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Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 Life Safety Code (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 9:30 AM and 2:30 PM on September 09, 2015, a review of documentation and interview with the Director of Maintenance (LC), revealed the facility failed to provide documentation for 2 out of the last 4 quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This deficient practice was verified by the Director of Maintenance (LC) and Housekeeping Coordinator (BI).

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between 9:30 AM and 2:30 PM on September 09, 2015, a review of documentation and interview with the Director of Maintenance (LC), revealed the facility failed to provide documentation for 2 out of the last 4 quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This deficient practice was verified by the Director of Maintenance (LC) and Housekeeping Coordinator (BI).

Based on observations and staff interview, the facility has failed to store large trash and linen carts in properly protected rooms in accordance with the NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.7.5.5. This deficient practice could affect the safety of all residents, staff and visitors if smoke or fire from one of these carts rendered the corridors untenable.

Findings include:

On the facility tour between 09:30 AM and 2:30 PM on September 09, 2015, it was found in that the facility was storing mobile trash containers that are greater than 32 gallons that are being stored in spaces that are greater than 64 square feet (in area) and the area was open to the corridors and not in the required hazardous storage areas.

This deficient practice was verified by the Director of Maintenance (LC) and Housekeeping Coordinator (BI).

Based on documentation review and staff interview, the facility failed to test the emergency generators in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between 09:30 AM and 2:30 PM on September 09, 2015, documentation review of the weekly emergency generator inspection documentation for the past 52 weeks revealed that the facility failed to conduct the required weekly inspection and document such in the past 52 weeks.



This deficient practice was verified by the Director of Maintenance (LC) and Housekeeping Coordinator (BI).

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to maintain the emergency generator per 2000 NFPA 101 - 9.1.3, and 1999 NFPA 110 section 6-3.1. This deficient practice could affect all patients, visitors and staff.

Findings include:

On facility tour between 09:30 AM and 2:30 PM on September 09, 2015, documentation review of the weekly emergency generator inspection documentation for the past 52 weeks revealed that the facility failed to conduct the required weekly inspection and document such in the past 52 weeks.


This deficient practice was verified by the Director of Maintenance (LC) and Housekeeping Coordinator (BI).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 Life Safety Code (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 9:30 AM and 2:30 PM on September 09, 2015, a review of documentation and interview with the Director of Maintenance (LC), revealed the facility failed to provide documentation for 2 out of the last 4 quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This deficient practice was verified by the Director of Maintenance (LC) and Housekeeping Coordinator (BI).

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between 9:30 AM and 2:30 PM on September 09, 2015, a review of documentation and interview with the Director of Maintenance (LC), revealed the facility failed to provide documentation for 2 out of the last 4 quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This deficient practice was verified by the Director of Maintenance (LC) and Housekeeping Coordinator (BI).

Based on observations and staff interview, the facility has failed to store large trash and linen carts in properly protected rooms in accordance with the NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 18.7.5.5. This deficient practice could affect the safety of all residents, staff and visitors if smoke or fire from one of these carts rendered the corridors untenable.

Findings include:

On the facility tour between 09:30 AM and 2:30 PM on September 09, 2015, it was found in that the facility was storing mobile trash containers that are greater than 32 gallons that are being stored in spaces that are greater than 64 square feet (in area) and the area was open to the corridors and not in the required hazardous storage areas.

This deficient practice was verified by the Director of Maintenance (LC) and Housekeeping Coordinator (BI).

Based on documentation review and staff interview, the facility failed to test the emergency generators in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between 09:30 AM and 2:30 PM on September 09, 2015, documentation review of the weekly emergency generator inspection documentation for the past 52 weeks revealed that the facility failed to conduct the required weekly inspection and document such in the past 52 weeks.



This deficient practice was verified by the Director of Maintenance (LC) and Housekeeping Coordinator (BI).

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to maintain the emergency generator per 2000 NFPA 101 - 9.1.3, and 1999 NFPA 110 section 6-3.1. This deficient practice could affect all patients, visitors and staff.

Findings include:

On facility tour between 09:30 AM and 2:30 PM on September 09, 2015, documentation review of the weekly emergency generator inspection documentation for the past 52 weeks revealed that the facility failed to conduct the required weekly inspection and document such in the past 52 weeks.


This deficient practice was verified by the Director of Maintenance (LC) and Housekeeping Coordinator (BI).