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Based on a tour of the facility and observation, the facility did not have a housekeeping and preventive maintenance program to ensure that all essential mechanical, electrical and patient care equipment is maintained in safe operating condition.

Findings were:

During a tour of the facility on 3-18-10, 1 of 1 medication room in the patient care area contained non-functional, uncapped pipes sticking out of the wall.

The above was confirmed in an interview with the Clinical Operation Director and the Director of Nurses in the conference room on the afternoon of 3-18-10.

Based on a tour of the facility, there was no preventive maintenance program to ensusre that drugs and biologicals are properly stored.

Findings were:

During a tour of the patient care unit, 1 of 1 unlocked medication room contained 12 bottles of patient
#25's home medications sitting on the countertop in an ice chest.

The above was confirmed in an interview with the Clinical Operation Director and the Director of Nurses in the conference room on the afternoon of 3-18-10.

Based on observation and a tour of the facility, the facility did not have a preventive program to ensure that there is proper lighting, ventilation and temperature control in all pharmaceutical, patient care and food preparation areas.

Findings were:

During a tour of the patient care unit on 3-18-10, 1 of 1 unlocked medication room contained 12 bottles of patient #25's home medications sitting on the countertop in an ice chest.

During a tour of the patient care unit on 3-18-10, the temperature log sheets for 2 of 2 medication refrigerators in the medication room gave no instructions to be followed in the event the refrigerator temperature was out of range.

During a tour of the pharmacy on 3-18-10, the temperature for 1 of 1 medication refrigerator had not been documented for 1 of 18 days in the current month.

During a tour of the pharmacy on 3-18-10, the temperature log sheet for 1 of 1 medication refrigerator in the pharmacy gave no instructions to be followed in the event the refrigerator temperature was out of range.

During a tour of the kitchen on 3-18-10, 1 of 1 freezer had temperatures that had been documented as being "out of range" for 6 days of 18 in the current month. Although the temperature log stated that the sheet should be initialed to indicate that maintenance was notified, no such documentation was found.

During a tour of the kitchen on 3-18-10, 1 of 2 refrigerators had temperatures that had been documented as being "out of range" for 46 days of 18 in the current month. Although the temperature log stated that the sheet should be initialed to indicate that maintenance was notified, no such documentation was found.

During a tour of the outpatient services area on 3-18-10, the temperature log sheets for 1 of 1 medication refrigerator in the outpatient services area gave no instructions to be followed in the event the refrigerator temperature was out of range.

The above was confirmed in an interview with the Clinical Operation Director and the Director of Nurses in the conference room on the afternoon of 3-18-10.