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Based on observations and staff interviews, the facility failed to ensure one exit discharge contained egress lighting in accordance with the code at 7.8. This could affect all patients in the facility. The total census during this visit was 11 patients.

Findings include:

During this visit from 01/23/12 through 01/26/12, a tour was conducted in the facility with Staff T and M. The tour times were as follows: On 01/24/12, between 1:30 PM and 4:30 PM, and on 01/25/12 and 01/26/12, between 8:30 AM and 4:30 PM each day.

During this tour, the exit discharge located between the West Maternity Wing and the 1993 building was observed and revealed there was no light outside the exit discharge. An interview with Staff T, during tour, verified the light was missing from the wall outside the exit discharge.

Based on observations and staff interviews, the facility failed to ensure one of two exit discharges contained an exit sign at the discharge in accordance with the code at 39.2.7 and 7.10.1.2. This could affect all patients in the facility. The total census during this visit was eleven patients.

Findings include:

On 01/25/12, between 4:28 PM and 4:48 PM, a tour was conducted with Staff W. The exit discharge door across from exam room 3 was observed with an exit access door which led to an 8 feet long by 9 and 1/2 feet wide vestibule. An exit discharge door was observed in this vestibule, approximately 8 feet away from the exit access door of exam room 3. Inside this vestibule, furnace and heating ductwork were observed in the alcove to the right of the exit discharge door. Based on observation, the exit discharge door lacked an exit sign at the door. This was verified with Staff W on tour. When this observation was shared with Staff T, on 01/27/12 at 2:15 PM, Staff T stated this exit door should be equipped with an exit sign.

Based on observations, and staff interviews, the facility failed to ensure the facility had a sprinkler head wrench available in accordance with NFPA 25, 2-4.1.6, and failed to maintain two sprinkler heads, one in the walk-in cooler and one in the walk-in freezer, per NFPA 25, 2-2.1.1. This could affect all patients in the facility. The total census during this visit was 11 patients.

Findings include:

During this visit from 01/23/12 through 01/26/12, a tour was conducted in the facility with Staff T and M. The tour times were as follows: On 01/24/12, between 1:30 PM and 4:30 PM, and on 01/25/12 and 01/26/12, between 8:30 AM and 4:30 PM each day.

During this tour, facility staff were unable to locate the wrench for the sprinkler heads. Staff T verified the sprinkler head wrench was missing from the sprinkler head box. Two corroded sprinkler heads were observed, one in the walk-in cooler, and one in the walk-in freezer in the dietary department.


An interview with Staff T during the tour verified the two sprinkler heads were corroded.

Based on observations, staff interviews, and review of the facility's medical gas inspection report, the facility failed to correct deficient areas identified in the medical gas inspection report, to be in compliance with NFPA 99, Chapter 4. This could affect all patients in the facility. The total census during this visit was 11 patients.

Findings include:

During this visit from 01/23/12 through 01/26/12, a tour was conducted in the facility with Staff T and M. The tour times were as follows: On 01/24/12, between 1:30 PM and 4:30 PM, and on 01/25/12 and 01/26/12, between 8:30 AM and 4:30 PM each day. Reviews of the facility's medical gas inspection report was conducted on 01/27/12.

During this tour, piped-in oxygen was observed throughout the facility. Bulk oxygen tanks were observed located outside the facility. An interview with Staff T on 01/27/12, at 2:30 PM verified the facility does have piped-in oxygen and uses general anesthesia on surgical patients.

The medical gas inspection report, dated 11/22/10, revealed deficient areas of the requirements that needed to be repaired. The deficient areas identified were as follows:
a) the bulk oxygen system tanks were not securely anchored,
b) the master alarm panels were in false alarm at both master alarm panels,
c) the emergency back-up vacuum system local alarm was missing,
d) there were issues with the Medical Air System gauge,
e) the Nitrogen System and Nitrous Oxide System, were missing the gauge on both systems downstream of the source relief valves,
f) the cylinder supply connections needed replacement,
g) the alarm for Labor and Delivery Observation area was not monitoring the pressure downstream of the valve box for this area,
h) the Operating rooms are double valved,
i) and the valve for oxygen at the surgery office leaks when the handle is being turned.

As of the survey exit date, 01/27/12, these areas have not been corrected, based on an interview with Staff T on 01/27/12. Although Staff T did provide documentation of a temporary field affidavit of an additional inspection/ testing of the medical gas systems and equipment by an outside servicing company dated 11/21/11. This temporary affidavit was valid for 60 days from that date. According to Staff T, the facility has not received the final report as of the 11/21/11, survey date.

Based on observations, staff interviews and review of the facility's generator logs, the facility failed to monitor the water jacket temperature of the two different generators when diesel fuel is used to power the generator, as required by the NFPA 99 code at 3-4.1.1.9. This could affect all patients in the facility. The total census during this visit was 11 patients.

Findings include:

During this visit from 01/23/12 through 01/26/12, a tour was conducted in the facility with Staff T and M. The tour times were as follows: On 01/24/12, between 1:30 PM and 4:30 PM, and on 01/25/12 and 01/26/12, between 8:30 AM and 4:30 PM each day. Reviews were conducted of the facility's generator logs on 01/27/12.

The tours of the facility conducted as indicated in the above paragraph revealed, the facility uses two different generators. A review of the generator logs revealed the engine coolant temperatures had been recorded only since 01/02/12 for both generators. These logs were silent as to when monitoring of the temperatures was conducted. An interview with Staff T, conducted on 01/27/12 at 2:45 PM, revealed both generators use diesel fuel as the power source. Staff T verified the logs lacked documentation of temperature monitoring prior to 01/02/12, and lacked documentation of the time of the week the temperatures were monitored after that date.