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Based on observations, the facility has failed to provide proper protection for 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practices could affect patients, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:00 AM to 4:30 PM on 07/17/2012, observation revealed that there was a 2 inch diameter penetration to the left of the fire sprinkler piping in the 1 hour fire rated wall located between the Mechanical Room 1395 and the Transcription Room.


This deficient practice was verified by the Manager of Purchasing and Maintenance (VD).

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift for all staff under varying times and conditions as required by 2000 NFPA 101, Section 4.2. This deficient practice could affect all patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM to 4:30 PM on 07/17/2012, during the review of the fire drill documentation and an interview with the Director of Facilities (RA), the facility was unable to provide any documentation verifying that the fire drills have been conducted once per shift per quarter.


This deficient practice was confirmed by the Director of Facilities (RA).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting 2 patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM to 4:30 PM on 07/17/2012, observation revealed that the smoke detectors in the OR Suite located in the corridor by rooms 1325 and 1331 were installed within 36 inches of the HVAC Vent.


This deficient practice was verified by the Manager of Purchasing and Maintenance (VD).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM to 4:30 PM on 07/17/2012, during a review of the available fire sprinkler test and inspection documentation, observations revealed and were confirmed by interview with the Director of Facilities (RA), that the facility failed conduct the fire sprinkler flow tests quarterly (1 test every 3 months), and was not able to provide documentation for 2 of 4 fire sprinkler flow tests of the facility's fire sprinkler system.

This deficient practice was confirmed by the Director of Facilities (RA).

Based on observations, the facility has failed to provide proper protection for 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practices could affect patients, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:00 AM to 4:30 PM on 07/17/2012, observation revealed that there was a 2 inch diameter penetration to the left of the fire sprinkler piping in the 1 hour fire rated wall located between the Mechanical Room 1395 and the Transcription Room.


This deficient practice was verified by the Manager of Purchasing and Maintenance (VD).

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift for all staff under varying times and conditions as required by 2000 NFPA 101, Section 4.2. This deficient practice could affect all patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM to 4:30 PM on 07/17/2012, during the review of the fire drill documentation and an interview with the Director of Facilities (RA), the facility was unable to provide any documentation verifying that the fire drills have been conducted once per shift per quarter.


This deficient practice was confirmed by the Director of Facilities (RA).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting 2 patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM to 4:30 PM on 07/17/2012, observation revealed that the smoke detectors in the OR Suite located in the corridor by rooms 1325 and 1331 were installed within 36 inches of the HVAC Vent.


This deficient practice was verified by the Manager of Purchasing and Maintenance (VD).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 9:00 AM to 4:30 PM on 07/17/2012, during a review of the available fire sprinkler test and inspection documentation, observations revealed and were confirmed by interview with the Director of Facilities (RA), that the facility failed conduct the fire sprinkler flow tests quarterly (1 test every 3 months), and was not able to provide documentation for 2 of 4 fire sprinkler flow tests of the facility's fire sprinkler system.

This deficient practice was confirmed by the Director of Facilities (RA).