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1. Based on observation and interview, it was determined the facility did not maintain penetrations for four (Medical Surgical Patient Unit, Courtyard, Manitenance Office and the Lab) of five smoke barrier walls with a fire rated material to resist the passage of smoke. The failed practice had the potential to affect all 12 patients on census. The findings follow:

A. On a tour of the facility with Maintenance Director on 01/12/10 at 1500, unsealed penetrations of the smoke barrier were observed at the following locations:
1) Four unsealed penetrations above the ceiling at the smoke barrier doors located at the Medical Surgical Patient Unit.
2) Two unsealed penetrations of the smoke barrier wall at the smoke barrier doors located near the Courtyard.
3) Two unsealed penetrations of the smoke barrier wall at the smoke barrier doors located near the Maintenance Office.
4) One unsealed penetration of the smoke barrier wall at the smoke barrier doors located near the Lab. The wall was also not sealed at the roof deck at this location.
B. The Maintenance Director verified the unsealed penetrations at the time of observation.

2. Based on observation and interview, it was determined one Soiled Linen Room was not protected by a one hour fire rated construction or an automatic fire extinguishing system as required. The failed practice had the potential to affect all 12 patients on census. The findings follow:

A. On a tour of the facility on 01/12/10 at 1300 with the Maintenance Director, the Soiled Linen Room located near the Nurse Station in the Medical Surgical Patient Unit was observed to be unsprinklered. An inspection above the ceiling revealed the room was not protected by one hour rated construction and the wall did not extend to the roof deck, forming an incomplete separation wall from the remainder of the building.
B. The Maintenance Director verified the the incomplete fire rated separation wall and that the room was unwrinkle at the time of observation.

1. Based on observation and interview, it was determined the facility did not maintain penetrations for four (Medical Surgical Patient Unit, Courtyard, Manitenance Office and the Lab) of five smoke barrier walls with a fire rated material to resist the passage of smoke. The failed practice had the potential to affect all 12 patients on census. The findings follow:

A. On a tour of the facility with Maintenance Director on 01/12/10 at 1500, unsealed penetrations of the smoke barrier were observed at the following locations:
1) Four unsealed penetrations above the ceiling at the smoke barrier doors located at the Medical Surgical Patient Unit.
2) Two unsealed penetrations of the smoke barrier wall at the smoke barrier doors located near the Courtyard.
3) Two unsealed penetrations of the smoke barrier wall at the smoke barrier doors located near the Maintenance Office.
4) One unsealed penetration of the smoke barrier wall at the smoke barrier doors located near the Lab. The wall was also not sealed at the roof deck at this location.
B. The Maintenance Director verified the unsealed penetrations at the time of observation.

2. Based on observation and interview, it was determined one Soiled Linen Room was not protected by a one hour fire rated construction or an automatic fire extinguishing system as required. The failed practice had the potential to affect all 12 patients on census. The findings follow:

A. On a tour of the facility on 01/12/10 at 1300 with the Maintenance Director, the Soiled Linen Room located near the Nurse Station in the Medical Surgical Patient Unit was observed to be unsprinklered. An inspection above the ceiling revealed the room was not protected by one hour rated construction and the wall did not extend to the roof deck, forming an incomplete separation wall from the remainder of the building.
B. The Maintenance Director verified the the incomplete fire rated separation wall and that the room was unwrinkle at the time of observation.