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Based on observation and staff interview the facility fails to maintain the integrity of the building construction by allowing construction work for the addition to be inadequately separated from the occupied building and by allowing gaps around sprinkler and other piping to remain open in the ceiling. This deficient practice would allow fire products to spread to the concealed ceiling area in four of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) Found construction work in progress that is inadequately separated from the occupied building on the basement level where the former Risk Manager's Office was located. The corridor wall above the door to the construction area has been penetrated and several block removed. The
door between the construction area, formerly the Risk Manager ' s office door, was found prevented from closing and latching properly by a large bolt that was placed between the door and the door frame. This door is not rated for 45 minutes of fire resistance, Fire watch was posted.

2) There are gaps around sprinkler piping, escutcheons and other piping where they pass through the ceiling tile or into the wall at the following locations:

a. North wing south stairwell in the ceiling.
b. Rest room between rooms 131 & 133 in the wall.
c. Rooms 136, 137 and 138 in the ceiling.
d. Dictation room.
e. South bath area

Staff A and Staff B were notified of the fire watch and fire watch procedures explained regarding the inadequacy of the separation in the basement level. Staff B was present during the tour when the gaps into the wall and ceiling were discovered.

Based on observation and staff interview the facility fails to provide vertical openings that are enclosed with construction having a fire resistance of at least one hour. The deficient practice of allowing inadequately protected vertical openings will allow smoke and fire products to move from floor to floor affecting four of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

A vertical opening between floors is located in the CT room. This vertical opening is found in the floor of the CT room where there are cable or wiring sleeves that pass through the floor. There are gaps around the sleeves where they pass through the floor and also the sleeves themselves are not sealed around the cable and wiring.

Staff B was present when the vertical opening was discovered and acknowledged the inadequacy of the fire resistance.

Based on observation and interview, the facility failed to assure that doors to the stairway enclosure are held open only by devices arranged to automatically close all such doors as required. This deficient practice prevents the door from closing and allows fire and smoke products to enter the stairway enclosure, affecting three of three floors of the building. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed that the door to the stairway from the conference room on the basement level was found wedged open.

Staff B remove the wedge from this door so that it self-closed and stated that wedging doors open would be addressed with the staff as soon as possible.

Based on observation, record review and staff interview the facility fails to identify the location of all smoke barriers within the facility and the facility also fails to maintain one of nine smoke barriers to at least one half hour fire resistance and ensure that all penetrations area properly sealed. The deficient practice of not identifying smoke barrier location prevents the facility from properly maintaining them and the deficient practice of not maintaining smoke barriers would prevent containment of fire and smoke, affecting two of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The facility has numerous doors that appear to be smoke barrier doors. When inspecting the construction of the smoke barrier above these doors it was discovered that no smoke barrier was present. Surveyor requested from Staff B a drawing of the facility indicating where the smoke barriers were located. Consulted drawing presented and no smoke barriers were identified.

2) The smoke barrier near the clinic area on the first floor has penetrations around conduit or wiring where it passes through the wall. These unsealed penetrations were found directly above the horn/strobe and strobe only on the barrier west of the clinic door.

Staff B verified the condition existed at the above locations and is aware of the findings.

Based on observation and staff interview the facility fails to provide doors that are self-closing or automatically closing in a smoke barrier. The deficient practice of not providing self-closing or automatically closing doors in a smoke barrier would prevent the door from closing as required allowing smoke and fire product to spread beyond the smoke barrier more rapidly, affecting two of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed that the clinic door is located in a smoke barrier and the self-closing device has been disabled and the door is not automatic closing.

Staff B was present and acknowledged the door closing device has been disabled. Staff within the clinic stated that doctors enter the room numerous times during the day and this may be why the self-closing device has been disabled.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the adjoining areas, affecting five of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The door from the solarium to the corridor is not latching properly.
2) Gaps around conduit on both the east and west walls in the laundry room.
3) Gap around insulted pipe on the west wall in the laundry room.
4) Self-closer disabled from the basement level data processing room.
5) Telephone room has horizontal penetration from room to the concealed space above the corridor ceiling tile where the data cables pass through the sleeve.
6) Gaps around conduit passing into the ceiling in the south bath area.
7) Gaps around conduit passing into the ceiling in the electrical room between the solarium and the stairway door.

