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Based upon staff interview and a review of records, the facility fails to assure that fire drills are held at unexpected times under varying conditions. This deficient practice potentially affects staff preparation and experience in providing for the safety and protection of all 25 residents in 4 of 4 smoke zones in the event of a fire or emergency. This facility has a capacity of 25 with a census of 2 at the time of inspection.

FINDINGS INCLUDE:

During record review on 8/08/2013 at 11:45 AM it is observed that the times that the Fire Drills are being conducted are not at varied times during 1 of 2 shifts.

1) Upon review, 2 of the last 4 drills for 2nd shift were both conducted at 3 AM.

The Director of Facilites was present during the review of records and acknowledged the deficiency.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation and staff interview, the facility did not ensure that all electrical installations meet the 1999 NFPA 70 standard and did not prohibit the use of multi-tap and un-fused adapters; and did not assure all 110 Volt electrical junction boxes have required covers. The deficient practice increases the potential for a electrical short or fire and potentially affects all 25 residents in 2 of 4 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of inspection.

FINDINGS INCLUDE:

During the tour on 8/08/2013 it is observed that:

1) At 2:15 PM in the Blood Draw Room there is a 6-plex multi-tap unfused adapter in use powering a small refrigerator.

2) At 3:00 PM in the CT Scanner Room there is a open electrical junction box in the wall behind the CT equipment.

Maintenance Staff A was present during the tour and acknowledged the deficencies.

NFPA Standards:

Electrical wiring and equipment shall be in accordance with the 1999 NFPA 70, Article 9.1.2.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

NFPA Standard: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or recepticals shall supply only the loads specified according to its size as specified in (a) thru (d) and as summarized in Section 210-24. A 15 or 20 ampere branch circuit shall be permitted to supply lighting units or other utilization equipment or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied. 1999 NFPA 70, 210-23

Based upon staff interview and a review of records, the facility fails to assure that fire drills are held at unexpected times under varying conditions. This deficient practice potentially affects staff preparation and experience in providing for the safety and protection of all 25 residents in 4 of 4 smoke zones in the event of a fire or emergency. This facility has a capacity of 25 with a census of 2 at the time of inspection.

FINDINGS INCLUDE:

During record review on 8/08/2013 at 11:45 AM it is observed that the times that the Fire Drills are being conducted are not at varied times during 1 of 2 shifts.

1) Upon review, 2 of the last 4 drills for 2nd shift were both conducted at 3 AM.

The Director of Facilites was present during the review of records and acknowledged the deficiency.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation and staff interview, the facility did not ensure that all electrical installations meet the 1999 NFPA 70 standard and did not prohibit the use of multi-tap and un-fused adapters; and did not assure all 110 Volt electrical junction boxes have required covers. The deficient practice increases the potential for a electrical short or fire and potentially affects all 25 residents in 2 of 4 smoke zones. The facility has a capacity of 25 with a census of 2 at the time of inspection.

FINDINGS INCLUDE:

During the tour on 8/08/2013 it is observed that:

1) At 2:15 PM in the Blood Draw Room there is a 6-plex multi-tap unfused adapter in use powering a small refrigerator.

2) At 3:00 PM in the CT Scanner Room there is a open electrical junction box in the wall behind the CT equipment.

Maintenance Staff A was present during the tour and acknowledged the deficencies.

NFPA Standards:

Electrical wiring and equipment shall be in accordance with the 1999 NFPA 70, Article 9.1.2.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

NFPA Standard: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or recepticals shall supply only the loads specified according to its size as specified in (a) thru (d) and as summarized in Section 210-24. A 15 or 20 ampere branch circuit shall be permitted to supply lighting units or other utilization equipment or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied. 1999 NFPA 70, 210-23