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Based on observation, the facility has failed to provide 1 of several operational exit signs that marks the means of egress path in accordance with NFPA Life Safety Code 101 (2000 edition), Sec. 7.10.5.2. This deficient practice could negatively affect ER patients, staff and visitors, if the lack of properly illuminated exit sign prevented a means of egress from being utilized in a timely manner in an emergency situation.

Findings include:

On facility tour between 11:00 AM and 3:00 PM on 08/13/2013, it was observed that the exit sign located at the ER exit door was found to be in-operative.

This was confirmed by the Maintenance Supervisor (PE).

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between the hours of 11:00 AM and 3:00 PM on 08/13/2013, the review of the available annual fire sprinkler inspection reports it was noted that the annual fire sprinkler test was not completed within the last 12 month period. The last annual fire sprinkler test report that the facility was able to provide at the time of the inspection was conducted on 07/26/2012, no other testing information was available at the time of this inspection.


This was confirmed by the Maintenance Supervisor (PE).

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between the hours of 11:00 AM and 3:00 PM on 08/13/2013, the review of the available annual fire sprinkler inspection reports it was noted that the annual fire sprinkler test was not completed within the last 12 month period. The last annual fire sprinkler test report that the facility was able to provide at the time of the inspection was conducted on 07/26/2012, no other testing information was available at the time of this inspection.


This was confirmed by the Maintenance Supervisor (PE).

Based on observation, the facility has failed to provide 1 of several operational exit signs that marks the means of egress path in accordance with NFPA Life Safety Code 101 (2000 edition), Sec. 7.10.5.2. This deficient practice could negatively affect ER patients, staff and visitors, if the lack of properly illuminated exit sign prevented a means of egress from being utilized in a timely manner in an emergency situation.

Findings include:

On facility tour between 11:00 AM and 3:00 PM on 08/13/2013, it was observed that the exit sign located at the ER exit door was found to be in-operative.

This was confirmed by the Maintenance Supervisor (PE).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow a delayed activation of the fire sprinkler system and could affect the ER Patients, visitors and staff of the facility.

Findings include:

On facility tour between 11:00 AM to 3:00 PM on 08/13/2013, it was observed that the fire sprinkler head located in the ER storage room #216 had boxes on shelving that are located within 18 inches of the sprinkler deflector.


This was confirmed by the Maintenance Supervisor (PE).

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between the hours of 11:00 AM and 3:00 PM on 08/13/2013, the review of the available annual fire sprinkler inspection reports it was noted that the annual fire sprinkler test was not completed within the last 12 month period. The last annual fire sprinkler test report that the facility was able to provide at the time of the inspection was conducted on 07/26/2012, no other testing information was available at the time of this inspection.


This was confirmed by the Maintenance Supervisor (PE).

Based on observation and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1998 NFPA 25, section 2-2.1.1. The deficient practice could affect all patients, staff, and visitors.

Findings include:

On facility tour between the hours of 11:00 AM and 3:00 PM on 08/13/2013, the review of the available annual fire sprinkler inspection reports it was noted that the annual fire sprinkler test was not completed within the last 12 month period. The last annual fire sprinkler test report that the facility was able to provide at the time of the inspection was conducted on 07/26/2012, no other testing information was available at the time of this inspection.


This was confirmed by the Maintenance Supervisor (PE).