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Based on observation, the facility failed to install battery powered emergency lighting in the operating room.

Findings include :

While on tour April 24, 2013, at 12:35 PM, with the facility Maintenance Director, in the operating room, there were no battery powered lights observed. NFPA 70 (1999 edition) article 517-63 (a) requires battery-powered lights in anesthetizing locations. The facility conducts invasive procedures for which lighting is required for the ten seconds allowed until the emergency generator provides power during a power outage.

Based on observation, the facility failed to supervise fire sprinkler control valves.

Findings include :

While on tour April 24, 2013, at 11:54 AM, with the facility Maintenance Director, at the facility West property line, adjacent to the street, the back-flow prevention assembly , serving potable and fire sprinkler water to the facility was observed with no electrical supervision on two control valves. NFPA 101 (2000 edition) ' chapter 9.7.1.1 requires at least a local alarm sound when the valves are closed two turns or more.

Based on observation, the facility failed to prevent the use of prohibited space heaters in the facility.

Findings include :

While on tour on April 24, 2013, at 12:19 PM, with the facility Maintenance Director, in the pharmacy office, a space heater not listed for use by a health care facility was observed under a desk. The space heater required a three foot separation from combustibles. NFPA 101(2000 edition) chapter 19.7.8 prohibits space heaters in a health care facility. Non sleeping employee areas may have space heaters if the element does not exceed 212 degrees Fahrenheit.

Based on observation, the facility failed to maintain a safe separation between alcohol based hand rub (abhr) and a source of ignition (light switch)

Findings include :

While on tour April 24, 2013, from 11:54 AM to 1:15 PM with the facility Maintenance Director, abhr dispensers were observed less than one inch to the side of a source of ignition (light switch) in the following locations :
1. In the emergency room
2. In room 129
If ignited, abhr can injure patients, visitors and staff.

Based on observation, the facility failed to install battery powered emergency lighting in the operating room.

Findings include :

While on tour April 24, 2013, at 12:35 PM, with the facility Maintenance Director, in the operating room, there were no battery powered lights observed. NFPA 70 (1999 edition) article 517-63 (a) requires battery-powered lights in anesthetizing locations. The facility conducts invasive procedures for which lighting is required for the ten seconds allowed until the emergency generator provides power during a power outage.

Based on observation, the facility failed to supervise fire sprinkler control valves.

Findings include :

While on tour April 24, 2013, at 11:54 AM, with the facility Maintenance Director, at the facility West property line, adjacent to the street, the back-flow prevention assembly , serving potable and fire sprinkler water to the facility was observed with no electrical supervision on two control valves. NFPA 101 (2000 edition) ' chapter 9.7.1.1 requires at least a local alarm sound when the valves are closed two turns or more.

Based on observation, the facility failed to prevent the use of prohibited space heaters in the facility.

Findings include :

While on tour on April 24, 2013, at 12:19 PM, with the facility Maintenance Director, in the pharmacy office, a space heater not listed for use by a health care facility was observed under a desk. The space heater required a three foot separation from combustibles. NFPA 101(2000 edition) chapter 19.7.8 prohibits space heaters in a health care facility. Non sleeping employee areas may have space heaters if the element does not exceed 212 degrees Fahrenheit.