Staff B was present and acknowledged penetrations or other separation problems in these hazard rooms as listed.

Based on observation and staff interview the facility failed to provide continuous illumination of floors and other walking surfaces within an exit to values of at least 1 ft-candle (10 lux) measured at the floor. This deficient practice does not insure that exit paths will be illuminated continuously and will delay egress affecting one of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

The normal illumination for means of egress lighting area are provided with wall switches that allow all lighting fixtures in the affected exit path to be turned off on the south end of the first floor in the patient care area south of the smoke barrier doors.

Staff B operated the light switches for this area to review the normal lighting present after turning off the switch and also acknowledged that this areas was deficient.

Based on observation, record review and staff interview the facility failed to provide and maintain emergency lighting as required for the medication rooms and exit paths. This deficient practice of not providing egress or task lighting when needed at the time of a power outage would impede exiting. This deficient practice was observed in affecting nine of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The normal illumination for means of egress lighting area are provided with wall switches that allow all lighting fixtures in the affected exit path to be turned off on the south end of the first floor in the patient care area south of the smoke barrier doors. Providing emergency lighting would require that the switch be on in order for the generator to power the lighting.

2) Medication rooms in the OB area and near the nurses charting area has lighting provided with a switch. Providing emergency lighting would require that the switch be on in order for the generator to power the lighting.

3) No documentation indicating that the battery powered emergency lighting devices have been tested for 90 minutes within the last 12 months.

Staff B operated the light switches for these areas to review if emergency lighting would be provided after turning off the switch and also acknowledged that these areas were deficient. Staff B also requested documentation for the annual 90 minute emergency light testing from Staff C. Record review did not indicate 90 minute duration on any of the test reports reviewed and interview with Staff C failed to determine when this test last occurred.

Based on observation, record review and staff interview the facility failed to provide exit signs marking the exit paths. The deficient practice may prevent the occupants of the building to be directed to the exit path and delay egress affecting two of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The exit sign in the cardiac rehab area does not have a directional arrow indicating to exit via the stairway.
2) The exit sign in the corridor near the business office does not have a directional arrow indicating the exit path.

Staff B indicated that the exit signs had not been updated since construction started on the new addition and the exit paths had changed. Record review and observation confirmed this.

Based on observation, record review and interview the facility fails to insure that the automatic sprinkler system is installed in accordance with the 1999 NFPA 13. This deficient practice prevents the facility from being adequately provided with a sprinkler system as required, increasing the risk of fire in two of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The built in closet in room 122 is not provided with a sprinkler head.
2) The laboratory has two quick response sprinkler heads in the same compartment that also has standard response sprinkler heads.

Staff B acknowledged that no sprinkler head was located in room 122's built in closet and that the sprinkler heads were mixed within the laboratory compartment. This mixing of sprinkler heads within a compartment was not listed as a deficiency on the records reviewed from the sprinkler inspection contractor.

Based on observation, record review and staff interview the facility failed to maintain the sprinkler system in accordance with NFPA 13. This deficient practice may prevent the effective operation of the fire suppression system in the event of a fire, affecting five of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The facility failed to maintain the sprinkler head free of lint and dust obstructions as follows:

OB supply room upright head, LDRP 57, women ' s restroom near surgery, exam room number 3, mammography room east head, middle restroom in the radiology area and several in laboratory.

2) The spare sprinkler head cabinet only has 5 sprinkler heads and does not have at least two of each type in use in the building.

3) Janitorial room outside of Xray has sidewall head that the escutcheon ring has dislodged from its mount and is hanging from the deflector.

Staff B was present at time of the discovery of these findings and acknowledged the findings also.

Based on observation and staff interview the facility failed to ensure that empty and full oxygen cylinders were not stored in the same rack. This deficient practice could cause an empty cylinder to be retrieved in an emergency situation, affecting one of nine moke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed that several empty oxygen cylinders were stored in the same rack as the full cylinders in the north wing oxygen storage room.

