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It was determined by observation during the course of the survey on 05/05/2011, that doors to the corridor were not capable of resisting fire and smoke as evidenced by the following:

The door to resident room #6 in the Child Acute Unit was not provided with a latching device to hold the door in place. (NFPA 101 Chapter 19.3.6.3.2)

It was determined by observation during the course of the survey 05/05/2011, that exits were not readily accessible as evidenced by the following:

The Ponderosa quadrant East exit door would not release without the activation of the fire alarm system. There was no primary means of releasing the door, such as a key, key pad or delayed egress device. (NFPA 101, Chapter 19.2.2.2.5)
(Corrected during the survey.)

It was determined by record review and staff interview, that fire drill procedures were not in compliance with NFPA 101, as evidenced by the following:

Fire drills were not conducted with the use of the audible fire alarm signal. It was indicated on fire drill reports that the alarm was silenced during drills. Interview with the Maintenance Director indicated that the alarm was not used in order not to disturb residents. Fire alarm signals must be used other than between 9:00 p.m. and 6:00 a.m. during which periods a coded announcement can be substituted for the alarm signal. (NFPA 101, Chapter 19.7.1.2)

It was determined by record review and confirmed by staff interview, that smoke detectors throughout the facility were not tested in accordance with NFPA 72, as evidenced by the following:

Smoke detectors throughout the facility were not tested for sensitivity at least every two years to determine if the units are operating as designed and according to manufacturer's recommendations.

The detectors were not tested in the previous two years and Maintenance staff indicated that they were not aware of this requirement. (NFPA 72 Chapter 7.3.2.1)

It was determined by record review during the course of the survey on 05/05/2011, that suppression equipment was not maintained in accordance with NFPA 13, as evidenced by the following:

The contractor's report, dated April 19, 2011, indicated that the fire hydrant #6 was difficult to open. The Maintenance Director indicated that he had taken bids, but had not had sufficient time to make the corrections.

It was determined by observation during the course of the survey on 05/05/2011, that corridors were not free from obstructions as evidenced by the following:

The corridor in the southwest Cottonwood quadrant was obstructed by two tables and five chairs. There can be no unattended obstructions to exit access.

It was determined by observation during the course of the survey on 05/05/2011, that the emergency generator was not maintained in compliance with NFPA 99, as evidenced by the following:

1. The diesel powered emergency generator remote annunciator was not located at a work site readily observable by personnel, as required. The remote annunciator was installed inside the main boiler room, which was not a work site readily observable by personnel. NFPA 110 Section 3-5.5.2 (d) (h), which requires that a remote audible alarm sound at a work site readily observable by personnel.

2. During the testing of the generator, the unit would not start automatically in accordance with NFPA 99 Chapter 3.5.4.11.

It was determined by observation during the course of the survey on 05/05/2011, that doors to the corridor were not capable of resisting fire and smoke as evidenced by the following:

The door to resident room #6 in the Child Acute Unit was not provided with a latching device to hold the door in place. (NFPA 101 Chapter 19.3.6.3.2)

It was determined by observation during the course of the survey 05/05/2011, that exits were not readily accessible as evidenced by the following:

The Ponderosa quadrant East exit door would not release without the activation of the fire alarm system. There was no primary means of releasing the door, such as a key, key pad or delayed egress device. (NFPA 101, Chapter 19.2.2.2.5)
(Corrected during the survey.)

It was determined by record review and staff interview, that fire drill procedures were not in compliance with NFPA 101, as evidenced by the following:

Fire drills were not conducted with the use of the audible fire alarm signal. It was indicated on fire drill reports that the alarm was silenced during drills. Interview with the Maintenance Director indicated that the alarm was not used in order not to disturb residents. Fire alarm signals must be used other than between 9:00 p.m. and 6:00 a.m. during which periods a coded announcement can be substituted for the alarm signal. (NFPA 101, Chapter 19.7.1.2)

It was determined by record review and confirmed by staff interview, that smoke detectors throughout the facility were not tested in accordance with NFPA 72, as evidenced by the following:

Smoke detectors throughout the facility were not tested for sensitivity at least every two years to determine if the units are operating as designed and according to manufacturer's recommendations.

The detectors were not tested in the previous two years and Maintenance staff indicated that they were not aware of this requirement. (NFPA 72 Chapter 7.3.2.1)

It was determined by record review during the course of the survey on 05/05/2011, that suppression equipment was not maintained in accordance with NFPA 13, as evidenced by the following:

The contractor's report, dated April 19, 2011, indicated that the fire hydrant #6 was difficult to open. The Maintenance Director indicated that he had taken bids, but had not had sufficient time to make the corrections.

It was determined by observation during the course of the survey on 05/05/2011, that corridors were not free from obstructions as evidenced by the following:

The corridor in the southwest Cottonwood quadrant was obstructed by two tables and five chairs. There can be no unattended obstructions to exit access.

It was determined by observation during the course of the survey on 05/05/2011, that the emergency generator was not maintained in compliance with NFPA 99, as evidenced by the following:

1. The diesel powered emergency generator remote annunciator was not located at a work site readily observable by personnel, as required. The remote annunciator was installed inside the main boiler room, which was not a work site readily observable by personnel. NFPA 110 Section 3-5.5.2 (d) (h), which requires that a remote audible alarm sound at a work site readily observable by personnel.

2. During the testing of the generator, the unit would not start automatically in accordance with NFPA 99 Chapter 3.5.4.11.