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BIG SOUTH FORK MEDICAL CENTER
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on record review and interview, the facility failed to inspect, test and maintain the automatic sprinkler system per the requirements of:
NFPA 101 2012 Ed. 19.3.5.1, 9.7, 9.7.5
NFPA 25 2011 Ed. Table 5.1.1.2
The findings include:
Record review and interview with the maintenance director on 6/7/18 at 10:00 AM revealed the last sprinkler inspection, test and maintenance was conducted on 11/9/17.
The administrator acknowledged the deficiency during the exit conference on 6/7/18.
Elevators
Tag No.: K0531
Based on observation, record review and interview, the facility failed to maintain all elevators per the requirements of:
NFPA 101 2012 Ed. 19.5.3, 9.4, 9.4.6.1, 9.4.6.3
The findings include:
1. Observation, record review and interview with the maintenance director on 6/7/18 at 10:20 AM failed to maintain elevators by following periodic inspections and tests. North elevator is a month past due for inspection due to facility not providing payment the contract company that provides testing and maintenance.
2. Observation, record review and interview with the maintenance director on 6/7/18 at 10:20 AM failed to maintain elevators by following periodic inspections and tests. South elevator has been locked and tagged out of service by the State Elevator inspector since 5/18/17.
The administrator acknowledged the deficiencies during the exit conference on 6/7/18.
Electrical Systems - Other
Tag No.: K0911
Based on record review and interview, the facility failed to conduct all electrical receptacle testing per the requirements of:
NFPA 101 2012 Ed. 19.7.6, 4.6.12, 4.6.12.1
NFPA 99 2012 Ed. 6.3.3.2.4
The findings include:
Record review and interview with the maintenance director on 6/7/18 at 10:45 AM revealed the retention force of the grounding blade for electrical receptacles is not being tested.
The administrator acknowledged the deficiency during the exit conference on 6/7/18.
Electrical Systems - Essential Electric Syste
Tag No.: K0918
Based on record review and interview, the facility failed to conduct all testing procedures on the generator per the requirements of:
NFPA 101 2012 Ed. 19.7.6, 4.6.12, 4.6.12.1
NFPA 110 2010 Ed. 8.4.2.3
The findings include:
Record review and interview with the maintenance director on 6/7/18 at 10:35 AM revealed the annual load bank testing is past due this year's test. Last annual load bank test was 4/20/17.
The administrator acknowledged the deficiency during the exit conference on 6/7/18.