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STANDARD is not met as evidenced by: Through record review and staff interview of the fire alarm system, the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 101 Life Safety Code (2012 Edition), section 19.3.4.3.1 and NFPA 72, section 18.5.1. Failure to maintain the fire alarm system has the potential to harm all occupants, staff and visitors if the fire alarm system failed to operate as designed if a fire was to occur. This was evidenced by the following:

The manual pull station 601 (Nurses Station) fail to activate the fire alarm system during annual testing and has not been corrected at the time of survey.

The Administrative Staff acknowledge the deficient condition of the pull station appliance during the record review.

2012 Life Safety Code 101 section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.

1) No records of the Annual Fire Suppression Testing being conducted in the past year.
2) No records of the Quarterly flow testing being conducted in the past year.
3) No records of the Back-flow device testing being conducted in the past year.

The Administrative Staff acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility.

NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following:

Fire drills are required to be conducted on each shift quarterly, the facility failed to conduct a fire drill on the first shift in the third quarter.

The Administrative Staff acknowledge the conditions of fire drills deficiency during record review of the facility.

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

STANDARD is not met as evidenced by: Based on observation, staff interview, during the course of the survey July 8, 2015 it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems 1999 edition Chapter 3 and 5 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was as evidenced by:

The facility failed to maintain the emergency power system:

Generator was not equipped with battery-powered lighting. 5-3.1 The Level I and Level 2 EPS equipment location shall be provided with batty-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

The emergency power supply system deficiency item was discussed with the Administrative Staff during the survey and again at the exit conference.

NFPA 110-2010 section 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is located outside the building.

NFPA 110-2010 section 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting.