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Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

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. 9.6.1.3

System defects and malfunctions shall be corrected. NFPA 72 14.2.1.2.2

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

Review of fire alarm system test records indicated the pull station at the north entry by the Emergency Room had failed during the fire alarm system annual test conducted by an outside company on 10/15/2024 and had not been replaced at the time of the survey.

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

The deficiency affected the complete fire alarm system, which serves the entire building.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years. 19.3.4.5, 9.6.2.10.1.1, NFPA 72 14.4.5.3

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm and Signaling Code.

Review of the fire alarm test results indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72.

Test records indicated the smoke detectors were last sensitivity tested on 09/09/2021 exceeding the required two-year test interval. The smoke detector sensitivity test results were not adequate to determine the use of the five-year interval.

Failure to test the smoke detection system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected all smoke detectors in the facility.