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Based on observation and interview, the facility failed to install a sprinkler system in accordance with the National Fire Protection Association 13, Standards for the Installation of Sprinkler Systems. These deficient practices affects all patients in the facility. The facility census was 59.

1. Observation on 6/5/17, during the facility tour, showed nine standard sprinkler heads and three quick response sprinkler heads mounted in the same compartment, on the third floor stairwell.

Observation on 6/5/17, during the facility tour, showed six standard sprinkler heads and one quick response sprinkler head mounted in the same compartment, on the second floor stairwell.

During an interview on 6/9/17, at 2:15 P.M., the Director of Facilities Management said that the different sprinkler heads in the same compartments were installed during previous remodels in the hospital.

Section 8.3.3.2 of the National Fire Protection Association (NFPA) 13 states: "Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3

2. Observation on 6/5/17, during the facility tour, showed six of nine elevator hoistway pits did not have sprinkler coverage. Observation showed all six elevators employ a hydraulic elevator lift mechanism that uses a petroleum-based hydraulic fluid, which is combustible.

During an interview on 6/9/17 at 2:05 P.M., the Director of Facilities Management said that the elevator hoistway pits did not have sprinkler coverage.

Section 8.15.5.1* of NFPA 13 states: " Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.

* The sprinklers in the pit are intended to protect against fires caused by debris, which can accumulate over time. Ideally, the sprinklers should be located near the side of the pit below the elevator doors, where most debris accumulates. However, care should be taken that the sprinkler location does not interfere with the elevator toe guard, which extends below the face of the door opening.
ASME A17.1, Safety Code for Elevators and Escalators, allow the sprinklers within 2 ft (0.65 m) of the bottom of the pit to be exempted from the special arrangements of inhibiting waterflow until elevator recall has occurred.

3. Observation on 6/5/17, during the facility tour, showed six of six elevator machine rooms did not have sprinkler coverage.

During an interview on 6/9/17 at 2:05 P.M., the Director of Facilities Management said that the elevator machine rooms did not have sprinkler coverage.

Section 8.15.5.3* of NFPA 13 states: "Automatic sprinklers in elevator machine rooms or at the tops of hoistways shall be of ordinary or intermediate temperature rating.

* ASME A17.1, Safety Code for Elevators and Escalators, requires the shutdown of power to the elevator upon or prior to the application of water in elevator machine rooms or hoistways. This shutdown can be accomplished by a detection system with sufficient sensitivity that operates prior to the activation of the sprinklers (see also NFPA 72, National Fire Alarm and Signaling Code). As an alternative, the system can be arranged using devices or sprinklers capable of effecting power shutdown immediately upon sprinkler activation, such as a waterflow switch without a time delay. This alternative arrangement is intended to interrupt power before significant sprinkler discharge.

Examples 2 and 3 have a Life Safety Code Waiver approved by CMS until August 31, 2017 to install the sprinkler heads in the elevator pits and elevator machine rooms.