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Based on observation, staff interview and record review, the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting 25 patients and all occupants in 2 of 2 smoke zones. The facility has a capacity of 25 with a census of 18.

During the tour conducted on 5/19/2016, between 9:30 am and 3:30 pm, the following is observed:

1.) At approximately 2:38 pm it is discovered that there is no documentation of the Fire Alarm System being tested as required within the last 12 months.

Maintenance Staff A was present and acknowledged the finding. The Facility was placed in Fire Watch at approximately 3 pm.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101 section 9.6.1.4.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 25 patients and all occupants in 2 of 2 smoke zones. The facility has a capacity of 25 with a census of 18.

During the tour conducted on 5/19/2016, between 9:30 am and 3:30 pm, the following is observed:

1.) At approximately 11:36 am it is discovered that there is no documentation of a quarterly fire sprinkler test being performed during the 1st quarter of 2016.

Maintenance Staff A was present and acknowledged the finding. The Facility was placed in Fire Watch at approximately 3 pm.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000 NFPA 101, 9.7.5.

Based on observation, staff interview and record review, the facility failed to provide and maintain documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting 25 patients and all occupants in 2 of 2 smoke zones. The facility has a capacity of 25 with a census of 18.

During the tour conducted on 5/19/2016, between 9:30 am and 3:30 pm, the following is observed:

1.) At approximately 2:38 pm it is discovered that there is no documentation of the Fire Alarm System being tested as required within the last 12 months.

Maintenance Staff A was present and acknowledged the finding. The Facility was placed in Fire Watch at approximately 3 pm.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101 section 9.6.1.4.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting 25 patients and all occupants in 2 of 2 smoke zones. The facility has a capacity of 25 with a census of 18.

During the tour conducted on 5/19/2016, between 9:30 am and 3:30 pm, the following is observed:

1.) At approximately 11:36 am it is discovered that there is no documentation of a quarterly fire sprinkler test being performed during the 1st quarter of 2016.

Maintenance Staff A was present and acknowledged the finding. The Facility was placed in Fire Watch at approximately 3 pm.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000 NFPA 101, 9.7.5.