Staff B was present and confirmed the cylinders were mixed. Staff B stated that staff had recently been instructed not to allow this type of deficiency and that it would be addressed with the staff again.

Based on record review and staff interview the facility failed to assure the generator is properly tested under load monthly. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting nine of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed that the generator log does not indicate that the load test performed monthly is being conducted with 30 percent of the capacity of the diesel generator nor was an annual load bank test completed within the last 12 months presented.

Staff C was present during record review on the generator and could not indicate on the logs that the load test being performed was within 30 percent of the data plate. The data plate indicates that the generator is rated at 250 kilowatts. The log does not indicate the kilowatts during the load test. Staff C was unable to indicate from the readings taken during the monthly load test if they represent 30 percent or greater of the rated capacity.

Staff C further indicated no annual load bank test was performed on the generator.

Staff B and Staff C were present at the record review and are aware of the findings.

Based on observation and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire sprinkler system is out of service for more than 4 hours in a 24-hour period, for 12 of 12 months of records reviewed, for 2009-2010. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic sprinkler compensatory provision when it occurred, and without appropriately prepared staff response, affecting nine of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed during record review that no written fire watch policy and procedures are available for when the fire sprinkler systems are out of service as required.

Staff B acknowledged that the facility does not have written firewatch policies and procedures. The facility has two separate fire sprinkler systems.

Based on observation and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire alarm system is out of service for more than 4 hours in a 24-hour period, for 12 of 12 months of records reviewed, for 2009-2010. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic detection compensatory provision when it occurred, and without appropriately prepared staff response, affecting nine of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed during record review that no written fire watch policy and procedures are available for when the fire alarm system is out of service as required.

Staff B acknowledged that the facility does not have written firewatch policies and procedures.

Based on observation and staff interview the facility fails to maintain the integrity of the building construction by allowing construction work for the addition to be inadequately separated from the occupied building and by allowing gaps around sprinkler and other piping to remain open in the ceiling. This deficient practice would allow fire products to spread to the concealed ceiling area in four of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) Found construction work in progress that is inadequately separated from the occupied building on the basement level where the former Risk Manager's Office was located. The corridor wall above the door to the construction area has been penetrated and several block removed. The
door between the construction area, formerly the Risk Manager ' s office door, was found prevented from closing and latching properly by a large bolt that was placed between the door and the door frame. This door is not rated for 45 minutes of fire resistance, Fire watch was posted.

2) There are gaps around sprinkler piping, escutcheons and other piping where they pass through the ceiling tile or into the wall at the following locations:

a. North wing south stairwell in the ceiling.
b. Rest room between rooms 131 & 133 in the wall.
c. Rooms 136, 137 and 138 in the ceiling.
d. Dictation room.
e. South bath area

Staff A and Staff B were notified of the fire watch and fire watch procedures explained regarding the inadequacy of the separation in the basement level. Staff B was present during the tour when the gaps into the wall and ceiling were discovered.

Based on observation and staff interview the facility fails to provide vertical openings that are enclosed with construction having a fire resistance of at least one hour. The deficient practice of allowing inadequately protected vertical openings will allow smoke and fire products to move from floor to floor affecting four of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

A vertical opening between floors is located in the CT room. This vertical opening is found in the floor of the CT room where there are cable or wiring sleeves that pass through the floor. There are gaps around the sleeves where they pass through the floor and also the sleeves themselves are not sealed around the cable and wiring.

Staff B was present when the vertical opening was discovered and acknowledged the inadequacy of the fire resistance.

Based on observation and interview, the facility failed to assure that doors to the stairway enclosure are held open only by devices arranged to automatically close all such doors as required. This deficient practice prevents the door from closing and allows fire and smoke products to enter the stairway enclosure, affecting three of three floors of the building. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed that the door to the stairway from the conference room on the basement level was found wedged open.

Staff B remove the wedge from this door so that it self-closed and stated that wedging doors open would be addressed with the staff as soon as possible.

