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Based on observations, the facility failed to maintain a complete manual fire alarm system as directed by NFPA 72 Chapter 10, and NFPA 101 section 9.6. The deficient practice affected all smoke compartments in facility on the day of survey.

Findings Include:

On 08/16/22 at 10:20 AM, observation revealed a "trouble signal" on the fire alarm system panel in the facility. The fire alarm system was functioning and capable of notifying emergency services. The Maintenance Supervisor was unable to reset the fire alarm panel to "normal" mode.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 08/16/22.

Based on the review of documentation, the facility failed to properly document records of testing the sprinkler system as required by NFPA 25 Table 2-1 and section 2-2.6. This deficient practice had potential of affecting the entire facility on the day of facility survey.

Findings Include:

On 08/16/22 at 2:34 PM, the facility could not produce the documentation for quarterly inspection of the fire sprinkler system for calendar years of 2021 and 2022.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 08/16/22.

Based on observations, the facility failed to provide 20-minute fire resistance rating smoke barrier door in accordance with NFPA 101 sections 19.3.7.6, 19.3.7.8, 19.3.7.9. This standard deficiency affected 14 of 84 residents in the facility on the day of survey.

Findings Include::

On 08/16/22 at 1:30 PM, observation revealed the smoke barrier door near the Lobby Area and at Therapy Unit of the facility did not properly close and latch upon activation of the fire alarm and sprinkler systems.

The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 08/16/22.