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1. Based on diet manual review and interview, it was determined the facility failed to ensure the approved diet manual was current. The failed practice had the potential to affect all patients admitted to the faciliyt. Evidence follows:

A. Review of the Fifth Edition of the American Dietetic Association Clinical Manual of Dietetics used by the facility revealed the publication date was 1996. No published revisions were provided.
B. The Dietary Director confirmed during interview at 1330 on 02/10/10 the diet manual was not the most current edition.

2. Based on observation and work order documentation review it was determined the health and safety of patients was not ensured due to exposure to walls and ceilings with loose, cracked, and peeling paint in 6 out of 28 rooms observed. The census on the day of the survey was one patient, but the failed practice had the potential to affect all patients admitted to the facility. The findings follow:

A. On a tour of the facility with the Maintenance Director on 02/11/10 at 1000 revealed loose, cracked and peeling paint on the walls and ceilings in 6 out of 18 areas observed:
1) Patient Room 213
2) Patient Room 214
3) Conference Room 200
4) Patient Room 221
5) Men's Bathroom
6) Janitors Closet 238.
B. On 02/11/10 at 1045, a review of work orders related to wall and ceilings revealed an open work order dated 06/09/08 requesting ceiling repair in Room 213. Another worker order dated 02/19/09 revealing Room 213 currently had cracking, peeling and flaking paint with a request for the room to be painted. At the time of the work order review, the Maintenance Director stated repairs were completed as money for repairs was made available.

3. Based on observation, generator log review, and interview it was determined the facility did not meet provisions of the Life Safety Code related to roller latches, fire protection of harazardous areas, and exercising the and inspection of the emergency generator. See CMS 2567 Tags K-18, K-29, and K-144.