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Based on observation and interview, the facility failed to ensure each path of egress was marked by approved readily visible signs directing persons to reach an exit. This has the potential to affect all patients, staff, and visitors to the facility. The census was nine patients.

Findings:

On 03/26/13 at 10:00 A.M. observation was made of the middle corridor that separated compartment C and A. The observation revealed the exit sign was blocked from view by two signs, one for medical imaging services and another for respiratory therapy services.

On 03/26/13 at 10:00 A.M., in an interview, Staff Y confirmed the finding.

On 03/26/13 at 10:00 A.M., a review of the evacuation plan posted by the nursing station in the ob/gyn area revealed a path of egress traveling north then turning west. However, at that time, observation of the exit sign revealed an arrow pointing to the east.

On 03/26/13 at 10:00 A.M. in an interview, Staff Y confirmed the observation.

On 03/26/13 at 2:12 P.M. a review of the evacuation plan outside the double doors to the laboratory revealed a path of egress traveling both north and south; however observation was made of the exit sign with an arrow pointing only to the north.

On 03.26/13 at 2:12 P.M. in an interview, Staff X confirmed the observation.

Based on observation and interview, the facility failed to maintain the integrity of its smoke barriers. This has the potential to affect all patients, staff and visitors in the facility. The facility ' s census was 9 patients.

Findings include:

On 03/25/13 at 2:45 P.M. a tour was conducted with Staff X, Y, and Z of the smoke wall that separated smoke compartment E from smoke compartments C and D. (Smoke compartment D contained sleeping patients, C contained operating rooms and post operative care areas), and E contained administrative and other business spaces.) At the double doors that bridged smoke compartment D with E, and above the drop down ceiling, a one to two inch penetration was observed with black wires coming out of it.
On 03/25/13 at 3:15 P.M. in the wall separating smoke compartment C from E, and dividing a housekeeping area from a chart analyst area, and above the drop down ceiling, two circular and one square shaped penetrations about an inch in diameter were observed.
On 03/25/13 at 3:25 P.M. in the wall separating smoke compartment C from E, and within the purchasing store room, and above the drop down ceiling, two wires coming from an open one inch conduit was observed.
On 03/25/13 at 3:27 P.M. the door to the decontamination/dirty equipment room was observed in the smoke wall and on a self closer; however, the self closer did not completely close the door.
During the tour in an interview, Staff X, Y, and Z, confirmed the findings.

On 03/26/13 at 9:15 A.M., the tour of the facility resumed. Tour of the western smoke wall that separated smoke compartment C from D and above the drop down ceiling and near the double doors by the chapel, a two inch conduit was observed open, and a conduit tray that carried cable was also observed to have open areas.
During the tour in an interview, Staff X, Y, and Z confirmed the findings.

On 03/26/13 at 2:05 P.M. the tour of the facility resumed. Observation above the drop down ceiling above the double doors in the smoke wall that separated compartment B from compartment D revealed an open two inch conduit. Just south of those double doors and above the drop down ceiling of another set of double doors an open one inch conduit was observed.
Observation above the drop down ceiling of the smoke wall that separated compartment A (compartment A contained an emergency department) from compartment C, and above the double doors that led to the emergency department, revealed a two inch conduit with blue and orange wires that was open to air. Just north of that penetration, between the double doors and the exit door, a one inch pipe with an annular space on top was observed.
During the tour in an interview, Staff X, Y, and Z confirmed the findings.

Based on observation the facility failed to comply with NFPA 110 5-3, referenced in NFPA 101 7.9, referenced in NFPA 101 19.2.9.1, by failing to have battery powered emergency lighting in the generator room. This has the potential to affect all patients, visitors and family to the facility. The facility's census was nine patients.

Findings:
In the afternoon of the 03/26/13, an observation of the facility's generator revealed the generator room lacked battery-powered emergency illumination.

On 03/26/13 at 3:28 P.M. in an interview Staff Z confirmed the lack of battery powered illumination in the generator room and said of the room, "we're dark," if the generator should break down and need repair in the middle of the night

Based on observation and interview, dirty sprinkler heads were observed in various parts of the facility including the pre/post operative area, and shelving was observed less than 18 inches from the ceiling. This has the potential to affect all patients, staff, and visitors. The census at the time of survey was nine patients.

Findings:
On 03/25/13 at 3:32 P.M. in the corridor, outside the soiled linen storage room of compartment E, a dirty sprinkler head was observed. The dirt on the sprinkler head prevented the visualization of the fluid in the bulb of the sprinkler head.
On 03/25/13 at 3:32 P.M. in an interview, Staff X, Y, and Z confirmed the finding.
On 03/26/13 at 10:00 A.M., observation revealed a dirty sprinkler head in the biohazard room in compartment D.
On 03/25/13 at 3:32 P.M. in an interview Staff X, Y, and Z confirmed the finding.

On 03/26/13 at 11:15 A.M. a dirty sprinkler head was observed in the office of the sleep laboratory.
On 03/26/13 at 11:15 A.M. in an interview, Staff X, Y, and Z confirmed the finding.

