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Based on record review the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects eleven of eleven smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 15 residents.

Findings include:

1. Record review of the facility's maintenance records on 04/01/14 revealed the documentation regarding the testing of the emergency battery lighting system did not contain actual dates of inspection. The documentation also did not provide locations of the battery operated emergency lights.
According to Maintenance Staff A, the lights were tested monthly. The documentation did show the monthly tests were conducted for 30 seconds but only the month was indicated. The annual test was completed for 90 minutes under load in January of 2014 but no actual date indicated only the month.

2. During the inspection the battery emergency back-up light in the generator location failed to operate when tested.

Maintenance Staff (A) verified these observations.

(A)
Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 15.

Findings include:

Observation and interview on 04/02/2014, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the Main Electrical room electrical panel LSA breakers #1,2 and 3 were not secured with a mechanical lock to assure that the breakers are not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff A verified this observation.

(B)
Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association 72, National Fire Code. All of the Jewell Clinic and all occupants would be directly affected by the deficient practice.

Findings include:

Record review and interview on 04/02/14, revealed the fire alarm had not been inspected since May 2012. The fire alarm system inspection tag indicated that the system was inspected 5-7-12 by MidWest Alarm. The facility was unable to produce documentation of an inspection after that date.

Maintenance Staff (A) verified this observation.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the Stratford Clinic and Jewell Clinic at risk in the event of a fire.

Findings Include:

1. Observation and interview on 04/02/14 at approximately 11:00 a.m., revealed the facility failed to prohibit the improper use of a surge-protector. On the above date a surge-protector was observed on the west wall of the Staff Break Room used for a microwave.

2. Observation and interview on 04/02/14 at approximately 11:30 a.m., revealed the facility failed to provide four Ground Fault Circuit Interrupter (GFCI) electrical outlet in the north wall of the Drug Dispensing area next to the sink.

3. Observation and interview on 04/02/14 at approximately 11:35 a.m., revealed the facility failed to provide two Ground Fault Circuit Interrupter (GFCI) electrical outlet in the walls of the Restrooms next to the sinks.

4. Observation and interview on 04/02/14 at approximately 10:00 a.m., revealed the facility failed to prohibit the use of extension cords. There was an orange extension cord located along the west wall under the Office desk used for computer equipment.

Maintenance Staff (A) verified these observations.

Based upon observation and interview, the facility failed to properly install alcohol based hand rub (ABHR) dispensers. This has the potential of affecting staff , visitors and residents. This facility has a capacity of 25 with a census of 15.

Findings include:

Observation and interview on 04/01/14 at approximately 11:40 a.m., there was an alcohol based hand rub dispenser located on the east wall of Examination Room #1509. The dispenser was located directly over a light switch.

Maintenance Staff (A) verified the observation.

Based on record review the facility failed to document the emergency egress lighting monthly and annually. This deficient practice affects eleven of eleven smoke compartments and all occupants of the facility. This facility has a capacity of 25 and a census of 15 residents.

Findings include:

1. Record review of the facility's maintenance records on 04/01/14 revealed the documentation regarding the testing of the emergency battery lighting system did not contain actual dates of inspection. The documentation also did not provide locations of the battery operated emergency lights.
According to Maintenance Staff A, the lights were tested monthly. The documentation did show the monthly tests were conducted for 30 seconds but only the month was indicated. The annual test was completed for 90 minutes under load in January of 2014 but no actual date indicated only the month.

2. During the inspection the battery emergency back-up light in the generator location failed to operate when tested.

Maintenance Staff (A) verified these observations.

(A)
Based on observation and interview, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 15.

Findings include:

Observation and interview on 04/02/2014, the facility failed to provide a properly maintained fire alarm system. The fire alarm breaker located in the Main Electrical room electrical panel LSA breakers #1,2 and 3 were not secured with a mechanical lock to assure that the breakers are not inadvertently shut off. All occupants would be directly affected by the deficient practice.

Maintenance Staff A verified this observation.

(B)
Based on record review and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association 72, National Fire Code. All of the Jewell Clinic and all occupants would be directly affected by the deficient practice.

Findings include:

Record review and interview on 04/02/14, revealed the fire alarm had not been inspected since May 2012. The fire alarm system inspection tag indicated that the system was inspected 5-7-12 by MidWest Alarm. The facility was unable to produce documentation of an inspection after that date.

Maintenance Staff (A) verified this observation.

Based on observation and interview, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the Stratford Clinic and Jewell Clinic at risk in the event of a fire.

Findings Include:

1. Observation and interview on 04/02/14 at approximately 11:00 a.m., revealed the facility failed to prohibit the improper use of a surge-protector. On the above date a surge-protector was observed on the west wall of the Staff Break Room used for a microwave.

2. Observation and interview on 04/02/14 at approximately 11:30 a.m., revealed the facility failed to provide four Ground Fault Circuit Interrupter (GFCI) electrical outlet in the north wall of the Drug Dispensing area next to the sink.

3. Observation and interview on 04/02/14 at approximately 11:35 a.m., revealed the facility failed to provide two Ground Fault Circuit Interrupter (GFCI) electrical outlet in the walls of the Restrooms next to the sinks.

4. Observation and interview on 04/02/14 at approximately 10:00 a.m., revealed the facility failed to prohibit the use of extension cords. There was an orange extension cord located along the west wall under the Office desk used for computer equipment.

Maintenance Staff (A) verified these observations.