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Based on observations and staff interview, the facility has failed to correctly position 1 of several operational exit signs that marks the means of egress path in accordance with NFPA Life Safety Code 101 (2000 edition), Sec. 7.10.5.2. This deficient practice could negatively affect patients staff and visitors, if the lack of properly positioned exit signs could misdirect and prevented a means of egress from being utilized in a timely manner in an emergency situation.

Findings include:

On facility tour between 9:00 AM and 5:30 PM on 09/23/2014, it was observed that the exit sign in the corridor servicing the Patient Care wing, OR Suite, and the Emergency Department that was located outside of the Emergency department that is located such that it will direct individuals to exit into the Emergency Department through a set of double doors that open up against the path of egress. The Emergency Department doors are not a part of the required exiting systems and that the exit sign was not the correct directional sign that is needed to direct egress traffic towards the required exit and exit discharge.


This deficient practices was confirmed by the Maintenance Supervisor (SG).

Based on observation and staff interview, it was revealed that the facility had 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 7.1. This deficient condition could adversely affect the functioning of the fire alarm system, and could delay the timely notification and emergency actions for the facility thus negatively affecting patients, staff, and visitors of the facility.


Findings include:

On facility tour between 9:00 AM and 5:30 PM on 09/23/2014, the following deficient conditions were found affecting the facility's fire alarm system.

1. During the facility walk through it was noted that the smoke detectors that were found in the physician on call room, in the OB department, and in numerous other location throughout the facility had smoke detectors that were installed within 36 inches of HVAC diffusers.

2. During the facility walk through it was noted that there was a smoke detector base located in the Medical Market storage room that was missing the smoke detector head. all fire safety equipments that is in place must be maintained according to code.

3. During the facility walk through it was noted that the room where the main fire alarm control panel was not protected by smoke detection located within 5 feet of the panel.


This deficient practices was confirmed by the Maintenance Supervisor (SG).

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). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect patients, visitors and staff of the facility.

Findings include:

On facility tour between 9:00 AM and 5:30 PM on 09/23/2014, observations reveled the following deficient conditions affecting the fire sprinkler system:

1. During the facility walk through it was noted that the sprinkler heads were being blocked by linen carts that are being stored in the alcoves located in the outpatient services department. The carts are covered with a water shedding cover type of cover that will divert the water pattern of the fire sprinkler head that is located above the carts. The height of the carts has placed the covered tops of the carts within 18 inches of the fire sprinkler head that is located in the alcoves outside of patient rooms 8 and 9.

2. During the facility walk through it was noted that in the lower level electrical room there was a support bracket that is not part of the fire sprinkler system attached to the fire sprinkler piping that was being used to support electrical conduit.


This deficient practices was confirmed by the Maintenance Supervisor (SG).

Observations and staff interview revealed that compressed gases storage room was not in accordance with NFPA 99 Health Care Facilities edition 1999. Improperly location of electric al equipment can be damaged by compressed gas cylinder and create an ignition hazard in the storage room. this deficient condition can the patients, staff and visitors of the facility.


Findings include:
On facility tour between 9:00 AM and 5:30 PM on 09/23/2014, it was observed that the light switch that was located in the compressed gas storage room was installed lower than 5 feet above the surface of the floor.

This deficient practices was confirmed by the Maintenance Supervisor (SG).

Based on observations and staff interview, the facility has failed to correctly position 1 of several operational exit signs that marks the means of egress path in accordance with NFPA Life Safety Code 101 (2000 edition), Sec. 7.10.5.2. This deficient practice could negatively affect patients staff and visitors, if the lack of properly positioned exit signs could misdirect and prevented a means of egress from being utilized in a timely manner in an emergency situation.

Findings include:

On facility tour between 9:00 AM and 5:30 PM on 09/23/2014, it was observed that the exit sign in the corridor servicing the Patient Care wing, OR Suite, and the Emergency Department that was located outside of the Emergency department that is located such that it will direct individuals to exit into the Emergency Department through a set of double doors that open up against the path of egress. The Emergency Department doors are not a part of the required exiting systems and that the exit sign was not the correct directional sign that is needed to direct egress traffic towards the required exit and exit discharge.


This deficient practices was confirmed by the Maintenance Supervisor (SG).

Based on observation and staff interview, it was revealed that the facility had 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 7.1. This deficient condition could adversely affect the functioning of the fire alarm system, and could delay the timely notification and emergency actions for the facility thus negatively affecting patients, staff, and visitors of the facility.


Findings include:

On facility tour between 9:00 AM and 5:30 PM on 09/23/2014, the following deficient conditions were found affecting the facility's fire alarm system.

1. During the facility walk through it was noted that the smoke detectors that were found in the physician on call room, in the OB department, and in numerous other location throughout the facility had smoke detectors that were installed within 36 inches of HVAC diffusers.

2. During the facility walk through it was noted that there was a smoke detector base located in the Medical Market storage room that was missing the smoke detector head. all fire safety equipments that is in place must be maintained according to code.

3. During the facility walk through it was noted that the room where the main fire alarm control panel was not protected by smoke detection located within 5 feet of the panel.


This deficient practices was confirmed by the Maintenance Supervisor (SG).

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). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that would affect patients, visitors and staff of the facility.

Findings include:

On facility tour between 9:00 AM and 5:30 PM on 09/23/2014, observations reveled the following deficient conditions affecting the fire sprinkler system:

1. During the facility walk through it was noted that the sprinkler heads were being blocked by linen carts that are being stored in the alcoves located in the outpatient services department. The carts are covered with a water shedding cover type of cover that will divert the water pattern of the fire sprinkler head that is located above the carts. The height of the carts has placed the covered tops of the carts within 18 inches of the fire sprinkler head that is located in the alcoves outside of patient rooms 8 and 9.

2. During the facility walk through it was noted that in the lower level electrical room there was a support bracket that is not part of the fire sprinkler system attached to the fire sprinkler piping that was being used to support electrical conduit.


This deficient practices was confirmed by the Maintenance Supervisor (SG).

Observations and staff interview revealed that compressed gases storage room was not in accordance with NFPA 99 Health Care Facilities edition 1999. Improperly location of electric al equipment can be damaged by compressed gas cylinder and create an ignition hazard in the storage room. this deficient condition can the patients, staff and visitors of the facility.


Findings include:
On facility tour between 9:00 AM and 5:30 PM on 09/23/2014, it was observed that the light switch that was located in the compressed gas storage room was installed lower than 5 feet above the surface of the floor.

This deficient practices was confirmed by the Maintenance Supervisor (SG).