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Based on policy review, interview and document review the facility failed to assure fire drills are being conducted at least quarterly on each shift. This deficient practice affects all occupants in the facility. The facility census was 33.

Findings included:

Record review of the facility's policy titled, "Fire Drills," dated 04/17/14 showed:
-Fire drills are to be conducted monthly.
-The drills will be performed on the 7:00am-3:00pm shift, the 3:00pm-11:00pm shift, or the 11:00pm-7:00am shift.
-The drills will rotate monthly and each shift will have a drill quarterly.

Review of the fire drill records for the previous 12 months, conducted on the morning of 03/08/16 showed the following:
-Three drills were documented as occurring on the 7:00am-3:00pm shift.
-Three drills were documented as occurring on the 3:00pm-11:00 pm shift.
-Two drills were documented as occurring on the 11:00pm-7:00am shift.
-Four drills lacked documentation to indicate which of the three shifts participated in that drill.

During an interview on 03/10/16 at 8:29 AM, Staff X, Maintenance, stated the time of the fire drill was not documented on four of the 12 fire drill records.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states: 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.

Based on interview and document review the facility failed to ensure the fire alarm smoke detectors were individually tested for smoke sensitivity. This deficient practice affects all occupants in the facility. The facility census was 33.

Findings included:

Review of the facility fire alarm inspection documents, conducted on the morning of 03/08/16, showed an outside contractor had conducted an annual certification of the fire alarm system on 08/28/15. This certification document did not show the sensitivity testing of any of the facility smoke detectors.

During an interview on 03/10/16 at 8:27 AM, Staff X, Maintenance, stated that testing of the smoke detector sensitivity range had not been conducted.

Section 10.4.3.2 of the National Fire Protection Association (NFPA 72) states: Sensitivity of smoke detectors and single- and multiple-station smoke alarms in other than one- and two- family dwellings shall be tested in accordance with 10.4.3.2.1 through 10.4.3.2.6.

Based on interview and document review the facility failed to conduct all required inspections of the sprinkler system throughout the year. This deficient practice affects all occupants in the facility. The facility census was 33.

Findings included:

Review of the facility sprinkler inspection documents, conducted on the morning of 03/08/16, showed an outside contractor had conducted an annual certification inspection of the sprinkler system on 08/28/15. There was no documentation showing quarterly inspections had been conducted after the annual certification inspection in August of 2015.

During an interview on 03/09/16 at 9:26 AM, Staff X, Maintenance, stated that quarterly inspections of the sprinkler system were not being conducted.

Section 2.1 and table 2.1 of the National Fire Protection Association (NFPA 25) states the minimum requirements for the routine inspections, testing, and maintenance of sprinkler systems.

Based on interview the facility failed to develop a written procedure to implement any time the facility sprinkler system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was 33.

Findings included:

During an interview, conducted on 03/10/16 at 8:28 AM, Staff X, Maintenance, stated the facility did not have a written procedure to implement if the facility sprinkler system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.7.6.2 of the National Fire Protection Association (NFPA 101) states: sprinkler impairment procedures shall comply with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Based on interview the facility failed to develop a written procedure to implement any time the facility fire alarm system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was 33.

Findings included:

During an interview, conducted on 03/10/16 at 8:28 AM, Staff X, Maintenance, stated the facility did not have a written procedure to implement if the facility fire alarm system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.6.1.8 of the National Fire Protection Association (NFPA 101) states: where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Based on policy review, interview and document review the facility failed to assure fire drills are being conducted at least quarterly on each shift. This deficient practice affects all occupants in the facility. The facility census was 33.

Findings included:

Record review of the facility's policy titled, "Fire Drills," dated 04/17/14 showed:
-Fire drills are to be conducted monthly.
-The drills will be performed on the 7:00am-3:00pm shift, the 3:00pm-11:00pm shift, or the 11:00pm-7:00am shift.
-The drills will rotate monthly and each shift will have a drill quarterly.

Review of the fire drill records for the previous 12 months, conducted on the morning of 03/08/16 showed the following:
-Three drills were documented as occurring on the 7:00am-3:00pm shift.
-Three drills were documented as occurring on the 3:00pm-11:00 pm shift.
-Two drills were documented as occurring on the 11:00pm-7:00am shift.
-Four drills lacked documentation to indicate which of the three shifts participated in that drill.

During an interview on 03/10/16 at 8:29 AM, Staff X, Maintenance, stated the time of the fire drill was not documented on four of the 12 fire drill records.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states: 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.

Based on interview and document review the facility failed to ensure the fire alarm smoke detectors were individually tested for smoke sensitivity. This deficient practice affects all occupants in the facility. The facility census was 33.

Findings included:

Review of the facility fire alarm inspection documents, conducted on the morning of 03/08/16, showed an outside contractor had conducted an annual certification of the fire alarm system on 08/28/15. This certification document did not show the sensitivity testing of any of the facility smoke detectors.

During an interview on 03/10/16 at 8:27 AM, Staff X, Maintenance, stated that testing of the smoke detector sensitivity range had not been conducted.

Section 10.4.3.2 of the National Fire Protection Association (NFPA 72) states: Sensitivity of smoke detectors and single- and multiple-station smoke alarms in other than one- and two- family dwellings shall be tested in accordance with 10.4.3.2.1 through 10.4.3.2.6.

Based on interview and document review the facility failed to conduct all required inspections of the sprinkler system throughout the year. This deficient practice affects all occupants in the facility. The facility census was 33.

Findings included:

Review of the facility sprinkler inspection documents, conducted on the morning of 03/08/16, showed an outside contractor had conducted an annual certification inspection of the sprinkler system on 08/28/15. There was no documentation showing quarterly inspections had been conducted after the annual certification inspection in August of 2015.

During an interview on 03/09/16 at 9:26 AM, Staff X, Maintenance, stated that quarterly inspections of the sprinkler system were not being conducted.

Section 2.1 and table 2.1 of the National Fire Protection Association (NFPA 25) states the minimum requirements for the routine inspections, testing, and maintenance of sprinkler systems.

Based on interview the facility failed to develop a written procedure to implement any time the facility sprinkler system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was 33.

Findings included:

During an interview, conducted on 03/10/16 at 8:28 AM, Staff X, Maintenance, stated the facility did not have a written procedure to implement if the facility sprinkler system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.7.6.2 of the National Fire Protection Association (NFPA 101) states: sprinkler impairment procedures shall comply with NFPA 25, Standards for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Based on interview the facility failed to develop a written procedure to implement any time the facility fire alarm system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was 33.

Findings included:

During an interview, conducted on 03/10/16 at 8:28 AM, Staff X, Maintenance, stated the facility did not have a written procedure to implement if the facility fire alarm system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.6.1.8 of the National Fire Protection Association (NFPA 101) states: where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.