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The inspector observed, while accompanied by the Lead Technician and the Director of Quality Management during the hours of the inspection from 8:30 am to 11:30 am on 5/17/2017 that there were the following issues. In the exterior fire riser room the spare sprinkler head box was missing the required sprinkler wrench.
Red Head Box: ''A supply of at least six spare sprinklers shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be replaced promptly. A minimum of two sprinklers of each type and temperature rating should be provided. For protected facilities having 300 to 1000 sprinklers, no fewer than 12 sprinklers shall be provided, and for over 1000 sprinklers, no fewer than 24 sprinklers. One sprinkler wrench shall be kept in the cabinet for each sprinkler type.'' - NFPA 13, 2002: 6.2.9 and Appendix

The inspector observed, while accompanied by the Lead Technician and the Director of Quality Management during the hours of the inspection from 8:30 am to 11:30 am on 5/17/2017 that there were the following issues. In the kitchen, a class ABC fire extinguisher was too close to the areas where grease fires could start, and the class K fire extinguisher was too far from the areas where grease fire could start.
Class K fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats) - NFPA 10, 2002: 5.7.1. Maximum travel distance shall not exceed 30 ft from the hazard to the extinguishers - NFPA 10, 2002: 5.7.2.

The inspector observed, while accompanied by the Lead Technician and the Director of Quality Management during the hours of the inspection from 8:30 am to 11:30 am on 5/17/2017 that there were the following issues. The electrical room located near the doctor's parking area had a rated wall penetration that needed to be sealed.

The inspector observed, while accompanied by the Lead Technician and the Director of Quality Management during the hours of the inspection from 8:30 am to 11:30 am on 5/17/2017 that there were the following issues. Documentation that the following requirements are being met. Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

The inspector observed, while accompanied by the Lead Technician and the Director of Quality Management during the hours of the inspection from 8:30 am to 11:30 am on 5/17/2017 that there were the following issues. The emergency generator did not have receptacles available for generator maintenance.
''The emergency system shall supply power for lighting, receptacles, and equipment as follows: (6) Task illumination and selected receptacles at the generator set location.'' NFPA 99, 2002, 4.5.2.2.2.

The inspector observed, while accompanied by the Lead Technician and the Director of Quality Management during the hours of the inspection from 8:30 am to 11:30 am on 5/17/2017 that there were the following issues. Outside the outdoor generator there was a j-box for the lighting that did not have a cover plate on it. This left the wiring exposed to the elements.

The inspector observed, while accompanied by the Lead Technician and the Director of Quality Management during the hours of the inspection from 8:30 am to 11:30 am on 5/17/2017 that there were the following issues.

In the medical gas cylinder storage area, the cylinders were not secured per the following requirements.
All medical gas cylinders (including E cylinders) must be physically supported, either in a stand or rack or chained or strapped to the wall. This requirement is intended to prevent mechanical hazards caused by a sudden release of gas if a tank falls over. Here, cylinders secured by chains shall not be secured more than two per section of chain.

In the medical gas storage area there were some copper gas lines that needed to be isolated from touching dissimilar metals per the following requirements.
''Copper medical gas piping shall be separated or insulated from dissimilar metal piping and supports to prevent bimetallic electrolyte action.'' - NFPA 99, 2002: 5.1.10.6.4

The inspector observed, while accompanied by the Lead Technician and the Director of Quality Management during the hours of the inspection from 8:30 am to 11:30 am on 5/17/2017 that there were the following issues. Documentation that the following features of fire protection and fire loss prevention in operating rooms were not available for review.
Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99)