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Based on observations made during the initial tour of the facility and interviews with the staff on March 21, 2011, it was determined the facility failed to ensure the fire alarm system was installed in accordance with NFPA 101 & 72, providing supervision to all sprinkler system control valves that can impair the system. On the day of the Revisit survey of 5/18/11, this citation remained uncorrected.

The findings include:

The Outside Stem and Yoke Valves on the backflow preventer portion of sprinkler system at The Wound Care Center did not have a tamper switches installed on them. These valves stop the water supply to the sprinkler system. No tamper switches result in no notification to the fire alarm panel that the sprinkler is inoperable.

The facility plan of correction stated the presence tamper switches would be verified, or the tamper switches would be installed. The completion date on the plan of correction is 4/24/11.

Observation of the backflow preventer at 11:30 a.m., revealed there were no tamper switches installed. The Off-site Facilities Manager stated she thought the tamper switches were already in place. No dispute, or contact to the state agency was made indicating conflict. The Manager stated she planned to tell the surveyor that the system was in compliance, during the revisit which she did. When the surveyor explained the survey process does not work that way, the manager stated the survey process was new to her, and she did not know to seek assistance from others. The manager was also not familiar with backflow preventers or outside stem and yoke valves on them.