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Based on record review, the facility failed to document the emergency egress lighting monthly. This deficient practice affects eleven of eleven smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 23 residents.

Findings include:

Record review of the facility's maintenance records on 3/17/11, revealed that there was no documentation regarding the monthly testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested weekly and monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds.

Based upon record review, the facility failed to hold fire drills under varied times of the day for two of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 23.

Findings include:

Record review on 3/17/11, the facility fire drill documentation showed that the facility failed to conduct fire drills for the third quarter of 2010 for the second and third shifts.

Maintenance Staff (A) verified the documentation.

Based on record review, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association 72, National Fire Code. All of the smoke compartments and all occupants would be directly affected by the deficient practice. This facility has a capacity of 25 and a census of 23 residents.

Findings include:

Record review on 3/17/11, revealed the fire alarm had not been inspected after the initial install. The fire alarm system was install by Siemens on 8/23/10 and the facility was unable to produce documentation of an inspection six months after the install.

Maintenance Staff (A) verified these observations.

(A)
Observation revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the facility failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This item could effect the operation of the heads by obstructing spray patterns. This facility with a capacity of 25 and a census of 23.

Findings include:

1. Observation on 3/17/11 at approximately 12:05 p.m., revealed that in the Ambulance Garage the sprinkler heads where located above the over head garage doors. When the doors are in the open position they would obstruct the spray patterns.

2. Observation on 3/17/11 at approximately 1:15 p.m., revealed that in the Supply Entrance the sprinkler heads where located above the over head door. When the door is in the open position it would obstruct the spray patterns.

Maintenance Staff (A) verified this observation.

(B)
Based on observation, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the sprinkler system is maintained with all component parts. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 23.

Findings include:

Observations on 3/17/11 at 12:30 p.m., showed that the sprinkler head located in the corridor next to room #149 on the ceiling was missing the escutcheon ring.

Maintenance Staff (A) verified this observation.

Based on record review, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by the facility not maintaining the system by providing quarterly inspection and testing. This deficient practice can place all occupants at risk in the event of a fire. The census was 23 with a capacity of 25.

Findings include:

Record review on 3/17/11, the facility was unable to provide documentation that the sprinkler system was tested quarterly. The facilities sprinkler protection system was installed on 06/09/2010 in the new building. The hospital was conducting inspections on the prior existing facility, but was unable to provide quarterly inspections for the new building.

This was verified with Maintenance Staff (A).

Based on record review, the facility failed to inspect the Hood Suppression system every 6 months as required. This could affect the Kitchen smoke compartment and all occupants in one of eleven smoke compartments in the building . This facility has a capacity of 25 and a census of 23 residents.

Findings include:

During the record review of the facility's fire safety components on 3/17/11, revealed that the Hood Suppression System was installed and inspected on 6-17-10 by Fairmont Fire Systems. The facility was unable to provide documentation of an inspection for the system six months after the initial install.

Maintenance Staff (A) confirmed this record review.

Based on record review, the facility failed to document the emergency egress lighting monthly. This deficient practice affects eleven of eleven smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 23 residents.

Findings include:

Record review of the facility's maintenance records on 3/17/11, revealed that there was no documentation regarding the monthly testing of the emergency battery lighting system. According to Maintenance Staff A, the lights were tested weekly and monthly, but there was no documentation to show that the monthly tests were conducted for 30 seconds.

Based upon record review, the facility failed to hold fire drills under varied times of the day for two of four quarters reviewed. This has the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This facility has a capacity of 25 with a census of 23.

Findings include:

Record review on 3/17/11, the facility fire drill documentation showed that the facility failed to conduct fire drills for the third quarter of 2010 for the second and third shifts.

Maintenance Staff (A) verified the documentation.

Based on record review, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association 72, National Fire Code. All of the smoke compartments and all occupants would be directly affected by the deficient practice. This facility has a capacity of 25 and a census of 23 residents.

Findings include:

Record review on 3/17/11, revealed the fire alarm had not been inspected after the initial install. The fire alarm system was install by Siemens on 8/23/10 and the facility was unable to produce documentation of an inspection six months after the install.

Maintenance Staff (A) verified these observations.

(A)
Observation revealed the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the facility failed to maintain the system with an acceptable clearance around sprinkler heads to prevent obstructions to spray patterns. This item could effect the operation of the heads by obstructing spray patterns. This facility with a capacity of 25 and a census of 23.

Findings include:

1. Observation on 3/17/11 at approximately 12:05 p.m., revealed that in the Ambulance Garage the sprinkler heads where located above the over head garage doors. When the doors are in the open position they would obstruct the spray patterns.

2. Observation on 3/17/11 at approximately 1:15 p.m., revealed that in the Supply Entrance the sprinkler heads where located above the over head door. When the door is in the open position it would obstruct the spray patterns.

Maintenance Staff (A) verified this observation.

(B)
Based on observation, the facility failed to maintain the sprinkler system in accordance with the 1998 edition of NFPA 25, by ensuring that the sprinkler system is maintained with all component parts. This item could effect the operation of the sprinkler system in the event of a fire emergency. This deficient practice affects all occupants in this facility with a capacity of 25 and a census of 23.

Findings include:

Observations on 3/17/11 at 12:30 p.m., showed that the sprinkler head located in the corridor next to room #149 on the ceiling was missing the escutcheon ring.

Maintenance Staff (A) verified this observation.

Based on record review, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of NFPA 25, and the 1999 edition of NFPA 13 by the facility not maintaining the system by providing quarterly inspection and testing. This deficient practice can place all occupants at risk in the event of a fire. The census was 23 with a capacity of 25.

Findings include:

Record review on 3/17/11, the facility was unable to provide documentation that the sprinkler system was tested quarterly. The facilities sprinkler protection system was installed on 06/09/2010 in the new building. The hospital was conducting inspections on the prior existing facility, but was unable to provide quarterly inspections for the new building.

This was verified with Maintenance Staff (A).

Based on record review, the facility failed to inspect the Hood Suppression system every 6 months as required. This could affect the Kitchen smoke compartment and all occupants in one of eleven smoke compartments in the building . This facility has a capacity of 25 and a census of 23 residents.

Findings include:

During the record review of the facility's fire safety components on 3/17/11, revealed that the Hood Suppression System was installed and inspected on 6-17-10 by Fairmont Fire Systems. The facility was unable to provide documentation of an inspection for the system six months after the initial install.

Maintenance Staff (A) confirmed this record review.