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Based on observation and interview, facility failed to ensure a smoke detection device was installed in the Doctors Sleeping Room. Not having detection devices installed in all sleeping rooms could result in an undetected fire, which presents a risk of potential harm by fire to all patients, staff and occupants of the facility. The findings are:

A. On 06/08/16, at 11:35 am, observation of no smoke detection device installed in the Doctors Sleeping Room.

B. On 06/08/16, at 2:30 pm, during interview, Administrator, Director of Maintenance and Safety Officer acknowledged the finding.

NFPA 13 INSTALLATION OF SPRINKLER SYSTEMS

4-7.2 Fire Department Connections.

4-7.2.1 A fire department connection shall be provided as described in this section.

Exception's:
1. Buildings located in remote areas that are inaccessible for fire department support.
2. Large-capacity deluge systems exceeding the pumping capacity of the fire department.
3. Single-story buildings not exceeding 2,000 sq. ft. in area.

4-7.2.2 Pipe size shall be 4 in. for fire engine connections and 6 in. for boat connection.

4-7.2.3 Arrangement.
4-7.2.3.1 The fire department connection shall be on the system side of the water supply check valve.

4-7.2.3.2 For single systems, the fire department connection shall be installed as follows:
(a) Wet System. On the system side of system control, check and alarm valves.
(b) Dry System. Between the preaction valve and the dry pipe valve.
(c) Preaction System. Between the preaction valve and the check valve on the system side of the preaction valve.
(d) Deluge System. On the system side of the deluge valve.

Exception: Connection of the fire department connection to underground piping is acceptable.

4-7.2.3.3 For multiple systems, the fire department connection shall be connected between the supply control valves and the system control valves.

Exception: Connection of the fire department connection to underground piping is acceptable.

4-7.2.3.4 Fire department connection shall be located and arranged so that hose can be readily and conveniently attached.
Each fire department connection to sprinkler systems shall be designated by a sign having raised letters at least 1 in. in height cast on plate or fitting reading service design, e.g. "AUTOSPKR.," "OPEN SPKR. AND STANDPIPE." A sign shall also indicate the pressure required at the inlets to deliver the greatest system demand.


Based on observation, facility failed to ensure signage was posted to indicate the location of the facilities FDC's (Fire Department Connections), two (2) FDCs, located on the north side of facility. Not having signage to indicate the location of the FDC could result in the delay from responding fire department to supply water to the fire sprinkler system. This failed practice presents a risk of potential harm by fire to all patients, staff and occupants of the facility. The findings are:

A. On 06/08/16, at 9:55 am, observation of no signage posted to indicate the location of the FDC's, two locations on the north side of property.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety Officer acknowledged the finding.




NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 1998 Edition

9-6 Backflow Prevention Assemblies.

9-6.1 Inspection of backflow prevention assemblies shall be as described in 9-6.1.1 and 9-6.1.2.

9-6.1 The double check assembly (DCA) valves and double check detector assembly (DCDA) valve shall be inspected weekly to ensure that the OS&Y isolation valves are in the normal open position.

Exception: Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.

9-6.1.2 Reduced pressure assemblies (RPA) and reduced pressure detector assemblies (RPAD) shall be inspected weekly to ensure that the differential-sensing valve relief port is not continuously discharging and the OS&Y isolation valves are in the normal open position. After any testing or repair, an inspection by the owner shall be made to ensure that the system is in service and all isolation valves are in the normal open position and properly locked or electrically supervised.

Exception: Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.

9-6.2 Testing.
9-6.2.1 All back flow preventers installed in fire protection system piping shall be tested annually in accordance with the following:

(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.

(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.

9-6.2.2 All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands if appropriate.


Based on observation and interview, facility failed to ensure the OS & Y Valves (open stem and yoke valves, which indicate fire protection water is being supplied to facility), were locked in the open position or electronically supervised. Not having OS & Y valves locked in the open position or electronically supervised, could result in the accidental or intentional shut down of water, which supplies the fire sprinkler system. This failed practice presents a risk of potential harm by fire to all patients, staff and occupants of the facility. The findings are:

A. On 06/08/16, at 12:45 pm, observation of OS & Y valves on the north side of facility grounds, were found not locked in the open position or electronically supervised.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety Officer stated they should be locked/supervised, acknowledging the finding.

NFPA 99 (1999 Edition)
8-6.4.2 Signs. Precautionary signs , readable from a distance of 5ft., shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means.


