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Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 19.2.9.1. This deficient practice could affect all residents, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:00 AM and 3:00 PM on 8/26/10, during a documentation review and interview with the Maintenance Supervisor (JG), it was revealed that there was no documentation of monthly 30 second testing, and the annual 1 1/2 hour testing for all of the battery powered emergency lights throughout the facility per NFPA 101, 2000 Edition Chapter 19, sec 19.2.9.1.


This deficient practice was confirmed by the Maintenance Supervisor (JG).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9.

Findings include:

On facility tour between 9:00 AM and 2:00 PM on 8/26/10, revealed the the following:

1. The review of the battery operated emergency lighting and exit sign testing documentation for the past 12 months revealed, that the facility failed to conduct monthly 30 second and yearly 90 minute testing and document such

2. All of the battery operated emergency lights thoughout the clinic did not operated when tested



This deficient practice was confirmed by the Maintenance Supervisor (JG).

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire drill documentation for the past 12 months (June 2009 to July 2010) revealed, that the facility failed to conduct a fire drill.



This deficient practice was confirmed by the Maintenance Supervisor (JG).

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 LSC (00) section 18.7.6, 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 residents, staff and visitors.

Findings include:

On facility tour between 9:00 AM and 11:30 AM on 7/27/10, a review of documentation and interview with the facility Maintenance Supvisor (JG), revealed the facility failed to provide documentation for anuy of the quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This deficient practice was confirmed by the Maintenance Supervisor (JG).

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 LSC (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 residents, staff and visitors.

Findings include:

On facility tour between 9:00 AM and 11:30 AM on 7/27/10, a review of documentation and interview with the facility Maintenance Supvisor (JG), revealed the facility failed to provide documentation for anuy of the quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This deficient practice was confirmed by the Maintenance Supervisor (JG).

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 19.2.9.1. This deficient practice could affect all residents, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 9:00 AM and 3:00 PM on 8/26/10, during a documentation review and interview with the Maintenance Supervisor (JG), it was revealed that there was no documentation of monthly 30 second testing, and the annual 1 1/2 hour testing for all of the battery powered emergency lights throughout the facility per NFPA 101, 2000 Edition Chapter 19, sec 19.2.9.1.


This deficient practice was confirmed by the Maintenance Supervisor (JG).

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9.

Findings include:

On facility tour between 9:00 AM and 2:00 PM on 8/26/10, revealed the the following:

1. The review of the battery operated emergency lighting and exit sign testing documentation for the past 12 months revealed, that the facility failed to conduct monthly 30 second and yearly 90 minute testing and document such

2. All of the battery operated emergency lights thoughout the clinic did not operated when tested



This deficient practice was confirmed by the Maintenance Supervisor (JG).

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.

Findings include:

On facility tour between 9:00 AM and 4:00 PM on 08/19/2010, the review of the fire drill documentation for the past 12 months (June 2009 to July 2010) revealed, that the facility failed to conduct a fire drill.



This deficient practice was confirmed by the Maintenance Supervisor (JG).

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 LSC (00) section 18.7.6, 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 residents, staff and visitors.

Findings include:

On facility tour between 9:00 AM and 11:30 AM on 7/27/10, a review of documentation and interview with the facility Maintenance Supvisor (JG), revealed the facility failed to provide documentation for anuy of the quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This deficient practice was confirmed by the Maintenance Supervisor (JG).

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 LSC (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 residents, staff and visitors.

Findings include:

On facility tour between 9:00 AM and 11:30 AM on 7/27/10, a review of documentation and interview with the facility Maintenance Supvisor (JG), revealed the facility failed to provide documentation for anuy of the quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This deficient practice was confirmed by the Maintenance Supervisor (JG).