Sunshine Children's Home and Rehab Center

Based on record review and interview the facility did not ensure that fire drills are conducted in all areas occupied by children in that three of three staff working in the modular building (treatment/classroom building) did not know how to evacuate children via the rear exit at this location.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Findings are:

On 1/5/11 at approximately 10:45AM, during life safety rounds, a staff member working in the modular building was asked if she knew how to evacuate the children from the building in the event of a fire if the main entrance ramp could not be utilized. She was unable to answer. She was then asked if she knew how to transport/carry the children out of the building using the rear exit stairs to which she replied "no". Two additional personnel, who were each working one-on-one with a child, were asked if they knew how to evacuate a child using the rear exit stairs. After much hesitation, one staff member stated that she was a teacher and was not familiar with any procedures, while the other teacher stated that she "guessed she would use a fireman's carry ".

The modular building has two exits. The main exit is connected to the main building via a ramp, while the rear exit consists of a wooden platform and stairs. Exiting from this secondary exit may prove to be challenging as many of the children are not mobile.

During record review, it was noted that none of the twelve drills conducted for 2010 occurred in the modular building. In addition, none of the fire drills conducted (12 of 12) had comments, corrective measures, hazards or observations noted.

In an interview on 1/5/11 the Administrator indicated that the teachers are not employees of the facility but all have been trained in life safety. She further stated that nursing staff are always present in the modular building and would give direction in the event of an emergency. Additionally, all personnel are familiar with "blanket" evacuations and that blankets are stored in the modular building for that purpose. She stated that staff had been trained and should have known the proper procedures.

NFPA 101 (2000 edition) 19.7.1.2
10NYCRR 711.2(a)(1)

Based on observation and interview it was determined that the fire alarm system is not being maintained in accordance with NFPA 70 National Electric Code and NFPA 72 in that strobe lights on two of two resident units were not functioning and/or were not synchronized.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

On 1/5/11 beginning at 10:10AM during a test of the fire alarm system it was observed that the strobes (visible notification appliances) located on two of two nursing units were not operating and, once repaired, were not synchronized. These nursing units had more than three strobe lights flashing out of sequence in any field of vision, which was further intensified by reflections off the glass doors.

In an interview on 1/5/11 at 1:20PM the Technician for Signal Electronics stated that he had turned off the strobes approximately two months prior when he replaced the fire alarm's "mother board". Although the strobes had not been functioning for the past two months, a review of weekly maintenance records indicated that the fire alarm system was checked off as operating properly. The Maintenance Director could offer no explanation as to why the problem was not observed by his staff.

NFPA 72 (1999 edition) 1-5.4.6, 5-4.2.1, 3-8.2.3
NFPA 101 (2000 edition) 19.3.4, 9.6.5.1, 9.6.5.4
10 NYCRR 711.2(a)(1)

Based on observation and interview the facility did not ensure that every door in an exit passageway is only held open by devices arranged to automatically close upon activation of the fire alarm system in that one of three barrier doors was locked in the open position.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

On 1/5/11 beginning at 10:10AM, during a test of the fire alarm system it was observed that the barrier door located between the lobby and dining room did not close. Upon further investigation, it was noted that the door was locked in the open position via a switch located at the top right corner of the door. This lock was not tied into the fire alarm system and had to be manually deactivated. This door is designed to automatically open and close via an electronic 'eye'.

In an interview on 1/5/11 at 10:20AM the Director of Maintenance stated that the door is routinely locked in the open position and that the switch is not tied into the fire alarm system.

NFPA 101 (2000 edition) 19.2.2.2.6, 7.2.1.8.1, 7.2.1.8.2
10NYCRR 711.2(a)(1)

The following waiver is on file with this office. A repeat waiver is granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waiver has been granted have not changed. Please indicate if t he facility wishes the waiver to be continued.

K17, S/S=B

The dayroom is not separated from the corridor. There are no fire rated doors. (Waiver granted with the provis i o n that a smoke detector be installed in the room .)

NFPA 101 LSC 2000: 19.3.6.3.1
NYCRR 713.2(a), 711.4, 483.70(a)