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Based on observation, staff interview, and record review, the facility failed to document drills occurring in a random and unexpected fashion for all shifts and for all annual quarters for 2010 and 2011. This condition could allow for improper action by the staff in the emergency evacuation of the facility. This condition would affect 7 of 7 smoke zones. The facility has a capacity of 25 and a census of 5.

Findings Include:
During the record review on 6/15/2011, between 1:00 PM and 4:30 PM, the following was observed;

All drills for the 2nd shift for the previous four quarters reviewed occurred between 3:09 PM and 3:30 PM or a 21 minute span.

Staff A and Staff M were present and verifed the consistent drill times for the previous quarters. Immediate plans were put in place to ensure timely drills would be conducted at random times for all shifts.


Record review of the following NFPA Standard revealed: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. Drills shall be random and unexpected. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2.

Based on record review and staff interview, the facility failed to continuously maintain the automatic sprinkler system in a reliable operating condition as per NFPA 13 and NFPA 25.
This condition could fail to assure the proper operation of the system in all conditions. This would affect 7 of the 7 smoke zones. The facility has a capacity of 25 and census of 5

FINDINGS INCLUDE:

During the record review on 6/15/2011, between the hours of 1:00 PM and 4:00 PM, the following conditions were observed:

1. Contractor's annual inspection report for the auto sprinkler system of 9/23/2010 and 3 subsequent quarterly reports of 2010 and 2011 shows deficiencies which have not been ordered or completed.

2. The main riser for the auto sprinkler sytem is obstructed with loose storage and equipment which only allows for limited or restricted access to the controls in an emergency or service condition.

This condition was observed and verified by Staff A and Staff M. The facility contacted the Contractor and made orders to perform required maintenance and repairs immediately. Orders were given to addtitional staff to clear the riser area of obstacles.

Record review of the following NFPA Standard revealed: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 1

Based on observation, staff interview, and record review, the facility failed to document drills occurring in a random and unexpected fashion for all shifts and for all annual quarters for 2010 and 2011. This condition could allow for improper action by the staff in the emergency evacuation of the facility. This condition would affect 7 of 7 smoke zones. The facility has a capacity of 25 and a census of 5.

Findings Include:
During the record review on 6/15/2011, between 1:00 PM and 4:30 PM, the following was observed;

All drills for the 2nd shift for the previous four quarters reviewed occurred between 3:09 PM and 3:30 PM or a 21 minute span.

Staff A and Staff M were present and verifed the consistent drill times for the previous quarters. Immediate plans were put in place to ensure timely drills would be conducted at random times for all shifts.


Record review of the following NFPA Standard revealed: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. Drills shall be random and unexpected. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2.

Based on record review and staff interview, the facility failed to continuously maintain the automatic sprinkler system in a reliable operating condition as per NFPA 13 and NFPA 25.
This condition could fail to assure the proper operation of the system in all conditions. This would affect 7 of the 7 smoke zones. The facility has a capacity of 25 and census of 5

FINDINGS INCLUDE:

During the record review on 6/15/2011, between the hours of 1:00 PM and 4:00 PM, the following conditions were observed:

1. Contractor's annual inspection report for the auto sprinkler system of 9/23/2010 and 3 subsequent quarterly reports of 2010 and 2011 shows deficiencies which have not been ordered or completed.

2. The main riser for the auto sprinkler sytem is obstructed with loose storage and equipment which only allows for limited or restricted access to the controls in an emergency or service condition.

This condition was observed and verified by Staff A and Staff M. The facility contacted the Contractor and made orders to perform required maintenance and repairs immediately. Orders were given to addtitional staff to clear the riser area of obstacles.

Record review of the following NFPA Standard revealed: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 1