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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 20 patients and any visitors or staff in 4 of 9 smoke zones. The Hospital has a capacity of 20 with a census of 2 and the LTCU has a capacity of 43 with a census of 33 at the time of the survey.

Findings include:

During the tour conducted on 05/16/2016, it is observed:

-- 1. At 1:35 p.m., missing ceiling tiles in Physical Therapy Room.

-- 2. At 2:34 p.m., missing ceiling tiles and unsealed penetrations around cables and wires in smoke barrier wall near Hospital nursing station.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: One story is permitted for a noncombustible type building protected with a one hour fire resistive rating, Type II (111) without a complete automatic sprinkler system. 2000 NFPA 101, Table 18/19.1.6.2

Based on observation and staff interview, the facility fails to ensure that corridor doors are not blocked open. This deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting approximately no patients and any visitors or staff 1 of 9 smoke zones. The Hospital has a capacity of 20 with a census of 2 and the LTCU has a capacity of 43 with a census of 33 at the time of the survey.

Findings Include:

During the tour conducted on 05/16/2016, at 1:45 p.m., it is observed that the rated door to the Ambulance Director's Office is held open with a non-approved device.

Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting no patients and any visitors or staff 1 of 9 smoke zones. The Hospital has a capacity of 20 with a census of 2 and the LTCU has a capacity of 43 with a census of 33 at the time of the survey.

Findings Include:

During the tour conducted on 05/16/2016, at approximately 1:37 p.m., in the wall separating Laundry and anteroom, it is observed that there are unsealed penetrations surrounding wires, cables and sprinkler piping.

Maintenance Supervisor was present and acknowledged the unsealed penetrations.

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 and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based on observation and staff interview the facility fails to assure that all electrical wiring complies with NFPA 70. This deficient practice could result in an electrical short causing a fire, affecting approximately 20 patients and any visitors or staff 4 of 9 smoke zones. The Hospital has a capacity of 20 with a census of 2 and the LTCU has a capacity of 43 with a census of 33 at the time of the survey.

Findings include:

During the tour conducted on 05/16/2016, it is observed:

-- 1. At 1:35 p.m., uncovered junction box in anteroom for Laundry Room and Physical Therapy.

-- 2. At 1:55 p.m., uncovered junction box in Housekeeping corridor.

This deficient practice was confirmed by the Maintenance Supervisor at the time of discovery.

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

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 20 patients and any visitors or staff in 4 of 9 smoke zones. The Hospital has a capacity of 20 with a census of 2 and the LTCU has a capacity of 43 with a census of 33 at the time of the survey.

Findings include:

During the tour conducted on 05/16/2016, it is observed:

-- 1. At 1:35 p.m., missing ceiling tiles in Physical Therapy Room.

-- 2. At 2:34 p.m., missing ceiling tiles and unsealed penetrations around cables and wires in smoke barrier wall near Hospital nursing station.

Maintenance Supervisor was present and acknowledged the findings.

NFPA Standard: One story is permitted for a noncombustible type building protected with a one hour fire resistive rating, Type II (111) without a complete automatic sprinkler system. 2000 NFPA 101, Table 18/19.1.6.2

Based on observation and staff interview, the facility fails to ensure that corridor doors are not blocked open. This deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting approximately no patients and any visitors or staff 1 of 9 smoke zones. The Hospital has a capacity of 20 with a census of 2 and the LTCU has a capacity of 43 with a census of 33 at the time of the survey.

Findings Include:

During the tour conducted on 05/16/2016, at 1:45 p.m., it is observed that the rated door to the Ambulance Director's Office is held open with a non-approved device.

Maintenance Supervisor was present and acknowledged the finding.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other spaces. The deficient practice would not prevent the passage of fire or smoke to other areas of the building, affecting no patients and any visitors or staff 1 of 9 smoke zones. The Hospital has a capacity of 20 with a census of 2 and the LTCU has a capacity of 43 with a census of 33 at the time of the survey.

Findings Include:

During the tour conducted on 05/16/2016, at approximately 1:37 p.m., in the wall separating Laundry and anteroom, it is observed that there are unsealed penetrations surrounding wires, cables and sprinkler piping.

Maintenance Supervisor was present and acknowledged the unsealed penetrations.

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 and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

Based on observation and staff interview the facility fails to assure that all electrical wiring complies with NFPA 70. This deficient practice could result in an electrical short causing a fire, affecting approximately 20 patients and any visitors or staff 4 of 9 smoke zones. The Hospital has a capacity of 20 with a census of 2 and the LTCU has a capacity of 43 with a census of 33 at the time of the survey.

Findings include:

During the tour conducted on 05/16/2016, it is observed:

-- 1. At 1:35 p.m., uncovered junction box in anteroom for Laundry Room and Physical Therapy.

-- 2. At 1:55 p.m., uncovered junction box in Housekeeping corridor.

This deficient practice was confirmed by the Maintenance Supervisor at the time of discovery.

NFPA Standard: Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2