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Based on observation, the facility failed to provide information on the automatic sprinkler system per the requirements of:

2012 NFPA 101, 4.6.12.3, 4.6.12.2, 18.3.5.1, and 9.7.1.1 (1)
2010 NFPA 13, 7.6.1.4, 7.6.1.5, TIA 10-2, 6.2.7.1, 6.2.7.2, 8.3.3.2, and 8.3.3.4

This deficiency affects the complete automatic sprinkler system.

Findings include:

During a tour of the facility, the surveyor observed the following:

1. The facility failed to have a placard mounted on the wet system riser feeding the remote antifreeze system for the courtyard. This placard shall indicate the following:

a. The number of all remote antifreeze systems supplied by that riser

b. The location of all remote antifreeze systems supplied by that riser

2. The facility failed to have a placard mounted on the main valve of the courtyard antifreeze system. This placard shall indicate the following:

a. The manufacture type and brand of the antifreeze solution

b. The volume of anti-freeze solution used in the system

3. During a tour of the facility, the surveyor observed 1 recessed ceiling automatic sprinkler head in Office 253 (100 Hall) with their escutcheon plates not in place.

4. During a tour of the facility, the surveyor observed five quick-response sprinkler heads installed in the same compartment (Radiology Hall) with five standard-response sprinkler heads.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 4.6.12.3, 4.6.12.2, 18.3.5.1, 9.7.5, and 9.7.8
2011 NFPA 25, 5.3.4, TIA 11-1, TIA 11-2, TIA 11-3, TIA 11-4, 15.3.1, 15.3.2, and 5.2.2.2

This deficiency affects the automatic sprinkler system.

Findings include:

During a tour of the facility, the surveyors observed the following:

1. The facility failed to provide documentation indicating the existing antifreeze solution had been drained and replaced with the new required premixed antifreeze solution.


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2. The facility failed to provide a tag, posted on the valve, indicating the antifreeze system at the Laundry Room (Old Loading Dock) had been removed from service.

3. Seven orange cables and one red cable (external loads) resting on the automatic sprinkler pipe above the ceiling near the 100 Hall Nurses' Station.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the electrical wiring and equipment per the requirements of:

2012 NFPA 101, 19.5.1.1, and 9.1.2
2011 NFPA 70, 110.26(A)(1), and Table 110.26(A)(1)

This deficiency affects 1 of 6 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed 2 stacks of cardboard boxes stored within 3' of the electrical panel in the Diaper Room. The stacks were as follows: broken down boxes - 3'-0" high and cardboard boxes with stuff in them - 4'-0" high and were in front of and to the side of the panel, with oly 18" of work space in between them.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation, the facility failed to prohibit a portable space heating device per the requirements of:

2012 NFPA 101, 19.7.8

This deficiency affects 1 of 6 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed a portable space heating device under a desk in the Housekeeping Supervisor's Office. The space heating device was not on or plugged in. The facility was unable to provide documentation that the heating element did not exceed 212 degrees.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the testing of the emergency generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3
2010 NFPA 110, 8.3.7.1

This deficiency affects 1 of 1 generator.

Findings include:

During a tour of the facility, the facility failed to provide documentation of performing monthly testing and recording of electrolyte specific gravity or conductance on the facility's emergency generator's battery for the past 12 months.

A member of the maintenance staff was present when this deficiency was identified.

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Based on review of documentation, the facility failed to maintain the testing of the emergency generators per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3
2010 NFPA 110, 8.3.7.1

This deficiency affects 2 of 2 generators.

Findings include:

During the review of the documentation, the facility failed to provide documentation of performing monthly testing and recording of electrolyte specific gravity or conductance on the facility's emergency generators' batteries for the past 12 months.

A member of the maintenance staff was present when this deficiency was identified.

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Based on observation, the facility failed to maintain the electrical equipment per the requirements of:

2012 NFPA 99, 10.2.3.6, and 10.2.4
2011 NFPA 70, 400.8
S&C: 14-46-LCS

This deficiency affects 1 of 2 Operating Rooms.

Findings include:

During a tour of the facility, the surveyor observed one tourniquet machine and one operating bed (patient care related electrical equipment) plugged into a power strip that was not the CMS approved 1363A power strip for patient care related electrical equipment. This was observed in Operating Room 2.

A member of the maintenance staff was present when this deficiency was identified.