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Based on observation and interview with staff, the facility failed to provide doors that have a means suitable for keeping the door closed. 19.3.6.3 Findings,

There is no latching hardware on the door to the Gift shop.

Based upon observation, interview with staff and review of records, the facility failed to test and maintain the fire alarm system in accordance with NFPA 72. 9.6.1.4 Findings,

The annual fire alarm inspection report did not document testing of the magnetic locks, the combination fire and smoke dampers or the smoke evacuation system in the operating room.

Based on observation, interview with staff and review of records, the facility failed to document and maintain humidity levels equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3 Findings,

The daily record provided recorded OR #1 as in compliance for the day, but OR #2 had humidity levels of 72% - 76 %, exceeding the 60% allowed. No other records were available.

(1) Based on observation and interview with Operating Room staff, Director of Maintenance and the CEO, for the Operating Room, the facility failed to provide records of Hazard Assessment, Fire Prevention & Emergency Procedures and Orientation and Training, as required by NFPA 99, 1999 edition, 12-4.1.2.10 (a, b, c, d). Findings,

(a) Records of Hazard Assessment, Fire Prevention & Emergency Procedures and Orientation and Training for Anesthetizing Locations were not provided.



(2) Based on observation and interview with staff, the facility failed to maintain documentation of inspection and testing of electrical equipment used for the care of patients as required by NFPA 99, 1999 edition, 7-6.2.1. Findings,

(a) The facility failed to provide documentation of inspection and testing of the Bear Warming Devices located in the recovery room.

Based on observation and interview with staff, the facility failed to provide doors that have a means suitable for keeping the door closed. 19.3.6.3 Findings,

There is no latching hardware on the door to the Gift shop.

Based upon observation, interview with staff and review of records, the facility failed to test and maintain the fire alarm system in accordance with NFPA 72. 9.6.1.4 Findings,

The annual fire alarm inspection report did not document testing of the magnetic locks, the combination fire and smoke dampers or the smoke evacuation system in the operating room.

Based on observation, interview with staff and review of records, the facility failed to document and maintain humidity levels equal to or greater than 35%. NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 19.3.2.3 Findings,

The daily record provided recorded OR #1 as in compliance for the day, but OR #2 had humidity levels of 72% - 76 %, exceeding the 60% allowed. No other records were available.

(1) Based on observation and interview with Operating Room staff, Director of Maintenance and the CEO, for the Operating Room, the facility failed to provide records of Hazard Assessment, Fire Prevention & Emergency Procedures and Orientation and Training, as required by NFPA 99, 1999 edition, 12-4.1.2.10 (a, b, c, d). Findings,

(a) Records of Hazard Assessment, Fire Prevention & Emergency Procedures and Orientation and Training for Anesthetizing Locations were not provided.



(2) Based on observation and interview with staff, the facility failed to maintain documentation of inspection and testing of electrical equipment used for the care of patients as required by NFPA 99, 1999 edition, 7-6.2.1. Findings,

(a) The facility failed to provide documentation of inspection and testing of the Bear Warming Devices located in the recovery room.