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Based on observation and staff interview the facility failed to maintain the two hour fire resistive wall. One of five smoke compartments in the facility, and all residents and staff are affected by the deficient practice. This facility has a capacity of 25 and a census of 4 patients.

Findings include:

Observation and staff interview on 2/9/15 at 3:20 p.m., revealed the two hour fire rated assembly separating the Speciality Clinic and the Hospital contained a 1/2 inch penetration surrounding a computer cable bundle.
Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two of five smoke compartments. This facility has a capacity of 25 and a census of 4 patients.

Findings include:

Observation and staff interview of the Purchasing/storage on 2/9/15 at 3:03 p.m. revealed three penetrations located in the West wall.
1. There was an open 1/2 inch conduit.
2. There was a 1/2 inch penetration surrounding a two inch pipe.
3. There was a 1/2 inch penetration surrounding an one inch penetration
Maintenance Staff confirmed these observations during the survey process.

Based on observation, staff interview and record review, the facility failed to maintain and test a complete automatic sprinkler system. This smoke compartment (one wing) and all residents and staff could be affected by the deficient practice. The facility has 22 certified beds and at the time of the survey the census was 22.

Findings include:

Observation, staff interview and record review of the facilities sprinkler documentation on 3/04/2014, showed that the first quarter testing of 2013 had not been conducted. Maintenance Staff verifed this observation during the survey process.

Based on observation and staff interview the facility failed to maintain the two hour fire resistive wall. One of five smoke compartments in the facility, and all residents and staff are affected by the deficient practice. This facility has a capacity of 25 and a census of 4 patients.

Findings include:

Observation and staff interview on 2/9/15 at 3:20 p.m., revealed the two hour fire rated assembly separating the Speciality Clinic and the Hospital contained a 1/2 inch penetration surrounding a computer cable bundle.
Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affected two of five smoke compartments. This facility has a capacity of 25 and a census of 4 patients.

Findings include:

Observation and staff interview of the Purchasing/storage on 2/9/15 at 3:03 p.m. revealed three penetrations located in the West wall.
1. There was an open 1/2 inch conduit.
2. There was a 1/2 inch penetration surrounding a two inch pipe.
3. There was a 1/2 inch penetration surrounding an one inch penetration
Maintenance Staff confirmed these observations during the survey process.

Based on observation, staff interview and record review, the facility failed to maintain and test a complete automatic sprinkler system. This smoke compartment (one wing) and all residents and staff could be affected by the deficient practice. The facility has 22 certified beds and at the time of the survey the census was 22.

Findings include:

Observation, staff interview and record review of the facilities sprinkler documentation on 3/04/2014, showed that the first quarter testing of 2013 had not been conducted. Maintenance Staff verifed this observation during the survey process.