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Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

- While performing the building tour on 4/15/14 at approximately 11:45 A.M., the following items were observed regarding hazardous areas:

1) The dining room doors are equipped with non-approved hold open devices. The doors must be manually closed as the devices have a chocking mechanism holding the doors open.

2) The Medical Storage room door is not equipped with a self closing device as required.

NOTE: The facility is not equipped with an automatic sprinkler system, therefore hazardous areas are required to have 1-hour separation.

This was acknowledged by the Executive Director during the exit interview process.

A review of the fire drill report documentation revealed that fire drills are not conducted as required. NFPA 101 Life Safety Code 2000 Edition Section 19.7.1.2 states fire drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

THE FINDINGS INCLUDE:

- A review of the facility fire drill documentation was conducted on 4/15/14 at 11: A.M.
The documents revealed that the fire drills on all three shifts are conducted without varying conditions/times as required. The fire drill dates & times are as follows:

First shift (7:00 A.M. - 3:00 P.M.):
03/31/14 at 9:20 A.M.
12/19/13 at 8:52 A.M.,
09/18/13 at 9:15 A.M., and
06/17/13 at 8:27 A.M.,

Second shift (3:00 P.M. - 11:00 P.M.):
01/29/14 at 6:01 P.M.
10/31/13 at 7:30 P.M.
07/30/13 at 6:36 P.M., and
04/30/13 at 6:30 P.M.,

Third shift (11:00 P.M. - 7:00 A.M.):
02/15/14 at 6:22 A.M.,
11/09/13 at 2:30 A.M.,
08/28/13 at 6:06 A.M., and
05/21/13 at 5:50 A.M.

1) Four of four 1st shift drill times varied between 8:27 A.M. to 9:15 A.M. There is a total time span of 48-minutes between the four drills conducted during the 1st shift.

2) Four of four 2nd shift drills times varied between 6:01 P.M. - 7:30 P.M. There is a total time span of 89-minutes between the four drill conducted during the 2nd shift.

3) Three out of four 3rd shift drills times varied between 5:00 A.M. - 6:22 A. M. There is a total time span of 32-minutes between three drills conducted during the 3rd shift.

This was acknowledged by the Executive Director during the exit interview process.

Based on record review and confirmed by staff, the facility failed to test and maintain records of the fire alarm system in accordance with NFPA 72. Table 7-3.2 #20 states Off-Premises Transmission Equipment shall be tested on a quarterly basis.
Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

- A review of the facility fire alarm system inspection documentation was conducted on 4/15/14 at 10:00 A.M. The fire alarm inspection documents, dated 3/31/14, 12/19/13, 9/18/13 and 6/17/13, revealed that the facility was not conducting the required testing in accordance with NFPA 72. The following items were noted regarding testing of the fire alarm system:

1) The off-premise transmission equipment was not inspected quarterly as required. The only documented test of the off premises equipment was conducted on 3/31/14.

2) The fire alarm reports do not indicate that the fire alarm control panel batteries were load tested semi-annually, or discharged annually as required.

3) The fire alarm batteries have an installation date of 12/1/09. The batteries are currently in excess of the 4-year replacement requirement.

This was acknowledged by the Executive Director during the exit interview process.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.3.2.1 requires smoke detector sensitivity to be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

THE FINDINGS INCLUDE:

- A review of the facility's fire alarm system inspection documentation was conducted on 4/15/14 at 10:00 A.M. The fire alarm reports dated 3/31/14, 12/19/13, 9/18/13 and 6/17/13 revealed that the facility is not conducting the required testing in accordance with NFPA 72. The fire alarm inspection reports do not indicate that the smoke detectors have had any of the required sensitivity testing performed.

This was acknowledged by the Executive Director during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that fire extinguishers are properly identified. NFPA 10 section 1.6.6 requires fire extinguishers not be obstructed or obscured from view. Section 1.6.12 requires fire extinguishers mounted in cabinets or wall recesses to be marked conspicuously. The signs must be conspicuous when viewed from looking down the corridors.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 4/15/14 while touring the facility, it was observed that most of the fire extinguishers (approximately 20) throughout the facility are mounted in recessed cabinets within corridor walls. None of these recessed cabinets are marked with two directional signage so that they are visible when looking down the corridors.

