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Based on record review and interview the facility failed to ensure that disaster drill training, testing, or participating with a community based functional exercise was conducted and/or documented during the year of 2017 and up until October 2018.

Findings include:

Record review during tour on 10/09/2019 between 8:00 a.m. and 9:00 a.m. with Staff D (Emergency Preparedness Coordinator) revealed that a documented (actual) power outage occurred 10/24/2018 with the activation of the Emergency Plan. Prior to the October 2018 date there failed to be documented training's or documented actual disaster events. Upon hire of Staff D in October 2018 as the EPC the facility has conducted the following trainings and exercises:
10/24/2018 Actual community power outage (1 day).
01/25/2019 Burst hot water pipe, affecting multiple locations and floors.
06/25/2019 Chipmunk Mumps, community-wide MACE (Multi-Agency Community Exercise) drill.
08/15/2019 Active shooter (actual) full facility lookdown.
09/18,19/2019 MACE tabletop training's.

Interview with Staff D could only verify the last 12 month's of documentation.

NFPA 80 Standard for Fire Doors and Other Opening Protective's (2010 edition)
4.2.1 Listed items shall be identified by a label.
4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ (Authority Having Jurisdiction) after installation of the assembly.
4.2.3 The label or listing shall be considered evidence that samplings of such devices or materials have been evaluated by tests and that such devices or materials are produced under an in-plant, follow-up inspection program.

Based on observations and interview the facility failed to ensure that 4, 90-minute fire rated stairwell doors could automatically close to a latched position and 3, fire rated stairwell doors are equipped with the required fire protection rating labels attached to the door slab for identification by the AHJ.

Findings include:

Observations during tour on 10/09/2019 between 10:00 a.m. and 3:30 p.m. with Staff A (Facilities Supervisor) and Staff C (Facilities Personnel) revealed the following 7 locations in which the fire doors failed to operate, be equipped with the proper hardware or be properly labeled for the fire rating:
1. The lower level stairwell fire door G-035, located between the Main Kitchen stairwell and the Building Plans storage room, failed to be equipped with an automatic door closing device and the fire rated label.
2. The lower level stairwell fire door G-033, located between the Main Kitchen stairwell and the utilities corridor, failed to automatically close to a latched position when released from the magnetic hold open device.
3. The lower level center stairwell double fire doors (I.D. # not present), located at the entrance to the utility corridor, failed to automatically close to a latched position when released from the magnetic hold open device.
4. The lower level center stairwell "EXIT"door (I.D. # not present), located between the center stairwell and the exit access corridor, failed to be equipped with the fire rated label.
5. The lower level stairwell fire door G-109, located in the X-ray department, failed to be equipped with the fire rated label.
6. The stairwell fire door, located in the Urgent Care department, failed to be equipped with the fire rated label.
7. The upper level stairwell fire door (I.D. # not present), located between the stairwell and the Main Kitchen, failed to automatically close to a latched position when released from the magnetic hold open device and failed to be equipped with the fire rated label.

Interview with Staff A and Staff C confirmed the above findings and locations of the 7 fire doors.

Based on observations and interview the facility failed to ensure that 1 vertical opening between the ground floor and the first floor was sealed to prevent the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 10/09/2019 between 11:15 a.m. and 11:30 a.m. with Staff A (Facilities Supervisor) and Staff C (Facilities Personnel) revealed a 3" hole, cored through the concrete floor from the ground level maintenance department and the 1st floor HVAC mechanical closet, located next to the Buckley Conference room. This penetration contains a 1" pipe within the unsealed penetration and will not resist the passage of smoke or the effects from fire.

Interview with Staff A and Staff B confirmed the above findings and the location.

NFPA 80 Standard for Fire Doors and Other Opening Protective's (2010 edition)
4.2.1 Listed items shall be identified by a label.
4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ (Authority Having Jurisdiction) after installation of the assembly.
4.2.3 The label or listing shall be considered evidence that samplings of such devices or materials have been evaluated by tests and that such devices or materials are produced under an in-plant, follow-up inspection program.

Based on observations and interview the facility failed to ensure that 4 doors protecting hazardous areas are equipped with automatic door closing devices and 1 door failed to be equipped with the required fire rated identification label.

Findings include:

Observations during tour on 10/09/2019 and 10/10/2019 with Staff A (Facilities Supervisor) and Staff C (Facilities Personnel) revealed the following locations in which the doors protecting hazardous areas, or exceed 50 sq. ft. failed to be equipped with an automatic door closing device or the required fire rated identification label:
1. The lower level X-ray film storage room door G-052, failed to be equipped with an automatic door closing device (hazardous).
2. The lower level Soiled Utility room door G-030, failed to be equipped with an automatic door closing device (exceeds 50 sq. ft.).
3. The lower level storage room door G-032, failed to be equipped with an automatic door closing device (exceeds 50 sq. ft.).
4. The lower level "Old Boiler Room" door, located in the Main Kitchen stairwell, failed to be equipped with an automatic door closing device that could completely close the door to a latched position. Currently the door is equipped with a single spring tension device (90 minute fire rating).
5. The Elevator Machine room door G-067, failed to be equipped with the required fire rated identification label (hazardous).


Interview with Staff A and Staff C confirmed the above findings and locations of the 5 doors protecting the hazardous or storage areas.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (2011 edition)

11.2 Inspection, Testing, and Maintenance of Fire Extinguishing Systems
11.2.1 Maintenance of the fire extinguishing systems and listed hoods containing a constant or fire actuated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction at least every 6 month's.

11.2.4 Fusible links of the metal alloy type and automatic sprinklers of the metal alloy type shall be replaced at least semiannually.

Based on record review and interview the facility failed to ensure that the Ansul suppression system (x 2) is serviced on a semi-annual basis (6 months).

Findings include:

Record review during tour on 10/08/19 between 11:15 a.m. and 12:15 p.m. with Staff A (Facilities Supervisor) and Staff C (Facilities Personnel) revealed the service vendor reports for the 2 Ansul Suppression System's in the main kitchen failed to be inspected and tested at not more than 6 month intervals (semi-annual).

The vendor report testing dates are as follows:

Suppression System # 1
07/17/2019 (7 1/2 months)
12/03/2018 (11 months +)
12/28/2017 (6 months)
06/29/2017 (7 months)
12/30/2016 (6 months)
05/31/2016 (7 months)

Suppression System # 2
07/17/2019 (7 1/2 months)
12/03/2018 (11 months +)
12/28/2017 (6 months)
06/29/2017 (7 months)
12/30/2016 (6 months)
05/31/2016 (7 months)

Interview with Staff A and Staff C confirmed the above findings.

Based on observations and interview the facility failed to ensure that 1 ABHR (Alcohol Based Hand Rub) dispenser was not placed directly over a potential ignition source.

Findings include:

Observations during tour on 10/10/2019 between 11:40 a.m. and 11:50 a.m. with Staff A (Facilities Supervisor) and Staff B (Biomedical Supervisor) revealed that 1 ABHR dispenser, was installed directly above an electrical outlet, located (approximately) near patient recovery room # 12 on the west side of the corridor.

Interview with Staff A and Staff B confirmed the above findings and location.

Based on observations and interview the facility failed to ensure that 4 locations are protected with proper sprinkler coverage.

Findings include:

Observations during tour on 10/10/2019 between 10 :00 a.m. and 2:00 p.m. with Staff A (Facilities Supervisor and Staff B (Biomedical Supervisor) the following locations and/or conditions that exist:
1. The newly created closet partition wall, near room door 1-023, failed to be equipped with sprinkler coverage.
2. The Business office, across from the employee dinning room, door 1-066, failed to be equipped with sprinkler coverage.
3. The 2 Elevator shafts for the 1958 Elevator's could not be verified at this time to ensure adequate coverage at the top and the bottom of the shaft.

Interview with Staff A and Staff B confirmed the office and closet findings and are researching the 2 elevator shafts for proper sprinkler coverage.

NFPA 25 (2011 edition) Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems

Chapter 14 Obstruction Investigation
14.2 Internal Inspection of Piping.
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
14.2.1.1 Alternative nondestructive examination methods shall be permitted.
14.2.1.2 Tubercles or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).
14.2.1.3 If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described in section 14.3.
14.2.1.4 Non-metallic pipe shall not be required to be inspected internally.
14.2.1.5 In dry pipe systems and pre-action systems, the sprinkler removed shall be from the most remote branch line from the source of water that is not equipped with the inspector's test valve.