Based on observation, record review and staff interview the facility fails to identify the location of all smoke barriers within the facility and the facility also fails to maintain one of nine smoke barriers to at least one half hour fire resistance and ensure that all penetrations area properly sealed. The deficient practice of not identifying smoke barrier location prevents the facility from properly maintaining them and the deficient practice of not maintaining smoke barriers would prevent containment of fire and smoke, affecting two of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The facility has numerous doors that appear to be smoke barrier doors. When inspecting the construction of the smoke barrier above these doors it was discovered that no smoke barrier was present. Surveyor requested from Staff B a drawing of the facility indicating where the smoke barriers were located. Consulted drawing presented and no smoke barriers were identified.

2) The smoke barrier near the clinic area on the first floor has penetrations around conduit or wiring where it passes through the wall. These unsealed penetrations were found directly above the horn/strobe and strobe only on the barrier west of the clinic door.

Staff B verified the condition existed at the above locations and is aware of the findings.

Based on observation and staff interview the facility fails to provide doors that are self-closing or automatically closing in a smoke barrier. The deficient practice of not providing self-closing or automatically closing doors in a smoke barrier would prevent the door from closing as required allowing smoke and fire product to spread beyond the smoke barrier more rapidly, affecting two of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed that the clinic door is located in a smoke barrier and the self-closing device has been disabled and the door is not automatic closing.

Staff B was present and acknowledged the door closing device has been disabled. Staff within the clinic stated that doctors enter the room numerous times during the day and this may be why the self-closing device has been disabled.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The area of deficient practice would provide a path for smoke and fire to travel into the adjoining areas, affecting five of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The door from the solarium to the corridor is not latching properly.
2) Gaps around conduit on both the east and west walls in the laundry room.
3) Gap around insulted pipe on the west wall in the laundry room.
4) Self-closer disabled from the basement level data processing room.
5) Telephone room has horizontal penetration from room to the concealed space above the corridor ceiling tile where the data cables pass through the sleeve.
6) Gaps around conduit passing into the ceiling in the south bath area.
7) Gaps around conduit passing into the ceiling in the electrical room between the solarium and the stairway door.

Staff B was present and acknowledged penetrations or other separation problems in these hazard rooms as listed.

Based on observation and staff interview the facility failed to provide continuous illumination of floors and other walking surfaces within an exit to values of at least 1 ft-candle (10 lux) measured at the floor. This deficient practice does not insure that exit paths will be illuminated continuously and will delay egress affecting one of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

The normal illumination for means of egress lighting area are provided with wall switches that allow all lighting fixtures in the affected exit path to be turned off on the south end of the first floor in the patient care area south of the smoke barrier doors.

Staff B operated the light switches for this area to review the normal lighting present after turning off the switch and also acknowledged that this areas was deficient.

Based on observation, record review and staff interview the facility failed to provide and maintain emergency lighting as required for the medication rooms and exit paths. This deficient practice of not providing egress or task lighting when needed at the time of a power outage would impede exiting. This deficient practice was observed in affecting nine of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The normal illumination for means of egress lighting area are provided with wall switches that allow all lighting fixtures in the affected exit path to be turned off on the south end of the first floor in the patient care area south of the smoke barrier doors. Providing emergency lighting would require that the switch be on in order for the generator to power the lighting.

2) Medication rooms in the OB area and near the nurses charting area has lighting provided with a switch. Providing emergency lighting would require that the switch be on in order for the generator to power the lighting.

3) No documentation indicating that the battery powered emergency lighting devices have been tested for 90 minutes within the last 12 months.

Staff B operated the light switches for these areas to review if emergency lighting would be provided after turning off the switch and also acknowledged that these areas were deficient. Staff B also requested documentation for the annual 90 minute emergency light testing from Staff C. Record review did not indicate 90 minute duration on any of the test reports reviewed and interview with Staff C failed to determine when this test last occurred.

Based on observation, record review and staff interview the facility failed to provide exit signs marking the exit paths. The deficient practice may prevent the occupants of the building to be directed to the exit path and delay egress affecting two of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The exit sign in the cardiac rehab area does not have a directional arrow indicating to exit via the stairway.
2) The exit sign in the corridor near the business office does not have a directional arrow indicating the exit path.

