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Based on observation and staff interview the facility failed to assure that battery operated emergency lights would operate when tested. This deficient practice fails to provide emergency lighting for the required 90 minute duration, affecting 2 of 7 smoke compartments. This facility has a capacity of 25 with a census of 9 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/13/10 from 11:25 to 11:45 it was observed that the battery operated emergency lights in the basement exercise room and the main floor physical therapy office hall would not operate when tested.

The Maintenance Supervisor was present and aware of the findings.

Based on observation and staff interview the facility failed to assure that exit signs are continuously illuminated. This deficiency practice fails to provide guidance to an exit door in an emergency, affecting 1 out of 7 smoke compartments. The facility has a capacity of 25 with a census of 9 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/13/10 at 11:10 A.M it was observed that the West basement EXIT sign was not illuminated.

The Maintenance Supervisor was present and aware of the findings.

Based on record review and staff interview the facility failed to assure that the partial sprinkler system is properly tested quarterly. This deficiency practice may leave the sprinkler system unreliable for operation, failing to prevent the spread of fire or smoke, affecting 1 of 7 smoke compartments. This facility has a capacity of 25 with a census of 9 residents at the time of the survey. .

FINDINGS INCLUDE:

During record review on 1/13/10 at 1:30 P.M., it was found that no quarterly test was performed during the 4th quarter of 2009.

The Maintenance Supervisor was present and aware of the findings.

Based on record review, observation and staff interview the facility failed to assure that the generator is properly tested monthly at the required 30% of its rated 607 AMP capacity. This deficiency practice may leave the hospital in darkness if the generator fails of operate properly, affecting 7 of 7 smoke compartments. The facility has a capacity of 25 with a census of 9 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/13/10 the following was observed during review of records:

1) January, February and March of 2009 did not meet the 30% of the rated capacity of the generator for the monthly test.

2) No Generator Malfunction policy is written in the manual.

The Maintenance Supervisor was present and aware of the findings.

Based on observation and staff interview the facility failed to assure extension cords are not used in lieu of permanent wiring. This deficient practice has the potential to cause an electrical fire, affecting 2 out of 7 smoke compartments. This facility has a capacity of 25 with a census of 9 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/13/10 from 11:00 to 11:30 A.M. the following was observed:

1.) Power strip was piggy backed into an extension cord in the basement purchasing office computer.
2.) Extension cord was piggy backed into a power strip in the basement purchasing office calculator.
3.) The toaster and coffee maker are plugged into extension cords located in the basement employee break room.

The Maintenance Supervisor was present and aware of the findings.

Based on observation and staff interview the facility failed to assure that battery operated emergency lights would operate when tested. This deficient practice fails to provide emergency lighting for the required 90 minute duration, affecting 2 of 7 smoke compartments. This facility has a capacity of 25 with a census of 9 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/13/10 from 11:25 to 11:45 it was observed that the battery operated emergency lights in the basement exercise room and the main floor physical therapy office hall would not operate when tested.

The Maintenance Supervisor was present and aware of the findings.

Based on observation and staff interview the facility failed to assure that exit signs are continuously illuminated. This deficiency practice fails to provide guidance to an exit door in an emergency, affecting 1 out of 7 smoke compartments. The facility has a capacity of 25 with a census of 9 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/13/10 at 11:10 A.M it was observed that the West basement EXIT sign was not illuminated.

The Maintenance Supervisor was present and aware of the findings.

Based on record review and staff interview the facility failed to assure that the partial sprinkler system is properly tested quarterly. This deficiency practice may leave the sprinkler system unreliable for operation, failing to prevent the spread of fire or smoke, affecting 1 of 7 smoke compartments. This facility has a capacity of 25 with a census of 9 residents at the time of the survey. .

FINDINGS INCLUDE:

During record review on 1/13/10 at 1:30 P.M., it was found that no quarterly test was performed during the 4th quarter of 2009.

The Maintenance Supervisor was present and aware of the findings.

Based on record review, observation and staff interview the facility failed to assure that the generator is properly tested monthly at the required 30% of its rated 607 AMP capacity. This deficiency practice may leave the hospital in darkness if the generator fails of operate properly, affecting 7 of 7 smoke compartments. The facility has a capacity of 25 with a census of 9 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/13/10 the following was observed during review of records:

1) January, February and March of 2009 did not meet the 30% of the rated capacity of the generator for the monthly test.

2) No Generator Malfunction policy is written in the manual.

The Maintenance Supervisor was present and aware of the findings.

Based on observation and staff interview the facility failed to assure extension cords are not used in lieu of permanent wiring. This deficient practice has the potential to cause an electrical fire, affecting 2 out of 7 smoke compartments. This facility has a capacity of 25 with a census of 9 residents at the time of the survey.

FINDINGS INCLUDE:

During the tour on 1/13/10 from 11:00 to 11:30 A.M. the following was observed:

1.) Power strip was piggy backed into an extension cord in the basement purchasing office computer.
2.) Extension cord was piggy backed into a power strip in the basement purchasing office calculator.
3.) The toaster and coffee maker are plugged into extension cords located in the basement employee break room.

The Maintenance Supervisor was present and aware of the findings.