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Based on observations, the facility failed to maintain doors to the corridor within proper standards This deficient practice would effect 4 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations on 03/16/2010, revealed the following:1.) A door wedge was present and in use with the following doors: The Sterile Supply Room, The Indian Hills Entrance.2.) In testing of the facility ' s doors, a failure to positively latch within the frame of the door was found on the door to The ICN Classroom, and the door to The SCIMC West Entrance.3.) A padlock assembly was found on the door to one of the Storage Rooms in the Basement.4.) A thumb-turn deadbolt was found on the hallway door to the X-ray Room.

Based on observations, the facility failed to maintain three sets of the smoke barrier doors 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 effect 4 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations on 03/16/2010, revealed the following:1.) Both sets of smoke barrier doors in the X-ray Corridor were not smoke tight, exhibiting a gap between said doors of more than one eighth of an inch.2.) The smoke barrier doors near the Main Fire Alarm Panel did not close and latch automatically as required.

Based on observations and documentation review, the facility failed to test and maintain 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 14 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations and documentation review on 03/12/2010 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.3.) An emergency light unit in the Public Health Area failed to illuminate upon testing.

Based on observations and documentation review, 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 effect 14 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations and documentation review on 03/16/2010, revealed the following:1.) Only one of two required fire alarm inspections in the previous twelve months was documented on NFPA 72 compliant paperwork.2.) The electrical breaker that serves the main fire alarm control panel was not equipped with a device designed to prevent the accidental turning off of the fire alarm system.3.) The Old OB Storage Room was not equipped with a heat detector or a smoke detector.

Based on documentation review, the facility failed to test smoke detectors for sensitivity in accordance with National Fire Protection Association (NFPA) 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. This deficient practice would effect 14 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Documentation review on 03/16/2010 revealed the facility was unable to produce documentation that the smoke detectors had a sensitivity test to ensure they were operating within the sensitivity range set forth by the manufacturer. Staff was unable to provide such documentation.

Based on observations, the facility failed to maintain 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 14 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations on 03/16/2010, revealed that three of the flow alarm devices located on the sprinkler riser assembly was not sufficiently attached to the system and had become unacceptably loose.

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 effect 5 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations on 03/16/2010 revealed smoke detectors mounted within thirty-six inches of HVAC vents in the Kitchen (1), the 100 Nursing Hall (5), the Public Health Corridor (1), the Specialty Clinic Nurses Station (2), and the corridor just outside the X-ray Room (1).

Based on observations and documentation review, the facility failed to provide and maintain the standby generator in accordance with Section 3-4.4.1, National fire Protection Association (NFPA) Standard 99, Standard for Health Care Facilities, 1999 edition. This deficient practice would effect 14 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations and documentation review on 03/16/2010, revealed the following:1.) The facility was not equipped with the required remote enunciator at a location that was manned twenty-four hours per day.2.) The facility was unable to provide documentation that showed that the generator had been tested within the last month.

Based on observations, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would effect 1 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations on 03/16/2010 revealed an air compressor that had it's power supply cable affixed to an electrical outlet with a piece of wire. The air compressor was located in the Basement. The air compressor must be direct wired.

Based on observations, the facility failed to maintain doors to the corridor within proper standards This deficient practice would effect 4 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations on 03/16/2010, revealed the following:1.) A door wedge was present and in use with the following doors: The Sterile Supply Room, The Indian Hills Entrance.2.) In testing of the facility ' s doors, a failure to positively latch within the frame of the door was found on the door to The ICN Classroom, and the door to The SCIMC West Entrance.3.) A padlock assembly was found on the door to one of the Storage Rooms in the Basement.4.) A thumb-turn deadbolt was found on the hallway door to the X-ray Room.

Based on observations, the facility failed to maintain three sets of the smoke barrier doors 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 effect 4 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations on 03/16/2010, revealed the following:1.) Both sets of smoke barrier doors in the X-ray Corridor were not smoke tight, exhibiting a gap between said doors of more than one eighth of an inch.2.) The smoke barrier doors near the Main Fire Alarm Panel did not close and latch automatically as required.

Based on observations and documentation review, the facility failed to test and maintain 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 14 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations and documentation review on 03/12/2010 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.3.) An emergency light unit in the Public Health Area failed to illuminate upon testing.

Based on observations and documentation review, 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 effect 14 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations and documentation review on 03/16/2010, revealed the following:1.) Only one of two required fire alarm inspections in the previous twelve months was documented on NFPA 72 compliant paperwork.2.) The electrical breaker that serves the main fire alarm control panel was not equipped with a device designed to prevent the accidental turning off of the fire alarm system.3.) The Old OB Storage Room was not equipped with a heat detector or a smoke detector.

Based on documentation review, the facility failed to test smoke detectors for sensitivity in accordance with National Fire Protection Association (NFPA) 72, 7-3.2.1. All of the smoke detectors throughout the building were affected and all occupants of the building could be affected by the deficient practice. This deficient practice would effect 14 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Documentation review on 03/16/2010 revealed the facility was unable to produce documentation that the smoke detectors had a sensitivity test to ensure they were operating within the sensitivity range set forth by the manufacturer. Staff was unable to provide such documentation.

Based on observations, the facility failed to maintain 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 14 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations on 03/16/2010, revealed that three of the flow alarm devices located on the sprinkler riser assembly was not sufficiently attached to the system and had become unacceptably loose.

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 effect 5 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations on 03/16/2010 revealed smoke detectors mounted within thirty-six inches of HVAC vents in the Kitchen (1), the 100 Nursing Hall (5), the Public Health Corridor (1), the Specialty Clinic Nurses Station (2), and the corridor just outside the X-ray Room (1).

Based on observations and documentation review, the facility failed to provide and maintain the standby generator in accordance with Section 3-4.4.1, National fire Protection Association (NFPA) Standard 99, Standard for Health Care Facilities, 1999 edition. This deficient practice would effect 14 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations and documentation review on 03/16/2010, revealed the following:1.) The facility was not equipped with the required remote enunciator at a location that was manned twenty-four hours per day.2.) The facility was unable to provide documentation that showed that the generator had been tested within the last month.

Based on observations, the facility failed to maintain the building's electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This deficient practice would effect 1 of 14 smoke zones in the case of a fire related emergency. This facility has a census of 14 residents and is certified for 25 beds. This facility was inspected on 3/12/10 and 3/16/10.Findings include: Observations on 03/16/2010 revealed an air compressor that had it's power supply cable affixed to an electrical outlet with a piece of wire. The air compressor was located in the Basement. The air compressor must be direct wired.