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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 101 (2012 edition) 19.3.5, and 9.7, and NFPA 13 (2010 edition) 8.15.5.1 requirements, with all rooms sprinkled when the code required full sprinkling. This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 06/05/2019 at 10:00 am, it was observed in the Basement Zone 2 smoke compartment on the basement floor in the elevator pit, that the pit was not sprinkler protected. In the elevator pit, there were no sidewall spray sprinklers located at the bottom of the elevator hoistway not more than 2 ft. above the floor of the pit. This was a hydraulic elevator.

The condition was confirmed at the time of discovery by a concurrent interview with staff G (Facilities Department), and staff H (Maintenance Tech).

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Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have 2 spare sprinklers of each type, as required by NFPA 101 (2012 edition), 9.7.5, and NFPA 25 (2011 edition). This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 06/05/2019 at 9:30 am, it was observed in the Basement Zone 2 smoke compartment on the basement floor in the riser room, that there was only 1 of each type of sprinkler head for an upright extended coverage standard response sprinkler head with a blue bulb, a green bulb and a quick response pendent sprinkler head with a red bulb.

The condition was confirmed at the time of discovery by a concurrent interview with staff G (Facilities Department) and staff H (Maintenance Tech).
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Based on record review and interview, the facility did not conduct fire drills as required by NFPA 101 (2012 edition), 19.7.1.6., to ensure that staff are familiar with fire response procedures with fire drills that fully test the staff's ability to respond to fire emergencies. This deficiency had the potential to affect all of the 25 patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 06/04/2019 at 12:30 pm, record review revealed that the fire drills were conducted in a pattern so they were not always at unexpected times. On the first shift the first Quarter drill was at 9:06 am, the third Quarter drill was at 9:25 am, and the fourth Quarter drill was at 8:38 am. On the second shift the first Quarter drill was at 3:23 pm, the Second Quarter drill was at 4:22 pm, the third Quarter drill was at 3:55 pm, and the fourth Quarter drill was at 3:16 pm. On the third shift the first Quarter drill was at 6:27 am, and the Second Quarter drill was at 6:37 am, the third Quarter drill was at 10:55 pm, and the fourth Quarter drill was at 11:12 pm.

The condition was confirmed at the time of discovery by an interview with staff E (Maintenance Mechanic), staff F (Construction Project Supervisor), and staff G (Facilities Department).
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