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Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection
per NFPA 72, National Fire Alarm and Signaling Code. This deficient practice has the potential to effect all facility patients, staff and visitors. This deficient practice could delay fire and emergency personnel response in the event of a fire. The facility census was 8.

Observations on 3/14-15/2018, during the facility tour, showed the following areas open to the designated exit corridors requiring smoke detectors:

-Second floor central nurse's station
-Emergency Department waiting room

During an interview on 3/15/2018, the Director of facilities management said he believed the fire alarm installation company installed smoke detectors per code requirements.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and facility staff interview, facility staff failed to ensure the building sprinkler system met NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. This deficient practice could delay prompt fire extinguishment and evacuation in the event of a fire. The facility census was 8.

Observations on 3/14-15/2018, during the facility tour, did not show a sprinkler installed in two of two elevator pits containing combustible hydraulic fluid.

During an interview on 3/15/2018, the Director of facilities management said the building was built without sprinkler coverage in the elevator pits.


NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS, 2010 Edition section 8.15.5 states:


"8.15.5 Elevator Hoistways and Machine Rooms.

8.15.5.1* Sidewall spray sprinklers shall be installed at the bottom
of each elevator hoistway not more than 2 ft (0.61 m)
above the floor of the pit.

8.15.5.2 The sprinkler required at the bottom of the elevator
hoistway by 8.15.5.1 shall not be required for enclosed, noncombustible
elevator shafts that do not contain combustible
hydraulic fluids."

Based on record review and facility staff interview, facility staff failed to provide an emergency stop switch for two of two emergency generators. The facility census was 8.

1) Observation during the facility tour showed the emergency generators emergency stop switches located within the generator enclosure.

During an interview on 3/15/2018, the Director of facilities management said the generators were installed over 10 years ago and he believed the generator installation company installed the associated devices per code requirements at the time.


NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition states:

5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.