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Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was maintained in accordance with the requirements of NFPA 25. Maintaing all required components of the sprinkler system allows for trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 6 of 6 residents.

Findings:

During the facility tour on 12/10/2018, between the hours of 8:30a-4:00p observation revealed missing escutcheons rings from the sprinkler system on the DON hall and several offices on that hall.

Interview with Administrator revealed the facility was not aware that the escutcheon rings were missing from the sprinkler system.

Based on visual observation the facility failed to assure that the gas and vacuum piped system was inspected and tested in accordance with the requirements of NFPA 99. Activation of the system will provide needed oxygen to patients, which results in protection of life. This deficiency has the potential to affect 6 of 6 residents.

Findings:

During the facility tour on 12/10/2018, between the hours of 8:30a-4:00p observation revealed the gas and vacuum piped system annual inspection had not been inspected since 9/2010.

Interview with Administrator revealed the facility was not aware that the annual inspections had not been conducted on the gas and vacuum piped system.