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Based on observation and testing, the facility failed to provide the one hour fire rated construction (with 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4. This condition affected 25% of the residents and staff or 1 of 4 smoke compartments.

Findings include:

On May 15, 2012 at 12:30 a.m., the maintenance person and the the surveyor found the following hazardous area to be deficient:

1) The storage room located by the kitchen had an unsealed 2 foot by 3 foot area above the door and lacked a self-closing device.
2) The fuel fired Water Heater Room had penetrations around various pipes passing through the adjoining walls.

This deficient practice has the potential of affecting 1 of 2 smoke compartments. The administrator and maintenance director were notified during the survey and the exit conference.