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Based on record review it was determined that the facility failed to ensure that fire drills were conducted at least quarterly on each shift. The facility had a census of three patients on the day of the survey.

Findings include:

An examination of the facility's fire drill records on May 7, 2010 at 8:57 AM, revealed that there was no documentation for a first shift drill during the first quarter, a third shift drill during the second quarter, and a second shift drill during the third quarter having been conducted during the previous twelve months. All findings were witnessed by the Surveyor and the Maintenance Supervisor. This deficiency affected all staff and patients present on the day of the survey.

Actual NFPA Standard
NFPA 101 - 2000 Edition, Chapter 19 Existing Health Care Occupancies
19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation the facility did not ensure that portable fire extinguishers were being checked on a monthly basis. The facility had a census of three patients on the day of the survey.

Findings include:

During the tour of the facility on May 7, 2010 between the hours of 8:40 AM and 10:30 AM, observation of the portable fire extinguishers revealed that they were not being checked on a monthly basis or being signed off on the affixed tag. This was observed by the Surveyor and the Maintenance Supervisor. This deficiency affected all staff and patients present on the day of the survey.

Actual Code Reference
NFPA 101 - 2000 Edition
Chapter 19 Existing Healthcare Occupancies
19.3.5.6
Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1
Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
NFPA 10
4-3 Inspection.
4-3.1* Frequency.
Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Based on record review it was determined that the facility failed to ensure the cooking operation was in compliance with the provisions of NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. The facility had a census of three patients on the day of the survey.

An examination of the facility's kitchen hood suppression system records on May 7, 2010 at 9:10 AM, revealed that the only documented system service was conducted in February 2010, during the previous twelve months. All findings were witnessed by the Surveyor and the Maintenance Supervisor. This deficiency affected all staff and patients present on the day of the survey.

Actual Code Reference
NFPA 96 - 1998 Edition
11.2 Inspection of Fire-Extinguishing Systems
11.2.1 An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Based on observation, it was determined that the facility failed to ensure electrical wiring and equipment is in accordance with NFPA 99, Standard for Health Care Facilities. The facility had a census of three patients on the day of the survey.

Findings include:

During the facility tour on May 7, 2010 at 9:30 AM, observation of the second floor Central Supply room revealed a multiple electrical adapter in use. This was observed by the Surveyor and the Maintenance Supervisor. This deficiency affected three staff and and three patients in one of two smoke compartments.

Actual Code Reference
NFPA 99 - 1999 Edition
3-3.2.1.2 All Patient Care Areas.
(d) 2. Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Based on record review it was determined that the facility failed to ensure that fire drills were conducted at least quarterly on each shift. The facility had a census of three patients on the day of the survey.

Findings include:

An examination of the facility's fire drill records on May 7, 2010 at 8:57 AM, revealed that there was no documentation for a first shift drill during the first quarter, a third shift drill during the second quarter, and a second shift drill during the third quarter having been conducted during the previous twelve months. All findings were witnessed by the Surveyor and the Maintenance Supervisor. This deficiency affected all staff and patients present on the day of the survey.

Actual NFPA Standard
NFPA 101 - 2000 Edition, Chapter 19 Existing Health Care Occupancies
19.7.1.2*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation the facility did not ensure that portable fire extinguishers were being checked on a monthly basis. The facility had a census of three patients on the day of the survey.

Findings include:

During the tour of the facility on May 7, 2010 between the hours of 8:40 AM and 10:30 AM, observation of the portable fire extinguishers revealed that they were not being checked on a monthly basis or being signed off on the affixed tag. This was observed by the Surveyor and the Maintenance Supervisor. This deficiency affected all staff and patients present on the day of the survey.

Actual Code Reference
NFPA 101 - 2000 Edition
Chapter 19 Existing Healthcare Occupancies
19.3.5.6
Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1
Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
NFPA 10
4-3 Inspection.
4-3.1* Frequency.
Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Based on record review it was determined that the facility failed to ensure the cooking operation was in compliance with the provisions of NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. The facility had a census of three patients on the day of the survey.

An examination of the facility's kitchen hood suppression system records on May 7, 2010 at 9:10 AM, revealed that the only documented system service was conducted in February 2010, during the previous twelve months. All findings were witnessed by the Surveyor and the Maintenance Supervisor. This deficiency affected all staff and patients present on the day of the survey.

Actual Code Reference
NFPA 96 - 1998 Edition
11.2 Inspection of Fire-Extinguishing Systems
11.2.1 An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Based on observation, it was determined that the facility failed to ensure electrical wiring and equipment is in accordance with NFPA 99, Standard for Health Care Facilities. The facility had a census of three patients on the day of the survey.

Findings include:

During the facility tour on May 7, 2010 at 9:30 AM, observation of the second floor Central Supply room revealed a multiple electrical adapter in use. This was observed by the Surveyor and the Maintenance Supervisor. This deficiency affected three staff and and three patients in one of two smoke compartments.

Actual Code Reference
NFPA 99 - 1999 Edition
3-3.2.1.2 All Patient Care Areas.
(d) 2. Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.