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Based on the observation during the survey on 07/16/2015, the facility failed to maintain the following systems. Findings include:

Per documentation and interview the facility had not corrected the comments and recommendations from the Medical Gas Report dated 05/28/2015.
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Review of 1999 NFPA 99, 5-4.1.2 Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion.

Review of 2000 NFPA 101, 19.3.4.2 Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.

Review of 1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.
(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.
(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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