Staff B indicated that the exit signs had not been updated since construction started on the new addition and the exit paths had changed. Record review and observation confirmed this.

Based on observation, record review and interview the facility fails to insure that the automatic sprinkler system is installed in accordance with the 1999 NFPA 13. This deficient practice prevents the facility from being adequately provided with a sprinkler system as required, increasing the risk of fire in two of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The built in closet in room 122 is not provided with a sprinkler head.
2) The laboratory has two quick response sprinkler heads in the same compartment that also has standard response sprinkler heads.

Staff B acknowledged that no sprinkler head was located in room 122's built in closet and that the sprinkler heads were mixed within the laboratory compartment. This mixing of sprinkler heads within a compartment was not listed as a deficiency on the records reviewed from the sprinkler inspection contractor.

Based on observation, record review and staff interview the facility failed to maintain the sprinkler system in accordance with NFPA 13. This deficient practice may prevent the effective operation of the fire suppression system in the event of a fire, affecting five of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM the following is observed:

1) The facility failed to maintain the sprinkler head free of lint and dust obstructions as follows:

OB supply room upright head, LDRP 57, women ' s restroom near surgery, exam room number 3, mammography room east head, middle restroom in the radiology area and several in laboratory.

2) The spare sprinkler head cabinet only has 5 sprinkler heads and does not have at least two of each type in use in the building.

3) Janitorial room outside of Xray has sidewall head that the escutcheon ring has dislodged from its mount and is hanging from the deflector.

Staff B was present at time of the discovery of these findings and acknowledged the findings also.

Based on observation and staff interview the facility failed to ensure that empty and full oxygen cylinders were not stored in the same rack. This deficient practice could cause an empty cylinder to be retrieved in an emergency situation, affecting one of nine moke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed that several empty oxygen cylinders were stored in the same rack as the full cylinders in the north wing oxygen storage room.

Staff B was present and confirmed the cylinders were mixed. Staff B stated that staff had recently been instructed not to allow this type of deficiency and that it would be addressed with the staff again.

Based on record review and staff interview the facility failed to assure the generator is properly tested under load monthly. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting nine of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed that the generator log does not indicate that the load test performed monthly is being conducted with 30 percent of the capacity of the diesel generator nor was an annual load bank test completed within the last 12 months presented.

Staff C was present during record review on the generator and could not indicate on the logs that the load test being performed was within 30 percent of the data plate. The data plate indicates that the generator is rated at 250 kilowatts. The log does not indicate the kilowatts during the load test. Staff C was unable to indicate from the readings taken during the monthly load test if they represent 30 percent or greater of the rated capacity.

Staff C further indicated no annual load bank test was performed on the generator.

Staff B and Staff C were present at the record review and are aware of the findings.

Based on observation and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire sprinkler system is out of service for more than 4 hours in a 24-hour period, for 12 of 12 months of records reviewed, for 2009-2010. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic sprinkler compensatory provision when it occurred, and without appropriately prepared staff response, affecting nine of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed during record review that no written fire watch policy and procedures are available for when the fire sprinkler systems are out of service as required.

Staff B acknowledged that the facility does not have written firewatch policies and procedures. The facility has two separate fire sprinkler systems.

Based on observation and interview the facility does not assure a fire watch procedure and policy is written and available for implementation when fire alarm system is out of service for more than 4 hours in a 24-hour period, for 12 of 12 months of records reviewed, for 2009-2010. This deficient practice would allow facility exposure to undetected smoke and/or fire without an automatic detection compensatory provision when it occurred, and without appropriately prepared staff response, affecting nine of nine smoke zones. The facility has a capacity of 25 and census of 13.

Findings Include:

During the tour on May 5, 2010 between 9:50 AM and 4:10 PM and May 6, 2010 8:30 AM and 1:45 PM it is observed during record review that no written fire watch policy and procedures are available for when the fire alarm system is out of service as required.

Staff B acknowledged that the facility does not have written firewatch policies and procedures.