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Based on observation, record review and interview the facility failed to ensure that the sprinkler system received periodic monthly inspections or quarterly testing of the flow alarm as required.. The facility failed to ensure that all portions of the facility required to have sprinkler protection had sprinkler heads for one area of the admitting office. The facility failed to ensure that all components of the sprinkler system functioned as designed for one alarm bell. The facility census was seven.
Findings included:
1. Record review of the sprinkler inspection report and the tag attached to the sprinkler control by the contracted company indicated that the last inspection of the sprinkler system was done on 01/13/11. The sprinkler inspection report done at that time did not indicate that the water flow alarm was tested at that time. There were no reports indicating sprinkler inspections or testing done other than annually.
During an interview on 04/13/11 at 12:55 PM Staff Q (maintenance director) stated that the sprinkler system only receives inspections on an annual basis and that no other inspection or testing was done on the sprinkler system. Any policy would only address the annual test of the sprinkler system.
2. Observation on 04/14/11 at 1:30 PM of the alarm bell located on an outer wall of the facility, near the fire department hose connection, showed that two sets of wires protruded from the bottom side of the alarm bell. One set of wires was white and were not connected to each other. The second set of wires was black and were twisted together by the exposed wire ends.
During an interview on 04/14/11 at 1:30 PM Staff Q stated that the bell was part of the sprinkler system and was not working according to the person who did the last inspection of the sprinkler system.
3. Observation on 04/12/11 at 3:05 PM of the admitting office showed that the approximately eight foot by eight foot office area did not have sprinkler protection. The office area was in a section of the facility that required complete sprinkler protection to every area.
During an interview on 04/12/11 at 3:05 PM Staff Q (maintenance supervisor) stated that the admitting office had been renovated and a wall had been added to create the admission office and the wall's new position, separating it from the previous larger office area, blocked the sprinkler which had once provided protection to the area and was now on the opposite side of the wall.



Chapter 9-2.6 of the 1998 edition of the National Fire Protection Association (NFPA) code 25 states that a main drain test shall be conducted annually at each water based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.
Chapter 9-2.7 states that all water flow alarms shall be tested quarterly in accordance with the manufacturer's instructions.
Chapter 9-2.8 states that gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained.
Chapter 9-2.8.2 states that gauges shall be replaced every five years or tested every five years by comparison with a calibrated gauge.
9-3.2.3 states that all valves shall be inspected weekly.
Chapter 9-3.4.1 states that each control valve shall be operated annually through its full range and returned to its normal position.
Chapter 9-3.4.3 states that valve supervisory switches shall be tested semiannually.

Based on observation the facility failed to ensure that fire extinguishers were protected from damage and mounted in a location that would protect them from potential damage. This affects four extinguishers that were observed to be mounted below the hand rail in three areas. The facility census was seven.
Findings included:
1. Observation on 04/12/11 during tour of the facility showed: two fire extinguishers in the main entrance hall of the facility showed two extinguishers which were mounted at a height that was measured as eight inches from the floor to the bottom of the extinguisher and 27 inches from the floor to the top of the extinguisher. Outside the central supply area of the facility there was one extinguisher that was mounted approximately 12 inches from the floor to the bottom of the extinguisher. Near the kitchen area of the facility was one extinguisher which was mounted below the handrail in the corridor of the facility.
2. The extinguishers were mounted on a standard bracket attached to the wall and all were mounted below handrail height in corridors subject to heavy traffic such as the main entrance and basement corridor where carts and pedestrians could strike extinguishers mounted at such a low height and not recessed into the wall of the corridors.
3. The National Fire Protection Association Code 10 (1998 edition) for fire extinguishers stated under Chapter 1-6.8 that fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem. Chapter 1-6.9 stated that fire extinguishers installed under conditions where they are subject to physical damage, (e.g. from impact, vibration, the environment) shall be adequately protected.

Based on observation the facility failed to individually secure all containers of compressed medical gasses to prevent them from falling. The facility census was seven.
Findings included:
Observation on 04/12/11 at 11:20 AM showed that ten large tanks of compressed medical gasses were in use in an outdoor storage enclosure and that one chain secured all ten tanks of medical gasses to a frame. The tanks were not secured individually and one tank falling or other circumstance that would remove the chain would leave the other tanks unprotected from falling.

Chapter 5.1.3.3.2 of the 2002 edition of the Code NFPA (National Fire Protection Association) 99 for Health Care Facilities states that locations for central supply systems and the storage of medical gases shall meet the following requirements:
(7) be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling.