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Based on review of available maintenance logs and records on August 1, 2011, the facility failed to provide documentation that the 30-day 30 second testing interval and annual 90 minute test of the battery-powered emergency lights was being conducted.

The findings include:

Emergency generator locations shall be provided with battery-powered emergency lighting per section 3-4.2.2.2(b)5 of NFPA 99, 1999 Edition and 5-3.1 of NFPA 110, 1999 Edition . The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. In accordance with 7.9.3 of the Life Safety Code a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The maintenance logs and records were reviewed at the facility on August 1, 2011. No documentation was available that the 30-day and annual tests of the battery-powered emergency lights in the room housing the generator or elsewhere installed in the building as a life safety device, such as the transfer switch room, had been performed.

Based on review of the fire alarm reports on August 1, 2011, the facility failed to activate the fire alarm system or denote such activation on fire drills held between 6 a.m. and 9 p.m. and failed to assure that a fire drill was conducted on each shift at least quarterly.

The findings include:

1. The fire drill reports were reviewed at the facility on August 1, 2011. Several drills held between the times of 6 a.m. and 9 p.m. did not denote that the fire alarm system was activated or verified that it was not. These include the following:
a) The drill held at 7 p.m. on June 30, 2011 noted "No" on the form line that stated "Pull the alarm (activate the alarm system)".
b) The drill held at 6:30 p.m. on February 28, 2011 did not denote that the fire alarm system was activated.
c) The drill held at 6:30 p.m. on December 28, 2010 did not denote that the fire alarm system was activated.
d) The drill held at 7 p.m. on October 6, 2010 did not denote that the fire alarm system was activated.

2. The fire drill reports were reviewed at the facility on August 1, 2011. Four fire drills were conducted during the third quarter (July, August and September) of 2010. All four drills were held on the 6 a.m. to 6 p.m. shift. No documentation was available that a fire drill was held on the 6 p.m. to 6 a.m. shift during that quarter.

Based on observations made on August 1, 2011, the facility failed to assure that portable fire extinguishers were readily accessible.

The findings include:

Periodic inspection of fire extinguishers per section 4-3.2 of NFPA 10, 1998 Edition shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place
When an inspection of any fire extinguisher reveals a deficiency in any of the conditions listed in 4-3.2 (a), (b), (h), and (i), immediate corrective action shall be taken per section 4-3.3 of NFPA 10.

The cabinet housing the portable fire extinguisher in the hallway of the Critical Access Hospital was examined at 11:50 a.m. on August 1, 2011. A portable stand for a blood pressure cuff was parked in front of the cabinet and the electrical cord for the cuff unit was run through the handle of the fire extinguisher cabinet. This arrangement did not meet condition (b) of 4-3.2 of NFPA 10. Note: The cord was withdrawn from the handle and the unit moved away from the front of the cabinet after the observation was made and confirmed by the surveyor while on-site.

Based on observations made on August 1, 2011, the facility failed to prevent the use of a portable heater in a patient care area.

The findings include:

A "Lasko" brand portable heater was plugged into a receptacle ready for use in Exam room 2 of the Critical Access Hospital. The exam room did not meet the exceptions allowed for in section 19.7.8 of the Life Safety Code and must be removed.

Based on review of the generator test logs for the facility on August 2, 2011, the facility failed to assure that the emergency generator was inspected weekly and exercised under load conditions for 30 minutes each month.

The findings include:

The generator test logs were supplied to the surveyor per fax transmittal on August 2, 2011 for review. Three tests were documented in August of 2010, all three being load tests. Four tests were documented in September of 2010, all four being load tests. One test each was documented for October of 2010, January of 2011 and February of 2011, with the one in October being a load test and those in January and February being weekly tests. Logs for testing starting from June 29, 2011 to July 27, 2011 were documented but did not include confirmation that any of them were conducted under load conditions. With the exception of the noted documentation supplied to the surveyor there was no complete record that the generator had been consistently tested/inspected weekly and tested under load conditions for a continuous twelve month period.

Based on observations made on August 1, 2011, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).
The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4(b)(3) of NFPA 70.

1. A multiple adaptor, without built-in circuit breaker protection, was in use in room 5 as observed at 10:14 a.m. on August 1, 2011.

2. A multiple adaptor, without built-in circuit breaker protection, was in use in room 9 as observed at 10:35 a.m. on August 1, 2011.

No grounded conductor shall be attached to any terminal or lead so as to reverse the designated polarity per Article 200-11 of NFPA 70. This requirement applies to receptacles per Article 410-58 of NFPA 70.

3. The tub in the bathing room was connected to a wall receptacle that was serviced by a GFCI breaker located in panel board "B" in the corridor. A receptacle tester was used to test this wall receptacle at 10:28 a.m. on August 1, 2011. It was determined that the hot and neutral connections had been reversed.

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip.

4. A microwave oven in the visiting nurse's room was plugged into a power strip as observed at 10:40 a.m. on August 1, 2011. Note: The microwave was plugged directly into a wall receptacle after the observation was made and confirmed by the surveyor while on-site.

Unused openings in boxes, raceways, auxiliary gutters, cabinets (panel boards), equipment cases or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment per In accordance with Article 110-12(a) of NFPA 70.

5. Panel board MDP located in the mechanical penthouse was examined at 1:07 p.m. on August 1, 2011. The protective knock-out plate for future breaker #32 was missing thus exposing the bus bar to accidental contact.

Based on review of available maintenance logs and records on August 1, 2011, the facility failed to provide documentation that the 30-day 30 second testing interval and annual 90 minute test of the battery-powered emergency lights was being conducted.

The findings include:

Emergency generator locations shall be provided with battery-powered emergency lighting per section 3-4.2.2.2(b)5 of NFPA 99, 1999 Edition and 5-3.1 of NFPA 110, 1999 Edition . The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. In accordance with 7.9.3 of the Life Safety Code a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and one-half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The maintenance logs and records were reviewed at the facility on August 1, 2011. No documentation was available that the 30-day and annual tests of the battery-powered emergency lights in the room housing the generator or elsewhere installed in the building as a life safety device, such as the transfer switch room, had been performed.

Based on review of the fire alarm reports on August 1, 2011, the facility failed to activate the fire alarm system or denote such activation on fire drills held between 6 a.m. and 9 p.m. and failed to assure that a fire drill was conducted on each shift at least quarterly.

The findings include:

1. The fire drill reports were reviewed at the facility on August 1, 2011. Several drills held between the times of 6 a.m. and 9 p.m. did not denote that the fire alarm system was activated or verified that it was not. These include the following:
a) The drill held at 7 p.m. on June 30, 2011 noted "No" on the form line that stated "Pull the alarm (activate the alarm system)".
b) The drill held at 6:30 p.m. on February 28, 2011 did not denote that the fire alarm system was activated.
c) The drill held at 6:30 p.m. on December 28, 2010 did not denote that the fire alarm system was activated.
d) The drill held at 7 p.m. on October 6, 2010 did not denote that the fire alarm system was activated.

2. The fire drill reports were reviewed at the facility on August 1, 2011. Four fire drills were conducted during the third quarter (July, August and September) of 2010. All four drills were held on the 6 a.m. to 6 p.m. shift. No documentation was available that a fire drill was held on the 6 p.m. to 6 a.m. shift during that quarter.

Based on observations made on August 1, 2011, the facility failed to assure that portable fire extinguishers were readily accessible.

The findings include:

Periodic inspection of fire extinguishers per section 4-3.2 of NFPA 10, 1998 Edition shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place
When an inspection of any fire extinguisher reveals a deficiency in any of the conditions listed in 4-3.2 (a), (b), (h), and (i), immediate corrective action shall be taken per section 4-3.3 of NFPA 10.

The cabinet housing the portable fire extinguisher in the hallway of the Critical Access Hospital was examined at 11:50 a.m. on August 1, 2011. A portable stand for a blood pressure cuff was parked in front of the cabinet and the electrical cord for the cuff unit was run through the handle of the fire extinguisher cabinet. This arrangement did not meet condition (b) of 4-3.2 of NFPA 10. Note: The cord was withdrawn from the handle and the unit moved away from the front of the cabinet after the observation was made and confirmed by the surveyor while on-site.

Based on observations made on August 1, 2011, the facility failed to prevent the use of a portable heater in a patient care area.

The findings include:

A "Lasko" brand portable heater was plugged into a receptacle ready for use in Exam room 2 of the Critical Access Hospital. The exam room did not meet the exceptions allowed for in section 19.7.8 of the Life Safety Code and must be removed.

Based on review of the generator test logs for the facility on August 2, 2011, the facility failed to assure that the emergency generator was inspected weekly and exercised under load conditions for 30 minutes each month.

The findings include:

The generator test logs were supplied to the surveyor per fax transmittal on August 2, 2011 for review. Three tests were documented in August of 2010, all three being load tests. Four tests were documented in September of 2010, all four being load tests. One test each was documented for October of 2010, January of 2011 and February of 2011, with the one in October being a load test and those in January and February being weekly tests. Logs for testing starting from June 29, 2011 to July 27, 2011 were documented but did not include confirmation that any of them were conducted under load conditions. With the exception of the noted documentation supplied to the surveyor there was no complete record that the generator had been consistently tested/inspected weekly and tested under load conditions for a continuous twelve month period.

Based on observations made on August 1, 2011, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and/or interpretations from the Centers for Medicare and Medicaid Services (CMS).
The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4(b)(3) of NFPA 70.

1. A multiple adaptor, without built-in circuit breaker protection, was in use in room 5 as observed at 10:14 a.m. on August 1, 2011.

2. A multiple adaptor, without built-in circuit breaker protection, was in use in room 9 as observed at 10:35 a.m. on August 1, 2011.

No grounded conductor shall be attached to any terminal or lead so as to reverse the designated polarity per Article 200-11 of NFPA 70. This requirement applies to receptacles per Article 410-58 of NFPA 70.

3. The tub in the bathing room was connected to a wall receptacle that was serviced by a GFCI breaker located in panel board "B" in the corridor. A receptacle tester was used to test this wall receptacle at 10:28 a.m. on August 1, 2011. It was determined that the hot and neutral connections had been reversed.

The limited use of circuit breaker protected power strips is acceptable by CMS provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to the power strip.

4. A microwave oven in the visiting nurse's room was plugged into a power strip as observed at 10:40 a.m. on August 1, 2011. Note: The microwave was plugged directly into a wall receptacle after the observation was made and confirmed by the surveyor while on-site.

Unused openings in boxes, raceways, auxiliary gutters, cabinets (panel boards), equipment cases or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment per In accordance with Article 110-12(a) of NFPA 70.

5. Panel board MDP located in the mechanical penthouse was examined at 1:07 p.m. on August 1, 2011. The protective knock-out plate for future breaker #32 was missing thus exposing the bus bar to accidental contact.