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Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1 1/2 hour duration is provided. The deficient practice could result in the failure to illuminate an exit pathway in the event of an emergency, affecting 7 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. No 30 second monthly functional testing of the emergency lighting units had been conducted for the months of March and April 2010.

-- 2. No 90 minute annual functional testing of the emergency lighting units had been conducted within the last 12 months.

Staff M and N were present and acknowledged the results of the records review. Staff M stated that another staff member, usually responsible for the monthly inspections, was temporarily out due to an injury and the inspections were missed.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 7 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records for the last 5 quarters, revealed the following:

-- 1. No fire drill conducted for the 2nd Shift, 3rd Qtr. 2010.
-- 2. No fire drills conducted during the 4th Qtr. 2010.
-- 3. Fire Drill for 1st Shift, 1st Qtr. 2011 did not contain a scenario.

Staff M was present and acknowledged the results of the record review. Staff M stated that another staff member, usually responsible for scheduling the fire drills, was temporarily out due to an injury and the drills were missed.

NFPA Standard: 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, 19.7.1.2

Based upon a review of records and staff interview, the facility fails to assure that the fire alarm is installed and maintained in accordance with NFPA 72. The deficient practice could result in reduced reliability of the fire alarm system to notify building occupants in the event of an emergency, affecting 7 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records revealed:

-- 1. Fire Alarm Inspection Report for the inspection services completed on January 25, 2011, indicated that two horns and strobes failed to operate properly.

Staff M and N were present and acknowledged the results of the records review.
Per facility staff, an attempt to correct the problem has been made, however, the repairs were not complete at the time of this survey.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101 section 9.6.1.4

Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic sprinkler system, affecting 7 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records for the past 5 quarters revealed that no monthly inspection of the automatic sprinkler system had been completed during the months of March and April 2010.

Staff M was present and acknowledged the results of the records review. Staff M stated that another staff member, usually responsible for the monthly inspections, was temporarily out due to an injury and the inspections were missed.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and record review, this facility is not providing a range hood suppression system that is in compliance with NFPA 96, NFPA 17 and with the standard UL-300. The deficient practice could result in the perpetuation of a kitchen range fire without proper fire suppression protection, affecting 1 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records revealed the following:

-- 1. Range Hood Systems Report dated 12/16/10 noted several discrepancies or deficiencies: Kitchen hood suppression does not report to Fire Alarm Panel, no electrical shutdown, improper coverage over range w/ overhead obstruction, detector needed in center of duct, cartridge due for hydrostatic test, due for 12 yr regulator test.

Staff M and N were present and acknowledged the results of the records review. Staff M stated that while semi-annual inspections have been completed on the system as required, this is the first time the listed deficiencies had been noted. Additionally,Staff M stated that new tanks were installed 09-21-09. Discussions are on-going with the servicing company.

NFPA Standard: Required fire extinguishing systems for commercial cooking applications shall comply with standard UL 300, required by 1998 NFPA 17, 7-3.2 and 1998 NFPA 17A, 3-1.1, and 1998 NFPA 96, 7-2.2

NFPA Standard: Hydrostatic testing shall be performed by persons trained in pressure-testing procedures and safeguards and having available suitable testing equipment, facilities, and an appropriate service manual(s). The following parts of dry chemical extinguishing systems shall be subjected to a hydrostatic pressure test at intervals not exceeding 12 years: Dry chemical containers, Auxiliary pressure containers and Hose assemblies. 1998 NFPA 17, 9-5

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting 1 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/24/2011, between 8:45 a.m. and 12:30 p.m., it is observed that unattended medical equipment was stored in the Emergency Room Hallway, reducing the exit egress pathway.

Staff M was present, acknowledged the presence of the items, and assured that the items in question would be relocated.

NFPA Standard: Requires that no furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom or visibility thereof.

Based upon observation and staff interview, the facility fails to assure that oxygen storage locations of greater than 3,000 cu.ft. are separated by a fire barrier of 1-hour fire-resistive construction. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 2 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey

Findings include:

During the tour conducted on 03/24/2011, between 8:45 a.m. and 12:30 p.m., it is observed:

-- 1. Unsealed penetrations in wall separating oxygen storage room and facility's laundry.