This was acknowledged by the Executive Director during the exit interview process.

Based on record review and confirmed by staff interview, the facility failed to ensure that the "Emergency Power Supply System" (EPSS) is maintained, tested, and inspected in accordance with NFPA 110.
LSC Section 7.9.3 states written records of visual inspections and tests to be kept by the owner for inspection by the authority having jurisdiction.
NFPA 110 Sections 6.4.1 requires the EPSS's, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly for a minimum of 30-minutes.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

- A review of the facility's emergency generator testing documentation was conducted on 4/15/14 at 10:30 A.M. The findings revealed that the facility is not conducting the testing in accordance with NFPA 110 as required. The following items were noted:

1) Although load testing is conducted monthly, the load test is not initiated from a cold start. The facility's Maintenance Director stated that the generator is first started and then transferred from normal power to emergency power.
2) There is no documentation of a weekly inspection of the generator.

This was acknowledged by the Executive Director during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that extension cords are used in accordance with NFPA 70. Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days. Article 400-8 prohibits flexible cords from being use as a substitute for the fixed wiring of a structure. LSC 19.5.1

THE FINDINGS INCLUDE:

- At approximately 12:15 P.M. of 4/15/14 while touring the facility, the following items but not limited to were observed regarding electrical wiring:

1) There is an extension cord plugged into a wall outlet of closet #A09, the cord travels through the corridor wall into closet #A08 where it is supplying power to an electrical device.
As per code, extension cords are prohibited as a substitute for permanent wiring.

2) There is an extension cord plugged into a wall outlet of the last corridor closet in the "C-Wing", the cord travels through the corridor wall where it is supplying power to a microwave located in the corridor.
As per code, extension cords are prohibited as a substitute for permanent wiring.

This was acknowledged by the Executive Director during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas are separated as required.

THE FINDINGS INCLUDE:

- While performing the building tour on 4/15/14 at approximately 11:45 A.M., the following items were observed regarding hazardous areas:

1) The dining room doors are equipped with non-approved hold open devices. The doors must be manually closed as the devices have a chocking mechanism holding the doors open.

2) The Medical Storage room door is not equipped with a self closing device as required.

NOTE: The facility is not equipped with an automatic sprinkler system, therefore hazardous areas are required to have 1-hour separation.

This was acknowledged by the Executive Director during the exit interview process.

A review of the fire drill report documentation revealed that fire drills are not conducted as required. NFPA 101 Life Safety Code 2000 Edition Section 19.7.1.2 states fire drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

THE FINDINGS INCLUDE:

- A review of the facility fire drill documentation was conducted on 4/15/14 at 11: A.M.
The documents revealed that the fire drills on all three shifts are conducted without varying conditions/times as required. The fire drill dates & times are as follows:

First shift (7:00 A.M. - 3:00 P.M.):
03/31/14 at 9:20 A.M.
12/19/13 at 8:52 A.M.,
09/18/13 at 9:15 A.M., and
06/17/13 at 8:27 A.M.,

Second shift (3:00 P.M. - 11:00 P.M.):
01/29/14 at 6:01 P.M.
10/31/13 at 7:30 P.M.
07/30/13 at 6:36 P.M., and
04/30/13 at 6:30 P.M.,

Third shift (11:00 P.M. - 7:00 A.M.):
02/15/14 at 6:22 A.M.,
11/09/13 at 2:30 A.M.,
08/28/13 at 6:06 A.M., and
05/21/13 at 5:50 A.M.

1) Four of four 1st shift drill times varied between 8:27 A.M. to 9:15 A.M. There is a total time span of 48-minutes between the four drills conducted during the 1st shift.

2) Four of four 2nd shift drills times varied between 6:01 P.M. - 7:30 P.M. There is a total time span of 89-minutes between the four drill conducted during the 2nd shift.

3) Three out of four 3rd shift drills times varied between 5:00 A.M. - 6:22 A. M. There is a total time span of 32-minutes between three drills conducted during the 3rd shift.

This was acknowledged by the Executive Director during the exit interview process.

Based on record review and confirmed by staff, the facility failed to test and maintain records of the fire alarm system in accordance with NFPA 72. Table 7-3.2 #20 states Off-Premises Transmission Equipment shall be tested on a quarterly basis.
Section 7.3.2 and Table 7.3.2 require systems with sealed batteries to have the battery charger tested annually, replace the battery every 4 years, to conduct a 30 minute battery discharge test annually, and to conduct a load voltage test semi-annually.

