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Based on observation and record review, the facility failed to provide documentation of annual inspection and testing of the fire alarm system as required by the 2010 edition of NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all residents in two of two smoke zones. The facility has a capacity of 60 and census of 41 at the time of the survey.

Findings include:

During record review on December 14, 2017 at 2:25 PM the fire alarm vendor inspection and testing report required by NFPA 72 and dated January 2017 is not referencing the 2010 edition of NFPA 72. This report is the four-page report that references the 1999 edition of NFPA 72, and does not contain all of the required information requested in NFPA 72, 14.6.2.4.

The Director of Operations was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 2012 NFPA 101, 19.3.4.1

Review of the following NFPA Standard revealed: Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 2012 NFPA 101, 4.6.12.4

Review of the following NFPA Standard revealed: To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2012 NFPA 101, 9.6.1.5

Review of the following NFPA Standard revealed: 14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Test of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Based on observation and interview the facility fails to ensure that the facility's automatic sprinkler system is being inspected, tested and maintained in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all patients in two of two smoke zones. The facility has a capacity of 60 with a census of 41 patients at the time of the survey.

Findings include:

Record review conducted on December 14th, 2017 at 2:10 p.m, of the facility's sprinkler inspection, testing and maintenance records for the last two quarters revealed that the following:

1. There is no documentation of monthly inspection of wet sprinkler system gauges.
2. The sprinkler system did not receive quarterly testing for the 3rd quarter of 2017.

The Chief Operating Officer was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. 2011 NFPA 25, 5.2.4.1

Review of the following NFPA Standard revealed: Waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage. 2011 NFPA 25, 5.2.5

Review of the following NFPA Standard revealed: The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. 2011 NFPA 25, 5.2.5

Review of the following NFPA Standard revealed: Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 2011 NFPA 25, 5.3.3.1

Review of the following NFPA Standard revealed: Testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector's test connection. 2011 NFPA 25, 5.3.3.3

Review of the following NFPA Standard revealed: Each control valve shall be operated annually through its full range and returned to its normal position. Post indicator valves shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicator and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming. 2011 NFPA 25, 13.3.3.1 through 13.3.3.3

Review of the following NFPA Standard revealed: Record Keeping and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based .Fire Protection Systems, shall be maintained at an approved, secured location. 2012 NFPA 101, 9.7.8