Based on observation and interview, facility failed to ensure precautionary signs indicating (NO SMOKING), was installed on all sides of exterior bulk (medical gas/oxygen storage location). Not having signage could result in a highly flammable fire, which presents a risk of potential harm by fire to all patients, staff and occupants within the facility. The findings are:

A. On 06/08/16, at 11:25 am, observation of the exterior bulk oxygen storage location, (north side of facility) revealed that it did not have signage indicating (NO SMOKING), visible from all sides.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety officer stated signage will be installed on all four sides as soon as signs are available.

NFPA 110 Standard for Emergency and Standby Power Systems

8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing specific gravity when applicable or warranted.

Based on record review and interview, the facility failed to ensure the New Emergency Generator batteries had specific gravity readings taken within the last twelve months. Not conducting specific gravity readings on the batteries could result in the failure of the Emergency Generator starting in the event of a main power outage, which presents a risk of potential harm to all patients within the hospital. The findings are:

A. Record review of the Emergency Generator log book revealed no documentation was provided to indicate specific gravity readings had been taken for the last twelve (12) months on the new emergency generator.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety Officer stated they were unaware specific gravity readings had not been taken for the new emergency generator.

Based on interview and record review of the facility's Emergency Procedures, facility failed to ensure procedures were in place, in the event the Fire Sprinkler System was out of service for more than four (4) hours. Not having the above mentioned procedures in place could result in the failure of initiating Fire Watch Procedures in a timely manner, which could result in the delay of detecting a fire in the facility. This presents a potential risk of injury by fire to all patients and staff. The findings are:

A. Record review of Facility's Emergency Procedures revealed no documentation was provided to indicate written procedures were in place in the event the Fire Sprinkler System was out of service for more than four (4) hours.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety Officer stated they were unable to locate the procedures.

Based on interview and record review of facility's Emergency Procedures, facility failed to ensure procedures were in place, in the event the Fire Alarm System was out of service for more than four (4) hours. Not having the above mentioned procedures in place could result in the failure of initiating Fire Watch Procedures in a timely manner, which could result in the delay of detecting a fire in the facility. This presents a potential risk of injury by fire to all patients, staff and occupants within the facility. The findings are:

A. Record record review of Facility's Emergency Procedures revealed no documentation was provided to indicate procedures were in place in the event the Fire Alarm System was out of service for more than four (4) hours.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety Officer stated they were unable to locate the procedures.

Based on observation and interview, facility failed to ensure a smoke detection device was installed in the Doctors Sleeping Room. Not having detection devices installed in all sleeping rooms could result in an undetected fire, which presents a risk of potential harm by fire to all patients, staff and occupants of the facility. The findings are:

A. On 06/08/16, at 11:35 am, observation of no smoke detection device installed in the Doctors Sleeping Room.

B. On 06/08/16, at 2:30 pm, during interview, Administrator, Director of Maintenance and Safety Officer acknowledged the finding.

NFPA 13 INSTALLATION OF SPRINKLER SYSTEMS

4-7.2 Fire Department Connections.

4-7.2.1 A fire department connection shall be provided as described in this section.

Exception's:
1. Buildings located in remote areas that are inaccessible for fire department support.
2. Large-capacity deluge systems exceeding the pumping capacity of the fire department.
3. Single-story buildings not exceeding 2,000 sq. ft. in area.

4-7.2.2 Pipe size shall be 4 in. for fire engine connections and 6 in. for boat connection.

4-7.2.3 Arrangement.
4-7.2.3.1 The fire department connection shall be on the system side of the water supply check valve.

4-7.2.3.2 For single systems, the fire department connection shall be installed as follows:
(a) Wet System. On the system side of system control, check and alarm valves.
(b) Dry System. Between the preaction valve and the dry pipe valve.
(c) Preaction System. Between the preaction valve and the check valve on the system side of the preaction valve.
(d) Deluge System. On the system side of the deluge valve.

Exception: Connection of the fire department connection to underground piping is acceptable.

4-7.2.3.3 For multiple systems, the fire department connection shall be connected between the supply control valves and the system control valves.

Exception: Connection of the fire department connection to underground piping is acceptable.

4-7.2.3.4 Fire department connection shall be located and arranged so that hose can be readily and conveniently attached.
Each fire department connection to sprinkler systems shall be designated by a sign having raised letters at least 1 in. in height cast on plate or fitting reading service design, e.g. "AUTOSPKR.," "OPEN SPKR. AND STANDPIPE." A sign shall also indicate the pressure required at the inlets to deliver the greatest system demand.


