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Based on a review of the facility records, observations made during fire safety tour of the facility and interviews with the staff, the facility failed to maintain the fire alarm system in reliable operating condition. Failure to make necessary repairs to the fire alarm system components that have been tested and failed, render the fire alarm system unreliable, and pose a significant threat to life safety for building occupants. The following fifteen inoperable devices would delay or deny the fire alarm system from providing effective warning to staff, patients and other building occupants of a hostile fire and/or smoke environment.

The findings included:

On 12/04/18 at 3:30 P.M. review of the fire alarm system annual certification and tagging dated 6/25/18, revealed that there were numerous inoperable devices in the system of the host structure.

They included:

1. Five Batteries in the 7 (Nodes) Fire alarm panels,
2. Six Air Handlers failed to shut down on Smoke Alarm activations,
3. Seventeen Duct Detectors failed the differential pressure test,
4. Fifteen broken Duct Detectors,
5. Three broken Manual Pull Stations,
6. Four broken Smoke Detectors,
7. One inoperable Heat Detector,
8. Three inoperable Audio Visual Devices,
9. Six Duct Detectors improperly installed,
10. One Open circuit trouble signals on an alarm panel,
11. One System Trouble not showing on the alarm panel,
12. Eight Visual devices inoperable,
13. One Cross Corridor Door, Magnetic Hold Open Device inoperable, and
14. One Smoke Detector too close to an Air Condition Supply Vent.
15. Five smoke detectors that failed sensitivity.

When questioned at the time of the finding the Master Service Mechanic said that some of these deficiencies have not been corrected.