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Based on observation and interview, it was determined the facility failed to maintain their piped-in medical gas system throughout the facility.

Findings include:

1. Observation on August 26, 2014, revealed the facilities most recent medical gas alarm inspection indicated a deficiency stating that the dew point was 45 degrees and the maximum allowable was 35 degrees. There was no documentation indicating this deficiency was corrected.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the medical gas issue.
**Note: During the revisit on November 10, 2014, at 10:30 a.m. item 1 was observed to have not been completed.

Interview with the Director of Operation of Plant on November 10, 2014, at 1:00 p.m. confirmed the medical gas deficiency.

Based on observation and interview, it was determined the facility failed to maintain their piped-in medical gas system throughout the facility.

Findings include:

1. Review of documentation on August 26, 2014, revealed the facility's most recent medical gas alarm inspection indicated a deficiency stating that the dew point was 45 degrees and the maximum allowable was 35 degrees. There was no documentation indicating this deficiency was corrected.

Interview with the facility administrator and maintenance director on August 26, 2014, at 1:30 p.m., confirmed the medical gas issue.

**Note: During the revisit on November 10, 2014, at 10:30 a.m. item 1 was observed to have not been completed.

Interview with the Director of Operation of Plant on November 10, 2014, at 1:00 p.m. confirmed the medical gas deficiency.