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Based on observation and interview the facility failed to provide a monthly inspection of the fire extinguisher or documentation of such inspection was done as per NFPA 10 (Standard of Portable Fire Extinguisher) for 6 of 6 extinguishers. This deficiency could affect all 15 residents in the facility.

Note: NFPA 10, 1998 Edition

NFPA 10, Chapter 4, "Inspection, Maintenance, and Recharging," 4-3.4.2. Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system, that provides a permanent record.

Findings:

During a tour of the facility on August 6, 2010 between 8:00 a.m. and 11:30 a.m., it was observed that none of the fire extinguishers in the facility indicated a current monthly inspection was done. The extinguishers have tags showing monthly inspection for years 2006 & 2007.

When asked the maintenance director stated the fire extinguisher contractor must have removed the tag when the annual inspection was done on November 19, 2009.

Based on visual observation the facility failed to provided smoking regulations that are in accordance with NFPA 101: 18.7.4., for 2 of 2 locations. This deficiency affects all 15 residents in the facility.

Note: NFPA 101, 2000 edition.

18.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited, unless under direct supervision.
(4) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(5) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During facility tour on August 6, 2010 between 8:00 a.m. and 11:30 a.m., it was observed that the smoking areas did not have a metal container with a self-closing cover device into which ashtrays can be emptied.