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Based on document review and staff interview, the facility failed to test and maintain the fire alarm system at required intervals.

On 9/11/23 the fire alarm system testing and maintenance records were reviewed. Annual fire alarm system inspections were documented, but there were no records of items being inspected or tested between annual fire alarm system inspections, such as duct detectors and fire alarm batteries.

NFPA 72, National Fire Alarm and Signaling Code 2010 edition defines frequencies at which the fire alarm system must be inspected, tested, and maintained. In addition to annual frequencies there are certain items that must be inspected, tested, or maintained at more frequent intervals. These are listed in the tables of NFPA 72.

The finding was reviewed with the Facilities Manager on 9/11/23 at 11:00 AM.

Based on document review and staff interview, the facility failed to test and maintain the sprinkler system at required intervals.

On 9/11/23 sprinkler system inspection records were reviewed. Annual and quarterly reports were documented, but there were no records of monthly gauge inspections.

NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems 2011 edition defines frequencies at which the sprinkler system must be inspected, tested, and maintained.

The finding was reviewed with the Facilities Manager on 9/11/23 at 11:00 AM.

Based on observation and staff interview, the facility failed to ensure elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators, and that existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators.

The facility was toured during the survey between 9/7/23 and 9/13/23. The Facilities Manager was interviewed on 9/13/23 at 10:00 AM related to elevator service. Existing elevators #2 and #3 do not include firefighters' service recall features. Both these elevators travel beyond 25 feet above the level that best serves the needs of emergency personnel for firefighting purposes.

On 9/13/23 documents pertaining to elevator inspections and testing were reviewed. Records did not include annual inspections for elevators #1, #4, and #5. Monthly Firefighter's Service records were also not available consistently; elevators #4 and #5 were last documented being done in May 2023, elevator #6 was last documented as being done in July 2023, elevator #7 was last documented as being done in June 2023, and elevator #1 monthly records could not be located.

The findings were reviewed with the Facilities Manager on 9/13/23 at 10:00 AM.

Based on document review and staff interview, the facility failed to provide documented evidence of a risk assessment in accordance with NFPA 99.

Findings include:

During document review throughout the survey between 9/7/23 and 9/13/23 it was determined that there was no formal documented risk assessment pertaining to the building system risk categories 1-4, as described in Chapter 4 of NFPA 99. This document was requested at the entrance conference on 9/7/23 at 10:00 AM. On 9/11/23 at 11:00 AM during document review the Facilities Manager was interviewed and could not locate a risk assessment as described in Chapter 4 of NFPA 99.

Based on observation and staff interview 4 of 5 operating rooms were not protected by either isolated power or ground-fault circuit interrupters.

Findings include:

On 9/8/23 at 3:00 PM while touring the operating rooms, it was observed that operating rooms 2, 3, 4, and 5 did not appear to have isolated power devices or ground-fault circuit interrupters. At this time the Facilities Manager was interviewed and confirmed this. During document review throughout the survey there was no risk assessment produced that would indicate the rooms were not considered wet procedure rooms.

The finding was reviewed with the Facilities Manager at the time of observation.

Based on observation and staff interview, the facility failed to provide proper storage for medical gases.

On 9/8/23 at 11:00 AM a tour of the basement floors of the facility was conducted. It was observed that some medical gas tanks were being stored indoors in a caged-in area within general space on the sub-basement floor. This space was open to an area used for washing and drying items that are laundered in house. There was estimated to be 5,000 cubic feet or more of gas. Types of gas included oxygen, nitrous, and nitrogen.

NFPA 99, Health Care Facilities Code 2012 edition defines location and safety parameters required for gas storage when gases are between 300 cubic feet and 3,000 cubic feet, as well as when gases are greater than 3,000 cubic feet.

It was also observed during the facility tour 2 oxygen tanks 251 cubic feet in volume each, a similarly sized tank of acetylene, and a smaller acetylene tank were in the boiler room. The Facilities Manager indicated these are setups for welding, but they are not typically used since the facility contracts out for welding needs now.

In addition to the gas storage requirements described above, flammable gases such as acetylene shall not be stored in rooms with gas cylinders.

These findings were reviewed with the Facilities Manager at the time of observation.