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Based on observation and staff interview, the facility failed to provide and maintain the fire alarm system as required by NFPA 72. The absence of operational communication with the Central Receiving Station by the Fire Alarm System fails to ensure reliability of the alarm system, increasing the response time by emergency services due to having to call 911 in the event of an automatic alarm, which results in an Immediate Jeopardy condition, affecting all 4 residents in 2 of 2 smoke zones. This facility has a capacity of 12 and a census of 4.

Findings include:

During the tour from 7/19/16 to 7/20/16 it is noted that:

1. At 11:20 AM on 7/19/16 the maintenance director informed the surveyor that the fire alarm panel experienced uninitiated alarms. The issue was reported to have started in December of 2015 and continued until the alarm panel was replaced on 7/5/16 by contractor M. No records were kept documenting the false alarms. No documented fire watches were performed while the alarm issue was ongoing. Review of the monitoring company activity report from 4/15 to 7/16 did not show any received signals for multiple events between 12/15 and 7/16. On 7/15/16 the new panel experienced the same uninitiated alarm. Nursing staff called the monitoring company and local emergency service dispatch on 7/15/16 however no signal was received. No acceptance fire alarm testing documentation was available for review for the new panel. Contractor M investigated the device wiring on 7/18/16 but made no repairs and suggested replacement of wiring to all devices. During the opening conference the maintenance director stated he was unsure the fire alarm was working as required.
On 7/19/16 the facility was put into fire watch at 11:30 AM at the request of the KSFMO as no assurance could be made that the fire alarm system is reliable.
On 7/19/16 the Contractor M arrived and completed the acceptance testing along with receiving verification with the monitoring company. The alarm panel was placed back into service at 5:00 PM on 7/19/16 while the surveyor was on site.
At 1:00 PM on 7/20/16 the facility ceased fire watch with the fire alarm panel operating and signaling as required.

The maintenance director was present during the findings.

NFPA Standard: Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational. 2000 NFPA 101, 4.2.3
NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2
NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based on record review and staff interview the facility failed to conduct and properly document testing, inspection and maintenance of the generator in accordance with NFPA 99 and NFPA 110. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, which results in an Immediate Jeopardy condition affecting all 4 residents in 2 of 2 smoke zones. This facility has a capacity of 12 and a census of 4.

Findings include:

During the tour from 7/19/16 to 7/20/16 it is noted that:

1. At 10:45 AM on 7/19/16 the generator failed to start when manually tested, the last recorded generator load test was documented June 2016 by the maintenance director. No generator testing documentation was available for review prior to January 2016.

2. At 10:45 AM on 7/19/16 generator annunciator panel lamps failed to illuminate when tested. An installed switch that turns off the audible alarm signal from the panel and was found in the off position. When maintenance staff turned the switch on no alarm signal was heard to indicate trouble with the generator system.


The maintenance director was present during the findings.

Contractor D determined the generator batteries had failed and replacements were installed at 5:00 PM on 7/19/16. The generator was tested and ran with a successful load test.
On 7/20/16 contractor E addressed the generator and annunciator panel connectivity issues. Bulbs were replaced and corroded wiring connections were repaired. The generator was tested and communicated with the annunciator panel. The generator system was placed in back into service at 1:00 PM on 7/20/16 while the surveyor was on site.




NFPA Standard: Level 1 and level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load monthly for a minimum of 30 minutes. 1999 NFPA 110, 6.4.1 and 6.4.2
NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1


NFPA Standard: A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: Individual visual signals shall indicate: when the emergency power source is operating to supply power to load and when the battery charger is malfunctioning. Individual visual signals plus an audible signal shall warn of the following engine-generator alarm conditions: low oil pressure, low water temperature, excessive water temperature, low fuel (main fuel storage tank contains less than a 3-hour supply), over crank (failed to start), and over speed. Where a regular workstation will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions occur, but need not display these conditions individually. 1999 NFPA 99, 3-4.1.1.15, 3-5.1, 3-6.1 and NFPA 110

Based on observation, record review and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire alarm system is out of service for more than 4 hours in a 24 hour period. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic detection compensatory provision when it occurred, and without appropriately prepared staff response, affecting all 4 residents in 2 of 2 smoke zones. This facility has a capacity of 12 and a census of 4.

Findings Include:

During the tour from 7/19/16 to 7/20/16 it is noted that:

1. At 12:00 PM on 7/19/16 no written fire watch policy was available for review.
2. At 12:00 PM on 7/19/16 no record of fire watch being performed from December 2015 to July 2016 when the facility was experiencing fire alarm malfunctions.

The maintenance director was present during the findings.

NFPA Standard: When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties until the fire alarm system has been returned to service. A fire watch should consist of trained personnel who continuously patrol the affected area, with ready access to fire extinguishers and the ability to promptly notify the fire department. During the patrol of the area, the person should look for fire, and that other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. 2000 NFPA 101, 9.6.1.8.