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Based on observation and interview, the facility failed to ensure each door protecting corridor openings was free of impediments to closing. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 21 patients.

Findings include:

On 09/23/14 at 8:52 A.M. a tour was taken of the second floor of the facility with Staff Q and R. On 09/23/14 at 9:20 A.M. the door to room 202 did not close completely, due to vinyl stripping in the frame.

On 09/23/14 at 9:20 A.M. in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to maintain the fire resistive rating of its fire resistive walls. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 21 patients.

Findings include:

1. On 09/23/14 at 8:52 A.M. a tour was taken of the second floor of the facility with Staff Q and R. The tour began from the East side and went to the West side. At 8:52 A.M. observation above the drop down ceiling of the one hour rated walls on the farthest east side of the floor revealed on the north side and south side open half inch conduits.

On 09/23/14 at 8:52 A.M. in an interview, Staff Q confirmed the observation.

2. On 09/23/14 at 9:05 A.M. observation above the drop down ceiling of the one hour rated wall in back of the janitor closet revealed an annular space around a sprinkler line.

On 09/23/14 at 9:05 A.M. in an interview, Staff Q confirmed the observation.

3. On 09/23/14 at 9:15 A.M. observation above the drop down ceiling of the one hour rated wall on the east side of room 202 revealed a half inch open conduit.

On 09/23/14 at 9:15 A.M. in an interview, Staff Q confirmed the observation.

4. On 09/23/14 at 9:31 A.M. observation above the drop down ceiling of the one hour rated wall in the patient room to the immediate east of the dining area revealed a ¾ inch open conduit.

On 09/23/14 at 9:31 P.M. in an interview, Staff Q confirmed the observation.

5. On 09/23/14 at 10:33 A.M. a tour was conducted of the facility's first floor with Staff Q and R. On 09/23/14 at 10:40 A.M. observation above the drop down ceiling of the one hour rated wall between rooms 101 and 103 revealed a half inch open conduit and a sprinkler line with an annular space.

On 09/23/14 at 10:40 A.M. in an interview, Staff Q confirmed the observation.

6. On 09/23/14 at 10:48 A.M. observation above the drop down ceiling of the one hour rated wall immediately west of room 103 revealed a half inch open conduit with three blue wires.

On 09/23/14 at 10:48 A.M. in an interview, Staff Q confirmed the observation.

7. On 09/23/14 at 11:03 A.M. observation above the drop down ceiling of the one hour rated wall above the central bathing room revealed a conduit leading from said wall to an open junction box.

On 09/23/14 at 11:03 A.M. in an interview, Staff Q confirmed the observation.

8. On 09/23/14 at 11:15 A.M. observation above the drop down ceiling of the one hour rated wall above room 105 revealed two half inch holes in the wall.

On 09/23/14 at 11:15 A.M. in an interview, Staff Q confirmed the observation.

9. On 09/23/14 at 1:55 P.M. observation above the drop down ceiling of the one hour rated wall over the picture next to room 109 revealed a ¾ inch open conduit and a ½ inch open conduit.

On 09/23/14 at 1:55 P.M. in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure hazardous areas protected with an approved automatic fire extinguishing system was separated from other areas by smoke resisting walls. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 21 patients.

Findings include:

1. On 09/23/14 at 8:52 A.M. a tour was taken of the second floor of the facility with Staff Q and R. At 9:35 A.M. in the back wall of the furnace room next to (east) of the dining room revealed below the drop down ceiling a one inch hole in the wall.

On 09/23/14 at 9:35 A.M. in an interview, Staff Q confirmed the observation.

2. On 09/23/14 at 10:33 A.M. a tour was conducted of the facility's first floor with Staff Q and R. At 10:56 A.M. observation of the soiled utility room door revealed it not to be on a self closer.

On 09/23/14 at 10:56 A.M. in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to enclose each stairway in at least one hour fire resistive construction. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 21 patients.

Findings include:

1. On 09/23/14 at 8:52 A.M. a tour was taken of the second floor of the facility with Staff Q and R. On 09/23/14 at 10:15 A.M. the door to the west stairwell was observed to be non-rated.

On 09/23/14 at 10:15 A.M. in an interview, Staff Q confirmed the observation.

2. On 09/23/14 at 10:33 A.M. a tour was conducted of the facility's first floor with Staff Q and R. On 09/23/14 at 10:51 A.M. observation above the east stair door revealed a wall opening with one red wire, and another opening with a red and blue wire.

