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Based on observation and interview, the facility did not provide a common separation wall that had and sealed wall penetrations. This deficiency occurred in 2 of the 5 smoke compartments, and would affect 8 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. On 4/26/2010 at 2:15 PM surveyor #12187 observed on the lower level floor in the boiler room, located in the zone 2 smoke compartment, that penetrations through the separation wall were not sealed according to approved UL designs. The deficiency included one 2" pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

2. On 4/27/2010 at 1:52 PM surveyor #12187 observed on the 1st floor in the women's OR locker room , located in the zone 4 smoke compartment, that penetrations through the separation wall were not sealed according to approved UL designs. The deficiency included a 2 inch gap on the bottom and one side of a duct that was not covered by sheet metal angle. In addition, there was a 2" X 4" hole located one foot below the duct. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide and maintain the required building construction type that has sealed floor penetrations. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 5 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 2:12 PM surveyor #12187 observed on the lower level floor in the electric room by the dialysis area, located in the zone 2 smoke compartment, that there were penetrations through the floor that were not fire stopped according to a UL design standard. Penetrations included 2 electrical conduits through the rated floor/ceiling assembly. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide and maintain the required building construction type because support steel was not covered with rated fire proofing. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 5 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 3:05 PM surveyor #12187 observed on the lower level floor in the maintenance shop, located in the zone 2 smoke compartment, that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide corridor separation doors that had doors with positive-latching hardware. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 5 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 2:08 PM surveyor #12187 observed on the lower level floor in the room 110, Dialysis, located in the zone 2 smoke compartment, that the corridor door would not positively self-latch when pushed to a closed position because the electrical door latch was programmed to stay open during dialysis hours. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 that had a visual appliance in the proper location . This deficiency occurred in 1 of the 5 smoke compartments, and would affect 5 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 2:04 PM surveyor #12187 observed on the lower level floor in the corridor by the LDRP rooms, located in the zone 3 smoke compartment, that the location of the visual appliance was not per spacing requirements of the code. The nearest strobe was 20 feet from the across corridor doors on one side and 50 feet on the other side of the doors. The Life Safety Code, section 9.6.1.4, requires compliance with NFPA 72 in all existing healthcare facilities, unless the authority having jurisdiction (AHJ) permits specific exceptions. CMS, as the AHJ, has not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities since inpatients are incapable of self preservation and rely on a fully reliable fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. This observed situation was not compliant with NFPA 72 (1999 edition), 4-4.4.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements that sprinklers provide full coverage of the floor area. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 4 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 4:00 PM surveyor #12187 observed on the lower level floor in the in the rehab area (PT) by the west door alcove, located in the zone 1 smoke compartment, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included the alcove wall. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes that require extinguishers be installed at required locations. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 3 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 11:07 AM surveyor #12187 observed on the 1st floor in the alcove by medical surgical nurse station, located in the zone 4 smoke compartment, that a fire extinguisher was not conspicuously located. It was hidden on the floor behind equipment. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.6, 9.7.4.1 and NFPA 10. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide a ventilation system in accordance with NFPA 90A that requires neutral airflow between the corridor and rooms. This deficiency occurred in 2 of the 5 smoke compartments, and would affect 3 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. On 4/26/2010 at 10:33 AM surveyor #12187 observed on the 1st floor in the clean supply room, located in the zone 5 smoke compartment, that airflow between the corridor and this room was not neutral. The clean supply room is being used as a med room. The air flow requirement for a med room is to be neutral to the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1.. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

2. On 4/26/2010 at 11:23 AM surveyor #12187 observed on the 1st floor in the Patient room 313, located in the zone 4 smoke compartment, that airflow between the corridor and this room was not neutral. There is an portable exhaust HEPA filter machine that could draw air out of the patient room out through a hole in the window. There is no supply air to the room. This would cause the room to become negative to the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide and implement a policy on the use of portable space heating devices that had space heaters that comply with code requirements. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 0 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 10:23 AM surveyor #12187 observed on the 1st floor in the nurse station of the emergency department, located in the zone 5 smoke compartment, that a space heater was used that had heating elements greater than 212 F because the heating elements were glowing red. The ER nurse station is located down the corridor from the sleeping rooms. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.8. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes that require properly sized storage containers for soiled/trash. This deficiency occurred in 2 of the 5 smoke compartments, and would affect 7 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. On 4/26/2010 at 12:50 PM surveyor #12187 observed on the 1st floor in the operating room, located in the zone 4 smoke compartment, that mobile collection receptacles exceeded the 32 gallon per 64 square foot density limit when located outside of a hazardous area. The two blue 25 gallon recycle containers were next to each other, and the 32 gallon trash can in the corner was next to the 32 gallon with soiled linen hopper. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

