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Tag No.: C0231
Based on observation, document review and staff interview it was determined the facility failed to meet the provisions applicable of the 2012 edition of Life Safety Code of the National Fire Protection Association (NFPA) 101. This failure has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 3.
Findings include:
1. On 08/23/17 at 9:40 a.m., document review revealed electrolyte levels were not being checked weekly for the emergency generator batteries in accordance with NFPA 110.
The above finding was verified with the Maintenance Supervisor at the time of discovery.
2. On 08/22/17 at approximately 3:45 p.m., document review revealed the facility failed to provide documentation of fire alarm system sensitivity testing.
The above finding was verified with the Maintenance Supervisor at the time of discovery.
3. On 08/22/17 at approximately 11:30 a.m., document review revealed that first shift fire drills for 01/16/17, 02/20/17 and 09/26/17 were conducted in approximately the same time frame instead of at unexpected times and under varying conditions.
The above finding was verified with the Maintenance Supervisor at the time of discovery.