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Based on observation, the facility failed to maintain their doors. This was evidenced by one corridor door that was obstructed from closing. This affected one of eight smoke compartments, and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff on 5/7/13, the doors in the facility were observed.

At 1:39 p.m., the corridor doors to the Unit 3 Day Room were equipped with self-closing devices and magnetic hold-open devices. The doors were released from their magnetic hold-open devices and allowed to close. The east door failed to close. The door was obstructed from closing by chairs located in the swing path of the door.

Based on record review, the facility failed to conduct a fire drill quarterly for each shift. This was evidenced by the facility's failure to conduct one of four quarterly AM shift fire drills during the past twelve months. This affected eight of eight smoke compartments, and could result in a delayed staff response in the event of a fire emergency.

Findings:

During record review with staff on 5/7/13, the facility's fire drill records were reviewed.

At 10:00 a.m., there was no documentation that indicated the facility had conducted an AM shift fire drill during the fourth quarter of 2012. The facility had conducted two PM shift fire drills and one NOC shift fire drill during the fourth quarter of 2012.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by one portable fire extinguisher that was unmounted, was not stored secured. This affected one of eight smoke compartments, and could result in a damaged or malfunctioning portable fire extinguisher.

NFPA 10, 1998 edition
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location.
1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.
1-6.9 Fire extinguishers installed under conditions where they are subject to physical damage, (e.g., from impact, vibration, the environment) shall be adequately protected.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a facility tour with staff on 5/7/13, the facility's portable fire extinguishers were observed.

At 11:27 a.m., the furnace room located on the west exterior side of the building was observed. A portable fire extinguisher in that room was stored unsecured on the floor in that room.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by the use of extension cords as a substitute for fixed wiring. This affected two of eight smoke compartments, and could result in an electrical fire to occur.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a facility tour with staff on 5/7/13, the facility's electrical equipment and wiring were observed.

1. At 12:59 p.m., office equipment in the Unit 2 Nursing Supervisor Office was plugged into two separate surge protected multi-outlet extension cords. The two surge protected multi-outlet extension cords were not plugged directly to electrical wall receptacles. The two surge protected multi-outlet extension cords were both plugged into a third surge protected multi-outlet extension cord.

2. At 1:01 p.m., a miniature refrigerator in the Unit 2 Medication Room was not plugged directly to an electrical wall receptacle. The miniature refrigerator was plugged into a surge protected multi-outlet extension cord.

3. At 2:10 p.m., the south end of the Medical Records Office was observed. Office equipment was plugged into a surge protected multi-outlet extension cord. The surge protected multi-outlet extension cord was not plugged directly to an electrical wall receptacle. The surge protected multi-outlet extension cord was plugged into a second surge protected multi-outlet extension cord.

Based on observation, the facility failed to maintain their doors. This was evidenced by one corridor door that was obstructed from closing. This affected one of eight smoke compartments, and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff on 5/7/13, the doors in the facility were observed.

At 1:39 p.m., the corridor doors to the Unit 3 Day Room were equipped with self-closing devices and magnetic hold-open devices. The doors were released from their magnetic hold-open devices and allowed to close. The east door failed to close. The door was obstructed from closing by chairs located in the swing path of the door.

Based on record review, the facility failed to conduct a fire drill quarterly for each shift. This was evidenced by the facility's failure to conduct one of four quarterly AM shift fire drills during the past twelve months. This affected eight of eight smoke compartments, and could result in a delayed staff response in the event of a fire emergency.

Findings:

During record review with staff on 5/7/13, the facility's fire drill records were reviewed.

At 10:00 a.m., there was no documentation that indicated the facility had conducted an AM shift fire drill during the fourth quarter of 2012. The facility had conducted two PM shift fire drills and one NOC shift fire drill during the fourth quarter of 2012.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by one portable fire extinguisher that was unmounted, was not stored secured. This affected one of eight smoke compartments, and could result in a damaged or malfunctioning portable fire extinguisher.

NFPA 10, 1998 edition
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions. Wheeled-type fire extinguishers shall be located in a designated location.
1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.
1-6.9 Fire extinguishers installed under conditions where they are subject to physical damage, (e.g., from impact, vibration, the environment) shall be adequately protected.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Findings:

During a facility tour with staff on 5/7/13, the facility's portable fire extinguishers were observed.

At 11:27 a.m., the furnace room located on the west exterior side of the building was observed. A portable fire extinguisher in that room was stored unsecured on the floor in that room.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by the use of extension cords as a substitute for fixed wiring. This affected two of eight smoke compartments, and could result in an electrical fire to occur.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a facility tour with staff on 5/7/13, the facility's electrical equipment and wiring were observed.

1. At 12:59 p.m., office equipment in the Unit 2 Nursing Supervisor Office was plugged into two separate surge protected multi-outlet extension cords. The two surge protected multi-outlet extension cords were not plugged directly to electrical wall receptacles. The two surge protected multi-outlet extension cords were both plugged into a third surge protected multi-outlet extension cord.

2. At 1:01 p.m., a miniature refrigerator in the Unit 2 Medication Room was not plugged directly to an electrical wall receptacle. The miniature refrigerator was plugged into a surge protected multi-outlet extension cord.

3. At 2:10 p.m., the south end of the Medical Records Office was observed. Office equipment was plugged into a surge protected multi-outlet extension cord. The surge protected multi-outlet extension cord was not plugged directly to an electrical wall receptacle. The surge protected multi-outlet extension cord was plugged into a second surge protected multi-outlet extension cord.