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Based on observation, interview and record review, the facility failed to maintain and test the fire alarm system in accordance with NFPA 72. Failure to maintain the fire alarm system in accordance with NFPA 72 can prevent the system from working as designed, components and initiating devices from working as designed and delaying notification of residents and staff in the event of a fire affecting all residents, visitors and staff. The facility has a capacity of 47 with a census of 28 at the time of this survey.

Findings include:

During the survey on 9/23/2020, between 10 a.m. and 1 p.m. the following was determined by interview.

1. It was verified by interview of the MRI on Staff A on 9/23/2020 at 10:20 A.M., and Maintenance staff A on 09/23/202 at 10:30 A.M.., that all building occupants where not notified of testing before the facility took the fire alarm system offline for testing. All building occupants not being notified that the fire alarm was going to be offline for testing resulted an immediate jeopardy.

On 09/23/2020 at 11:30 A.M. fire marshal verified the MRI room was totally damaged by the fire along with the MRI machine. The damage of the fire, which was contained to the MRI room only, left the room to be unable to use.

On 09/25/2020 at 8:00 a.m. from record review of documentation provided by Maintenance Staff A the facility did not follow the Emergency Procedure Plan they had in place to notify the building staff that the alarm system was offline for testing.

Fire Marshal staff was on site on 9/25/2020 at 1:00 P.M. to verify the Emergency Procedure Plan was completed by Staff member A. After review of the documentation the Immediate Jeopardy was removed at 5:15 pm on 09/25/2020 with staff education of the fire preparedness plan. The fire preparedness plan was also revised to address the notification of all occupants of the building, when the fire alarm is offline for testing. All Staff also, signed a document stating they had received and reviewed the information provided by Administrative Staff A.

The facility provided an acceptable plan for removal of the immediate jeopardy on 09/25/2020 at 5:15 PM. The survey team validated the immediate jeopardy was removed on 09/25/2020 at 5:15 PM following the facility's implementation by Administrative Staff A of the plan for removal of the immediate jeopardy. The deficient practice remained at a E scope and severity following the removal of the immediate jeopardy.

14.2.3.1 Before proceeding with any testing, all persons and facilities receiving alarm, supervisory, or trouble signals and all building occupants shall be notified of testing to prevent unnecessary response.

Based on observation, staff interview, and record review the facility failed to provide a sprinkler system installed in accordance with NFPA 13. The pre-action suppression system was not designed or installed to operate as a supervised, automatic sprinkler system. The manual pull station for the pre-action suppression system was inaccessible. This deficient practice increases the risk of fire suppression failure and fire products to occupants of the building and affects all residents, staff, and visitors. The facility has a capacity of 47 and census of 28 at the time of the survey.

Findings include:

During the survey on 9/23/2020, between 10 a.m. and 1 p.m. the following was determined by interview.

1. It was verified by interview of the sprinkler contractor at 11:00 a.m., that the pre-action suppression system was not designed or installed to operate as a supervised, automatic sprinkler system.

2. It was verified by interview of sprinkler contractor 11:00 a.m., and maintenance staff A at 10:30 a.m., that the manual pull station for the pre-action suppression system in the MRI Room was inaccessible and installed more than 200 feet from the MRI Room and is located on the floor level below the MRI Room.

On 09/23/2020 at 10:35 A.M. fire marshal verified the MRI room was totally damaged by the fire along with the MRI machine. The damage of the fire, which was contained to the MRI room only, left the room to be unable to use.

On 09/23/2020 at 11:30 A.M. the finding of the evidence that pre-action suppression system had not been designed or installed to operate as a supervised, automatic sprinkler system resulted in an immediate jeopardy.

The finding of the manual pull station for the pre-action suppression system being inaccessible and installed more than 200ft from the MRI room resulted in an immediate jeopardy.

The facility provided an acceptable plan for removal of the immediate jeopardy on 09/25/2020 at 5:15 PM. The survey team validated the immediate jeopardy was removed on 09/25/2020 at 5:15 PM following the facility's implementation by Administrative Staff A of the plan for removal of the immediate jeopardy. The deficient practice remained at a E scope and severity following the removal of the immediate jeopardy. The Immediate Jeopardy was removed at 5:15 p.m., on 9/25/2020 with a fire watch in the oncology suite.

7.4.2.1* Combined automatic dry pipe and pre-action systems
shall be so constructed that failure of the detection system
shall not prevent the system from functioning as a conventional
automatic dry pipe system.
19.3.5.3 Where required by 19.1.6, buildings containing hospitals
or limited care facilities shall be protected throughout by an
approved, supervised automatic sprinkler system in accordance
with Section 9.7, unless otherwise permitted by 19.3.5.5.

Based upon interview and record review, the facility fails to train the staff on basic response, the fire safety plan and for the evacuation of the building's smoke zones directly affected by fire. The deficient practice affects all residents, staff and visitors. The facility has a capacity of 47 with a census of 28 at the time of this survey.

Findings include:

During the survey on 09/23/2020, between 10 A.M. and 1 P.M., the following was determined by interview.

1. It was verified by interview of the sprinkler contractor on 09/23/202 at 11:00 A.M., Maintenance Staff A on 09/23/202 at 10:30 A.M.., Maintenance Staff B on 09/23/202 at 1:30 P.M., Administration Staff A on 09/23/202 at 11:00 a.m., Administration Staff B on 09/23/202 at 11:00 a.m., that staff failed to pull the manual pull station in the basement to manually activate the pre-action suppression system in the MRI room.

On 09/23/2020 at 11:30 A.M. verified the manual pull station, located more than 200 ft located in the basement from the MRI was not use by MRI Staff A during the fire. The MRI room is located on the first floor. The findings that the staff failed to pull the manual pull station in the basement to manually activate the pre-action suppression system in the MRI room resulted an immediate jeopardy.

On 09/23/2020 at 10:35 A.M. fire marshal verified the MRI room was totally damaged by the fire along with the MRI machine. The damage of the fire, which was contained to the MRI room only, left the room to be unable to use.

The facility provided an acceptable plan for removal of the immediate jeopardy on 09/25/2020 at 5:15 PM. The survey team validated the immediate jeopardy was removed on 09/25/2020 at 5:15 PM by Administrative Staff A putting the facility into a formal Fire Watch in the oncology suite. The deficient practice remained at a E scope and severity following the removal of the immediate jeopardy. The Immediate Jeopardy was removed at 5:15 p.m. on 09/25/2020 with staff education of the fire preparedness plan.
NFPA Standard: A written health care occupancy fire safety plan shall provide for all of the following: (1) use of alarms; (2) transmission of alarms to fire department; (3) emergency phone call to fire department; (4) response to alarms; (5) isolation of fire; (6) evacuation of immediate area; (7) evacuation of smoke compartment; (8) preparation of floors and building for evacuation; (9) extinguishment of fire. 2012 NFPA 101 18/19.7.2.2