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Based on observation and review of documentation, the facility failed to have the fire alarm system fully operational as per National Fire Protection Association (NFPA) 72 (National Fire Alarm Code) and NFPA 101 (Life Safety Code) for 1 of 1 system. This deficiency affects all 9 patients in the facility.

Note: NFPA 72, 1999 edition:

NFPA 72:1-5.6 In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.
And
NFPA 101: 9.6.1.4
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Findings:

An observation was made on July 8, 2014 at 1:30 p.m. of the fire alarm system. It was observed that there was no smoke detector above the fire alarm communication panel located in the electrical rooms in the atrium.

Based on review of documentation the facility failed to provide routine inspection, testing and maintenance to all parts of the sprinkler system as per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) for 2 of 2 systems. This deficiency could affect all 9 patients in the facility.

Note: NFPA 25, 1998 Edition:
NFPA 25, Chapter 2, "General" 2-1 This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Findings:

During review of the sprinkler system documentation on July 8, 2014 between 3:00 p.m. and 4:00 p.m. it was revealed that facility failed to have all devices on the sprinkler system routinely inspected or tested at the proper intervals or failed to document such actions.

Interview with the new facility maintenance director during the survey process and at the exit interview verified that no additional documentation of the sprinkler system inspection was available. The maintenance director stated that he was unaware of all the required routine inspection of the sprinkler system.

Based on observation, the facility failed to exercise the generator under load each month for 1 of 1 generator as per NFPA 99:3-4.4.1.1 and NFPA 110. This deficiency affects all 9 residents in the facility.

Note: NFPA 110:6-4.1 Level 1 and Level 2 EPSSs, including all components, shall be inspected weekly and shall be exercised at least once monthly under load, for a minimum of 30 minutes of not less than 30 percent of the EPS nameplate rating.

Findings:

Review of the generator log on July 8, 2014 between 3:00 p.m. and 4:00 p.m. revealed that there was no documentation of a load test been done or the generator was not being exercised each month for at least 30 minutes under load. The facility was only able to provide the weekly test of the generator.

Interview with the facility maintenance director during the survey process and at the exit interview verified that no additional documentation of the monthly load test was available.

Based on observation and review of documentation, the facility failed to have the fire alarm system fully operational as per National Fire Protection Association (NFPA) 72 (National Fire Alarm Code) and NFPA 101 (Life Safety Code) for 1 of 1 system. This deficiency affects all 9 patients in the facility.

Note: NFPA 72, 1999 edition:

NFPA 72:1-5.6 In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.
And
NFPA 101: 9.6.1.4
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Findings:

An observation was made on July 8, 2014 at 1:30 p.m. of the fire alarm system. It was observed that there was no smoke detector above the fire alarm communication panel located in the electrical rooms in the atrium.

Based on review of documentation the facility failed to provide routine inspection, testing and maintenance to all parts of the sprinkler system as per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) for 2 of 2 systems. This deficiency could affect all 9 patients in the facility.

Note: NFPA 25, 1998 Edition:
NFPA 25, Chapter 2, "General" 2-1 This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Findings:

During review of the sprinkler system documentation on July 8, 2014 between 3:00 p.m. and 4:00 p.m. it was revealed that facility failed to have all devices on the sprinkler system routinely inspected or tested at the proper intervals or failed to document such actions.

Interview with the new facility maintenance director during the survey process and at the exit interview verified that no additional documentation of the sprinkler system inspection was available. The maintenance director stated that he was unaware of all the required routine inspection of the sprinkler system.

Based on observation, the facility failed to exercise the generator under load each month for 1 of 1 generator as per NFPA 99:3-4.4.1.1 and NFPA 110. This deficiency affects all 9 residents in the facility.

Note: NFPA 110:6-4.1 Level 1 and Level 2 EPSSs, including all components, shall be inspected weekly and shall be exercised at least once monthly under load, for a minimum of 30 minutes of not less than 30 percent of the EPS nameplate rating.

Findings:

Review of the generator log on July 8, 2014 between 3:00 p.m. and 4:00 p.m. revealed that there was no documentation of a load test been done or the generator was not being exercised each month for at least 30 minutes under load. The facility was only able to provide the weekly test of the generator.

Interview with the facility maintenance director during the survey process and at the exit interview verified that no additional documentation of the monthly load test was available.