-- 2. No sprinkler coverage in oxygen storage room.

Staff M and N were present and acknowledged that the room is not separated from use areas and is not sprinklered.

NFPA Standard: Storage for nonflammable gases greater than 3000 cubic feet shall comply with 4-3.1.1.2 and 4-3.5.2.2 per 1999 NFPA 99, 8-3.1.11.1

Based upon a review of records and staff interview, the facility fails to assure that generators are inspected and exercised in accordance with NFPA 99. The deficient practice could result in a reduction of reliability of the generator in the event of an emergency, affecting 7 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records for the last 5 quarters revealed that no monthly load test was conducted for the months of March and December 2010.

Staff M and N were present and acknowledged the results of the records review.

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

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire, affecting 1 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 03/24/2011, between 8:45 a.m. and 12:30 p.m., it is observed that electrical outlets near hand sinks in the Laboratory are not protected by Ground Fault Circuit Interrupter breakers

Staff M and N were present and aware of the findings. Staff M stated that he would contact an electrician and have the appropriate breakers installed.

NFPA Standard: All 125-volt, single-phase, 15- and 20-ampere receptacles installed in bathrooms, garages, storage areas, work areas, and area of similar use shall have Ground-Fault Circuit-Interrupter (GFCI) protection. 1999 NFPA 70, 210-8.

Based upon a review of records and staff interview, the facility fails to assure that emergency lighting of at least 1 1/2 hour duration is provided. The deficient practice could result in the failure to illuminate an exit pathway in the event of an emergency, affecting 7 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records for the last 5 quarters revealed the following:

-- 1. No 30 second monthly functional testing of the emergency lighting units had been conducted for the months of March and April 2010.

-- 2. No 90 minute annual functional testing of the emergency lighting units had been conducted within the last 12 months.

Staff M and N were present and acknowledged the results of the records review. Staff M stated that another staff member, usually responsible for the monthly inspections, was temporarily out due to an injury and the inspections were missed.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based upon a review of records and staff interview, the facility fails to assure that fire drills are held at unexpected times, under varying conditions and at least once per shift per quarter. This has the potential of affecting staff preparation and experience in providing for the protection of all residents, staff and visitors in the event of a fire, affecting 7 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records for the last 5 quarters, revealed the following:

-- 1. No fire drill conducted for the 2nd Shift, 3rd Qtr. 2010.
-- 2. No fire drills conducted during the 4th Qtr. 2010.
-- 3. Fire Drill for 1st Shift, 1st Qtr. 2011 did not contain a scenario.

Staff M was present and acknowledged the results of the record review. Staff M stated that another staff member, usually responsible for scheduling the fire drills, was temporarily out due to an injury and the drills were missed.

NFPA Standard: 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, 19.7.1.2

Based upon a review of records and staff interview, the facility fails to assure that the fire alarm is installed and maintained in accordance with NFPA 72. The deficient practice could result in reduced reliability of the fire alarm system to notify building occupants in the event of an emergency, affecting 7 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records revealed:

-- 1. Fire Alarm Inspection Report for the inspection services completed on January 25, 2011, indicated that two horns and strobes failed to operate properly.

Staff M and N were present and acknowledged the results of the records review.
Per facility staff, an attempt to correct the problem has been made, however, the repairs were not complete at the time of this survey.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101 section 9.6.1.4

Based upon a review of records and staff interview, the facility fails to assure that the automatic sprinkler system is inspected, tested and maintained in accordance with NFPA 25. The deficient practice could result in the unexpected failure of the automatic sprinkler system, affecting 7 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records for the past 5 quarters revealed that no monthly inspection of the automatic sprinkler system had been completed during the months of March and April 2010.

