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NFPA 101 (2000 ed)19.3.4.5.1 Detection systems, where required, shall be in accordance with section 9.6.
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 National Fire Protection Association (NFPA) 70, National Electric Code, and NFPA 72, National Fire Alarm Code...

NFPA 72 Chapter 10, 10.4.3.2 Sensitivity of smoke detectors and single and multiple-station smoke alarms in other than one and two-family dwellings shall be tested in accordance with 10.4.3.2.1 through 10.4.3.2.6.
10.4.3.2.1. Sensitivity shall be checked within 1 year after installation.
10.4.3.2.1 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 10.4.3.2.3.



Based on document review, the facility failed to ensure that documentation was available on-site, to confirm that alternate-year, sensitivity testing was being performed.

Findings include:

On 8/19/14 a review of the facility maintenance documents revealed that the most current smoke detector, sensitivity testing was done on 2/22/11.

NFPA 101 (2000 ed) 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7.

Based on observation the facility failed to ensure complete sprinkler coverage for all portions of the hospital.

Findings Include:

On 8/18/14 at 2:15 PM two closets (10 sq.ft. each) in the first floor Conference Room did not have sprinklers installed within them. On 8/19/14 at 9:10 AM, in the Dietary Department, both the freezer walk-in box (63 sq.ft.) and the refrigerator walk-in box (60 sq.ft.) did not have sprinklers installed within them.

NFPA 25 (2008 ed.), 5.2.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage... 5.2.1.1.2 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or in the improper orientation.

NFPA 25 (1998 ed.), 2-3.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing...

NFPA 13, Chapter 4-4.1.6 states: A minimum of 18 inches (457 mm) clearance shall be maintained between the top of storage and ceiling sprinkler deflectors.

Based on observation the facility failed to ensure that; one sprinkler head was free of corrosion, all sprinkler heads were less than 50 years old, and all items in storage were at least 18 inches below a sprinkler deflector.

Findings include:

On 8/19/14 at 9:10 AM, one-of-two sprinkler heads in the Dietary Department's exhaust hood, exhibited signs of corrosion.

On 8/18/14 at 1:40 PM, the Director of Maintenance was uncertain when asked if any sprinkler heads in the facility were over 50 years old. On 8/20/14 at 11:00 AM, in the facility's Riser Room, one of 13 spare sprinkler heads in the metal storage box, had the year "1962" (52 years old) stamped on it.

On 8/18/14 at 3:55 PM a blue, plastic box was on the top shelf in the Emergency Management Supply closet. The box was ten inches, directly below, a sprinkler deflector. On 8/18/14 at 4:00 PM the (empty) top shelf, in the Housekeeping Closet, in Same Day Surgery Department, was 16 inches directly below a sprinkler deflector.

NFPA 10 (2002 ed) 1.5.10 Fire extinguishers having a gross weight not exceeding 40 lbs. shall be installed so that the top of the fire extinguisher is not more than 5 ft. above the floor...

Based on observation the facility failed to ensure that two fire extinguishers, in the patient care area, were installed at a height where they could be easily accessible to all staff.

Findings include:

On 8/18/14 at 2:20 PM two fire extinguishers stored in recessed cabinets, had a distance of five feet ten inches from the top of the extinguisher to the floor. These extinguishers were located near the Nurses Station (extinguisher #56) and Patient Room #108 (extinguisher #55).

NFPA 96 (1991 ed) Chapter 7 Fire Extinguishing Equipment. 7-2 Types of Equipment. 7-2.2.1 Automatic fire extinguishing systems specifically listed for the hazard installed in accordance with the terms of their listing, the manufacturer's instructions, and NFPA 17, Standard for Dry Chemical Extinguishing Systems, or NFPA 17A, Standard for Wet Chemical Extinguishing Systems...

Based on observation and staff interview, the facility failed to ensure that only an approved fire extinguishing system was installed in the hood over the Dietary Department's; range, griddle, and deep fryer.

Findings include:

On 8/19/14 at 9:10 AM both an Ansul System and a Wet Sprinkler System were observed in the hood covering cooking appliances. One of two sprinkler heads on the Wet Sprinkler System exhibited signs of corrosion and appeared to have a reflective substance on it (possibly water). The Director of Maintenance indicated that the valve to the Wet Sprinkler System was closed, and the reflective substance on the sprinkler head was possibly grease. The Wet Sprinkler System had a "T" fitting on it, with a branch pipe running up and into the exhaust duct.

NFPA 99 (1999 ed) Chapter 3 Electrical Systems. 3-4.1.1 On-Site Generator Set. 3-4.1.1.1 Design Considerations. 3-4.1.1.15 Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)...Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15 (a) and (b) occur, but need not display these conditions individually. [110:3-5.5.2]

Based on observation and staff interview, the facility failed to install a remote alarm annunciator on one-of-three (Cummings) emergency generators. Also, the facility failed to locate two remote alarm annunciators (Generac #1 and Generac #2) where they could be continuously monitored.

Findings include:

On 8/18/14 at 1:55 PM, the Director of Maintenance indicated that the 125 kW, Cummings, diesel emergency generator did not have a remote alarm annunciator. The remote alarm annunciators for the two, 230 kW, Generacs were located in the North basement area, which had no staff coverage during the night shift.

Based on observation the facility failed to ensure that four, Alcohol Based Hand Rub (ABHR) dispensers were not installed directly above three electrical outlets and one light fixture.

