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Based on record review and staff interview the facility failed to repair a deficiency noted during the annual fire alarm system inspection report. Failing to repair deficiencies noted on the fire alarm system inspection report may result in an inappropriate response to fire alarm activation affecting the staff located in the basement level of the facility. The facility has a capacity of 12 and census of 1at the time of the survey.

Findings include:

During record review on January 13, 2016 at 10:00 AM it is noted on fire alarm inspection report dated December 11, 2015 that the audio visual device in the basement purchasing department did not active when the fire alarm activated.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101, 9.6.1.4

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Based on observation and record review, the facility failed to assure that the sprinkler system is maintained and inspected in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all occupants in all smoke zones. The facility has a capacity of 12 with a census of 1 at the time of the survey.

Findings include:

During the survey on January 13, 2016 the following is observed:

1. At 9:45 AM it is observed that there is an upright sprinkler head in the pendent position in the community relations office.

2. At 10:00 AM during record review it is observed that there is no documentation for the 4th quarter of 2015 of sprinkler system testing.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Review of the following NFPA Standard revealed: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1

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. 2000 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. 1998 NFPA 25, 2-3.3.1

Review of the following NFPA Standard revealed: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

Review of the following NFPA Standard revealed: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3.

Based on record review and staff interview the facility failed to repair a deficiency noted during the annual fire alarm system inspection report. Failing to repair deficiencies noted on the fire alarm system inspection report may result in an inappropriate response to fire alarm activation affecting the staff located in the basement level of the facility. The facility has a capacity of 12 and census of 1at the time of the survey.

Findings include:

During record review on January 13, 2016 at 10:00 AM it is noted on fire alarm inspection report dated December 11, 2015 that the audio visual device in the basement purchasing department did not active when the fire alarm activated.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101, 9.6.1.4

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Based on observation and record review, the facility failed to assure that the sprinkler system is maintained and inspected in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all occupants in all smoke zones. The facility has a capacity of 12 with a census of 1 at the time of the survey.

Findings include:

During the survey on January 13, 2016 the following is observed:

1. At 9:45 AM it is observed that there is an upright sprinkler head in the pendent position in the community relations office.

2. At 10:00 AM during record review it is observed that there is no documentation for the 4th quarter of 2015 of sprinkler system testing.

The Maintenance Director was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1

Review of the following NFPA Standard revealed: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1

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. 2000 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. 1998 NFPA 25, 2-3.3.1

Review of the following NFPA Standard revealed: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

Review of the following NFPA Standard revealed: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1-11.3.