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Based on observation and staff interview the facility fails to maintain hazardous areas with construction that will resist the passage of smoke. This deficient practice could result in the spread of smoke between hazardous areas and occupied smoke zones affecting 2 of 4 smoke zones. The facility has a capacity of 18 and a census of 1 at the time of this survey.

Findings include:

During the tour on 11/17/2010 between 12:00 pm and 4:30 pm, observations revealed the following:

The furnace room across from x-ray has holes in the ceiling and unsealed penetrations.

The boiler room by the physical therapy area has unsealed penetrations and part of the ceiling is sagging.

Staff A was present and confirmed the above conditions.

NFPA Standard: Any hazardous area shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. When the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self closing or automatic closing.

Based on record review and staff interview the facility fails to ensure the automatic sprinkler system is
continuously maintained in a reliable operating condition. This deficient practice of not correcting deficiencies found by the sprinkler contractor does not ensure proper operation and prompt repair of the system. This affects all occupants in 4 of 4 smoke zones. The facility has a capacity of 18 and a census of 1 at the time of this survey.

Findings include:

Review of the facility's sprinkler system inspection records on 11/17/2010 between 12:00 pm and 4:30 pm revealed that the last three sprinkler inspection reports dated 03/18/2010, 06/25/2010 and 09/16/2010 stated that the tamper switches for the sprinkler system valves do not report to the fire alarm panel. No documentation present showing this condition has been corrected. Staff A was present and confirmed the reports stated the above condition.

Review of the following NFPA Standard revealed: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection and test every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1
Review of the following NFPA Standard revealed: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

NFPA Standard: Required automatic sprinkler systems shall have valves supervised so that at least a local alarm will sound when the valves are closed. NFPA 72

Based on observation and staff interview the facility fails to maintain hazardous areas with construction that will resist the passage of smoke. This deficient practice could result in the spread of smoke between hazardous areas and occupied smoke zones affecting 2 of 4 smoke zones. The facility has a capacity of 18 and a census of 1 at the time of this survey.

Findings include:

During the tour on 11/17/2010 between 12:00 pm and 4:30 pm, observations revealed the following:

The furnace room across from x-ray has holes in the ceiling and unsealed penetrations.

The boiler room by the physical therapy area has unsealed penetrations and part of the ceiling is sagging.

Staff A was present and confirmed the above conditions.

NFPA Standard: Any hazardous area shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. When the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self closing or automatic closing.

Based on record review and staff interview the facility fails to ensure the automatic sprinkler system is
continuously maintained in a reliable operating condition. This deficient practice of not correcting deficiencies found by the sprinkler contractor does not ensure proper operation and prompt repair of the system. This affects all occupants in 4 of 4 smoke zones. The facility has a capacity of 18 and a census of 1 at the time of this survey.

Findings include:

Review of the facility's sprinkler system inspection records on 11/17/2010 between 12:00 pm and 4:30 pm revealed that the last three sprinkler inspection reports dated 03/18/2010, 06/25/2010 and 09/16/2010 stated that the tamper switches for the sprinkler system valves do not report to the fire alarm panel. No documentation present showing this condition has been corrected. Staff A was present and confirmed the reports stated the above condition.

Review of the following NFPA Standard revealed: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection and test every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1
Review of the following NFPA Standard revealed: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

NFPA Standard: Required automatic sprinkler systems shall have valves supervised so that at least a local alarm will sound when the valves are closed. NFPA 72