THE FINDINGS INCLUDE:

- A review of the facility fire alarm system inspection documentation was conducted on 4/15/14 at 10:00 A.M. The fire alarm inspection documents, dated 3/31/14, 12/19/13, 9/18/13 and 6/17/13, revealed that the facility was not conducting the required testing in accordance with NFPA 72. The following items were noted regarding testing of the fire alarm system:

1) The off-premise transmission equipment was not inspected quarterly as required. The only documented test of the off premises equipment was conducted on 3/31/14.

2) The fire alarm reports do not indicate that the fire alarm control panel batteries were load tested semi-annually, or discharged annually as required.

3) The fire alarm batteries have an installation date of 12/1/09. The batteries are currently in excess of the 4-year replacement requirement.

This was acknowledged by the Executive Director during the exit interview process.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.3.2.1 requires smoke detector sensitivity to be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

THE FINDINGS INCLUDE:

- A review of the facility's fire alarm system inspection documentation was conducted on 4/15/14 at 10:00 A.M. The fire alarm reports dated 3/31/14, 12/19/13, 9/18/13 and 6/17/13 revealed that the facility is not conducting the required testing in accordance with NFPA 72. The fire alarm inspection reports do not indicate that the smoke detectors have had any of the required sensitivity testing performed.

This was acknowledged by the Executive Director during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that fire extinguishers are properly identified. NFPA 10 section 1.6.6 requires fire extinguishers not be obstructed or obscured from view. Section 1.6.12 requires fire extinguishers mounted in cabinets or wall recesses to be marked conspicuously. The signs must be conspicuous when viewed from looking down the corridors.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 4/15/14 while touring the facility, it was observed that most of the fire extinguishers (approximately 20) throughout the facility are mounted in recessed cabinets within corridor walls. None of these recessed cabinets are marked with two directional signage so that they are visible when looking down the corridors.

This was acknowledged by the Executive Director during the exit interview process.

Based on record review and confirmed by staff interview, the facility failed to ensure that the "Emergency Power Supply System" (EPSS) is maintained, tested, and inspected in accordance with NFPA 110.
LSC Section 7.9.3 states written records of visual inspections and tests to be kept by the owner for inspection by the authority having jurisdiction.
NFPA 110 Sections 6.4.1 requires the EPSS's, including all appurtenant components, to be inspected weekly and to be exercised under load at least monthly for a minimum of 30-minutes.
Section 6-4.3 states load tests of generator sets shall include complete cold starts.

THE FINDINGS INCLUDE:

- A review of the facility's emergency generator testing documentation was conducted on 4/15/14 at 10:30 A.M. The findings revealed that the facility is not conducting the testing in accordance with NFPA 110 as required. The following items were noted:

1) Although load testing is conducted monthly, the load test is not initiated from a cold start. The facility's Maintenance Director stated that the generator is first started and then transferred from normal power to emergency power.
2) There is no documentation of a weekly inspection of the generator.

This was acknowledged by the Executive Director during the exit interview process.

Based on observations and confirmed by staff, the facility failed to ensure that extension cords are used in accordance with NFPA 70. Article 305-3 permits temporary wiring to be used during periods of construction, remodeling, maintenance, and repair of buildings, during emergencies, and for a period not to exceed 90 days. Article 400-8 prohibits flexible cords from being use as a substitute for the fixed wiring of a structure. LSC 19.5.1

THE FINDINGS INCLUDE:

- At approximately 12:15 P.M. of 4/15/14 while touring the facility, the following items but not limited to were observed regarding electrical wiring:

1) There is an extension cord plugged into a wall outlet of closet #A09, the cord travels through the corridor wall into closet #A08 where it is supplying power to an electrical device.
As per code, extension cords are prohibited as a substitute for permanent wiring.

2) There is an extension cord plugged into a wall outlet of the last corridor closet in the "C-Wing", the cord travels through the corridor wall where it is supplying power to a microwave located in the corridor.
As per code, extension cords are prohibited as a substitute for permanent wiring.

This was acknowledged by the Executive Director during the exit interview process.