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Based on observations, the facility failed to maintain the integrity of the building's smoke barriers as required. This deficient practice would affect 3 of 7 smoke zones, and 20 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/19/2010, revealed the following:1.) There was a two-inch pipe penetration, that included a gap of approximately one-half inch, was found, above the ceiling tiles and above the smoke door assembly near Room A147.2.) There was an irregularly-shaped hole was found, approximately one-inch by two-inches in shape, above the ceiling tiles and above the smoke door assembly at the smoke barrier near Room C119.

Based on observations, the facility failed to maintain doors to the corridor within proper standards This deficient practice would effect 3 of 7 smoke zones, and 10 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/19/2010, revealed thumb-turn deadbolts on the following doors: two of four Dish Room doors, and the door between the Business Office and the Records Office.

Based on observations, the facility failed to maintain two of the smoke barrier door assemblies in the facility. This deficient practice would not prevent the spread of smoke, affecting the building's occupants, in the case of a fire related emergency. This deficient practice would affect 4 of 7 smoke zones, and 15 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/18/2010, revealed that the following smoke barrier doors were not smoke tight, exhibiting a gap between said doors of less than one eighth of an inch: The Garage Smoke Doors and the East Surgery Smoke Doors.

Based on observations, the facility failed to maintain hazardous rooms in the facility in safe and required conditions. This deficient practice would effect 1 of 7 smoke zones, and 5 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/18/2010, revealed that in the testing of the facility ' s doors, a failure to positively latch within the frame of the door was found on the door to the A15, the Soiled Utility Room.

Based on documentation review, the facility failed to test the emergency lighting in the building to verify that it is in proper working condition as required by 7.9. This deficient practice would effect 7 of 7 smoke zones, and 50 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Documentation review on 08/18/2010, revealed the following:1.) No complete documentation of the required ninety-minute testing of the emergency illumination devices was available for the last year. This testing is required to be performed and documented once per year.2.) No complete documentation of all of the required thirty-second testing of the emergency illumination devices was available for the last year. This testing is required to be performed and documented once per month.

Based on observations, the facility failed to maintain the facility fire alarm system in accordance with National Fire Protection Association (NFPA) standard 72, National Fire Alarm Code 1999 edition. This deficient practice would affect 7 of 7 smoke zones, and 50 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/18/2010, revealed the following:1.) The source circuit of alternating current power was not labeled on the front or the inside of the fire alarm control panel in an easily noticeable fashion.2.) The electrical breaker that serves the fire alarm control panel was not equipped with a mechanism which would secure the breaker in the " on " position. Such device deters accidental switching to the " off " position.

Based on documentation review, the facility failed to test the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition. This deficient practice would effect 7 of 7 smoke zones, and 50 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Documentation review on 08/18/2010, revealed that system testing documents were unavailable for all required quarterly testing of the building's sprinkler system for the previous twelve months.

Based on observations, the facility failed to install the heating, ventilation, and air conditioning system (HVAC system) properly by placing air vents within thirty-six inches of fire alarm components. This deficient practice would affect 1 of 7 smoke zones, and 5 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/19/2010, revealed a smoke detector mounted within thirty-six inches of a HVAC vent in the Surgical Mechanical Room.

Based on documentation review, the facility failed to provide a policy in writing that meets the requirements of 2000 Life Safety Code 9.6.1.8 (plans for fire alarm systems out of service for more than 4 hours in a 24 hour period). This deficient practice would affect 7 of 7 smoke zones, and 50 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Documentation review on 08/19/2010, revealed that the facility was unable to provide a written policy that meets the requirements of 2000 Life Safety Code 9.6.1.8 (plans for fire suppression systems out of service for more than 4 hours in a 24 hour period).

Based on documentation review, the facility failed to provide a policy in writing that meets the requirements of 2000 Life Safety Code 9.6.1.8 (plans for fire suppression systems out of service for more than 4 hours in a 24 hour period). This deficient practice would affect 7 of 7 smoke zones, and 50 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Documentation review on 08/19/2010, revealed that the facility was unable to provide a written policy that meets the requirements of 2000 Life Safety Code 9.6.1.8 (plans for fire alarm systems out of service for more than 4 hours in a 24 hour period).

Based on observations, the facility failed to maintain the integrity of the building's smoke barriers as required. This deficient practice would affect 3 of 7 smoke zones, and 20 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/19/2010, revealed the following:1.) There was a two-inch pipe penetration, that included a gap of approximately one-half inch, was found, above the ceiling tiles and above the smoke door assembly near Room A147.2.) There was an irregularly-shaped hole was found, approximately one-inch by two-inches in shape, above the ceiling tiles and above the smoke door assembly at the smoke barrier near Room C119.

Based on observations, the facility failed to maintain doors to the corridor within proper standards This deficient practice would effect 3 of 7 smoke zones, and 10 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/19/2010, revealed thumb-turn deadbolts on the following doors: two of four Dish Room doors, and the door between the Business Office and the Records Office.

Based on observations, the facility failed to maintain two of the smoke barrier door assemblies in the facility. This deficient practice would not prevent the spread of smoke, affecting the building's occupants, in the case of a fire related emergency. This deficient practice would affect 4 of 7 smoke zones, and 15 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/18/2010, revealed that the following smoke barrier doors were not smoke tight, exhibiting a gap between said doors of less than one eighth of an inch: The Garage Smoke Doors and the East Surgery Smoke Doors.

Based on observations, the facility failed to maintain hazardous rooms in the facility in safe and required conditions. This deficient practice would effect 1 of 7 smoke zones, and 5 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/18/2010, revealed that in the testing of the facility ' s doors, a failure to positively latch within the frame of the door was found on the door to the A15, the Soiled Utility Room.

Based on documentation review, the facility failed to test the emergency lighting in the building to verify that it is in proper working condition as required by 7.9. This deficient practice would effect 7 of 7 smoke zones, and 50 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Documentation review on 08/18/2010, revealed the following:1.) No complete documentation of the required ninety-minute testing of the emergency illumination devices was available for the last year. This testing is required to be performed and documented once per year.2.) No complete documentation of all of the required thirty-second testing of the emergency illumination devices was available for the last year. This testing is required to be performed and documented once per month.

Based on observations, the facility failed to maintain the facility fire alarm system in accordance with National Fire Protection Association (NFPA) standard 72, National Fire Alarm Code 1999 edition. This deficient practice would affect 7 of 7 smoke zones, and 50 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/18/2010, revealed the following:1.) The source circuit of alternating current power was not labeled on the front or the inside of the fire alarm control panel in an easily noticeable fashion.2.) The electrical breaker that serves the fire alarm control panel was not equipped with a mechanism which would secure the breaker in the " on " position. Such device deters accidental switching to the " off " position.

Based on documentation review, the facility failed to test the sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13, Standard for the Installation of Sprinkler Systems, 1999 edition. This deficient practice would effect 7 of 7 smoke zones, and 50 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Documentation review on 08/18/2010, revealed that system testing documents were unavailable for all required quarterly testing of the building's sprinkler system for the previous twelve months.

Based on observations, the facility failed to install the heating, ventilation, and air conditioning system (HVAC system) properly by placing air vents within thirty-six inches of fire alarm components. This deficient practice would affect 1 of 7 smoke zones, and 5 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Observations on 08/19/2010, revealed a smoke detector mounted within thirty-six inches of a HVAC vent in the Surgical Mechanical Room.

Based on documentation review, the facility failed to provide a policy in writing that meets the requirements of 2000 Life Safety Code 9.6.1.8 (plans for fire alarm systems out of service for more than 4 hours in a 24 hour period). This deficient practice would affect 7 of 7 smoke zones, and 50 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Documentation review on 08/19/2010, revealed that the facility was unable to provide a written policy that meets the requirements of 2000 Life Safety Code 9.6.1.8 (plans for fire suppression systems out of service for more than 4 hours in a 24 hour period).

Based on documentation review, the facility failed to provide a policy in writing that meets the requirements of 2000 Life Safety Code 9.6.1.8 (plans for fire suppression systems out of service for more than 4 hours in a 24 hour period). This deficient practice would affect 7 of 7 smoke zones, and 50 residents, staff and visitors in the case of a fire related emergency. This facility has a census of 5 residents and is certified for 25 beds.Findings include: Documentation review on 08/19/2010, revealed that the facility was unable to provide a written policy that meets the requirements of 2000 Life Safety Code 9.6.1.8 (plans for fire alarm systems out of service for more than 4 hours in a 24 hour period).