2. On 4/26/2010 at 3:15 PM surveyor #12187 observed on the lower level floor in the Laboratory, located in the zone 1 smoke compartment, that mobile collection receptacles exceeded the 32 gallon per 64 square feet density limit when located outside of a hazardous area. The 25 gallon blue recycling containers, the 25 gallon trash container, the 32 gallon metal trash can and the 32 gallon shredded paper container are all located in a 30 square foot area near a work table. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 that had accessible valves. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 3 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 11:03 AM surveyor #12187 observed on the 1st floor in the housekeeping, room 301, located in the zone 4 smoke compartment, that medical gas valves were not in plane view. 4 coats covered the medical gas zone valve from view. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 4-3.1.2.3(i). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services)

Based on observation, interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes that require weekly inspections of the emergency generators. This deficiency occurred in all of the 5 smoke compartments, and would affect all of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/27/2010at 11:30 am surveyor #12187 observed during a review of documents that weekly visual inspections of the generator fluids and general condition were not documented. In addition, there was no documentation that the generator was tested monthly. This observed situation was not compliant with NFPA 110 (1999 edition), 6-3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide a Type I essential electrical system that had emergency power receptacles with distinctive color or markings. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 2 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 10:50 AM surveyor #12187 observed on the 1st floor in the all patient rooms on the west side of the building, located in the zone 4 smoke compartment, that the emergency power receptacles did not have a distinct color or marking to identify them as emergency outlets. This observed situation was not compliant with NFPA 99 (1999 edition) 3-4.2.2.4(b)2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide a common separation wall that had and sealed wall penetrations. This deficiency occurred in 2 of the 5 smoke compartments, and would affect 8 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. On 4/26/2010 at 2:15 PM surveyor #12187 observed on the lower level floor in the boiler room, located in the zone 2 smoke compartment, that penetrations through the separation wall were not sealed according to approved UL designs. The deficiency included one 2" pipe. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

2. On 4/27/2010 at 1:52 PM surveyor #12187 observed on the 1st floor in the women's OR locker room , located in the zone 4 smoke compartment, that penetrations through the separation wall were not sealed according to approved UL designs. The deficiency included a 2 inch gap on the bottom and one side of a duct that was not covered by sheet metal angle. In addition, there was a 2" X 4" hole located one foot below the duct. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.1.4. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide and maintain the required building construction type that has sealed floor penetrations. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 5 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 2:12 PM surveyor #12187 observed on the lower level floor in the electric room by the dialysis area, located in the zone 2 smoke compartment, that there were penetrations through the floor that were not fire stopped according to a UL design standard. Penetrations included 2 electrical conduits through the rated floor/ceiling assembly. Penetrations adversely affected the ability of the building to compartmentalize fires to a single floor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.1.6 and 8.2.3.2.4.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide and maintain the required building construction type because support steel was not covered with rated fire proofing. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 5 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 3:05 PM surveyor #12187 observed on the lower level floor in the maintenance shop, located in the zone 2 smoke compartment, that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 edition), 19.1.6.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide corridor separation doors that had doors with positive-latching hardware. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 5 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 2:08 PM surveyor #12187 observed on the lower level floor in the room 110, Dialysis, located in the zone 2 smoke compartment, that the corridor door would not positively self-latch when pushed to a closed position because the electrical door latch was programmed to stay open during dialysis hours. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.6.3.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 that had a visual appliance in the proper location . This deficiency occurred in 1 of the 5 smoke compartments, and would affect 5 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 2:04 PM surveyor #12187 observed on the lower level floor in the corridor by the LDRP rooms, located in the zone 3 smoke compartment, that the location of the visual appliance was not per spacing requirements of the code. The nearest strobe was 20 feet from the across corridor doors on one side and 50 feet on the other side of the doors. The Life Safety Code, section 9.6.1.4, requires compliance with NFPA 72 in all existing healthcare facilities, unless the authority having jurisdiction (AHJ) permits specific exceptions. CMS, as the AHJ, has not identified any exceptions to permit non-compliance with NFPA 72 in an existing healthcare facility. The AHJ considers any non-compliance a distinct hazard to life in existing facilities since inpatients are incapable of self preservation and rely on a fully reliable fire alarm system to defend in place. This is consistent with NFPA 72 (1999 edition) 1-2.3, which notes that while NFPA 72 is not normally applied to existing facilities, the AHJ can apply it in cases where the AHJ feels there is a distinct hazard to life or property. This observed situation was not compliant with NFPA 72 (1999 edition), 4-4.4.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements that sprinklers provide full coverage of the floor area. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 4 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 4:00 PM surveyor #12187 observed on the lower level floor in the in the rehab area (PT) by the west door alcove, located in the zone 1 smoke compartment, that a wall obstructed the discharge of sprinkler water from reaching an unprotected area on the other side of the wall. The obstruction included the alcove wall. This observed situation was not compliant with NFPA 13 (1999 edition), 5-6.5. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide and maintain portable fire extinguishers as required by the codes that require extinguishers be installed at required locations. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 3 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 11:07 AM surveyor #12187 observed on the 1st floor in the alcove by medical surgical nurse station, located in the zone 4 smoke compartment, that a fire extinguisher was not conspicuously located. It was hidden on the floor behind equipment. This observed situation was not compliant with NFPA 101 (2000 edition), 18.3.5.6, 9.7.4.1 and NFPA 10. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide a ventilation system in accordance with NFPA 90A that requires neutral airflow between the corridor and rooms. This deficiency occurred in 2 of the 5 smoke compartments, and would affect 3 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. On 4/26/2010 at 10:33 AM surveyor #12187 observed on the 1st floor in the clean supply room, located in the zone 5 smoke compartment, that airflow between the corridor and this room was not neutral. The clean supply room is being used as a med room. The air flow requirement for a med room is to be neutral to the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1.. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