Based on record review and interview the facility failed to ensure that the sprinkler system "obstruction test" was completed every 5 years as required.

Findings include:

Record review during tour on 10/08/2019 between 8:00 a.m. and 10:00 a.m. with Staff A (Facilities Supervisor) and Staff C (Facilities Personnel) revealed the previous sprinkler system "obstruction tests" were conducted on 06/28/2012 with the most recent "obstruction tests" conducted on 09/20/2019, with a time span of almost 7 years and 3 month's (well beyond the every 5 year requirement).

Interview with Staff A confirmed the above findings.

NFPA 13 Standard for the Installation of Sprinkler Systems (2010 edition)

6.2.9 Stock of spare sprinklers
6.2.9.1 A supply of at least 6 spare sprinklers shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced.
6.2.9.2 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property.
6.2.9.3 The sprinklers shall be kept in a cabinet located where the temperature to which they are subject will at no time exceed 100*F.
6.2.9.4 Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required provided that a means of returning the system to service is furnished.
6.2.9.5 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:
(1) under 300 sprinklers - no fewer than 6 spares
(2) between 300 - 1000 - no fewer than 12 spares
(3) over 1000 - no fewer than 24 spares
6.2.9.6 One sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system.
6.2.9.7 A list of sprinklers installed on the property shall be posted in the sprinkler cabinet.
6.2.9.7.1 The list shall include the following:
(1) Sprinkler identification # if equipped or the manufacturer, model, orifice, deflector type, thermal sensitivity and pressure rating.
(2) General description.
(3) Quantity of each type to be contained in the cabinet.
(4) Issue or revision date of the list.

Based on observations, record review and interview the facility failed to ensure that a stock of spare sprinkler heads and service wrench's is maintained on the premises and an inventory list is maintained and current.

Findings include:

Observations during tour on 10/09/2019 and 10/10/2019 with Staff A (Facilities Supervisor), Staff B (Biomedical Supervisor) and Staff B (Facilities Personal) revealed that the facility has 3 sprinkler systems installed on the premises. After a thorough search of the property, the facilities personal was unable to locate any spare sprinklers, service wrench's, or spare sprinkler inventory lists.

Interview with Staff A, Staff B and Staff C confirmed the above findings.


NFPA 25 (2011 edition) Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems

13.4.4.2 Testing.

13.4.4.2.1 The priming water level shall be tested quarterly.
13.4.4.2.2 Each dry pipe valve shall be trip tested annually during warm weather.
13.4.4..2.2.1 Dry pipe valves protecting freezers shall be trip tested in a manner that does not introduce moisture into the piping in the freezers.
13.4.4.2.2.2 Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service.

Based on record review and interview the facility failed to ensure that documentation of a "full trip test" on the dry type sprinkler system was available to prove completion.

Findings include:

Record review during tour on 10/08/2019 and 10/09/2019 with Staff A (Facilities Supervisor) and Staff C (Facilities Personal) revealed that no documentation was available to prove if a "full trip test" had been conducted in the last 5 years.

Interview with Staff A confirmed the above finding's and documentation.

NFPA 10 Standard for Portable Fire Extinguishers (2010 edition)

7.1.2.3 Persons performing 30 day inspections shall not be required to be certified.
7.2.1.2 Fire extinguishers shall be inspected either manually or by means of an eletronic monitoring device/system at a minimum of 30 - day intervals.

Based on observations and interview the facility failed to ensure that at least 2 fire extinguishers received monthly inspections.

Findings include:

Observations during tour on 10/10/2019 between 12:15 p.m. and 12:30 p.m. with Staff A (Facilities Supervisor) and Staff B (Biomedical Supervisor) revealed at least 2 ABC fire extinguishers, located in the HVAC penthouse, failed to be inspected for the previous 4 month's.

Interview with Staff A and Staff B confirmed the above findings and locations.

NFPA 80 Standard for Fire Doors and Other Opening Protective's (2010 edition)

5.2 Inspections
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ (Authority Having Jurisdiction).

5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware
5.2.4.1 Fire door assemblies shall be visually inspected from both side to assess the overall condition of the door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and non-combustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.


