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Based on observation, the facility failed to protect hazardous areas from other areas, as evidenced by a door that was not self closing. This affected 1 of 2 smoke compartments and had the potential to allow the spread of smoke in a fire.

Findings:

During the facility tour with Staff I and Staff J on May 20, 2010, the hazardous areas were observed. Resident Room 24 was used for storage and is greater than 50 square feet in size.

At 2:07 p.m., the corridor door to Room 24, was not a self closing door. There were at least 10 cardboard boxes stored in the room.

NFPA 101 (2000 Edition) 7.9.3 Periodic testing of emergency lighting equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Based on observation and interview, the facility failed to ensure testing and maintenance of the emergency lighting, as evidenced by the failure to provide documentation for the tests. This affected 2 of 2 smoke compartments and had the potential to delay evacuation if the lighting failed in a fire.

Findings:

During the facility tour with Staff I and Staff J on May 20, 2010, the emergency lighting was observed.

Between 10:30 a.m. and 11:40 a.m., there were emergency lights with battery back-ups observed in the boiler room and both operating rooms. At 11:40 a.m., Staff I stated there were no records available documenting testing of the emergency lights.

Based on document review, the facility failed to conduct fire drills at unexpected times and under varying conditions. This was evidenced by 4 of 4 fire drills conducted at approximately the same time on the 2nd shift and by utilizing staff from two shifts. This affected the entire facility and had the potential for a delayed staff response to a fire.

Findings:

During the document review on May 20, 2010, the facility fire drill report logs were reviewed.

At 9:20 a.m., the facility fire drills for the 2nd shift showed 4 of 4 drills were conducted between the hours of 7:00 p.m. and 7:30 p.m.

During an interview, Staff I stated this was at shift change when additional staff were available and that this was not a realistic staffing level during the remainder of the shift.

NFPA 72 (1999 Edition),
Table 7-3.2 Testing Frequencies, Item 23 - Supervising Station Fire Alarm Systems DACR receiving stations are tested on a monthly basis.

Based on observation, the facility failed to ensure maintenance and testing of the fire alarm system, as evidenced by the failure to provide instructions for resetting the fire alarm system and by incomplete documentation, from the monitoring company, confirming the company tested its DACR during 11 of 12 months. This had the potential for a delay in resetting the alarm panel and for potential alarm transmission failure.

Findings:

During the facility tour and document review with Staff I and Staff J on May 20, 2010, the fire alarm test records were reviewed and the fire alarm system was tested.

At 3:11 p.m., the facility was unable to reset the alarm system after testing. The facility was able to silence the fire alarm but they could not reset the panel. Staff contacted the alarm company for instructions for resetting the panel. During an interview, Staff I stated the instructions at the panel were for the old panel that had been replaced a few months ago.

At 3:15 p.m., the facility failed to provide documentation confirming the monitoring company tested the company receiver on a monthly basis during 11 of 12 previous months. The alarm system test, dated 3-6-10, confirmed the monitoring company DACR was functional. Staff I stated there were no other records available for review.

NFPA 25 (1998 Edition), 2-4.1.4 A supply of at least 6 spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not exposed to moisture, dust, corrosion or a temperature exceeding 100 degrees F (38 degrees C).

Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

Based on observation, the facility failed to maintain the sprinkler system, as evidenced by the failure to provide spare sprinkler heads representative of the type and temperature ratings of the system sprinklers and by a missing sprinkler escutcheon. This affected 1 of 2 smoke compartments and had the potential to delay replacement of sprinkler heads when required, and could allow the potential spread of smoke around a sprinkler pipe.

Findings:

During the facility tour with Staff I and Staff J on May 20, 2010, the facility sprinkler system was observed.

At 2:03 p.m., the sprinkler escutcheon ring was missing on the sprinkler head just inside Room 26. The escutcheon ring covers the penetration around the sprinkler pipe.

At 3:15 p.m., side wall sprinkler heads were observed at the nurse station. There was only one spare side wall sprinkler head in the spare sprinkler head box. Staff I confirmed there was only one spare side wall sprinkler head in the spare sprinkler head box.

NFPA 10 (1998 Edition), 4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

NFPA 96 (1998 Edition) 7-2.1.1 A placard identifying the use of the extinguisher as secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

Based on observation, the facility failed to maintain the portable fire extinguishers, as evidenced by no warning sign by the Class K extinguisher in the kitchen, and by a fire extinguisher that was missing the tamper indicator. This affected 1 of 2 smoke compartments and had the potential for improper use of the fire extinguisher and potential extinguisher failure.

Findings:

During the facility tour with Staff I and Staff J on May 20, 2010, the fire extinguishers were observed.

At 1:52 p.m., the fire extinguisher in the dietary office was missing the tamper indicator tag. Staff I confirmed the tamper indicator was missing.

At 1:58 p.m., there was no sign in the kitchen near the K-Class fire extinguisher warning staff to activate the fire extinguishing system prior to using the Class K fire extinguisher. Staff I confirmed there was no warning sign.

Based on observation, the facility failed to provide ashtrays of a safe design and a metal self-closing container for emptying the ashtrays. This was evidenced by an ashtray with combustible trash in the ashtray and by no self-closing container for emptying the ashtrays. This affected 1 of 2 smoke compartments and had the potential for an increased risk of fire.

Findings:

During the facility tour with Staff I and J on May 20, 2010, the designated smoking areas and exterior of the facility were observed.

At 11:37 a.m., there was combustible trash in the open ashtray outside the main entrance of the facility. There was no container, with a self-closing cover, provided for emptying the ashtray.
Staff I confirmed the combustibles were in the ashtray and that there was no self-closing container available in the area for the emptying the ashtray.