On 03/26/13 at 2:45 P.M. a dirty sprinkler head was observed in the family practice area.
On 03/26/13 at 2:45 P.M. in an interview, Staff X, Y, and Z confirmed the finding.

On 03/26/13 at 2:55 P.M. a dirty sprinkler head was observed near the nursing station by the pre/post operative area.
On 03/26/13 at 2:55 P.M. in an interview, Staff X, Y, and Z confirmed the finding.

On 03/26/13 at 3:05 P.M. a dirty sprinkler head was observed in the scrub area between operating room 1 and 2.
On 03/26/13 at 2:55 P.M. in an interview, Staff X, Y, and Z confirmed the finding.

On 03/26/13 at 3:17 P.M. a tour was conducted of the pharmacy area in smoke compartment A-which also contained the emergency department. The tour revealed shelving for medications in the middle of the room and less than 18 inches from the ceiling. The room contained sprinklers, one of which was over the shelving.

On 03/26/13 at 3:17 P.M. in an interview, Staff Z confirmed the finding.

Based on observation and interview, the facility failed to ensure humidity levels in all four of the facility's anesthetizing locations were maintained with humidity levels of more than 35 percent. This deficient practice could potentially affect all patients and staff utilizing these rooms. The census was 9 patients.

Findings:
Review of the humidity logs for the three surgery rooms and one c-section room was completed on 03/28/13. The review revealed in January, 2013, in operating room three, except for three days, the humidity was less than 35 percent, with the lowest humidity level being 15.74 percent on 01/02/13. The c-section room had humidity levels less than 35 percent for 20 days, with the lowest humidity level being 17.04 percent on 01/22/13. Operating room two had three days with humidity levels less than 35 percent, the lowest humidity level was 21.9 percent on 01/02/13. Operating room one had eleven days with humidity levels less than 35 percent, the lowest was 22.79 percent on 01/01/13 and on 01/02/13.
For March, 2013 until the day of exit, the humidity levels for operating room 3 was less than 35 percent every day except for one. Operating room one had thirteen days with humidity levels less than 35 percent, the lowest humidity level was 26.7 percent on 03/09/13. Operating room two had two days with humidity levels less than 35 percent, the lowest was 24.19 percent on 03/09/13.
On 03/27/13 at 10:30 A.M. in an interview, Staff Z stated they try to maintain the humidity level at around 20 percent in the operating rooms.
On 03/28/13 at 8:45 A.M. in an interview, Staff X stated they did not have a policy dictating what the humidity level should be, but presented a standard from the American Society of Healthcare Engineering (that he/she said they follow), that stated the humidity level was to be kept at 20 percent.

Based on observation and interview, the facility failed to ensure each path of egress was marked by approved readily visible signs directing persons to reach an exit. This has the potential to affect all patients, staff, and visitors to the facility. The census was nine patients.

Findings:

On 03/26/13 at 10:00 A.M. observation was made of the middle corridor that separated compartment C and A. The observation revealed the exit sign was blocked from view by two signs, one for medical imaging services and another for respiratory therapy services.

On 03/26/13 at 10:00 A.M., in an interview, Staff Y confirmed the finding.

On 03/26/13 at 10:00 A.M., a review of the evacuation plan posted by the nursing station in the ob/gyn area revealed a path of egress traveling north then turning west. However, at that time, observation of the exit sign revealed an arrow pointing to the east.

On 03/26/13 at 10:00 A.M. in an interview, Staff Y confirmed the observation.

On 03/26/13 at 2:12 P.M. a review of the evacuation plan outside the double doors to the laboratory revealed a path of egress traveling both north and south; however observation was made of the exit sign with an arrow pointing only to the north.

On 03.26/13 at 2:12 P.M. in an interview, Staff X confirmed the observation.

Based on observation and interview, the facility failed to maintain the integrity of its smoke barriers. This has the potential to affect all patients, staff and visitors in the facility. The facility ' s census was 9 patients.

Findings include:

On 03/25/13 at 2:45 P.M. a tour was conducted with Staff X, Y, and Z of the smoke wall that separated smoke compartment E from smoke compartments C and D. (Smoke compartment D contained sleeping patients, C contained operating rooms and post operative care areas), and E contained administrative and other business spaces.) At the double doors that bridged smoke compartment D with E, and above the drop down ceiling, a one to two inch penetration was observed with black wires coming out of it.
On 03/25/13 at 3:15 P.M. in the wall separating smoke compartment C from E, and dividing a housekeeping area from a chart analyst area, and above the drop down ceiling, two circular and one square shaped penetrations about an inch in diameter were observed.
On 03/25/13 at 3:25 P.M. in the wall separating smoke compartment C from E, and within the purchasing store room, and above the drop down ceiling, two wires coming from an open one inch conduit was observed.
On 03/25/13 at 3:27 P.M. the door to the decontamination/dirty equipment room was observed in the smoke wall and on a self closer; however, the self closer did not completely close the door.
During the tour in an interview, Staff X, Y, and Z, confirmed the findings.

