HospitalInspections.org

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The facility failed to maintain the interior finish per code. Findings include:

During the survey the following are examples of what was observed:
The following rooms were observed with wood paneling, the facility failed to provide flame spread documentation:
1. X-ray Room One - all walls full height
2. Chapel - all walls full height
3. Registration Office - all walls 4'-0" high
4. Administration Office - all walls full height

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2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
(2) Newly installed materials - Class A
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The facility failed to maintain the corridor walls per code. Findings include:

During the survey, the following are examples of what was observed:
1. Unsealed sleeve penetrations were observed throughout this part of the building
2. At room 204 unsealed penetration of a pipe and HVAC duct
3. Between rooms 314 and 312 a piece of wood was observed stuck in a penetration

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2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 19.3.6.2.2 Corridor walls shall form a barrier to limit the transfer of smoke.

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The facility failed to maintain the exit signs per code. Findings include:

During the survey, the following is an example of what was observed:
The exit sign at room 300 had indicating arrows directing the path of travel into either room on each side of the exit door

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2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
1. The smoke barrier did not go to the roof deck and had a wood member unprotected at the following locations:
a. In the corridor at the Waiting Room
b. In the Waiting Room
2. The smoke barrier in the Waiting Room was observed with an unsealed penetration below the ceiling

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2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:a. It shall be filled with a material that is capable of limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were over 50 sq. ft. and had combustibles stored in them:
1. The Old Nursery:
a. Had vision panels (could not verify rating)
b. Door was not 45 minute rated
c. Door did not have positive latching hardware
2. The following rooms did not have a 45 minute rated door and the door was not self closing:
a. Room 318
b. Room 320
c. Room 200

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
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The facility failed to maintain the emergency lighting per code. Findings include:

During the survey the following is an example of what was observed:
The battery operated emergency lighting in the MRI unit failed to illuminate when tested. The MRI Unit was not connected to the generator, instead it was observed with battery operated emergency lighting.

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2000 NFPA 101, 7.9.2.1 Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.
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The facility failed to maintain the exit signs per code. Findings include:

During the survey, the following is an example of what was observed:
The exit sign in the C.T. Unit was not illuminated

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2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
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The facility failed to maintain the smoke detectors per code. Findings include:

During the survey, the following is an example of what was observed:
The last documented sensitivity test provided by the facility had a date of 05/19/2011.

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1999 NFPA 72, 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
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The facility failed to provide an automatic sprinkler system per code. Findings include:

During the survey the following are examples of what was observed:
This building does not require automatic sprinkler coverage due to the construction type, but the surveyor observed the following:
1. Galvanized pipe used for the automatic sprinkler pipe, this pipe was tied into the other buildings automatic sprinkler pipe system (which is required)
2. Improper hangers, used wire to secure the pipe
3. A shut off valve was observed where this building ties into building 0102:
a. The shut off valve was observed in the off position
b. The shut off valve was not electronically monitored

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2000 NFPA 101, 9.7.1.4 Automatic sprinkler systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code that apply to required systems.
2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
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The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following are examples of what was observed:
1. The following areas were observed with external loads by materials either resting on the pipe or hung from the automatic sprinkler pipes
a. The Radiology Room between the two X-ray Rooms had data lines
b. Above the ceiling in the corridor at the Waiting Room - wires and cables attached and laying on
2. The facility failed to provide documentation of testing the Halogen Fire Suppression System in the MRI Unit
3. The facility failed to provide proper signage (FDC) for the exterior of the building at connection to riser
4. The facility failed to provide required documentation of maintenance of anti-freeze system
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1998 NFPA 25, 2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
1998 NFPA 25, 1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1998 NFPA 25, 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1998 NFPA 25, 1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
1998 NFPA 25, 1-9.1 System components shall be inspected at intervals specified in the appropriate chapters.
1998 NFPA 25, 9-7.1
Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly

