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Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 72. This was evidenced by:

Fire alarm report says two duct detectors not tested.

Life Safety Code section 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 section 14.4.5 requires, in part, testing shall be performed in accordance with the schedules in Table 14.4.5.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 of 5 smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 25. This was evidenced by:

Freezer-Escutcheon more than an 1/8 of an inch gap, CT Control Room Escutcheon more than an 1/8 of an inch gap. , EMS Storage Escutcheon more than an 1/8 of an inch gap.
Hallway by Room 215 Sprinkler head needs adjusted as it the deflector plate is higher than the escutcheon.

6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the facility administrator and maintenance director during the exit conference.