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Based on observation and staff interview the facility failed to assure that emergency lights operate under test. This deficient practice fails to provide emergency lighting of at least 90 minutes in the event of an emergency, affecting approximately 9 patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 10:00 AM it is observed that in OR #2, the emergency light battery back-up failed when tested.

The Facility Director was present and acknowledged the finding.

NFPA Standard: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1

Based on observation and staff interview the facility failed to assure exit signs are properly displayed. This deficiency practice fails to direct occupants to a safe path of egress in case of an emergency, affecting approximately 9 patients in 1 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 11:15 AM there is an exit sign by room #207 obstructed by a light fixture.

The Facility Director was present and acknowledged the finding.

NFPA Standard - Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted. 2000 NFPA 101, 7.10.1.7

Based on observation and staff interview the facility failed to assure that sprinklers are properly maintained in accordance with the NFPA 25. The deficient practice fails to ensure sprinkler will operate properly in the event of a fire ,affecting approximately 9 patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 10:45 AM the OR mechanic closet, is missing the sprinkler escutcheon.

The Facility Director was present and acknowledged the finding.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

Based on observation, records review and staff interview the facility failed to maintain HVAC as required. The deficient practice of not identifying, testing and maintaining the equipment as required could result in failure of dampers, affecting approximately all patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 11:20 AM the vendor's report did not clarify if all the dampers are functioning.

The Facility Director was present and acknowledged the finding.

NFPA Standard: At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. 1999 NFPA 90A, 3-4.7

Based on observation, records review and staff interview the facility failed to assure that, piped in medical gas is in accordance with NFPA 99, 4-3.1.2.10. This deficient practice fails to shows the piped in medical gas has been certified, affecting approximately all patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 11:30 AM no piped in medical gas documentation was available for review.

The Facility Director was present and acknowledged the finding.

NFPA Standard: The installation of individual components shall be made in accordance with the instructions of the manufacturer. Instructions shall include directions and information deemed by the manufacturer to be adequate for attaining proper installation, testing, maintenance, and operation of the medical gas systems and shall be left with the owner. The installer of medical gas piping and equipment shall maintain on-the-job site documentation regarding the qualification of brazing procedures and individual brazers per 4-3.1.2.12 prior to installation. Two or more medical gas piping systems shall not be interconnected for testing or for any other reason. Leak testing shall be accomplished by separately charging and testing the individual piping system. 1999 NFPA 99, 4-3.1.2.10

Based on observation and staff interview the facility failed to assure that medical gas shut-off valves are properly labeled. This deficient practice fails to ensure that each anesthetizing room is isolated from the others, affecting approximately all patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 10:20 AM it was observed medical gas system shut-off valves are not properly identified.

The Facility Director was present and acknowledged the finding.

NFPA Standard - Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves. NFPA 99 4-3.1.2.3

Based on observation, records review and staff interview the facility failed to conduct and properly documented testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator, affecting approximately all patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 11:00 AM no transfer time is being documented on the generator report.
2. At 11:10 AM an on-site tranfer time test of the generator failed.

The Facility Director was present and acknowledged the finding.

NFPA Standard: The generator shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. 1999 NFPA 99, 3-4.1.1.8, 3-5.1 and 3-6.1
NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and staff interview the facility failed to assure that emergency lights operate under test. This deficient practice fails to provide emergency lighting of at least 90 minutes in the event of an emergency, affecting approximately 9 patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 10:00 AM it is observed that in OR #2, the emergency light battery back-up failed when tested.

The Facility Director was present and acknowledged the finding.

NFPA Standard: Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 foot-candle. 2000 NFPA 101, 7.9.2.1

Based on observation and staff interview the facility failed to assure exit signs are properly displayed. This deficiency practice fails to direct occupants to a safe path of egress in case of an emergency, affecting approximately 9 patients in 1 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 11:15 AM there is an exit sign by room #207 obstructed by a light fixture.

The Facility Director was present and acknowledged the finding.

NFPA Standard - Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted. 2000 NFPA 101, 7.10.1.7

Based on observation and staff interview the facility failed to assure that sprinklers are properly maintained in accordance with the NFPA 25. The deficient practice fails to ensure sprinkler will operate properly in the event of a fire ,affecting approximately 9 patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 10:45 AM the OR mechanic closet, is missing the sprinkler escutcheon.

The Facility Director was present and acknowledged the finding.

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

Based on observation, records review and staff interview the facility failed to maintain HVAC as required. The deficient practice of not identifying, testing and maintaining the equipment as required could result in failure of dampers, affecting approximately all patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 11:20 AM the vendor's report did not clarify if all the dampers are functioning.

The Facility Director was present and acknowledged the finding.

NFPA Standard: At least every 4 years, fusible links shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. 1999 NFPA 90A, 3-4.7

Based on observation, records review and staff interview the facility failed to assure that, piped in medical gas is in accordance with NFPA 99, 4-3.1.2.10. This deficient practice fails to shows the piped in medical gas has been certified, affecting approximately all patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 11:30 AM no piped in medical gas documentation was available for review.

The Facility Director was present and acknowledged the finding.

NFPA Standard: The installation of individual components shall be made in accordance with the instructions of the manufacturer. Instructions shall include directions and information deemed by the manufacturer to be adequate for attaining proper installation, testing, maintenance, and operation of the medical gas systems and shall be left with the owner. The installer of medical gas piping and equipment shall maintain on-the-job site documentation regarding the qualification of brazing procedures and individual brazers per 4-3.1.2.12 prior to installation. Two or more medical gas piping systems shall not be interconnected for testing or for any other reason. Leak testing shall be accomplished by separately charging and testing the individual piping system. 1999 NFPA 99, 4-3.1.2.10

Based on observation and staff interview the facility failed to assure that medical gas shut-off valves are properly labeled. This deficient practice fails to ensure that each anesthetizing room is isolated from the others, affecting approximately all patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 10:20 AM it was observed medical gas system shut-off valves are not properly identified.

The Facility Director was present and acknowledged the finding.

NFPA Standard - Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves. NFPA 99 4-3.1.2.3

Based on observation, records review and staff interview the facility failed to conduct and properly documented testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator, affecting approximately all patients in 2 of 2 smoke zones. This facility has a capacity of 24 and a census of 9 at the time of the survey.

Findings include:

During the survey on January 14, 2016 between 9:45 AM and 12:00 PM, the following is observed:

1. At 11:00 AM no transfer time is being documented on the generator report.
2. At 11:10 AM an on-site tranfer time test of the generator failed.

The Facility Director was present and acknowledged the finding.

NFPA Standard: The generator shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. 1999 NFPA 99, 3-4.1.1.8, 3-5.1 and 3-6.1
NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1