Staff M was present and acknowledged the results of the records review. Staff M stated that another staff member, usually responsible for the monthly inspections, was temporarily out due to an injury and the inspections were missed.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and record review, this facility is not providing a range hood suppression system that is in compliance with NFPA 96, NFPA 17 and with the standard UL-300. The deficient practice could result in the perpetuation of a kitchen range fire without proper fire suppression protection, affecting 1 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records revealed the following:

-- 1. Range Hood Systems Report dated 12/16/10 noted several discrepancies or deficiencies: Kitchen hood suppression does not report to Fire Alarm Panel, no electrical shutdown, improper coverage over range w/ overhead obstruction, detector needed in center of duct, cartridge due for hydrostatic test, due for 12 yr regulator test.

Staff M and N were present and acknowledged the results of the records review. Staff M stated that while semi-annual inspections have been completed on the system as required, this is the first time the listed deficiencies had been noted. Additionally,Staff M stated that new tanks were installed 09-21-09. Discussions are on-going with the servicing company.

NFPA Standard: Required fire extinguishing systems for commercial cooking applications shall comply with standard UL 300, required by 1998 NFPA 17, 7-3.2 and 1998 NFPA 17A, 3-1.1, and 1998 NFPA 96, 7-2.2

NFPA Standard: Hydrostatic testing shall be performed by persons trained in pressure-testing procedures and safeguards and having available suitable testing equipment, facilities, and an appropriate service manual(s). The following parts of dry chemical extinguishing systems shall be subjected to a hydrostatic pressure test at intervals not exceeding 12 years: Dry chemical containers, Auxiliary pressure containers and Hose assemblies. 1998 NFPA 17, 9-5

Based on observation and staff interview, the facility fails to assure that means of egress are continuously maintained free of all obstructions or impediments. The deficient practice would prevent the full instant use of the egress pathway, affecting 1 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/24/2011, between 8:45 a.m. and 12:30 p.m., it is observed that unattended medical equipment was stored in the Emergency Room Hallway, reducing the exit egress pathway.

Staff M was present, acknowledged the presence of the items, and assured that the items in question would be relocated.

NFPA Standard: Requires that no furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom or visibility thereof.

Based upon observation and staff interview, the facility fails to assure that oxygen storage locations of greater than 3,000 cu.ft. are separated by a fire barrier of 1-hour fire-resistive construction. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting 2 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey

Findings include:

During the tour conducted on 03/24/2011, between 8:45 a.m. and 12:30 p.m., it is observed:

-- 1. Unsealed penetrations in wall separating oxygen storage room and facility's laundry.

-- 2. No sprinkler coverage in oxygen storage room.

Staff M and N were present and acknowledged that the room is not separated from use areas and is not sprinklered.

NFPA Standard: Storage for nonflammable gases greater than 3000 cubic feet shall comply with 4-3.1.1.2 and 4-3.5.2.2 per 1999 NFPA 99, 8-3.1.11.1

Based upon a review of records and staff interview, the facility fails to assure that generators are inspected and exercised in accordance with NFPA 99. The deficient practice could result in a reduction of reliability of the generator in the event of an emergency, affecting 7 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

Findings include:

During the tour conducted on 03/23/2011, between 1:00 p.m. and 2:30 p.m., a review of records for the last 5 quarters revealed that no monthly load test was conducted for the months of March and December 2010.

Staff M and N were present and acknowledged the results of the records review.

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

Based upon observation and staff interview, the facility fails to assure that electrical wiring is in accordance with NFPA 70. The deficient practice increases the risk of an electrical fire, affecting 1 of 7 smoke zones. The facility has a capacity of 41 with a census of 26 at the time of the survey.

FINDINGS INCLUDE:

During the tour conducted on 03/24/2011, between 8:45 a.m. and 12:30 p.m., it is observed that electrical outlets near hand sinks in the Laboratory are not protected by Ground Fault Circuit Interrupter breakers

Staff M and N were present and aware of the findings. Staff M stated that he would contact an electrician and have the appropriate breakers installed.

NFPA Standard: All 125-volt, single-phase, 15- and 20-ampere receptacles installed in bathrooms, garages, storage areas, work areas, and area of similar use shall have Ground-Fault Circuit-Interrupter (GFCI) protection. 1999 NFPA 70, 210-8.