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Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting approximately 10 residents in 2 of 3 smoke zones. The facility has a capacity of 26 with a census of 20 at the time of the survey.

Findings include:

During the tour conducted on 06/06/2014, it is observed:
-- 1. At approximately 11:55 a.m., smoke barrier wall for Hall 2 has unsealed gaps around wire, conduit and pipes. Non-approved expanding foam insulation is also present.
-- 2. At approximately 12:30 p.m., smoke barrier wall for Hall 1 has unsealed gaps around wire, conduit and pipes.


Maintenance Staff A was present and acknowledged the presence of unsealed penetrations in the smoke barrier walls and the use of non-approved expanding foam.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based upon observation and staff interview, the facility fails to assure that draperies, curtains and other loosely hanging materials are flame-retardant in accordance with provisions of NFPA 101, 10.3.1 The deficient practice increases the risk of fire and smoke, affecting no patients, any visitors or staff in 2 of 3 smoke zones. The facility has a capacity of 26 with a census of 20 at the time of the survey.

Findings include:

During the tour conducted on 06/06/2014, it is observed:
-- 1. At 12:15 p.m., non-labeled vinyl mini blinds located in staff break room.
-- 2. At 1:30 p.m., non-labeled vinyl mini blinds located at West exit.

No documentation was available to assure compliance with NFPA 701.

Maintenance Staff A was present and acknowledged that no documentation was available at the time of inspection.

NFPA Standard: Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701. 2000 NFPA 101, 10.3.1