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Based on observation and staff interview the facility failed to assure the self closing fire doors are operating properly. This deficient practice may cause fire and smoke to spread to adjacent areas of the building. This may affect 2 out of 8 smoke zones. This facility has a capacity of 25 with a census of 9 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/3/11 from 12:30 to 4:30 PM it was found that the ambulance bay 1.5 hour fire door did not latch properly when released.

Staff "M" was present and aware of the finding.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire-resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

Based on record review and staff interview the facility failed to assure that the fire drills are held once each shift for each quarter. This deficient practice may cause a delay in exiting the building. This will affect all 8 smoke zones of the building. This facility has a capacity of 25 with a census of 9 at the time of the survey.

FINDINGS INCLUDE:

No fire drill was conducted for the night shift in the 3rd quarter of 2010.

Staff "M" was present and aware of the finding.

Record review of the following NFPA Standard revealed: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2.

Based on observation and staff interview the facility failed to assure that the sprinkler system is properly installed to cover all portions of the building. This may cause failure of the sprinkler to suppress the fire in 1 out of 8 smoke zones. This facility has a capacity of 25 with a census of 9 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/3/11 from 12:30 to 4:30 PM it was found that the ambulance bay sprinkler system will not cover the area if the garage door is in the open position due to sprinkler heads above but not below the door.

Staff "M" was present and aware of the finding.

NFPA Standard: Where required by 18/19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NFPA 101, 18/19.3.5.1

Based on observation, record review and staff interview the facility failed to assure that the generator is properly tested monthly. This will affect all 8 smoke zones in the building causing darkness and failure of electrical equipment. This facility has a capacity of 25 with a census of 11 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/3/11 from 12:30 to 4:30 PM it was found that the generator monthly testing shows that no load was documented in January, April and June of 2010, the other months show 50-80 amps. The generator is rated for 120/240 volts at 421/300 amps maximum. None of the monthly testing is meeting the required 30% of the load rating capacity of the generator.

Staff "M" was present and aware of the finding.

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

NFPA Standard: Inspection and Testing of Level 3 generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b). 1999 NFPA 99, 3-6.4.1.1

Based on observation and staff interview the facility failed to assure that extension cord/power strip policies are enforced and NFPA 70 codes are met. This may cause wiring to overload starting a fire or smoke hazard in 2 out of 8 smoke zones. This facility has a capacity of 25 with a census of 9 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/3/11 from 12:30 to 4:30 PM the following deficiencies were found:

1.) Mechanical room #4 has an electrical panel missing a breaker/blank leaving an open space.
2.) Equipment storage room on the 2nd floor has a wire molded power strip for charging medical equipment plugged into an outlet.
3.) The O.B. room on 2nd floor has a electric bed plugged into a power strip and a TV plugged into an extension cord.
4.) Trish room on 2nd floor has an extension cord for the alarm clock.
5.) Kristin room on 2nd floor has an extension cord for the alarm clock.

Staff "M" was present and aware of the findings.

NFPA Standard: Temporary electrical power and lighting installations shall be permitted (600 volts or less): (a) During Construction - temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities; (b) 90 Days - temporary electrical power and lighting installations shall be permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes; (c) Emergencies and Tests - temporary electrical power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work.; (d) Removal - temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. 1999 NFPA 70, 3-1.2.1
NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and staff interview the facility failed to assure the self closing fire doors are operating properly. This deficient practice may cause fire and smoke to spread to adjacent areas of the building. This may affect 2 out of 8 smoke zones. This facility has a capacity of 25 with a census of 9 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/3/11 from 12:30 to 4:30 PM it was found that the ambulance bay 1.5 hour fire door did not latch properly when released.

Staff "M" was present and aware of the finding.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire-resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

Based on record review and staff interview the facility failed to assure that the fire drills are held once each shift for each quarter. This deficient practice may cause a delay in exiting the building. This will affect all 8 smoke zones of the building. This facility has a capacity of 25 with a census of 9 at the time of the survey.

FINDINGS INCLUDE:

No fire drill was conducted for the night shift in the 3rd quarter of 2010.

Staff "M" was present and aware of the finding.

Record review of the following NFPA Standard revealed: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2.

Based on observation and staff interview the facility failed to assure that the sprinkler system is properly installed to cover all portions of the building. This may cause failure of the sprinkler to suppress the fire in 1 out of 8 smoke zones. This facility has a capacity of 25 with a census of 9 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/3/11 from 12:30 to 4:30 PM it was found that the ambulance bay sprinkler system will not cover the area if the garage door is in the open position due to sprinkler heads above but not below the door.

Staff "M" was present and aware of the finding.

NFPA Standard: Where required by 18/19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NFPA 101, 18/19.3.5.1

Based on observation, record review and staff interview the facility failed to assure that the generator is properly tested monthly. This will affect all 8 smoke zones in the building causing darkness and failure of electrical equipment. This facility has a capacity of 25 with a census of 11 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/3/11 from 12:30 to 4:30 PM it was found that the generator monthly testing shows that no load was documented in January, April and June of 2010, the other months show 50-80 amps. The generator is rated for 120/240 volts at 421/300 amps maximum. None of the monthly testing is meeting the required 30% of the load rating capacity of the generator.

Staff "M" was present and aware of the finding.

NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2

NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

NFPA Standard: Inspection and Testing of Level 3 generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b). 1999 NFPA 99, 3-6.4.1.1

Based on observation and staff interview the facility failed to assure that extension cord/power strip policies are enforced and NFPA 70 codes are met. This may cause wiring to overload starting a fire or smoke hazard in 2 out of 8 smoke zones. This facility has a capacity of 25 with a census of 9 at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/3/11 from 12:30 to 4:30 PM the following deficiencies were found:

1.) Mechanical room #4 has an electrical panel missing a breaker/blank leaving an open space.
2.) Equipment storage room on the 2nd floor has a wire molded power strip for charging medical equipment plugged into an outlet.
3.) The O.B. room on 2nd floor has a electric bed plugged into a power strip and a TV plugged into an extension cord.
4.) Trish room on 2nd floor has an extension cord for the alarm clock.
5.) Kristin room on 2nd floor has an extension cord for the alarm clock.

Staff "M" was present and aware of the findings.

NFPA Standard: Temporary electrical power and lighting installations shall be permitted (600 volts or less): (a) During Construction - temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities; (b) 90 Days - temporary electrical power and lighting installations shall be permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes; (c) Emergencies and Tests - temporary electrical power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work.; (d) Removal - temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. 1999 NFPA 70, 3-1.2.1
NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8