Findings include:

On 8/18/14, from 2:00 to 4:00 PM, four ABHR's were observed to have been installed over electrical ignition sources. In Patient Room 102, an ABHR was installed directly over a night light. In Patient Rooms 107 and 108, ABHR's were installed directly over duplex electrical outlets. In the Clean Processing's Supply Room, an ABHR was installed over a duplex electrical outlet.

NFPA 101 (2000 ed)19.3.4.5.1 Detection systems, where required, shall be in accordance with section 9.6.
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 National Fire Protection Association (NFPA) 70, National Electric Code, and NFPA 72, National Fire Alarm Code...

NFPA 72 Chapter 10, 10.4.3.2 Sensitivity of smoke detectors and single and multiple-station smoke alarms in other than one and two-family dwellings shall be tested in accordance with 10.4.3.2.1 through 10.4.3.2.6.
10.4.3.2.1. Sensitivity shall be checked within 1 year after installation.
10.4.3.2.1 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 10.4.3.2.3.



Based on document review, the facility failed to ensure that documentation was available on-site, to confirm that alternate-year, sensitivity testing was being performed.

Findings include:

On 8/19/14 a review of the facility maintenance documents revealed that the most current smoke detector, sensitivity testing was done on 2/22/11.

NFPA 101 (2000 ed) 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7.

Based on observation the facility failed to ensure complete sprinkler coverage for all portions of the hospital.

Findings Include:

On 8/18/14 at 2:15 PM two closets (10 sq.ft. each) in the first floor Conference Room did not have sprinklers installed within them. On 8/19/14 at 9:10 AM, in the Dietary Department, both the freezer walk-in box (63 sq.ft.) and the refrigerator walk-in box (60 sq.ft.) did not have sprinklers installed within them.

NFPA 25 (2008 ed.), 5.2.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage... 5.2.1.1.2 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or in the improper orientation.

NFPA 25 (1998 ed.), 2-3.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing...

NFPA 13, Chapter 4-4.1.6 states: A minimum of 18 inches (457 mm) clearance shall be maintained between the top of storage and ceiling sprinkler deflectors.

Based on observation the facility failed to ensure that; one sprinkler head was free of corrosion, all sprinkler heads were less than 50 years old, and all items in storage were at least 18 inches below a sprinkler deflector.

Findings include:

On 8/19/14 at 9:10 AM, one-of-two sprinkler heads in the Dietary Department's exhaust hood, exhibited signs of corrosion.

On 8/18/14 at 1:40 PM, the Director of Maintenance was uncertain when asked if any sprinkler heads in the facility were over 50 years old. On 8/20/14 at 11:00 AM, in the facility's Riser Room, one of 13 spare sprinkler heads in the metal storage box, had the year "1962" (52 years old) stamped on it.

On 8/18/14 at 3:55 PM a blue, plastic box was on the top shelf in the Emergency Management Supply closet. The box was ten inches, directly below, a sprinkler deflector. On 8/18/14 at 4:00 PM the (empty) top shelf, in the Housekeeping Closet, in Same Day Surgery Department, was 16 inches directly below a sprinkler deflector.

NFPA 10 (2002 ed) 1.5.10 Fire extinguishers having a gross weight not exceeding 40 lbs. shall be installed so that the top of the fire extinguisher is not more than 5 ft. above the floor...

Based on observation the facility failed to ensure that two fire extinguishers, in the patient care area, were installed at a height where they could be easily accessible to all staff.

Findings include:

On 8/18/14 at 2:20 PM two fire extinguishers stored in recessed cabinets, had a distance of five feet ten inches from the top of the extinguisher to the floor. These extinguishers were located near the Nurses Station (extinguisher #56) and Patient Room #108 (extinguisher #55).

NFPA 96 (1991 ed) Chapter 7 Fire Extinguishing Equipment. 7-2 Types of Equipment. 7-2.2.1 Automatic fire extinguishing systems specifically listed for the hazard installed in accordance with the terms of their listing, the manufacturer's instructions, and NFPA 17, Standard for Dry Chemical Extinguishing Systems, or NFPA 17A, Standard for Wet Chemical Extinguishing Systems...

Based on observation and staff interview, the facility failed to ensure that only an approved fire extinguishing system was installed in the hood over the Dietary Department's; range, griddle, and deep fryer.

Findings include:

On 8/19/14 at 9:10 AM both an Ansul System and a Wet Sprinkler System were observed in the hood covering cooking appliances. One of two sprinkler heads on the Wet Sprinkler System exhibited signs of corrosion and appeared to have a reflective substance on it (possibly water). The Director of Maintenance indicated that the valve to the Wet Sprinkler System was closed, and the reflective substance on the sprinkler head was possibly grease. The Wet Sprinkler System had a "T" fitting on it, with a branch pipe running up and into the exhaust duct.

NFPA 99 (1999 ed) Chapter 3 Electrical Systems. 3-4.1.1 On-Site Generator Set. 3-4.1.1.1 Design Considerations. 3-4.1.1.15 Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)...Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15 (a) and (b) occur, but need not display these conditions individually. [110:3-5.5.2]

Based on observation and staff interview, the facility failed to install a remote alarm annunciator on one-of-three (Cummings) emergency generators. Also, the facility failed to locate two remote alarm annunciators (Generac #1 and Generac #2) where they could be continuously monitored.

Findings include:

On 8/18/14 at 1:55 PM, the Director of Maintenance indicated that the 125 kW, Cummings, diesel emergency generator did not have a remote alarm annunciator. The remote alarm annunciators for the two, 230 kW, Generacs were located in the North basement area, which had no staff coverage during the night shift.