On 03/26/13 at 9:15 A.M., the tour of the facility resumed. Tour of the western smoke wall that separated smoke compartment C from D and above the drop down ceiling and near the double doors by the chapel, a two inch conduit was observed open, and a conduit tray that carried cable was also observed to have open areas.
During the tour in an interview, Staff X, Y, and Z confirmed the findings.

On 03/26/13 at 2:05 P.M. the tour of the facility resumed. Observation above the drop down ceiling above the double doors in the smoke wall that separated compartment B from compartment D revealed an open two inch conduit. Just south of those double doors and above the drop down ceiling of another set of double doors an open one inch conduit was observed.
Observation above the drop down ceiling of the smoke wall that separated compartment A (compartment A contained an emergency department) from compartment C, and above the double doors that led to the emergency department, revealed a two inch conduit with blue and orange wires that was open to air. Just north of that penetration, between the double doors and the exit door, a one inch pipe with an annular space on top was observed.
During the tour in an interview, Staff X, Y, and Z confirmed the findings.

Based on observation the facility failed to comply with NFPA 110 5-3, referenced in NFPA 101 7.9, referenced in NFPA 101 19.2.9.1, by failing to have battery powered emergency lighting in the generator room. This has the potential to affect all patients, visitors and family to the facility. The facility's census was nine patients.

Findings:
In the afternoon of the 03/26/13, an observation of the facility's generator revealed the generator room lacked battery-powered emergency illumination.

On 03/26/13 at 3:28 P.M. in an interview Staff Z confirmed the lack of battery powered illumination in the generator room and said of the room, "we're dark," if the generator should break down and need repair in the middle of the night

Based on observation and interview, dirty sprinkler heads were observed in various parts of the facility including the pre/post operative area, and shelving was observed less than 18 inches from the ceiling. This has the potential to affect all patients, staff, and visitors. The census at the time of survey was nine patients.

Findings:
On 03/25/13 at 3:32 P.M. in the corridor, outside the soiled linen storage room of compartment E, a dirty sprinkler head was observed. The dirt on the sprinkler head prevented the visualization of the fluid in the bulb of the sprinkler head.
On 03/25/13 at 3:32 P.M. in an interview, Staff X, Y, and Z confirmed the finding.
On 03/26/13 at 10:00 A.M., observation revealed a dirty sprinkler head in the biohazard room in compartment D.
On 03/25/13 at 3:32 P.M. in an interview Staff X, Y, and Z confirmed the finding.

On 03/26/13 at 11:15 A.M. a dirty sprinkler head was observed in the office of the sleep laboratory.
On 03/26/13 at 11:15 A.M. in an interview, Staff X, Y, and Z confirmed the finding.

On 03/26/13 at 2:45 P.M. a dirty sprinkler head was observed in the family practice area.
On 03/26/13 at 2:45 P.M. in an interview, Staff X, Y, and Z confirmed the finding.

On 03/26/13 at 2:55 P.M. a dirty sprinkler head was observed near the nursing station by the pre/post operative area.
On 03/26/13 at 2:55 P.M. in an interview, Staff X, Y, and Z confirmed the finding.

On 03/26/13 at 3:05 P.M. a dirty sprinkler head was observed in the scrub area between operating room 1 and 2.
On 03/26/13 at 2:55 P.M. in an interview, Staff X, Y, and Z confirmed the finding.

On 03/26/13 at 3:17 P.M. a tour was conducted of the pharmacy area in smoke compartment A-which also contained the emergency department. The tour revealed shelving for medications in the middle of the room and less than 18 inches from the ceiling. The room contained sprinklers, one of which was over the shelving.

On 03/26/13 at 3:17 P.M. in an interview, Staff Z confirmed the finding.

Based on observation and interview, the facility failed to ensure humidity levels in all four of the facility's anesthetizing locations were maintained with humidity levels of more than 35 percent. This deficient practice could potentially affect all patients and staff utilizing these rooms. The census was 9 patients.

Findings:
Review of the humidity logs for the three surgery rooms and one c-section room was completed on 03/28/13. The review revealed in January, 2013, in operating room three, except for three days, the humidity was less than 35 percent, with the lowest humidity level being 15.74 percent on 01/02/13. The c-section room had humidity levels less than 35 percent for 20 days, with the lowest humidity level being 17.04 percent on 01/22/13. Operating room two had three days with humidity levels less than 35 percent, the lowest humidity level was 21.9 percent on 01/02/13. Operating room one had eleven days with humidity levels less than 35 percent, the lowest was 22.79 percent on 01/01/13 and on 01/02/13.
For March, 2013 until the day of exit, the humidity levels for operating room 3 was less than 35 percent every day except for one. Operating room one had thirteen days with humidity levels less than 35 percent, the lowest humidity level was 26.7 percent on 03/09/13. Operating room two had two days with humidity levels less than 35 percent, the lowest was 24.19 percent on 03/09/13.
On 03/27/13 at 10:30 A.M. in an interview, Staff Z stated they try to maintain the humidity level at around 20 percent in the operating rooms.
On 03/28/13 at 8:45 A.M. in an interview, Staff X stated they did not have a policy dictating what the humidity level should be, but presented a standard from the American Society of Healthcare Engineering (that he/she said they follow), that stated the humidity level was to be kept at 20 percent.