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Based on observation and interview, the facility failed to install 1 of 1 fire alarm systems in accordance with NFPA 72, the National Fire Alarm Code. NFPA 72, 1-5.4.6 requires trouble signals to be located in an area where it is likely to be heard. NFPA 72, 1-5.4.4 requires fire alarms, supervisory signals, and trouble signals to be distinctive and descriptively annunciated. This deficient practice could affect all occupants.

Findings include:

Based on an observation with the Maintenance Foreman on 08/09/11 at 3:10 p.m., when the automatic dialer component was placed in trouble from phone line failure a local trouble alarm was initiated at the main fire alarm panel located in the electrical room which was not continually occupied. The trouble signal was transmitted to the annunciator panel at the main entrance which was not continually occupied. The trouble signal was not located in an area where it was likely to be heard. The Maintenance Foreman confirmed the trouble signal could not be heard at the 100 hall nurses' station, an area continually occupied.

This deficiency was cited on 06/20/11. The facility failed to implement a systemic plan of correction to prevent recurrence.