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Based on observation the facility failed to continuously maintain the required automatic sprinkler system in a reliable operating condition as required by NFPA 101, 19.7.6, 9.7.5, 4.6.12, NFPA 13, and NFPA 25. This practice does not ensure occupant safety.

Findings include:

1. On 04/01/11, the second day of survey, at approximately 9:45 a.m., observation during the interior tour of the medical office building in which facility inpatients and outpatients receive services, accompanied by facility staff, revealed a medical records closet on the 4th floor between the Wound Care Center and a physicians' office in which a required sprinkler head had not been installed.

2. On 03/31/11, observation during the interior tour of the facility, at approximately 2:30 p.m., accompanied by facility staff, revealed 2 sprinkler heads corroded and in need of replacement in the space identified by staff as the "Old OR, (operating room),


3. On 04/01/11, observation at approximately 11:30 a.m., during the interior tour of the medical office building in which facility inpatients and outpatients receive services, accompanied by facility staff, revealed a pendant sprinkler head in the "Board Room" on the first floor in which the "deflector" was less than one inch from the ceiling and the escutcheon was distorted and compressed into the ceiling tile.

5/1/11

Based on observation the facility failed to maintain smoke barriers free of penetrations as required by NFPA 101, 8.2.4, 8.2.4.2, and 8.3.6. This practice does not ensure occupant safety.

Findings include:

1. On 03/31/11, observation at approximately 1:45 p.m., accompanied by a facility representative, revealed 5 of 7 sprinkler head escutcheons missing in the corridor for rooms 228 through and including room 242, thereby allowing, in the event of fire, the passage of smoke from the corridor into the interstitial space above the suspended ceiling.

2. On 03/31/11, observation at approximately 1:30 p.m., accompanied by a facility representative, revealed multiple penetrations of the suspended ceiling by electrical conduit in Electrical Closets 2R and 3R, thereby allowing, in the event of fire, the passage of smoke from the electrical closet into the interstitial space above the suspended ceiling.

5/1/11