Based on observations and interview the facility failed to ensure that at least 14 out of 25 patient room double door sets, for corridor access, could resist the passage of smoke or the effects from fire.

Findings include:

Observations during tour on 10/10/2019 between 11:00 a.m. and 12:20 p.m. with Staff A (Facilities Supervisor and Staff B (Biomedical Supervisor) revealed that at least 14 double door sets have a 16"side door leaf (approximately), usually left in the closed and secured position, The normal operating door leaf (approximately 36"), opens and closes against the side leaf with a rubber edge seal to complete the smoke tight seal. At least 14 pairs of doors have a rubber edge seal that has been torn or broken leaving approximately a 1/2" gap on the lower portions of the door sets and will not resist the passage of smoke or the effects from fire.

Interview with Staff A and Staff B confirmed the above findings.

Based on observations and interview the facility failed to ensure that smoke barriers are maintained to resist the passage of smoke and the effects from fire.

Findings include:

Observations during tour on 10/10/2019 between 10:00 a.m. and 2:30 p.m. with Staff A (Facilities Supervisor) and Staff B (Biomedical Supervisor) revealed at least 5 locations and conditions where the smoke barriers failed to be maintained.

These conditions and locations are as follows:

1. Electrical room (door labeled 1-173) has an unprotected penetration through the wall with a 2 1/2" PVC conduit penetrating the wall.
2. In the stairwell, above door labeled G-102 has an unprotected penetration from a sprinkler pipe penetrating the wall.
3. Next to the Elevator shaft, above the suspended ceiling, in the ground floor outpatient suite, has HVAC ductwork passing through the 1- hour fire rated barrier with unprotected penetrations on all four sides, approximately 2" gaps.
4. In the 1st floor electrical room, above the suspended ceiling, next to the rehab gym, has 2 unprotected penetrations with with metal conduit's penetrating through the side wall.

Interview with Staff A and Staff B confirmed the above findings and locations.

Based on record review and interview the facility failed to ensure that fire drills were held quarterly for each shift and at varying times for 2016, 2017, 2018, and 2019 (current).

Findings include:

Record review during tour on 10/10/2019 between 8:00 a.m. and 9:00 a.m. with Staff A (Facilities Supervisor) and Staff D (Emergency Preparedness Coordinator) revealed the fire drill records for the 3 shifts failed to conduct some of the required quarterly drills and/or failed to vary some of the fire drill times.

The fire drill times and dates are as follows:

1st shift 7:00 a.m. - 3:00 p.m.
2016 drills were completed and varied
01/31/2017 10:50 a.m.
03/31/2017 10:50 a.m.
05/09/2017 10:55 a.m.
05/18/2017 11:16 a.m.
07/31/2017 1:40 p.m.
10/13 2017 11:35 a.m.
01/31/2018 10:37 a.m.
02/24/2018 10:36 a.m.
04/06/2018 1:34 p.m.
07/03/2018 8:25 a.m.
10/22/2018 7:53 a.m.
03/08/2019 2:38 p.m.
05/28/2019 10:55 a.m.
08/06/2019 10:30 a.m.
Failure to vary drill times.

2nd shift 3:00 p.m. - 11:00 p.m.
02/11/2016 9:18 p.m.
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07/22/2016 5:55 p.m.
09/19/2016 5:17 p.m.
11/30/2016 5:36 p.m.
12/10/2016 7:49 p.m.
02/08/2017 8:41 p.m.
03/02/2017 8:05 p.m.
04/15/2017 6:44 p.m.
05/31/2017 4:11 p.m.
07/31/2017 3:40 p.m.
? ?
02/08/2018 6:28 p.m.
04/07/2018 7:00 p.m.
06/29/2018 7:45 p.m.
? ?
10/01/2018 8:02 p.m.
12/13/2018 7:42 p.m.
03/29/2019 7:14 p.m.
05/20/2019 5:00 p.m.
09/30/2019 9:10 p.m.
Failure to vary drill times and 3 missed quarterly fire drills.

