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Based on visual observation the facility failed to assure that the fire alarm system was installed to provide effective warning to all parts of the building. The devices installed for the system ' s activation shall be by manual, detection or extinguishing operation which gives a sense of security to offer an advance warning in an emergency. The remote panel shall be installed in an occupied area. This deficiency could potentially affect 10 of 10 residents.

Findings:

During the facility tour on 4/29/2021, between the hours of 8:00a-5:00p observation revealed the fire alarm system remote panel shall be installed in an occupied location.

Interview with the Administrator revealed the facility was not aware that additional devices, such as the remote panel were needed.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect 10 of 10 residents.
4 of 4 quarters in 2020-2021 were deficient.

Findings:

During the record review on 4/29/2021, between the hours of 8:00a-5:00p record review revealed 1 of 12 fire drills were completed for the last 12 months.

Interview with the Administrartor revealed the facility was not aware fire drills were not being held as required.

Based on visual observation, the facility failed to provide a remote annunciator to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect 10 of 10 residents.

Findings:

During the facility tour on 4/29/2021, between the hours of 8:00a-5:00p observation revealed the remote annunciator for the generator was not in a location readily observed by operating personnel.

Interview with the Administrator revealed the facility was not aware that a remote annunciator was not installed in a readily observed location to indicate alarm conditions of the emergency generator.