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Based on document review, the facility failed to conduct fire drills as required. Fire drills are essential to the training of staff and residents in proper procedure in emergency situations. Untrained staff can allow confusion and possible delays in proper procedure in an emergency and jeopardize all within the facility.

During document review with the Director of Maintenance at 11:00 am on 5/27/2015, it was found that the facility had not performed the required fire drills for the 3rd shift in the last 3 quarters of 2014. Each shift must perform 1 fire drill each quarter per NFPA 101.

Based on document review, the facility failed to maintain proper testing and proper documentation for the testing of smoke detector sensitivity. Testing of the smoke detectors helps to ensure proper function in emergency conditions. Failure of a smoke detector will delay or hinder the detection of fire or smoke, this may endanger all of the occupants within the facility.

The findings include:
During the document review with the Maintenance Director 5/27/2015 at 11:35 am, it was found that testing of the smoke detector sensitivity was not being performed or documented. Smoke detectors must be tested for their sensitivity every 2 years. "Sensitivity shall be checked within one year of installation and shall be checked every alternate year. NFPA 72 10.4.3

Based on document review and observation, the facility failed to maintain proper inspection and testing of the sprinkler system. Failure to maintain the sprinkler system could cause a delay or malfunction in the system which could affect all persons within the facility

The findings include:
During the facility tour at 1:30 PM on 5/27/2015 with the Director of Maintenance, it was found that there were sprinkler heads with paint on them located in: Pre-op room 5C112, 1st floor electrical room 5C116, and 1st floor room 3C108. This condition would allow the Sprinkler not to activate properly in a Fire situation. According to NFPA 13, 3-2.6.3* unless applied by the manufacturer, sprinklers shall not be painted, and any sprinklers that have been painted shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

During the facility tour with the Director of Maintenance at 2:00 pm on 5/27/2015, it was found that the gauges on the fire sprinkler riser were out of date. Gauges on wet pipe systems must be replaced every 5 years per NFPA 25 Chapter 2 - 3.2.

During document review and observation during facility tour at 2:30 PM on 5/27/2015 with the Director of Maintenance, it was found that the backflow preventer was not supervised with the required tamper switch which are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observations, the facility failed to adhere to proper electrical safety as prescribed by the national electric code. All electrical outlets within 6 feet of an open water source must be equipped with a ground fault indicator type outlet (GFCI). This protects those around the receptacle in case of water intrusion.

The findings include:

During the facility tour with the maintenance director on 5/27/2015 at 1:30 PM, it was found that several areas in the Emergency Room & Intensive Care Unit, it was noted that no GFCI outlets were used by sinks thruout these areas. All requirements for electrical safety shall be complied with per the NFPA 70, National Electrical Code, and NFPA 99, Health Care Facilities Code.

Based on document review, the facility failed to conduct fire drills as required. Fire drills are essential to the training of staff and residents in proper procedure in emergency situations. Untrained staff can allow confusion and possible delays in proper procedure in an emergency and jeopardize all within the facility.

During document review with the Director of Maintenance at 11:00 am on 5/27/2015, it was found that the facility had not performed the required fire drills for the 3rd shift in the last 3 quarters of 2014. Each shift must perform 1 fire drill each quarter per NFPA 101.

Based on document review, the facility failed to maintain proper testing and proper documentation for the testing of smoke detector sensitivity. Testing of the smoke detectors helps to ensure proper function in emergency conditions. Failure of a smoke detector will delay or hinder the detection of fire or smoke, this may endanger all of the occupants within the facility.

The findings include:
During the document review with the Maintenance Director 5/27/2015 at 11:35 am, it was found that testing of the smoke detector sensitivity was not being performed or documented. Smoke detectors must be tested for their sensitivity every 2 years. "Sensitivity shall be checked within one year of installation and shall be checked every alternate year. NFPA 72 10.4.3

Based on document review and observation, the facility failed to maintain proper inspection and testing of the sprinkler system. Failure to maintain the sprinkler system could cause a delay or malfunction in the system which could affect all persons within the facility

The findings include:
During the facility tour at 1:30 PM on 5/27/2015 with the Director of Maintenance, it was found that there were sprinkler heads with paint on them located in: Pre-op room 5C112, 1st floor electrical room 5C116, and 1st floor room 3C108. This condition would allow the Sprinkler not to activate properly in a Fire situation. According to NFPA 13, 3-2.6.3* unless applied by the manufacturer, sprinklers shall not be painted, and any sprinklers that have been painted shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

During the facility tour with the Director of Maintenance at 2:00 pm on 5/27/2015, it was found that the gauges on the fire sprinkler riser were out of date. Gauges on wet pipe systems must be replaced every 5 years per NFPA 25 Chapter 2 - 3.2.

During document review and observation during facility tour at 2:30 PM on 5/27/2015 with the Director of Maintenance, it was found that the backflow preventer was not supervised with the required tamper switch which are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observations, the facility failed to adhere to proper electrical safety as prescribed by the national electric code. All electrical outlets within 6 feet of an open water source must be equipped with a ground fault indicator type outlet (GFCI). This protects those around the receptacle in case of water intrusion.

The findings include:

During the facility tour with the maintenance director on 5/27/2015 at 1:30 PM, it was found that several areas in the Emergency Room & Intensive Care Unit, it was noted that no GFCI outlets were used by sinks thruout these areas. All requirements for electrical safety shall be complied with per the NFPA 70, National Electrical Code, and NFPA 99, Health Care Facilities Code.