2. On 4/26/2010 at 11:23 AM surveyor #12187 observed on the 1st floor in the Patient room 313, located in the zone 4 smoke compartment, that airflow between the corridor and this room was not neutral. There is an portable exhaust HEPA filter machine that could draw air out of the patient room out through a hole in the window. There is no supply air to the room. This would cause the room to become negative to the corridor. This observed situation was not compliant with NFPA 101 (2000 edition), 18.5.2.1 9.2 and NFPA 90A, 2-3.11.1. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide and implement a policy on the use of portable space heating devices that had space heaters that comply with code requirements. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 0 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 10:23 AM surveyor #12187 observed on the 1st floor in the nurse station of the emergency department, located in the zone 5 smoke compartment, that a space heater was used that had heating elements greater than 212 F because the heating elements were glowing red. The ER nurse station is located down the corridor from the sleeping rooms. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.8. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes that require properly sized storage containers for soiled/trash. This deficiency occurred in 2 of the 5 smoke compartments, and would affect 7 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
1. On 4/26/2010 at 12:50 PM surveyor #12187 observed on the 1st floor in the operating room, located in the zone 4 smoke compartment, that mobile collection receptacles exceeded the 32 gallon per 64 square foot density limit when located outside of a hazardous area. The two blue 25 gallon recycle containers were next to each other, and the 32 gallon trash can in the corner was next to the 32 gallon with soiled linen hopper. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

2. On 4/26/2010 at 3:15 PM surveyor #12187 observed on the lower level floor in the Laboratory, located in the zone 1 smoke compartment, that mobile collection receptacles exceeded the 32 gallon per 64 square feet density limit when located outside of a hazardous area. The 25 gallon blue recycling containers, the 25 gallon trash container, the 32 gallon metal trash can and the 32 gallon shredded paper container are all located in a 30 square foot area near a work table. This observed situation was not compliant with NFPA 101 (2000 edition), 18.7.5.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 that had accessible valves. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 3 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 11:03 AM surveyor #12187 observed on the 1st floor in the housekeeping, room 301, located in the zone 4 smoke compartment, that medical gas valves were not in plane view. 4 coats covered the medical gas zone valve from view. This observed situation was not compliant with NFPA 101 (2000 edition), 19.3.2.4 and NFPA 99 (1999 edition), 4-3.1.2.3(i). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services)

Based on observation, interview and a review of documents, the facility did not test the emergency electrical generator in accordance with the codes that require weekly inspections of the emergency generators. This deficiency occurred in all of the 5 smoke compartments, and would affect all of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/27/2010at 11:30 am surveyor #12187 observed during a review of documents that weekly visual inspections of the generator fluids and general condition were not documented. In addition, there was no documentation that the generator was tested monthly. This observed situation was not compliant with NFPA 110 (1999 edition), 6-3.6. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .

Based on observation and interview, the facility did not provide a Type I essential electrical system that had emergency power receptacles with distinctive color or markings. This deficiency occurred in 1 of the 5 smoke compartments, and would affect 2 of the 17 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 25.

FINDINGS INCLUDE:
On 4/26/2010 at 10:50 AM surveyor #12187 observed on the 1st floor in the all patient rooms on the west side of the building, located in the zone 4 smoke compartment, that the emergency power receptacles did not have a distinct color or marking to identify them as emergency outlets. This observed situation was not compliant with NFPA 99 (1999 edition) 3-4.2.2.4(b)2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff A (Director of Environmental Services) .