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Based on record review and interview, the facility failed to maintain the fire alarm system. This deficient practice could allow the spread of fire and smoke throughout the facility affecting approximately 3 occupants in four of four smoke compartments. This facility has a capacity of 15 and census of 3 patients at the time of the survey.

Findings are:

On 10/10/2024 at 1:15 P.M., record review revealed that the facility failed to provide the required semi-annual testing and maintenance of the fire alarm system. Previous testing and maintenance had been conducted on 12/21/2023 at the time of acceptance testing for the system.

During interview conducted on 8/1/2024 at 1:15 P.M., Maintenance personnel stated that they were unaware that the system had not been checked since the acceptance test date.

Based on record review and interview, the facility failed to provide documentation for testing and maintenance of the fire sprinkler system. This has the potential of affecting approximately 3 occupants in four of four smoke compartments. This deficient practice has the potential to affect the effectiveness of the sprinkler system if activated. This facility has a capacity of 15 patients with a census of 3 patients at the time of the survey.

Finding are:

On 10/10/2024 at 1:45 P.M., record review revealed the facility could not produce documentation for the testing and maintenance of the sprinkler system.

During interview conducted on 10/10/2024 at 1:45 P.M., Maintenance personnel stated that they could not produce the required documentation for the testing and maintenance for the automatic fire sprinkler system.