, it was found that testing of the smoke detector sensitivity was not being performed or documented. Smoke detectors must be tested for their sensitivity every 2 years. "Sensitivity shall be checked within one year of installation and shall be checked every alternate year. NFPA 72 10.4.3

Based on document review the facility failed to maintain documentation for the annual inspection of the Backflow Preventer. Inspection and/or maintenance helps to ensure proper operation of the valve and supply for the sprinkler system.

The findings include:

During document review on 12/17/2012 with the Director of Maintenance, it was found that the annual inspection was overdue for the facilities backflow preventer. Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observations and interview during the facility tour with Director of Maintenance, the facility failed to prohibit the use of electrical strips (surge protectors). The use of surge protectors and extension cords allow the possibility of overloading the wiring dedicated to the outlet which can cause a fire hazard. Electrical fires can start in the walls or attic where it can go undetected, giving the hazard time to spread without being identified, placing the entire facility at risk.

The findings include:

During the facility tour with maintenance staff on 12/17/2012 at 2:00pm, it was found that there were electrical strips in 3 staff offices which were daisy chained. There were also 2 offices in which appliances (refrigerator, etc) were plugged into extension cords/power strips This is not in accordance with NFPA 99 - 3.2.1.2 or NFPA 1. Conducted an interview with the director of maintenance at that time and he confirmed the violations.

NFPA 99 - 3.2.1.2
2. Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 1 - 11.1.5
Extension cords shall not be used as a substitute for permanent wiring.

Based on document review and interview with the Director of Maintenance, it was noted that the facility failed to maintain documentation on the exercising of the main and feeder breakers. Not exercising as required by the manufacturer can lead to corrosion among other issues which can cause delay or the inability to transfer power in a time of emergency.

The findings include:

During document review with the Director of Maintenance on 12/17/2012, it was found that the proper documentation for maintenance and testing was not being keptin accordance with NFPA 70, National Electrical Code. 9.1.2 for the exercise of the Main and Feeder Breaker. Conducted an interview with the director of maintenance at that time and he confirmed the findings.

Based on document review, the facility failed to maintain proper testing and proper documentation for the testing of smoke detector sensitivity. Testing of the smoke detectors helps to ensure proper function in emergency conditions. Failure of a smoke detector will delay or hinder the detection of fire or smoke, this may endanger all of the occupants within the facility.

The findings include:

During the document review with the Maintenance Director and the Safety Coordinator on 12/17/2012 at 11:30am, it was found that testing of the smoke detector sensitivity was not being performed or documented. Smoke detectors must be tested for their sensitivity every 2 years. "Sensitivity shall be checked within one year of installation and shall be checked every alternate year. NFPA 72 10.4.3

Based on document review the facility failed to maintain documentation for the annual inspection of the Backflow Preventer. Inspection and/or maintenance helps to ensure proper operation of the valve and supply for the sprinkler system.

The findings include:

During document review on 12/17/2012 with the Director of Maintenance, it was found that the annual inspection was overdue for the facilities backflow preventer. Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observations and interview during the facility tour with Director of Maintenance, the facility failed to prohibit the use of electrical strips (surge protectors). The use of surge protectors and extension cords allow the possibility of overloading the wiring dedicated to the outlet which can cause a fire hazard. Electrical fires can start in the walls or attic where it can go undetected, giving the hazard time to spread without being identified, placing the entire facility at risk.

The findings include:

During the facility tour with maintenance staff on 12/17/2012 at 2:00pm, it was found that there were electrical strips in 3 staff offices which were daisy chained. There were also 2 offices in which appliances (refrigerator, etc) were plugged into extension cords/power strips This is not in accordance with NFPA 99 - 3.2.1.2 or NFPA 1. Conducted an interview with the director of maintenance at that time and he confirmed the violations.

NFPA 99 - 3.2.1.2
2. Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 1 - 11.1.5
Extension cords shall not be used as a substitute for permanent wiring.

Based on document review and interview with the Director of Maintenance, it was noted that the facility failed to maintain documentation on the exercising of the main and feeder breakers. Not exercising as required by the manufacturer can lead to corrosion among other issues which can cause delay or the inability to transfer power in a time of emergency.

The findings include:

During document review with the Director of Maintenance on 12/17/2012, it was found that the proper documentation for maintenance and testing was not being keptin accordance with NFPA 70, National Electrical Code. 9.1.2 for the exercise of the Main and Feeder Breaker. Conducted an interview with the director of maintenance at that time and he confirmed the findings.