3rd shift 11:00 p.m. - 7:00 a.m.
? ?
? ?
09/30/2016 11:57 p.m.
12/22/2016 4:53 a.m.
03/10/2017 11:58 p.m.
? ?
09/30/2017 11:02 p.m.
? ?
? ?
04/01/2018 5:28 a.m.
04/06/2018 1:35 a.m.
06/30/2018 11:15 p.m.
? ?
10/03/2018 1:42 a.m.
12/28/2018 5:42 a.m.
01/08/2019 12:15 a.m.
06/29/2019 11:54 p.m.
? ?
Failure to vary drill times and 7 missed quarterly fire drills

Interview with Staff A and Staff D confirmed the above findings.

NFPA 80 Standard for Fire Doors and Other Opening Protective's (2010 edition)

5.2 Inspections
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ (Authority Having Jurisdiction).

5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware
5.2.4.1 Fire door assemblies shall be visually inspected from both side to assess the overall condition of the door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and non-combustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on record review and interview the facility failed to ensure that the annual fire door inspection and testing was completed and records are available for review.

Findings include:

Record review during tour on 10/09/2019 between 8:00 a.m. and 10:00 a.m. with Staff A (Facilities Supervisor) and Staff C (Facilities Personnel) revealed that the documentation for the Environmental Safety rounds, completed for the last 4 years, does include a mention of the doors' operations located in some departments; however, a complete documented fire door inspection failed to have been conducted in the facility.

Interview with Staff A and Staff C confirmed the above findings.

NFPA 110 Standard for Emergency and Standby Power Systems

8.3.5* Transfer switches shall be subject to an annual maintenance and testing program that includes all of the following operations:
1. Checking of connections
2. Inspection or testing for evidence of overheating and excessive contact erosion
3. Removal of all dust and dirt
4. Replacement of contacts when required

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 manufacturers 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 of specific gravity when applicable or warranted.
8.3.7.2 Defective batteries shall be replaced immediately upon discovery of defects.


Based on record review and interview the facility failed to ensure that the emergency generator batteries are inspected, tested and documented on a weekly/monthly basis, the ATS (Automatic Transfer Switch) electrical panels received the annual maintenance and testing and documentation of the 36 - month, 4 hour load bank test was performed on both Emergency Generator set's (300 KW).

Findings include:

Record review during tour on 10/08/2019 and 10/10/2019 with Staff A (Facilities Supervisor) and Staff B (Biomedical Supervisor) revealed that documentation failed to be available for 2016, 2017, and 2018 for both Emergency Generators Battery banks, to verify and document the electrolyte specific gravity (documented for 2019) or if a sealed battery, the battery conductance test. The facility also failed to provide any documentation to prove the 36 - month, 4 - hour load bank test, annual ATS service, inspection, and testing for both Generator sets and ATS sets.

Interview with Staff A and Staff B confirmed that the documentation was not available for review.

Based on observations and interview the facility failed to ensure that 2 extension cords, and 2 relocateable power tabs (plug strips) were not being used as a substitute for a fixed wiring source.

Findings include:

Observations during tour on 10/09/2019 and 10/10/2019 with Staff A (Facilities Supervisor) and Staff C (Facilities Personnel) revealed 3 locations with extension cords or non-compliant relocateable power tabs in current use.

These conditions and locations are as follows:

1. Employee office, door labeled 1-048, has 1 extension cord fastened to the wall, up and around a doorway. The extension cord was found providing power to a non-compliant relocateable power tab which had 1 microwave oven and 1 refrigerator plugged in.
2. Conference room # 2, door labeled 1-072, has an extension cord with a multi-plug adaptor built in, and is being used to provide power to multiple pieces of office computer equipment. This cord was located under the desk.
3. Employee office, door labeled 1-221, has a non-compliant relocateable power tab being used to power a microwave oven and a small refrigerator.

Interview with Staff A and Staff C confirmed the above findings and locations.

NFPA 99 Health Care Facilities Code (2012 edition)

11.3.1 Storage for non-flamable gases equal to or greater than 3000 ft3 at STP (Standard Temperature and Pressure) shall comply with 5.1.3.3.2 and 5.1.3.3.3.

