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Based on record review and staff interview, it was determined that the facility failed to properly maintain the automatic sprinkler system as required as evidenced by lack of documentation for timely quarterly inspection and testing. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings:

During the record review process between 10:30 am and 3:00 pm on 03/22/2016 with the Maintenance Director, it was revealed that there was no documentation for inspection and testing of the automatic sprinkler system between 07/15/2015 and 12/30/2015. Documentation provided during survey was dated 01/27/2015, 04/28/2015, 07/15/2015, and 12/30/2015.

During the Staff Interview between 10:30 am and 3:00 pm on 03/22/2016, the Maintenance Director acknowledged there was no documentation for inspection and testing of the automatic sprinkler system between 07/15/2015 and 12/30/2015. He was unable to provide any additional documentation during survey.

NFPA 101 (2000 Edition) 19.3.5
NFPA 25 (1998 Edition) Table 2-1

Based on observations and staff interview, it was determined that the facility failed to properly maintain the medical gas storage as required as evidenced by 16 oxygen cylinders stored with other combustibles. This deficiency could affect occupants of the facility in case of a fire or other emergency.

Findings:

During the Life Safety tour of the facility at 3:40 pm on 03/22/2016 with the Maintenance Director, it was revealed that there were 16 oxygen cylinders stored with other combustibles in the Clean Work Room.

During the Staff Interview at 3:40 pm on 03/22/2016, the Maintenance Director acknowledged that there were 16 oxygen cylinders stored with other combustibles in the Clean Work Room.

NFPA 101 (2000) 19.3.2.4
NFPA 99 (1999) 4-3.1.1.2, 8-3.1.11.1