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Based on observation, the facility failed to maintain clear and unobstructed corridors.

Findings include:

At 2:00 p.m., on 1-24-12, it was observed that the corridor in the Geriatrics Unit was obstructed with couches, chairs, tables, etc.

Based on record review, the facility failed to conduct fire drills as required.

Findings include:

At 1:00 p.m., on 1-24-12 the facility was unable to produce records of fire drills for the past 12 months.

Based on record review, the facility failed to conduct an annual inspection of the fire alarm system.

Findings include:

At 1:15 p.m., on 1-24-12, the facility was unable to produce records of the annual inspection of the fire alarm system.

NFPA 72 Table 7-3-1 requires annual inspection of the fire alarm system.

Based on record review, the facility failed to maintain the smoke detectors as required.

Findings include:

At 1:30 p.m., on 1-24-12, the facility was unable to provide records for the sensitivity testing of the smoke detectors.

NFPA 72, 7-3.2.1 Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter.

Based on record review, the facility failed to conduct required test of the sprinkler system.

Findings include:

At 1:30 p.m., on 1-24-12, the facility was unable to provide records for the quarterly testing of the fire alarm system.

NFPA 25, 2-1 requires the sprinkler alarm components shall be tested quarterly.

Based on record review, the facility failed to maintain the generator as required.

Findings include:

(1) At 1:40 p.m., on 1-24-12, the facility was unable to provide documentation of the monthly load testing of the generator. NFPA 110, 6-4.2 requires generator to be exercised under load for 30 minutes monthly.

(2) At 2;30 p.m., on 1-24-12 it was observed that no task illumination was provided for the emergency generator. NFPA 99 3-4.2.2.2 requires emergency battery light for task illumination for emergency power at the generator set location.

(3) At 2:30 p.m., on 1-24-12 it was observed that there was no remote common audible alarm for the emergency generator. NFPA 110 sect. 3-5.6.1 requires a remote, common audible alarm powered by the storage battery. This remote alarm shall be located outside the EPS service room at a work station readily observable by personnel.

Based on observation, the facility failed to maintain clear and unobstructed corridors.

Findings include:

At 2:00 p.m., on 1-24-12, it was observed that the corridor in the Geriatrics Unit was obstructed with couches, chairs, tables, etc.

Based on record review, the facility failed to conduct fire drills as required.

Findings include:

At 1:00 p.m., on 1-24-12 the facility was unable to produce records of fire drills for the past 12 months.

Based on record review, the facility failed to conduct an annual inspection of the fire alarm system.

Findings include:

At 1:15 p.m., on 1-24-12, the facility was unable to produce records of the annual inspection of the fire alarm system.

NFPA 72 Table 7-3-1 requires annual inspection of the fire alarm system.

Based on record review, the facility failed to maintain the smoke detectors as required.

Findings include:

At 1:30 p.m., on 1-24-12, the facility was unable to provide records for the sensitivity testing of the smoke detectors.

NFPA 72, 7-3.2.1 Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter.

Based on record review, the facility failed to conduct required test of the sprinkler system.

Findings include:

At 1:30 p.m., on 1-24-12, the facility was unable to provide records for the quarterly testing of the fire alarm system.

NFPA 25, 2-1 requires the sprinkler alarm components shall be tested quarterly.

Based on record review, the facility failed to maintain the generator as required.

Findings include:

(1) At 1:40 p.m., on 1-24-12, the facility was unable to provide documentation of the monthly load testing of the generator. NFPA 110, 6-4.2 requires generator to be exercised under load for 30 minutes monthly.

(2) At 2;30 p.m., on 1-24-12 it was observed that no task illumination was provided for the emergency generator. NFPA 99 3-4.2.2.2 requires emergency battery light for task illumination for emergency power at the generator set location.

(3) At 2:30 p.m., on 1-24-12 it was observed that there was no remote common audible alarm for the emergency generator. NFPA 110 sect. 3-5.6.1 requires a remote, common audible alarm powered by the storage battery. This remote alarm shall be located outside the EPS service room at a work station readily observable by personnel.