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

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, Table 6.1.1.2, 5.3.2.1 and 5.2.4.1

Findings include:

A. On 05/15/2018, during a tour of the facility from 9:45 am to 3:30 pm, the facility failed to provide documentation that the standpipe system had been:

1. Flow tested within the past 5 years
2. Serviced annually with the sprinkler system, testing all standpipe valves


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B. On 05/15/2018, during a tour of the facility from 9:45 am to 3:30 pm, the facility failed to provide the following documentation on the automatic sprinkler system riser gauges:

1. Replaced or calibrated within the past 5 years (gauges were installed on 05/07/2012)
2. Monthly inspections on the wet gauges

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to install the portable fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 6.1.3.8.1

Findings include:

On 05/15/2018, during a tour of the facility from 9:45 am to 3:30 pm, the surveyor observed the portable fire extinguishers throughout facility were installed more than 5 ft. (approximately 64") from the floor to the top of the fire extinguishers.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, 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, 408.38

Findings include:

On 05/15/2018, during a tour of the facility from 9:45 am to 3:30 pm, the surveyor observed 1/2 inch open spaces in the following electrical panels (located side by side) in the Physical Therapy Mech. Room:

1. (1) space in panel EPEW
2. (3) spaces in panel LPEW

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

2012 NFPA 101, 19.7.8(1)

Findings include:

On 05/15/2018, during a tour of the facility from 9:45 am to 3:30 pm, the surveyor observed a portable space heating device beside the bed in the Doctors' Sleep Room in the West Wing.

A member of the maintenance staff was present when this deficiency was identified.
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Based on observation and interview, the facility failed to protect the liquid oxygen system per the requirements of:

2012 NFPA 99, 5.1.3.3.1.1 (3), and 5.1.3.5.12.1
2010 NFPA 55, 4.11

Findings include:

On 05/15/2018, during a tour of the facility from 9:45 am to 3:30 pm, the surveyor observed the oxygen manifold system was unprotected and subject to vehicular damage. A non-maintenance vehicle was observed parked at/on the manifold's service access pad. The facility has a 1500 gallon liquid oxygen tank and eight compressed O2 gas cylinders (reserves) in this area.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to maintain the diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.8, 8.4.1, 8.4.2, and 8.4.2.3

Findings include:

On 05/15/2018, during a tour of the facility from 9:45 am to 3:30 pm, the facility failed to provide documentation on the following:

1. Test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate kW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

2. To have a fuel quality test performed at least annually using tests approved by ASTM standards.

A member of the maintenance staff was present when this deficiency was identified.
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Based on review of documentation and interview, the facility failed to ensure the continuous training of personnel on the handling and risk of medical gases and cylinders per the requirements of:

2012 NFPA 99, 11.5.2.1

Findings include:

On 05/15/2018, during the review of documentation from 9:45 am to 3:30 pm, the facility failed to provide documentation on the continuous training of personnel for new hire and annually,on the handling and risk of medical gases and cylinders.

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