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Based on record review and staff interview the facility failed to conduct fire drills at least quarterly on each shift as required by NFPA 101, 19.7.1.2.

Findings include:

1. On 09/21/11, the first day of survey, record review conducted from 11:00 a.m. to 12:30 p.m. revealed that staffing patterns are based on two 12 hour shifts and that 2 fire drills were conducted in each of the preceding four quarters, however in the 4th quarter of 2010, and the 1st and 2nd quarters of 2011, both quarterly fire drills were conducted on the 7 a.m. to 7 p.m. shift and no fire drills were conducted on the 7 p.m. to 7 a.m. shift.

2. On 09/21/11, staff interview of the Director of Plant Operations concurrently with the record review from 11:00 a.m. to 12:30 p.m., revealed the facility had transitioned from a three shift to two shift staffing pattern resulting in the missing of 3 of 4 quarterly fire drills for the 7 p.m. to 7 a.m. shift .

Class III
NFPA 101, 19.7.1.2.

Based on observation and staff interview the facility failed to continuously maintain the required automatic sprinkler system in a reliable operating condition as required by NFPA 101, 9.7.5, 19.7.6, 4.6.12, NFPA 13, and NFPA 25, 2-2.1.1.

Findings include:

1. On 09/21/11, the first day of survey, observation during the interior tour from 1:30 to 3:30 p.m. of the second floor revealed sprinkler heads with a build-up of foreign material, (dust), in 1 of 2 sprinkler heads in rooms 228, 229, 231, 232, 262 and a escutcheon missing in 1 of 2 sprinkler heads in room 209.

2. On 09/22/11, the second day of survey, observation during the interior tour from 9:30 a.m. to 1:30 p.m. of the first floor revealed sprinkler heads with a build-up of foreign material, (dust), in 1 of 2 sprinkler heads in rooms labeled as Soiled Utility, Case Manager, and Chief Clinical Office.

3. On 09/21/11 and 09/22/11, staff interview of the Director of Plant Operations concurrent with the interior tours of the second and first floors revealed concurrence with the observations of foreign material on 1 of 2 sprinkler heads in rooms 228, 229, 231, 232, 262, as well as the escutcheon missing in 1 of 2 sprinkler heads in room 209 and the build-up of foreign material, (dust), in 1 of 2 sprinkler heads in rooms labeled as Soiled Utility, Case Manager, and Chief Clinical Office.

Class III
NFPA 101, 9.7.5, 19.7.6, 4.6.12
NFPA 13
NFPA 25, 2-2.1.1

Based on observation the facility failed to maintain the heating and air conditioning through wall, (PTAC), units in accordance with NFPA 19.5.2.1, 19.5.2.2, 9.2, and NFPA 90A, B-3.

Findings include:

1. On 09/21/11, observation during the interior tour conducted from 1:30 to 3:30 p.m., accompanied by the Director of Plant Operations revealed air filters installed in through wall air conditioning units, (PTAC's), with excessive dust in rooms 228, 232 and 262. The Director of Plant Operations acknowledged the excessive amounts of dust.

2. On 09/21/11, observation during the interior tour conducted from 1:30 to 3:30 p.m., accompanied by the Director of Plant Operations revealed the air filter installed in the through wall air conditioning unit, (PTAC), with excessive dust inthe room labeled Case Manager. The Director of Plant Operations acknowledged the excessive amount of dust.

Class III
NFPA 19.5.2.1, 19.5.2.2, and 9.2
NFPA 90A, B-3 Filters
B-3.1 All air filters should be kept free of excess dust and combustible material. Unit filters should be renewed or cleaned when the resistance to airflow has increased to two times the original resistance or when the resistance has reached a value of recommended replacement by the manufacturer.

Base on observation the facility failed to maintain the electrical wiring as required by NFPA 101, 9.1.2, NFPA 70, National Electrical Code, Table 400-5(A) and NFPA 99, Health Care Facilities, 7-5.1.2.3 and 9-2.1.2.2.

Findings include:

1. On 09/22/11, the second day of survey, observation during the interior tour conducted from 9:30 a.m. to 1:30 p.m., accompanied by the Director of Plant Operations, revealed power strips and/or surge protectors, one plugged into another, (daisy chaining), potentially exceeding the amperage capacity of the one 20 amp duplex receptacle as a source of power in the rooms labeled Accounting Specialist and Admissions Coordinator. The Director of Plant Operations concurred with the observation.

Class III
NFPA 101, 9.1.2
NFPA 70, National Electrical Code, Table 400-5(A)
NFPA 99, Health Care Facilities, 7-5.1.2.3 and 9-2.1.2.2