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Based on observation and interview the facility failed to ensure all portable medical gas cylinders were individually secured. This deficient practice affects the operation of the facility. The facility census was 17.

Findings included:

Observation, during a tour of the facility conducted on the afternoon of 06/09/11 at 2:10 PM, showed a total six portable medical gas cylinders not individually secured in the medical gas room.

Staff P, Maintenance Manager, confirmed at that time the medical gas cylinders were not individually secured.

Chapter 5.1.3.3.2 of the 2002 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 99) states that locations for the central supply systems and the storage of medical gas shall meet the following requirements: (7) be provided with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty from falling.

Based on observation and interview the facility failed to install Alcohol Based Hand Rub dispenser in locations away from an ignition source. This deficient practice affects all patients in the facility. The facility census was 17.

Findings included:

Observation on 06/09/11 at 2:16 PM showed an alcohol based hand rub dispenser mounted to the wall just above an electrical light switch in the laboratory. This dispenser contained eight ounces of 62 % Ethyl Alcohol.

Observation on 06/09/11 at 2:44 PM showed an alcohol based hand rub dispenser mounted to the wall just above an electrical light switch in patient room 117. This dispenser contained eight ounces of 62 % Ethyl Alcohol.

Observation on 06/09/11 at 2:49 PM showed an alcohol based hand rub dispenser mounted to the wall just above an electrical light switch in patient room 111. This dispenser contained eight ounces of 62 % Ethyl Alcohol.

Staff P, Maintenance Manager, confirmed at that time the alcohol based hand rub dispensers were mounted above electrical light switches.