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Based on observation and staff interview, the facility failed to maintain the monolithic ceiling located in one of four smoke zones on 1st floor. This facility is a Type II (111) with a complete sprinkler system. This facility is certified for 25 beds and a census of 8 patients.

Findings include:

Observation and staff interview on 2/25/15 at 1:29 p.m., revealed an ecshoen ring was missing from the sprinkler head in the ceiling of the Lab Hallway by the double fire doors (at the 2-hour separation). Maintenance Staff verified 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 one of four smoke compartments on the first floor. This facility is certified for 25 beds and had a census of 8 patients.

Findings include:

Observation and staff interview of the Oxygen/Storage Room on 2/23/15 at 1:35 p.m., revealed several penetrations:
- 1/2 inch hole above the door
- 1/4 inch penetration surrounding a 1/2 inch copper pipe
- 1/2 inch penetration surrounding a vent pipe
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 in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all patients and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

Observation, staff interview and record review of the facilities fire safety components on 2/23/15 at 3 p.m., revealed the quarterly inspections of the sprinkler system had not been completed as required by code. Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview, the facility failed to maintain positive action locking devices on doors. This could affect one (Surgical area) of four smoke compartments on 1st floor, and patients and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

Observation and staff interview on 2/23/15 at 1:43 p.m., revealed that the north doors in the Surgical Area contained a dead bolt locking device, which is not allowed in code. Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview, the facility failed to maintain the monolithic ceiling located in one of four smoke zones on 1st floor. This facility is a Type II (111) with a complete sprinkler system. This facility is certified for 25 beds and a census of 8 patients.

Findings include:

Observation and staff interview on 2/25/15 at 1:29 p.m., revealed an ecshoen ring was missing from the sprinkler head in the ceiling of the Lab Hallway by the double fire doors (at the 2-hour separation). Maintenance Staff verified 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 one of four smoke compartments on the first floor. This facility is certified for 25 beds and had a census of 8 patients.

Findings include:

Observation and staff interview of the Oxygen/Storage Room on 2/23/15 at 1:35 p.m., revealed several penetrations:
- 1/2 inch hole above the door
- 1/4 inch penetration surrounding a 1/2 inch copper pipe
- 1/2 inch penetration surrounding a vent pipe
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 in accordance with National Fire Protection Association (NFPA) 25, 1998 edition. All smoke compartments in the building and all patients and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

Observation, staff interview and record review of the facilities fire safety components on 2/23/15 at 3 p.m., revealed the quarterly inspections of the sprinkler system had not been completed as required by code. Maintenance Staff confirmed this observation during the survey process.

Based on observation and staff interview, the facility failed to maintain positive action locking devices on doors. This could affect one (Surgical area) of four smoke compartments on 1st floor, and patients and staff could be affected by the deficient practice. The facility has 25 certified beds and at the time of the survey the census was 8.

Findings include:

Observation and staff interview on 2/23/15 at 1:43 p.m., revealed that the north doors in the Surgical Area contained a dead bolt locking device, which is not allowed in code. Maintenance Staff confirmed this observation during the survey process.