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Based on record review and interview, the facility failed to comply with the fire drill requirements by failing to alter the times of the fire drills. This would affect all 7 smoke zones, affecting all occupants and staff at the facility. The facility had a capacity of 50 patients and a census of 26 patients.

Findings include:

Record review and interview on 10-13-15 at approximately 11:16 am, revealed the facility failed to alter the times of the fire drills that were conducted on the 3rd nursing shift during the previous 12 months. The times of 3 of the 4 documented drills only varied approximately 7 minutes (5:38 am to 5:45 am).

Maintenance Staff A verified this observation at the time of the survey process.

Based on observations and interview, the facility failed to provide the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition, as well as NFPA 101, 2000 edition, Section 9.6.3.6 by failing to ensure that audible and visual devices are properly installed. This affects 1 of 7 smoke zones. The facility had a license of 50 patients and a census of 26 patients.

Findings include:

Observations and interview on 10-13-15 at approximately 11:29 am, revealed the absence of a required horn and strobe notification device located in the enclosed courtyard. Since occupants that are in the enclosed courtyard are required to re-enter the building to eventually exit the building to a public way, horn and strobe notification devices that are automatically connect to the buildings fire alarm system are required.

Maintenance Staff A verified this observation during the survey process.

Based on observations and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm Code, 1999 edition by failing to manually lock the electrical breaker that is dedicated to the buildings fire alarm system. This affects all 7 smoke zones, affecting all occupants within the facility. The facility had a license of 50 patients and a census of 26 patients.

Findings include:

Observations and interview on 10-15-15 at approximately 11:01 am, revealed the absence of a manual locking mechanism on the electrical breaker that is dedicated to the buildings fire alarm system. This breaker shall be locked in the "On" position.

Maintenance Staff A verified this observation during the survey process.

(A)
Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by allowing unapproved electrical items to be plugged into a surge protector. This affects 1 of 7 smoke zones. The facility had a capacity of 50 patients and a census of 26 patients.

Findings include:

Observation and interview on 10-13-15 at approximately 10:02 a.m,, revealed a refrigerator that was plugged into a surge protector in the Doctors Sleeping Room.

Maintenance Staff A verified this observation at the time of the survey process.

(B)
Based on observations and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition by failing to have a Ground Fault Circuit Interrupter electrical outlet installed in a required area. This affects 1 of 7 smoke zones. The facility had a capacity of 50 patients and a census of 26 patients.

Findings include:

Observations and interview on 10-13-15 at approximately 9:39 am, revealed the absence of a required Ground Fault Circuit Interrupter (GFCI) electrical outlet near the sink in the Surgery Lounge.

Maintenance Staff A verified these observations at the time of the survey process.