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Based on record review and interview, the facility failed to ensure each documented fire drill included the transmission of a fire alarm signal to the monitoring company for 3 of 3 shifts during 4 of 4 quarters. NFPA at 19.7.1.2 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

Based on review of the facility's Fire Drill Log book on 01/27/10 at 9:45 a.m. with the Maintenance Director and the Maintenance Assistant present, the reports for all thirteen documented fire drills performed since January of 2009 during all three shifts did not include information regarding the transmission of the fire alarm signal to the monitoring company. During an interview on 01/27/10 at the time of record review, the Maintenance Director indicated the monitoring company was always contacted before and after a fire drill was conducted during all shifts, but acknowledged all the fire drill reports did not include this information.

Based on record review, interview and observation; the facility failed to ensure 1 of 1 sprinkler system's gauges were replaced or recalibrated within the past 5 years. NFPA 101 Section 9.7.5 refers to NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2-3.2 requires gauges to be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice could affect all patients, as well as staff and visitors while in sprinklered areas of the facility.

Findings include:

Based on review of the facility's Sprinkler Inspection Reports on 01/27/10 at 10:15 a.m. with the Maintenance Director and the Maintenance Assistant present, there was no evidence the gauges on the sprinkler system have been replaced or recalibrated within the past five years. During an interview at the time of record review, the Maintenance Director indicated the the water gauges on the sprinkler system have not been replaced or recalibrated within the past five years. Based on observation at 12:45 p.m. during a tour of the facility with the Maintenance Director and the Maintenance Assistant, the two sprinkler gauges on the sprinkler riser had dates of 1984. This was acknowledged by the Maintenance Director and the Maintenance Assistant.

Based on record review and interview, the facility failed to ensure each documented fire drill included the transmission of a fire alarm signal to the monitoring company for 3 of 3 shifts during 4 of 4 quarters. NFPA at 19.7.1.2 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

Based on review of the facility's Fire Drill Log book on 01/27/10 at 9:45 a.m. with the Maintenance Director and the Maintenance Assistant present, the reports for all thirteen documented fire drills performed since January of 2009 during all three shifts did not include information regarding the transmission of the fire alarm signal to the monitoring company. During an interview on 01/27/10 at the time of record review, the Maintenance Director indicated the monitoring company was always contacted before and after a fire drill was conducted during all shifts, but acknowledged all the fire drill reports did not include this information.

Based on record review, interview and observation; the facility failed to ensure 1 of 1 sprinkler system's gauges were replaced or recalibrated within the past 5 years. NFPA 101 Section 9.7.5 refers to NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2-3.2 requires gauges to be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice could affect all patients, as well as staff and visitors while in sprinklered areas of the facility.

Findings include:

Based on review of the facility's Sprinkler Inspection Reports on 01/27/10 at 10:15 a.m. with the Maintenance Director and the Maintenance Assistant present, there was no evidence the gauges on the sprinkler system have been replaced or recalibrated within the past five years. During an interview at the time of record review, the Maintenance Director indicated the the water gauges on the sprinkler system have not been replaced or recalibrated within the past five years. Based on observation at 12:45 p.m. during a tour of the facility with the Maintenance Director and the Maintenance Assistant, the two sprinkler gauges on the sprinkler riser had dates of 1984. This was acknowledged by the Maintenance Director and the Maintenance Assistant.