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This STANDARD is not met as evidenced by:

Based on observations, the facility has failed to provide proper protection for 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 8:30 AM and 5:30 PM on 9/22/11, observation revealed, that the there were several penetrations located in the Maintenance office and in the Mechanical Room located next to the IT Exit.


These deficient practices were confirmed by the Maintenance Staff (SG).

This STANDARD is not met as evidenced by:

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system in accordance with NFPA 72 (99), Sec. 7-3.2.1. This deficient practice could affect all Patients, visitors, and staff.

Findings include:

On facility tour between 8:30 AM and 5:30 PM on 9/22/11, a review of the facility's available fire alarm test documentation revealed that the facility failed to provide documentation or have conducted the required sensitivity test of each smoke detector in the facility.


These deficient practices were confirmed by the Maintenance Staff (SG).

This STANDARD is not met as evidenced by:

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). This failure to maintain the sprinkler system in compliance with NFPA 13 (99) and could effect the fire sprinkler system and allow a fire development that would reduce the egress conditions affecting all Patients, staff and visitors of the facility.

Findings include:

On facility tour between 8:30 AM and 5:30 PM on 9/22/11, it was observed that the fire sprinkler piping located in the North Nurses Station has wires and other non-system components attached to the pipes.


These deficient practices were confirmed by the Maintenance Staff (SG).

This STANDARD is not met as evidenced by:

Based on observations, the facility has failed to provide proper protection for 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 8:30 AM and 5:30 PM on 9/22/11, observation revealed, that the there were several penetrations located in the Maintenance office and in the Mechanical Room located next to the IT Exit.


These deficient practices were confirmed by the Maintenance Staff (SG).

This STANDARD is not met as evidenced by:

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 8:30 AM and 5:30 PM on 9/22/11, the review of the fire drill documentation for the past 12 months revealed, that the facility failed to conduct a fire drill.


These deficient practices were confirmed by the Maintenance Staff (SG).

This STANDARD is not met as evidenced by:

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system in accordance with NFPA 72 (99), Sec. 7-3.2.1. This deficient practice could affect all Patients, visitors, and staff.

Findings include:

On facility tour between 8:30 AM and 5:30 PM on 9/22/11, a review of the facility's available fire alarm test documentation revealed that the facility failed to provide documentation or have conducted the required sensitivity test of each smoke detector in the facility.


These deficient practices were confirmed by the Maintenance Staff (SG).

This STANDARD is not met as evidenced by:

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). This failure to maintain the sprinkler system in compliance with NFPA 13 (99) and could effect the fire sprinkler system and allow a fire development that would reduce the egress conditions affecting all Patients, staff and visitors of the facility.

Findings include:

On facility tour between 8:30 AM and 5:30 PM on 9/22/11, it was observed that the fire sprinkler piping located in the North Nurses Station has wires and other non-system components attached to the pipes.


These deficient practices were confirmed by the Maintenance Staff (SG).