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Based observation and staff interview, the facility fails to maintain the integrity of the building construction by allowing openings into the ceiling. This deficient practice could allow fire products to spread to the concealed ceiling space above the corridor. This deficient practice could affect approximately 10 patients and any visitors or staff in 1 of 6 smoke zones. The facility has a capacity of up to 15 in the LTCU portion with a census of 13 and a capacity of up to 10 in the hospital portion with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 09/29/2016, it is observed:

-- 1. At 4:07 p.m., in the IT Office, an incomplete ceiling tile which has wires and cables passing through it has been covered with non-approved tape and a plastic material in a makeshift attempt to prevent the passage of smoke.

Maintenance Director and Maintenance Staff A were present and acknowledged the findings.

NFPA Standard: One story is permitted with complete sprinkler coverage and one-hour rated ceilings for all parts of a facility composed of wood frame construction, type V (111). 2000 NFPA 101, table 18/19.1.6.2

Based on observation, record review and interview, the facility failed to provide self-closing devices on doors to hazardous areas. The deficient practice would prevent self-closing of doors when released to self-closing action, affecting approximately 10 patients and any visitors or staff in 1 of 6 smoke zones. The facility has a capacity of up to 15 in the LTCU portion with a census of 13 and a capacity of up to 10 in the hospital portion with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 09/29/2016, at approximately 4:28 p.m., it is observed that a patient room located on the northeast side of the hospital patient wing has been converted to a combustible storage room in excess of 50 square feet. The corridor door is not equipped with a self-closing device.

Maintenance Director was present and confirmed the observations and findings at the time of discovery.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on record review and staff interview, it is observed that the facility fails to maintain and test the fire alarm system in accordance with NFPA 72, 2000 ed. This deficient practice could cause the fire alarm system to fail or malfunction in the event of an emergency affecting all occupants and all residents in 6 of 6 smoke zones. The facility has a capacity of up to 15 in the LTCU portion with a census of 13 and a capacity of up to 10 in the hospital portion with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 09/29/2016, at approximately 2:30 p.m., a review of the last annual fire alarm inspection and testing record dated 02/16/2016 indicated that 2 duct detectors located in the Activity Room Closed and Soiled Utility Room were inaccessible and not tested.

Maintenance Director and Maintenance Staff A were present and acknowledged the results of the records review.

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based observation and staff interview, the facility fails to maintain the integrity of the building construction by allowing openings into the ceiling. This deficient practice could allow fire products to spread to the concealed ceiling space above the corridor. This deficient practice could affect approximately 10 patients and any visitors or staff in 1 of 6 smoke zones. The facility has a capacity of up to 15 in the LTCU portion with a census of 13 and a capacity of up to 10 in the hospital portion with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 09/29/2016, it is observed:

-- 1. At 4:07 p.m., in the IT Office, an incomplete ceiling tile which has wires and cables passing through it has been covered with non-approved tape and a plastic material in a makeshift attempt to prevent the passage of smoke.

Maintenance Director and Maintenance Staff A were present and acknowledged the findings.

NFPA Standard: One story is permitted with complete sprinkler coverage and one-hour rated ceilings for all parts of a facility composed of wood frame construction, type V (111). 2000 NFPA 101, table 18/19.1.6.2

Based on observation, record review and interview, the facility failed to provide self-closing devices on doors to hazardous areas. The deficient practice would prevent self-closing of doors when released to self-closing action, affecting approximately 10 patients and any visitors or staff in 1 of 6 smoke zones. The facility has a capacity of up to 15 in the LTCU portion with a census of 13 and a capacity of up to 10 in the hospital portion with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 09/29/2016, at approximately 4:28 p.m., it is observed that a patient room located on the northeast side of the hospital patient wing has been converted to a combustible storage room in excess of 50 square feet. The corridor door is not equipped with a self-closing device.

Maintenance Director was present and confirmed the observations and findings at the time of discovery.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on record review and staff interview, it is observed that the facility fails to maintain and test the fire alarm system in accordance with NFPA 72, 2000 ed. This deficient practice could cause the fire alarm system to fail or malfunction in the event of an emergency affecting all occupants and all residents in 6 of 6 smoke zones. The facility has a capacity of up to 15 in the LTCU portion with a census of 13 and a capacity of up to 10 in the hospital portion with a census of 1 at the time of the survey.

Findings include:

During the tour conducted on 09/29/2016, at approximately 2:30 p.m., a review of the last annual fire alarm inspection and testing record dated 02/16/2016 indicated that 2 duct detectors located in the Activity Room Closed and Soiled Utility Room were inaccessible and not tested.

Maintenance Director and Maintenance Staff A were present and acknowledged the results of the records review.

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4