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Based on review of the fire alarm and smoke detection service and test records on April 10, 2013, the facility failed to assure that sensitivity tests were conducted in accordance with NFPA 72, 1999 Edition. This deficiency affects all portions of both buildings.

The findings include:

Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter per section 7-3.2.1 of NFPA 72. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. It is being required by Centers for Medicare and Medicaid Services, as the authority having jurisdiction, that those systems that automatically monitor sensitivity shall have a paper printout available verifying the calibration of each detector.

The fire alarm and smoke detector service and test records were reviewed at the facility on April 10, 2013. The facility has smoke detectors throughout the corridor system of all the smoke compartments and additionally has duct detectors and several individual rooms with smoke detectors. A new Fire Alarm Control Panel (FACP) was installed in 2009 with the retention of many of the existing smoke detectors being interfaced to the new panel. The last documented sensitivity testing recorded by previous surveys occurred on November 9, 2004 and the five year sensitivity tests was due before the end of 2009. With the installation of a new FACP all of the detectors were subject to sensitivity testing upon completion of the new installation and within one year thereafter. No documentation was available that a sensitivity test was conducted on the smoke detectors after the installation of the new FACP or in the subsequent years of 2010, 2011, 2012 or thus far in 2013.

At the time of the revisit on May 28, 2013, the fire alarm and smoke detector service and test records were reviewed. The fire alarm contractor had conducted a sensitivity test of the smoke detectors on May 16, 2013. According to that report, eleven of the smoke detectors had failed the sensitivity test. These smoke detectors were identified on the report as customer devices 079, 080, 35, 25, 26, 23, 24, 21, 22, 092 and 40. At the time of the revisit, these smoke detectors had not been replaced or recalibrated. This deficiency could affect all patients, staff and visitors in the facility.

Based on review of the service reports for the automatic fire sprinkler system and on observations made on April 10, 2013, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13, 1999 Edition and NFPA 25, 1998 Edition. These deficiencies affect all portions of both buildings.



The findings include:

Check valves, detector check valves, and backflow preventers, that are installed in the water supply piping system shall be inspected and maintained so that they do not impede the flow of water and fire main pressure in accordance with Chapter 9 of NFPA 25 per section 8-2.8 of NFPA 25. Check valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition per section 9-4.2.1 of NFPA 25. All backflow preventers installed in fire protection system piping shall be tested annually per one of two test methods noted in section 9-6.2.1 of NFPA 25.

The sprinkler riser located in the basement of the facility, which provides protection for the entire facility, was examined at 2:32 p.m. on April 10, 2013. The riser was provided with what appeared to be a double check valve assembly. In reviewing the sprinkler report for March 4, 2013, it was noted by the licensed and endorsed contractor that this was a "backflow" device. Dependent upon the actual use of the valve in place, there was no documentation available that it had been tested on either an annual basis for a backflow preventer or on a five year basis for a check valve installation.

At the time of the revisit on May 28, 2013, items 1, 2, 3, 4 and 5 had been corrected. The fire sprinkler service and test records were reviewed in regards to item 6 as originally cited. The fire sprinkler contractor had conducted a backflow test of the double check valve system on the sprinkler riser on May 9, 2013. The double check valve system failed the test. At the time of the revisit, the double check valve system had not been replaced or repaired. This deficiency could affect all patients, staff and visitors in the facility.