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Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 53 of 53 residents.

Findings:

During the facility tour, between the hours of 9:00 AM and 3:00 PM on 4/5/16, it was observed that the sprinkler system did not activate the fire alarm system within the required 90 seconds.

Interview with administrator revealed the facility was not aware the automatic sprinkler system would not activate the fire alarm system, which was acknowledged by the Administrator during the exit meeting.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier was filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 53 of 53 residents.
3 of 3 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 9:00 AM and 3:00 PM on 4/5/16, it was observed that penetrations were not sealed in the following smoke barriers; smoke barrier near admissions office, smoke barrier at Zone 6 and smoke barrier near room #142.

Interview with administrator revealed the facility was not aware that the smoke barriers had penetrations that were not sealed

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property. This deficiency has the potential to affect 53 of 53 residents.

Findings:

During the facility tour, between the hours of 9:00 AM and 3:00 PM on 4/5/16, it was observed that the sprinkler system did not activate the fire alarm system within the required 90 seconds.

Interview with administrator revealed the facility was not aware the automatic sprinkler system would not activate the fire alarm system, which was acknowledged by the Administrator during the exit meeting.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier was filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. Unprotected penetrations would permit the movement of smoke from one compartment to the other in the facility. The deficient practice had the potential to affect 53 of 53 residents.
3 of 3 smoke barriers were deficient.

Findings:

During the facility tour, between the hours of 9:00 AM and 3:00 PM on 4/5/16, it was observed that penetrations were not sealed in the following smoke barriers; smoke barrier near admissions office, smoke barrier at Zone 6 and smoke barrier near room #142.

Interview with administrator revealed the facility was not aware that the smoke barriers had penetrations that were not sealed