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Based upon staff interview and observations made in the presence of the plant manager on 8/8/13, it was determined that the facility did not maintain exit access to be readily accessible at all times in accordance with NFPA 101 19.2.1.

This deficiency affects 3 of 3 smoke compartments.

Findings include:

The egress doors at the main entrance, the lab entrance and the dock door were all observed to be access controlled egress doors with a night time magnetic lock system that was not in accordance with NFPA 101 7.2.1.6.2. The doors were observed to be lacking the sensor that deactivates the magnetic lock on a person approaching, and a manual release device mounted on the wall near the exit.

Based upon observations made in the presence of the plant manager on 8/8/13, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 7.9.2.

This deficiency affects 1 of 3 smoke compartments.

Findings Include:

The transfer switch for the emergency power system for the upgraded x-ray area was observed to be lacking a battery backup light in accordance with NFPA 110 5-3.

Based upon staff interview and record review made in the presence of the administrator and plant manager on 8/8/13, it was determined that the facility did not conduct fire drills held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.2.

This deficiency affects 1 of 8 required fire drills.

Findings include:

The facility failed to provide documentation that 1 of the required 8 fire drills were conducted quarterly on each shift.
The fire drill for the first quarter second shift was not documented.

Based upon observations made in the presence of the plant manager on 8/8/13, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affects 1 of 3 smoke compartments.

Findings include:

The long term nurses ' station was observed to have two refrigerators plugged into a surge protected power strip.

Based upon staff interview and observations made in the presence of the plant manager on 8/8/13, it was determined that the facility did not maintain exit access to be readily accessible at all times in accordance with NFPA 101 19.2.1.

This deficiency affects 3 of 3 smoke compartments.

Findings include:

The egress doors at the main entrance, the lab entrance and the dock door were all observed to be access controlled egress doors with a night time magnetic lock system that was not in accordance with NFPA 101 7.2.1.6.2. The doors were observed to be lacking the sensor that deactivates the magnetic lock on a person approaching, and a manual release device mounted on the wall near the exit.

Based upon observations made in the presence of the plant manager on 8/8/13, it was determined that the facility did not provide an emergency lighting system in accordance with NFPA 101 7.9.2.

This deficiency affects 1 of 3 smoke compartments.

Findings Include:

The transfer switch for the emergency power system for the upgraded x-ray area was observed to be lacking a battery backup light in accordance with NFPA 110 5-3.

Based upon staff interview and record review made in the presence of the administrator and plant manager on 8/8/13, it was determined that the facility did not conduct fire drills held at unexpected times under varying conditions at least quarterly on each shift in accordance with NFPA 101 19.7.1.2.

This deficiency affects 1 of 8 required fire drills.

Findings include:

The facility failed to provide documentation that 1 of the required 8 fire drills were conducted quarterly on each shift.
The fire drill for the first quarter second shift was not documented.

Based upon observations made in the presence of the plant manager on 8/8/13, it was determined that the facility did not maintain electrical equipment in accordance with NFPA 101 19.5.1 and 9.1.2.

This deficiency affects 1 of 3 smoke compartments.

Findings include:

The long term nurses ' station was observed to have two refrigerators plugged into a surge protected power strip.