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Based on observations, the facility failed to properly protect hazardous areas. This condition affected 100% of the residents and staff.

Findings Include:

On June 15,2010 at 10:15 p.m., the maintenance person and surveyor found the following hazardous areas to be improperly protected;

1) Film storage room in x ray
2) Med storage room near nurses station
3) Maintenance area
4) Accounting storage room
5) Record storage
6) Business office storage.


All hazardous areas must have 1 hour fire rated walls, 1 hour fire rated ceilings, 45 minute rated doors, proper ducting, and automatic door closers.

Based on observations and interviews, the facility failed to properly protect all of the generator ' s required components. This deficiency had the potential to effect to 100% of the residents and staff.

Findings Include:

On June 15, 2010 at 10:45 a.m., the maintenance person and surveyor found that the facility lacked remote annunciator at a continuously occupied location. The annunciator was located in the reception area but the reception area is not continuously manned.

NFPA 99 3-4.1.1.15 + Alarm Annunciator.
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]