1998 NFPA 25, 2-3.4* Antifreeze Systems.
The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary. Solutions shall be in accordance with Tables 2-3.4(a) and (b).
The use of antifreeze solutions shall be in accordance with any state or local health regulations. [See Table 2-3.4(b).]
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
The MRI unit's fire extinguishers:
1. One fire extinguisher's last inspection date was 2007
2. The other fire extinguisher did not have a tag on it or any where else

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1998 NFPA 10, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

1998 NFPA 10, 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following are examples of what was observed:
The Outside Oxygen Storage Area:
1. No "No Smoking" signs
2. Two unsecured oxygen cylinders
3. Empty and full oxygen cylinders were not separated and did not have the signage required by code

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1999 NFPA 99, 8-3.8-3.1.11.3 A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
1999 NFPA 99, 4-5.5.2.2 Storage of Cylinders and Containers
(a) Facility authorities, in consultation with facility staff and other trained personnel, shall provide and enforce regulations for the storage and handling of cylinders and containers of oxygen and nitrous oxide in storage rooms of approved construction, and for the safe handling of these agents in treatment locations.
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
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The facility failed to provide a generator per code. Findings include:

During the survey, the following is an example of what was observed:
The generator remote annunciator had an indicator light for "not in auto" . When this was tested the generator remote annunciator visual indicating light below the "not in auto" indicating light was illuminated.

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1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
1999 NFPA 110, 3-5.6.1
A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

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The facility failed to maintain the following electrical requirements per code. Findings include:

During the survey, the following is an example of what was observed:
The cover plates were missing for three electrical junction boxes located in Hall 200 at fire doors above ceiling.
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1999 NFPA 70, 370-25 Covers and Canopies In completed installations, each box shall have a cover, faceplate, or fixture canopy.

1999 NFPA 70, 410-12. Outlet Boxes to Be Covered In a completed installation, each outlet box shall be provided with a cover unless covered by means of a fixture canopy, lampholder, receptacle, or similar device.

1999 NFPA 70, 370-28. Pull and Junction Boxes
Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(a) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

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The facility failed to maintain the interior finish per code. Findings include:

During the survey the following are examples of what was observed:
The following rooms were observed with wood paneling, the facility failed to provide flame spread documentation:
1. X-ray Room One - all walls full height
2. Chapel - all walls full height
3. Registration Office - all walls 4'-0" high
4. Administration Office - all walls full height

________________

2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
(2) Newly installed materials - Class A
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The facility failed to maintain the corridor walls per code. Findings include:

During the survey, the following are examples of what was observed:
1. Unsealed sleeve penetrations were observed throughout this part of the building
2. At room 204 unsealed penetration of a pipe and HVAC duct
3. Between rooms 314 and 312 a piece of wood was observed stuck in a penetration

_________________

2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 19.3.6.2.2 Corridor walls shall form a barrier to limit the transfer of smoke.

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The facility failed to maintain the exit signs per code. Findings include:

During the survey, the following is an example of what was observed:
The exit sign at room 300 had indicating arrows directing the path of travel into either room on each side of the exit door

____________

2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
1. The smoke barrier did not go to the roof deck and had a wood member unprotected at the following locations:
a. In the corridor at the Waiting Room
b. In the Waiting Room
2. The smoke barrier in the Waiting Room was observed with an unsealed penetration below the ceiling

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2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
2000 NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:a. It shall be filled with a material that is capable of limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were over 50 sq. ft. and had combustibles stored in them:
1. The Old Nursery:
a. Had vision panels (could not verify rating)
b. Door was not 45 minute rated
c. Door did not have positive latching hardware
2. The following rooms did not have a 45 minute rated door and the door was not self closing:
a. Room 318
b. Room 320
c. Room 200

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2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
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The facility failed to maintain the emergency lighting per code. Findings include:

During the survey the following is an example of what was observed:
The battery operated emergency lighting in the MRI unit failed to illuminate when tested. The MRI Unit was not connected to the generator, instead it was observed with battery operated emergency lighting.

