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Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 21 and a census of 5 patients.
Findings are:

1. Review of the facility ' s fire drill records on 03-15-11 at approximately 12:30, revealed that only 8 fire drills were conducted during the last survey year and that the first quarter drills were conducted on the day shift only and that there were no drills conducted on the third quarter. Results of the record review were acknowledged by Maintenance Staff.

Based on observations and Staff interview, the facility failed to provide the proper storage space for their oxygen supply cylinders from combustible materials. This deficient practice occurred in one of four smoke compartments. This facility has a capacity of 21 and a census of 5 patients.
Findings are:

1. On 03/15/11 at approximately 12:10 hours, it was observed that the storage room in the Cardiac Rehab had oxygen stored in it and was also a storage room for combustible supplies. Observations were acknowledged by the Maintenance Staff at the time of the observations and/or at the exit interview.

Based on observation, staff interview, the facility is not assuring that a generator is operational in accordance with NFPA 99 and NFPA 70 with the appropriate items wired to the appropriate branches of the generator. This deficient practice affects all occupants of the building, including staff, visitors and patients. This facility has a capacity of 21 with a census of 5 patients in the hospital.
Findings are:

1) On 03/15/11 at approximately 11:30 hours, it was observed that the facility's generator had only two transfer switches and the maintenance staff did not know what was on each transfer switch. The code requires that a Type I generator be divided into three branches Life Safety Branch, Critical Branch and Equipment Branch which would require three transfer switches. Observations were acknowledged by the Maintenance Staff at the time of the observations and/or at the exit interview.

Based on observation, on03-15-11, the facility failed to maintain the use of relocatable power taps. Which are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas.

General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found. This facility has a census of 29 with a capacity of 40.

Findings are:
1. Observation on 03-15-11 at approximately 12:07, revealed that in the stress testing room a power strip was being used to power the treadmill. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

Based on record review and staff interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 21 and a census of 5 patients.
Findings are:

1. Review of the facility ' s fire drill records on 03-15-11 at approximately 12:30, revealed that only 8 fire drills were conducted during the last survey year and that the first quarter drills were conducted on the day shift only and that there were no drills conducted on the third quarter. Results of the record review were acknowledged by Maintenance Staff.

Based on observations and Staff interview, the facility failed to provide the proper storage space for their oxygen supply cylinders from combustible materials. This deficient practice occurred in one of four smoke compartments. This facility has a capacity of 21 and a census of 5 patients.
Findings are:

1. On 03/15/11 at approximately 12:10 hours, it was observed that the storage room in the Cardiac Rehab had oxygen stored in it and was also a storage room for combustible supplies. Observations were acknowledged by the Maintenance Staff at the time of the observations and/or at the exit interview.

Based on observation, staff interview, the facility is not assuring that a generator is operational in accordance with NFPA 99 and NFPA 70 with the appropriate items wired to the appropriate branches of the generator. This deficient practice affects all occupants of the building, including staff, visitors and patients. This facility has a capacity of 21 with a census of 5 patients in the hospital.
Findings are:

1) On 03/15/11 at approximately 11:30 hours, it was observed that the facility's generator had only two transfer switches and the maintenance staff did not know what was on each transfer switch. The code requires that a Type I generator be divided into three branches Life Safety Branch, Critical Branch and Equipment Branch which would require three transfer switches. Observations were acknowledged by the Maintenance Staff at the time of the observations and/or at the exit interview.

Based on observation, on03-15-11, the facility failed to maintain the use of relocatable power taps. Which are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas.

General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found. This facility has a census of 29 with a capacity of 40.

Findings are:
1. Observation on 03-15-11 at approximately 12:07, revealed that in the stress testing room a power strip was being used to power the treadmill. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.