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Based on observation and staff interview, the facility failed to ensure fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire in accordance with NFPA 101 - 2012 Edition 19.3.4.3.2 and 9.6.4. This deficient practice had the potential to affect an isolated number residents and an indeterminate number of staff.

Findings include:

Observation during facility tour with the Director of Maintenance (DM) on 04/12/24 between 11:35 A.M. and 12:15 P.M. noted the fire alarm system did not transmit to the monitoring company. The fire alarm system had the contractor on site during the survey changing the dialer from two dedicated phone lines to an internet and cell phone based dialer. The fire alarm was tested at 12:05 P.M. to verify it functioned with the notification devices and release of door hold opens. No issues were noted with the local function.

Interview with the DM verified the finding at the time of observation. Further interview found that the previous fire alarm monitoring company had discontinued service due to non payment in June of 2023 and the alarm has been a local only since then.

Interview with the Fire Alarm Contractor (FAC) verified that the panel currently will not call the fire department. Further interview found that the company has been hired to provide monitoring services and the system will be able to transmit and notify emergency services after completion of his installation.

NFPA 101 2- 2012 Edition
19.3.4.3.2 Emergency Forces Notification.
19.3.4.3.2.1 Fire department notification shall be accomplished in accordance with 9.6.4.
19.3.4.3.2.2 Smoke detection devices or smoke detection systems equipped with reconfirmation features shall not be required to automatically notify the fire department, unless the alarm condition is reconfirmed after a period not exceeding 120 seconds.

9.6.4 Emergency Forces Notification.
9.6.4.1 Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.
9.6.4.2 Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code:
(1) Auxiliary fire alarm system
(2) Central station fire alarm system
(3) Proprietary supervising station fire alarm system
(4) Remote supervising station fire alarm system
9.6.4.3 For existing installations where none of the means of notification specified in 9.6.4.2(1) through (4) are available, an approved plan for notification of the municipal fire department shall be permitted.

Based on observation, record review, and staff interview, the facility failed to ensure Fire Watch Policy was developed and being conducted in accordance with NFPA 101 - 2012 Edition 9.6.1.6. and 9.7.1.6. This deficient practice had the potential to affect an isolated number of residents and an indeterminate number of staff.

Findings include:

During the record review on 04/12/24 at 11:10 A.M. with the Director of Maintenance (DM) it was found that there is no documented of a fire watch being conducted. The facility had no documentation verifying that the staff knew the fire alarm was still out of service or that a verified responsible on site person would call 911 during a fire alarm.


Interview with the DM verified the finding at the time of review. The DM stated that "an email went out in June to all users that they had to call 911 during a fire alarm." When asked if it was documented who specifically would be responsible for that call and that a log was being maintained to verify the responsibility was passed on at the end of shift the DM stated "that is not happening."

NFPA 101 - 2012 Edition
9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

9.7.6 Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Based on record review and staff interview the facility failed to ensure the fire plan contained all components of a fire safety plan in accordance with NFPA 101 2012 Edition 19.7.2.2. This deficient practice had the potential to affect an isolated number of residents and an indeterminate number of staff

Findings include:

Record review on 04/12/24 at 8:00 11:10 A.M. noted the facility's Fire Safety Plan had not been properly implemented. The fire alarm dialer was found to have been out of service since June of 2023 and was no longer transmitting signals to the emergency services. There was no documented fire watch in place to verify a responsible person was dedicated to call 911 and notify the emergency services.

Interview with the DM verified the finding at the time of review.

NFPA 101 - 2012 Edition
19.7.2.1* Protection of Patients.
19.7.2.1* Protection of Patients.
19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.
19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan
19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire19.7.2.3 Staff Response.
19.7.2.3 Staff Response.
19.7.2.3.1 All health care occupancy personnel shall be instructed in the use of and response to fire alarms.
19.7.2.3.2 All health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
19.7.2.3.3 Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Based on observation, record review, and staff interview, the facility failed to ensure inspection and testing of fire alarm monitoring in accordance with NFPA 101 - 2012 Edition 19.3.4.3.2, 19.7, 9.6.1.3, 9.6.4, NFPA 72 - 2010 Edition Section 10.18.3.

This deficient practice had the potential to affect an isolated number of residents and an indeterminate number of staff.

Findings include:

Record review on 04/12/24 in the facility at 11:10 A.M. found that the fire alarm drill sheets from June 2023 until March 2024 did not contain factual or accurate information. The supervisory signal received section had times of alarm transmittal and receipt even though there was no monitoring company actively receiving the signals. The comments section failed to identify the requirement of an on site dedicated individual calling 911 or verifying emergency service would be notified.

Interview with the Director of Maintenance verified the finding at the time of review.

NFPA 101 2012 Edition
19.3.4.3.2 Emergency Forces Notification.
19.3.4.3.2.1 Fire department notification shall be accomplished in accordance with 9.6.4.
19.3.4.3.2.2 Smoke detection devices or smoke detection systems equipped with reconfirmation features shall not be required to automatically notify the fire department, unless the alarm condition is reconfirmed after a period not exceeding 120 seconds.

19.7* Operating Features.
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.
19.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.
19.7.1.3 A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center.
19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation,

9.6.4 Emergency Forces Notification.
9.6.4.1 Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.
9.6.4.2 Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code:
(1) Auxiliary fire alarm system
(2) Central station fire alarm system
(3) Proprietary supervising station fire alarm system
(4) Remote supervising station fire alarm system
9.6.4.3 For existing installations where none of the means of notification specified in 9.6.4.2(1) through (4) are available, an approved plan for notification of the municipal fire department shall be permitted.

NFPA 72 - 2010 Edition
10.18.3 Records.
10.18.3.1 A complete record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter.
10.18.3.2 The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
10.18.3.3 If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.