5.1.3.3.2 Design and Construction. Locations for central supply systems and the storage of positive pressure gases shall meet the following requirements:
(1) They shall be constructed with access to move cylinders, equipment, and so forth, in and out of the location on hand trucks complying with 11.4.3.1.1.
(2) They shall be secured with lockable doors or gates or otherwise secured.
(3) If outdoors they shall be provided with an enclosure (wall or fencing) constructed of non-combustible materials with a minimum of 2 entry/exits.
(4) If indoors, they shall be constructed and use interior finishes of non-combustible or limited combustible materials such that all walls, floors,ceilings, and doors are of a minimum 1-hour fire resistance rating.
(5) They shall be compliant with NFPA 70, National Electrical Code, for ordinary locations.

A.5.1.3.3.2(5) Electrical devices shall be physically protected, such as by use of a protective barrier around the electrical devices, such that it will avoid causing physical damage to the cylinders or containers, for example, the device could be located at or above 5 ft. above finished floor or other location that will not allow the possibillity of the cylinders or containers to come in contact with the electrical device as required by this section.

5.1.11.1.1 Piping shall be labeled by stenciling or adhesive markers that identify the patient medical gas, the support gas, and the vacuum system and include the following:
(1) Name of the gas or vaccum system or the chemical symbol.
(2) Gas or vacuum system color code per Table 5.1.11
(3) Where positive pressure gas piping systems operate at pressures other than standard guage pressure in Table 5.1.11, the operateing pressure in addition to the name of the gas.
5.1.11.2 Pipe labels shall be located as follows:
(1) At intervals not more than 20 ft.
(2) At least once in or above every room.
(3) On both sides of walls or partitions penetrated by the piping.
(4) At least once on every story in height traversed by risers.
5.1.11.1.3 Medical gas piping shall not be painted.

NFPA 55 (2010 edition)

4.11 Protection from vehicle damage.
4.11.1 Where required, guard postss or other approved means shall be provided to protect against physical damage.
4.11.1.1 Guard posts or other approved means shall be provided to protect the following areas where subject to vehicular damage:
(1) Storage tanks and connected piping, valves and fittings.
(2) Dispensing areas
(3) Use areas

4.11.1.2 Where guard posts are installed, the posts shall meet the following criteria:
(1) They shall be constructed of steel not less than 4" in. diameter and filled with concrete.
(2) They shall be spaced not more than 4' between posts on center.
(3) They shall be set not less than 3' deep in a concrete footing, not less than a 15" diameter.
(4) They shall be set with the top of the posts not less than 3' above the ground.
(5) they shall be located at not less than 5' from the tank.

Based on observation, record review and interview the facility failed to ensure that the Medical Gas manifold room (indoors) and the Bulk Oxygen Tank enclosure (outdoors) are properly maintained and protected.

Findings include:

Observations and record review during tour on 10/08/2019, 10/09/2019, and 10/10/2019 with Staff A (Facilities Supervisor) and Staff B (Biomedical Supervisor) revealed several deficiencies concerning the Medical Gas Manifold room and the Bulk Oxygen Supply enclosure that were reported on the last annual Medical Gas inspection completed on 07/18/2019.

The reported deficiencies are as follows:

Nitrous Oxide Manifold room (indoors)
1. Entrance door to the manifold room failed to have a 1-hour fire resistance rating.
2. There is an unprotected 4-gang electrical outlet box below 5 ft. from the finished floor.
3. The source valve needs to be relabeled with the name of the specific medical gas, rooms, or area served.
4. Pressure releif vent lines need to be relabeled which also includes the gas color code to distinguish itself from the medical gas pipeline.

Bulk Oxygen Systems (outdoors)
1. The Bulk Oxygen tank enclosure fails to have two points of entry/exit.
2. The Main line valve needs needs to be relabeled with the name of the specific medical gas, rooms or areas served.
3. The Piping on the bulk oxygen pad needs to be relabeled by stenciling or adhesive markers.
4. The Bulk Oxygen enclosure was found unlocked with a broken padlock hanging on the gate latch.
5. The Bulk Oxygen enclosure fails to be protected from vehicle impacts.

Medical Air Compressor
1. The source valve needs to be relabeled with the name of the specific medical gas, rooms, or areas served.
2. The Medical air inlet is not located a minimum of 20 ft above the ground.

Interview with Staff A confirmed the above findings.