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Based on observation, not all portions of the building's fire alarm system are installed as required. This deficient practice could affect patients, staff, and visitors in the building because they could be unaware of a fire condition if the fire alarm system is not properly installed.

The finding is:

On 09/23/2024 at 11:20AM while in the company of the FM, it was observed that the 6th floor exit passageway serving the exit stair lacked a manual pull station within 5' of the passageway entry door to comply with NFPA 72-2010, 17.14.6.

Based on observation, staff interview, and document review the facility failed to provide maintenance of equipment within the ventilation system. Failure to install and maintain equipment could result in system failure. This deficient practice may affect patients, staff and visitors by not providing adequate ventilation within the environment during a fire smoke incident.

Findings include:

On 09/23/2024 while in the company of the FM, the surveyor observed multiple portible chiller units thorugh out the facility located within the means of egress. The FM indicated failure of the main chiller unit and subsequent replacement. However, multiple portable chiller units were observed within corridors and other means of egress. There was no documentation available concerning the installation of the new unit. This condition does not comply with NFPA 90A - 2012, 4.2.4, ASHRAE/ASHE standard 170 2008 Section 4, 6.1 and NFPA 101 9.2.1