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2000 NFPA 101, 7.9.2.1 Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.
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The facility failed to maintain the exit signs per code. Findings include:

During the survey, the following is an example of what was observed:
The exit sign in the C.T. Unit was not illuminated

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2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
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The facility failed to maintain the smoke detectors per code. Findings include:

During the survey, the following is an example of what was observed:
The last documented sensitivity test provided by the facility had a date of 05/19/2011.

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1999 NFPA 72, 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
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The facility failed to provide an automatic sprinkler system per code. Findings include:

During the survey the following are examples of what was observed:
This building does not require automatic sprinkler coverage due to the construction type, but the surveyor observed the following:
1. Galvanized pipe used for the automatic sprinkler pipe, this pipe was tied into the other buildings automatic sprinkler pipe system (which is required)
2. Improper hangers, used wire to secure the pipe
3. A shut off valve was observed where this building ties into building 0102:
a. The shut off valve was observed in the off position
b. The shut off valve was not electronically monitored

_____________

2000 NFPA 101, 9.7.1.4 Automatic sprinkler systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code that apply to required systems.
2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
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The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following are examples of what was observed:
1. The following areas were observed with external loads by materials either resting on the pipe or hung from the automatic sprinkler pipes
a. The Radiology Room between the two X-ray Rooms had data lines
b. Above the ceiling in the corridor at the Waiting Room - wires and cables attached and laying on
2. The facility failed to provide documentation of testing the Halogen Fire Suppression System in the MRI Unit
3. The facility failed to provide proper signage (FDC) for the exterior of the building at connection to riser
4. The facility failed to provide required documentation of maintenance of anti-freeze system
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1998 NFPA 25, 2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
1998 NFPA 25, 1-8* Records.
Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1998 NFPA 25, 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1998 NFPA 25, 1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
1998 NFPA 25, 1-9.1 System components shall be inspected at intervals specified in the appropriate chapters.
1998 NFPA 25, 9-7.1
Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly

1998 NFPA 25, 2-3.4* Antifreeze Systems.
The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary. Solutions shall be in accordance with Tables 2-3.4(a) and (b).
The use of antifreeze solutions shall be in accordance with any state or local health regulations. [See Table 2-3.4(b).]
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The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following is an example of what was observed:
The MRI unit's fire extinguishers:
1. One fire extinguisher's last inspection date was 2007
2. The other fire extinguisher did not have a tag on it or any where else

_____________

1998 NFPA 10, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

1998 NFPA 10, 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

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The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following are examples of what was observed:
The Outside Oxygen Storage Area:
1. No "No Smoking" signs
2. Two unsecured oxygen cylinders
3. Empty and full oxygen cylinders were not separated and did not have the signage required by code

____________

1999 NFPA 99, 8-3.8-3.1.11.3 A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
1999 NFPA 99, 4-5.5.2.2 Storage of Cylinders and Containers
(a) Facility authorities, in consultation with facility staff and other trained personnel, shall provide and enforce regulations for the storage and handling of cylinders and containers of oxygen and nitrous oxide in storage rooms of approved construction, and for the safe handling of these agents in treatment locations.
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
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The facility failed to provide a generator per code. Findings include:

During the survey, the following is an example of what was observed:
The generator remote annunciator had an indicator light for "not in auto" . When this was tested the generator remote annunciator visual indicating light below the "not in auto" indicating light was illuminated.

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1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
1999 NFPA 110, 3-5.6.1
A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

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The facility failed to maintain the following electrical requirements per code. Findings include:

During the survey, the following is an example of what was observed:
The cover plates were missing for three electrical junction boxes located in Hall 200 at fire doors above ceiling.
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1999 NFPA 70, 370-25 Covers and Canopies In completed installations, each box shall have a cover, faceplate, or fixture canopy.

1999 NFPA 70, 410-12. Outlet Boxes to Be Covered In a completed installation, each outlet box shall be provided with a cover unless covered by means of a fixture canopy, lampholder, receptacle, or similar device.

1999 NFPA 70, 370-28. Pull and Junction Boxes
Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(a) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.