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Based on visual observation and interview the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 7 of the 7 residents and guest of the facility.


Findings:
During the facility tour on 11/14/2014, between the hours of 9:00am and 2:30pm it was observed that the public restrooms, through-out the facility did not have visual devices to notify hearing impaired persons in the event of a fire or smoke emergency.


Actual NFPA Standard: NFPA 101, 9.6.1.4. A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
Actual NFPA Standard: NFPA 101, 9.6.5.1. A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.
Actual NFPA Standard: NFPA 72, 3-9.6.3. All door hold-open release and integral door release and closure devices used for release service shall be monitored for integrity in accordance with 3-9.2.

Based on visual observation the facility failed to assure that the complete, supervised, automatic sprinkler system was inspected and tested in accordance with the requirements of NFPA 13. This deficiency has the potential to affect 7 of the 7 residents.

Findings:
During the facility tour on 11/14/2014, between the hours of 9:00am and 2:30pm, it was observed that on 5 of the 5 corridors in the facility, three used only by the facility have sprinkler heads that are missing escutcheon rings that are leaving 1/4 to 1/2 inch gaps between the sprinkler head and the ceiling.

Note: The other two corridors belong to the old nursing home facility that are not being occupied or used at this time.

Based on visual observation the facility failed to assure that the fire extinguishers were inspected and tested in accordance with the Life Safety Code and NFPA 10. Fire extinguishers are available to extinguish small fire or smoke emergencies. This deficient practice could potentially affect 7 of 7 residents.

Findings:

During the facility tour and the record review on 11/14/2014, between the hours of 9:00am and 2:30pm, it was observed that the facility had four fire extinguishers in the following areas (1) B-Hall, (2) C-Hall, (3) Spare Hall and (4) Back Hall by the Kitchen that were yellow tagged because of being past due for their 6 year testing. Fire extinguishers were fully charged but yellow tagged on 11/13/2014.