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Based on observations during the facility walk through on 08/17/2010 with the plant maintenance supervisor, it was noted that the Fire Sprinkler system maintenance was last documented on 07/21/2009. This was based on the most recent tags connected on the main fire sprinkler connections. NFPA 13 and 25 require that fire sprinkler piping be inspected annually and all alarm devices be inspected/tested quarterly.

Based on observation during the onsite walk through of the facility on 08/17/2010 with the maintenance supervisor and safety officer, it was noted that the nitros oxide medical gas tanks at the manifold location were not individually secured to protect cylinders from accidental damage or dislocation as required under NFPA 99 (1999)4-3.1.1.2(a)3. Chains provided at the location for this purpose were hanging free and loose.

Based on observation during the onsite walk through of this facility on 08/17/2010, with the maintenance supervisor, it was noted that the medical air compressor lacked any piping for source air located so that it could draw from a clean fresh air location as required by NFPA 99. the medical air compressor was located within the main mechanical boiler space, with no apparent connection to an ouside source for fresh air. NFPA 99 requires that thefreash air intake be located outdoors above the roof level, at a minimum distance of 10 feet from any door, window, exhaust, other intake, or opening in the building and a minim um distance of 20 feet above the ground.

Based on review of the documentation and discussions with the maintenance supervisor during this survey of 08/17/2010, it was noted that the load testing for the emergency generator has not been documented since 2008. the hospital's written policy stated that the generator was to be tested under 20% load quarterly plus a full load test annually. However no documentation was available on generator testing for two years (since 2008). Note that the 2008 load test documentation did not state the length of time the generator was under full load. Annual load testing shall be under full load for a minimum of 4 hours. Monthly load testing on at least 30% capacity for 30 minutes may be substituted for the annualy load test if documented.

Based on observations during the facility walk through on 08/17/2010 with the plant maintenance supervisor, it was noted that the Fire Sprinkler system maintenance was last documented on 07/21/2009. This was based on the most recent tags connected on the main fire sprinkler connections. NFPA 13 and 25 require that fire sprinkler piping be inspected annually and all alarm devices be inspected/tested quarterly.

Based on observation during the onsite walk through of the facility on 08/17/2010 with the maintenance supervisor and safety officer, it was noted that the nitros oxide medical gas tanks at the manifold location were not individually secured to protect cylinders from accidental damage or dislocation as required under NFPA 99 (1999)4-3.1.1.2(a)3. Chains provided at the location for this purpose were hanging free and loose.

Based on observation during the onsite walk through of this facility on 08/17/2010, with the maintenance supervisor, it was noted that the medical air compressor lacked any piping for source air located so that it could draw from a clean fresh air location as required by NFPA 99. the medical air compressor was located within the main mechanical boiler space, with no apparent connection to an ouside source for fresh air. NFPA 99 requires that thefreash air intake be located outdoors above the roof level, at a minimum distance of 10 feet from any door, window, exhaust, other intake, or opening in the building and a minim um distance of 20 feet above the ground.

Based on review of the documentation and discussions with the maintenance supervisor during this survey of 08/17/2010, it was noted that the load testing for the emergency generator has not been documented since 2008. the hospital's written policy stated that the generator was to be tested under 20% load quarterly plus a full load test annually. However no documentation was available on generator testing for two years (since 2008). Note that the 2008 load test documentation did not state the length of time the generator was under full load. Annual load testing shall be under full load for a minimum of 4 hours. Monthly load testing on at least 30% capacity for 30 minutes may be substituted for the annualy load test if documented.