Based on observation, facility failed to ensure signage was posted to indicate the location of the facilities FDC's (Fire Department Connections), two (2) FDCs, located on the north side of facility. Not having signage to indicate the location of the FDC could result in the delay from responding fire department to supply water to the fire sprinkler system. This failed practice presents a risk of potential harm by fire to all patients, staff and occupants of the facility. The findings are:

A. On 06/08/16, at 9:55 am, observation of no signage posted to indicate the location of the FDC's, two locations on the north side of property.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety Officer acknowledged the finding.




NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 1998 Edition

9-6 Backflow Prevention Assemblies.

9-6.1 Inspection of backflow prevention assemblies shall be as described in 9-6.1.1 and 9-6.1.2.

9-6.1 The double check assembly (DCA) valves and double check detector assembly (DCDA) valve shall be inspected weekly to ensure that the OS&Y isolation valves are in the normal open position.

Exception: Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.

9-6.1.2 Reduced pressure assemblies (RPA) and reduced pressure detector assemblies (RPAD) shall be inspected weekly to ensure that the differential-sensing valve relief port is not continuously discharging and the OS&Y isolation valves are in the normal open position. After any testing or repair, an inspection by the owner shall be made to ensure that the system is in service and all isolation valves are in the normal open position and properly locked or electrically supervised.

Exception: Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.

9-6.2 Testing.
9-6.2.1 All back flow preventers installed in fire protection system piping shall be tested annually in accordance with the following:

(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.

(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.

9-6.2.2 All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands if appropriate.


Based on observation and interview, facility failed to ensure the OS & Y Valves (open stem and yoke valves, which indicate fire protection water is being supplied to facility), were locked in the open position or electronically supervised. Not having OS & Y valves locked in the open position or electronically supervised, could result in the accidental or intentional shut down of water, which supplies the fire sprinkler system. This failed practice presents a risk of potential harm by fire to all patients, staff and occupants of the facility. The findings are:

A. On 06/08/16, at 12:45 pm, observation of OS & Y valves on the north side of facility grounds, were found not locked in the open position or electronically supervised.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety Officer stated they should be locked/supervised, acknowledging the finding.

NFPA 99 (1999 Edition)
8-6.4.2 Signs. Precautionary signs , readable from a distance of 5ft., shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means.


Based on observation and interview, facility failed to ensure precautionary signs indicating (NO SMOKING), was installed on all sides of exterior bulk (medical gas/oxygen storage location). Not having signage could result in a highly flammable fire, which presents a risk of potential harm by fire to all patients, staff and occupants within the facility. The findings are:

A. On 06/08/16, at 11:25 am, observation of the exterior bulk oxygen storage location, (north side of facility) revealed that it did not have signage indicating (NO SMOKING), visible from all sides.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety officer stated signage will be installed on all four sides as soon as signs are available.

NFPA 110 Standard for Emergency and Standby Power Systems

8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing specific gravity when applicable or warranted.

Based on record review and interview, the facility failed to ensure the New Emergency Generator batteries had specific gravity readings taken within the last twelve months. Not conducting specific gravity readings on the batteries could result in the failure of the Emergency Generator starting in the event of a main power outage, which presents a risk of potential harm to all patients within the hospital. The findings are:

A. Record review of the Emergency Generator log book revealed no documentation was provided to indicate specific gravity readings had been taken for the last twelve (12) months on the new emergency generator.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety Officer stated they were unaware specific gravity readings had not been taken for the new emergency generator.

Based on interview and record review of the facility's Emergency Procedures, facility failed to ensure procedures were in place, in the event the Fire Sprinkler System was out of service for more than four (4) hours. Not having the above mentioned procedures in place could result in the failure of initiating Fire Watch Procedures in a timely manner, which could result in the delay of detecting a fire in the facility. This presents a potential risk of injury by fire to all patients and staff. The findings are:

A. Record review of Facility's Emergency Procedures revealed no documentation was provided to indicate written procedures were in place in the event the Fire Sprinkler System was out of service for more than four (4) hours.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety Officer stated they were unable to locate the procedures.

Based on interview and record review of facility's Emergency Procedures, facility failed to ensure procedures were in place, in the event the Fire Alarm System was out of service for more than four (4) hours. Not having the above mentioned procedures in place could result in the failure of initiating Fire Watch Procedures in a timely manner, which could result in the delay of detecting a fire in the facility. This presents a potential risk of injury by fire to all patients, staff and occupants within the facility. The findings are:

A. Record record review of Facility's Emergency Procedures revealed no documentation was provided to indicate procedures were in place in the event the Fire Alarm System was out of service for more than four (4) hours.

B. On 06/08/16, at 2:30 pm, during interview, Director of Maintenance and Safety Officer stated they were unable to locate the procedures.