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The facility failed to install the fire alarm system in accordance with NFPA 72, National Fire Alarm Code.

The fire alarm panel was located in the Boiler Room.

Observation determined an annunciation panel was not provided at a constantly occupied area (Nurses Station). The annunciation panel must monitor the fire alarm panel's primary functions:

1) Audible and visible signal that would indicate system trouble.

2) Visible signals that indicated which fire alarm zone is into alarm.

3) Audible and visible monitor the of fire alarm system supervisory signal.

Failure to install the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) fire alarm system in the facility, which serves the entire building.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code.

1) Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72 7-3.2

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The most current fire alarm system batteries load voltage test was conducted on 10/26/2016 and the previous test was conducted on 11/03/2015, exceeding the required semiannual testing requirement.

Failure to test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year.

2) System defects and malfunctions shall be corrected. NFPA 72 7-1.1.2

Review of fire alarm system test records indicated seven (7) heat detectors failed when tested on 10/26/2016 and had not been replaced.

Failure to maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected seven (7) of sixteen (16) heat detectors in the facility.

The sealed lead acid batteries and heat detectors are components of the complete fire alarm system, which serves the entire facility.

1) All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110 3-5.5.6

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation determined there was no remote stop switch for the generator located outside of the generator room.

2) A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. NFPA 99 3-4.1.1.15

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities.

Observation determined there was no remote annunciator located outside of the Generator Room at a work site readily observable by personnel.

Failure to ensure the emergency generator is in compliance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power for the building.