2014-04-15
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Inspection Results
Recertification/State Licensure/Life Safety Code - (16-OCT-09)
Facility failed to meet the following Requirement(s):Date CorrectedLevel of HarmResidents Affected
Emergency lighting of at least 1 hour duration is provided in accordance with 7.9. 19.2.9.1. 30-NOV-09No actual Harm with potential for More than minimal harm that is not immediate jeopardyMany
Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. 19.7.1.2 30-NOV-09No actual Harm with potential for More than minimal harm that is not immediate jeopardyMany
(I) Facilities that have a sprinkler system in accordance with NFPA 13, 1999 edition, shall have smoke detectors interconnected to the complete fire alarm system in all corridors and spaces open to the corridor. Smoke detectors shall be no more than thirty feet (30') apart with no point on the ceiling more than twenty-one feet (21') from a smoke detector. I/II 07-DEC-09Refer to definitions of Class I, I/II, II, II/III, III deficiencies
(25) Facilities shall have emergency lighting of sufficient intensity to provide for the safety of residents and other people using any exit, stairway, and corridor. The lighting shall be supplied by an emergency service, an automatic emergency generator or battery lighting system. This emergency lighting system shall be equipped with an automatic transfer switch. In an existing licensed facility, battery lights, if used, shall be wet cell units or other rechargeable-type batteries that shall be UL-approved and capable of operating the light for at least one and one-half (1 ) hours. Battery-operated emergency lighting shall be tested for at least thirty (30) seconds every thirty (30) days, and an annual function test shall be conducted for the full operational duration of one and one-half (1 ) hours. Records of these tests shall be documented and maintained for review. II 30-NOV-09Refer to definitions of Class I, I/II, II, II/III, III deficiencies
(D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a simulated resident evacuation that involves the local fire department or emergency service at least once a year. II/III 30-NOV-09Refer to definitions of Class I, I/II, II, II/III, III deficiencies