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Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects 32 residents and all occupants in 4 of 4 smoke zones. This facility has a capacity of 32 and a census of 20.

Findings Include:

On 4/17/2013 between 10:00 A.M. and 2:00 P.M. the following is observed:

1.) Documentation of fire drill scenarios, times and locations of simulated fire are not available or being recorded as required for the last 5 quarters.

Safety Officer A and B were present and acknowledged the finding.

NFPA Standard: 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. 2000 NFPA 101, 19.7.1.2.

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to prevent obstructions to spray patterns, affecting 32 residents and all occupants in 4 of 4 smoke zones. This facility has a capacity of 32 and a census of 20.

Findings Include:

On 4/17/2013 between 10:00 A.M. and 2:00 P.M. the following is observed:

1.) There is dust and/or debris covering sprinkler heads throughout the facility.

Safety Officer A and B were present and acknowledged the finding.

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1 11.3.

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects 32 residents and all occupants in 4 of 4 smoke zones. This facility has a capacity of 32 and a census of 20.

Findings Include:

On 4/17/2013 between 10:00 A.M. and 2:00 P.M. the following is observed:

1.) Documentation of fire drill scenarios, times and locations of simulated fire are not available or being recorded as required for the last 5 quarters.

Safety Officer A and B were present and acknowledged the finding.

NFPA Standard: 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. 2000 NFPA 101, 19.7.1.2.

Based on observation and staff interviews, the facility does not assure that the automatic fire sprinkler system is maintained properly. This deficient practice fails to prevent obstructions to spray patterns, affecting 32 residents and all occupants in 4 of 4 smoke zones. This facility has a capacity of 32 and a census of 20.

Findings Include:

On 4/17/2013 between 10:00 A.M. and 2:00 P.M. the following is observed:

1.) There is dust and/or debris covering sprinkler heads throughout the facility.

Safety Officer A and B were present and acknowledged the finding.

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1 11.3.