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Based on observation, the facility failed to provide emergency task illumination at the emergency generator and transfer switch location of at least one and one-half hour duration. The emergency generator would affect all smoke compartments and all of the facility patients and staff. The facility has 12 certified beds and a census of 4.
Findings are:

1. Observation on 05/24/12 at 10:40 a.m., revealed that a battery emergency light was not provided at the emergency generator or the emergency generator transfer switch location to provide task illumination. Maintenance Staff confirmed observations during the survey process.

Based on record review and interview, the facility failed to provide a properly tested and maintained fire alarm system. This deficient practice effects all occupants including staff, visitors and patients. The facility has a capacity for 12 certified beds with a census of 4 the day of the survey.
Findings are:

1. During the review of the facility's records on 05-24-12 at approximately 11:30, the facility was unable to provide documentation of any current inspection of the facility's fire alarm system. Review of the facility's records indicated the last inspection was 06-10-10. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

2. Observation of the fire alarm panel and the facility's records on 05-24-12 at approximately 10:35 a.m., the facility was unable to provide documentation of the monthly inspection records of the fire alarm panel. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

Based on observation and interview, the facility failed to maintain and test fire extinguishers as required. All of fire extinguishers in the facility were affected by the deficient practice. The deficient practice could affect all the patients and staff in the facility. This facility has a capacity of 12 and a census of 4 patients.
Findings are:

1) Observation of the fire extinguishers on 05/24/12 between 9:00 p.m. and 11:30 a.m. found that all of the extinguishers were missing monthly inspections. There was no date or initials marked on the extinguisher tags as required. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

Based on observation, the facility did not post warning signs on a room where oxygen was being stored. The deficient practice affected one smoke compartment and all occupants in that zone. This facility has a capacity of 12 and a census of 4 patients. Findings are:

1. On 5/24/12 at 10:00 a.m, it was observed that there was an oxygen tank stored in the utility room in the north corridor and did not have the proper warning signage outside on the room door. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

A) Based on observation, on 05/24/12 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 4 with a capacity of 12.
Findings are:

1. Observation on 05-24-12 at approximately 09:30, revealed that in the endoscopy room the facility was using a power strip which was not an approved one. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

2. Observation on 05-24-12 at approximately 09:36, revealed that in the endoscopy room the facility was using a make shift electrical receptacle which was not an approved one. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

3. Observation on 05-24-12 at approximately 09:48, revealed that in the mammogram room the facility was using a power strip which was not an approved one. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.


B) Based on observation, the facility did not prohibit the use of extension cords and power strips as a substitute for adequate wiring to prevent overloaded circuits. The location of deficient practice was located in one of three smoke compartments affecting all of the patients in that compartment. This facility has a census of 4 with a capacity of 12.
Findings are:

1. Observation on 5/24/12 revealed that in the employee dining room which is located in the patient wing had a three-way adapter plugged into a duplex receptacle along the east wall, with two freezers and one refrigerator plugged into the adapter. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

Based on observation, the facility failed to provide emergency task illumination at the emergency generator and transfer switch location of at least one and one-half hour duration. The emergency generator would affect all smoke compartments and all of the facility patients and staff. The facility has 12 certified beds and a census of 4.
Findings are:

1. Observation on 05/24/12 at 10:40 a.m., revealed that a battery emergency light was not provided at the emergency generator or the emergency generator transfer switch location to provide task illumination. Maintenance Staff confirmed observations during the survey process.

Based on record review and interview, the facility failed to provide a properly tested and maintained fire alarm system. This deficient practice effects all occupants including staff, visitors and patients. The facility has a capacity for 12 certified beds with a census of 4 the day of the survey.
Findings are:

1. During the review of the facility's records on 05-24-12 at approximately 11:30, the facility was unable to provide documentation of any current inspection of the facility's fire alarm system. Review of the facility's records indicated the last inspection was 06-10-10. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

2. Observation of the fire alarm panel and the facility's records on 05-24-12 at approximately 10:35 a.m., the facility was unable to provide documentation of the monthly inspection records of the fire alarm panel. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

Based on observation and interview, the facility failed to maintain and test fire extinguishers as required. All of fire extinguishers in the facility were affected by the deficient practice. The deficient practice could affect all the patients and staff in the facility. This facility has a capacity of 12 and a census of 4 patients.
Findings are:

1) Observation of the fire extinguishers on 05/24/12 between 9:00 p.m. and 11:30 a.m. found that all of the extinguishers were missing monthly inspections. There was no date or initials marked on the extinguisher tags as required. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

Based on observation, the facility did not post warning signs on a room where oxygen was being stored. The deficient practice affected one smoke compartment and all occupants in that zone. This facility has a capacity of 12 and a census of 4 patients. Findings are:

1. On 5/24/12 at 10:00 a.m, it was observed that there was an oxygen tank stored in the utility room in the north corridor and did not have the proper warning signage outside on the room door. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

A) Based on observation, on 05/24/12 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 4 with a capacity of 12.
Findings are:

1. Observation on 05-24-12 at approximately 09:30, revealed that in the endoscopy room the facility was using a power strip which was not an approved one. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

2. Observation on 05-24-12 at approximately 09:36, revealed that in the endoscopy room the facility was using a make shift electrical receptacle which was not an approved one. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.

3. Observation on 05-24-12 at approximately 09:48, revealed that in the mammogram room the facility was using a power strip which was not an approved one. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.


B) Based on observation, the facility did not prohibit the use of extension cords and power strips as a substitute for adequate wiring to prevent overloaded circuits. The location of deficient practice was located in one of three smoke compartments affecting all of the patients in that compartment. This facility has a census of 4 with a capacity of 12.
Findings are:

1. Observation on 5/24/12 revealed that in the employee dining room which is located in the patient wing had a three-way adapter plugged into a duplex receptacle along the east wall, with two freezers and one refrigerator plugged into the adapter. Observations were acknowledged by and verified by Maintenance Staff at the time of the observations and/or at the exit interview.