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Based on observation and interview with staff, the facility failed to provide an fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. 9.6.1.4 Findings:

The annual fire alarm test was not documented in accordance with NFPA 72. The test was not signed, all equipment was not documented on the test report, and three devices (3 duct detectors) were noted as unable to get to and was not on the report as tested.

Based on observation and interview with staff,the facility failed to provide Anesthetizing locations protected in accordance with NFPA 99, Standard for Health Care Facilities.
NFPA 99 4.3.1.2.3(an) and 5.4.1.1, 19:3.2.3 Findings:

The Operation Log Book documenting surgeries and the time and temperature recorded a few days scattered through out that had humidity levels that were below 35%.

Based on observation , interview with the Director of Surgery, the facility failed to train and evaluate the hazards associated with operational, electrical, and hazards associated with the nature of the environment in the anesthetizing location in accordance with NFPA 99 1999 edition chapter 12-4.1.2.10.

The Director stated that the facility had not provided all surgical suite personal including physicians and surgeons with training on general safety practices for area specific equipment and practices.

Based on observation and review of the generator logs, the generator report logs adopted by the facility did not document the percent the generator was tested under. NFPA 110 requires 30% load of the generators EPS nameplate kW rating.

Based on observation and interview with staff, the facility failed to provide an fire alarm system required for life safety that is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. 9.6.1.4 Findings:

The annual fire alarm test was not documented in accordance with NFPA 72. The test was not signed, all equipment was not documented on the test report, and three devices (3 duct detectors) were noted as unable to get to and was not on the report as tested.

Based on observation and interview with staff,the facility failed to provide Anesthetizing locations protected in accordance with NFPA 99, Standard for Health Care Facilities.
NFPA 99 4.3.1.2.3(an) and 5.4.1.1, 19:3.2.3 Findings:

The Operation Log Book documenting surgeries and the time and temperature recorded a few days scattered through out that had humidity levels that were below 35%.

Based on observation , interview with the Director of Surgery, the facility failed to train and evaluate the hazards associated with operational, electrical, and hazards associated with the nature of the environment in the anesthetizing location in accordance with NFPA 99 1999 edition chapter 12-4.1.2.10.

The Director stated that the facility had not provided all surgical suite personal including physicians and surgeons with training on general safety practices for area specific equipment and practices.

Based on observation and review of the generator logs, the generator report logs adopted by the facility did not document the percent the generator was tested under. NFPA 110 requires 30% load of the generators EPS nameplate kW rating.