On 09/23/14 at 10:51 A.M. in an interview, Staff Q confirmed the observation.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 21 patients.

Findings include:

Review of the facility's life safety documentation did not reveal any fire drills for the past 12 months.

On 09/24/14 at 11:30 A.M. in an interview, Staff Q confirmed fire drills had not been conducted in the past 12 months.

Based on observation and interview, the facility failed to maintain its sprinkler system in operating condition and in accordance with National Fire Protection Association 13. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 21 patients.

Findings include:

1. On 09/23/14 at 10:33 A.M. a tour was conducted of the facility's first floor with Staff Q and R. Observation of the ceiling in the sally port entrance revealed an open hole.

On 09/23/14 at 10:33 A.M. in an interview, Staff Q said they were waiting for a replacement head because the old one had frozen over last winter.

2. On 09/23/14 at 2:42 P.M. a tour was taken of the kitchen with Staff Q. The tour revealed two sprinkler heads with missing escutcheon rings.

On 09/23/14 at 2:42 P.M. in an interview Staff Q confirmed the observation.

3. On 09/23/14 at 4:04 P.M. observation of room four in the basement revealed multiple beds stacked lengthwise to the ceiling in rows along the wall. The observation revealed the beds completed occluded the sprinklers along the wall.

On 09/23/14 at 4:04 P.M. in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to provide portable fire extinguishers in accordance with National Fire Protection Association 10, specifically 1-6.3. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 21 patients.

Findings include:

On 09/23/14 at 8:52 A.M. a tour was taken of the second floor of the facility with Staff Q and R and on 09/23/14 at 10:33 A.M. a tour was conducted of the facility's first floor with Staff Q and R. During both tours the portable fire extinguishers were observed in locked cabinets.

On 09/23/14 at 11:22 A.M. in an interview, Staff S was asked to access a fire extinguisher from a locked cabinet. The staff member was unable to access the fire extinguisher without assistance.

On 09/23/14 at 11:25 A.M. in an interview, Staff T was asked to access a fire extinguisher from a locked cabinet. The staff member was only able to open the cabinet after several attempts. He/she explained he/she had never used it before.

On 09/23/14 at 11:25 A.M. the locking mechanism for the cabinet was examined by Staff Q. In an interview at that time with Staff Q it was revealed the locking mechanism for the cabinet required the key to be inserted upside down. It was further revealed in the interview that the vast majority of the locks in the building required the key to be inserted right side up.

Based on observation and interview, the facility failed to ensure its smoking policy was implemented. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 21 patients.

Findings include:

On 09/23/14 at 8:00 A.M. multiple cigarette butts were observed in mulch and around evergreen trees at the entrance to the facility. On 09/24/14 at 8:00 A.M. multiple cigarette butts were observed in the same mulch and around the same evergreen trees at the entrance to the facility. This area was not observed to be a designated smoking area.

On 09/24/14 at 2:23 P.M. in an interview Staff Q confirmed the observation. He/she explained the area is unmonitored at night, and, as only employees have access to this locked area, the cigarette butts came from them.

Based on observation and interview, the facility failed to ensure each exit was readily accessible at all times in accordance with 7.1.10, Life Safety Code 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 21 patients.

Findings include:

On 09/23/14 at 2:42 P.M. a tour was conducted of the kitchen with Staff Q. A 30 gallon trash can was observed in front of the exit door.

On 09/23/14 at 3:15 P.M. the kitchen was revisited and the 30 gallon trash can was observed still against the kitchen exit door.

On 09/23/14 at 3:15 P.M. in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure a life safety feature obvious to the public, performed as indicated as required by the National Fire Protection Association 101, Chapter 4.6.12.2. This has the potential to affect all patients, staff, and visitors to the facility. The facility's census was 21 patients.

Findings include:

On 09/23/14 at 8:52 A.M. a tour was taken of the second floor of the facility with Staff Q and R and on 09/23/14 at 10:33 A.M. a tour was conducted of the facility's first floor with Staff Q and R. Observation revealed 13 blue pull stations behind a clear locking case with the wording "pull fire alarm" on it.

On 09/23/14 at 3:31 P.M. in an interview, Staff Q explained the blue pull stations are not fire pull stations. In case of an emergency, they only release the locked door they are nearby.