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Based on observation and staff interview, the facility failed to assure that hazardous rooms are separated from other spaces This deficient practice does not provide smoke resistant wall and ceilings, affecting 1 of the 4 smoke zones. The facility has a capacity of 25 residents with a census of 4 residents.

Findings Include:

During the survey on 6/7/16 at 1:30 p.m. the following was observed:

Two holes, one approximately 2"x2" in diameter and the other approximately 12"x8" in diameter were identified in phone room 309.

Facilities Management Director was present and aware of the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1. When the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting ceilings, partitions, and doors. The doors shall be self closing or automatic closing. 2000 NFPA 101.

Based on observation and staff interview, the facility failed to ensure that emergency lights operate under test. This deficient practice fails to provide emergency lighting of at least 90 minutes, affecting 1 of 4 smoke zones. The facility has a capacity of 25 patients with a census of 4 patients.

Findings Include:

During the survey on 6/7/16 at 3:00 p.m. the following was observed:

The emegency light in the maintenance garage did not fucntion when tested.

Facilities Management Director was present and aware of the finding.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based on observation and staff interview the facility failed to ensure that all sprinkler system control valves are appropriately supervised and operational. This deficient practice could result in tampering and/or closing of control valves, affecting 4 of 4 smoke zones. The facility has a capacity of 25 and a census of 4 at the time of the survey.

Findings Include:

During the survey on 6/7/16 at 10:30 a.m. the following was observed:

1. 2015-2016 backflow preventer annual test report indicates that the check valve needs to be repaired.

2. 2015-2016 sprinkler system annual test report indicates that the PIV tamper device needs to be repaired.

Facilities Management Director was present and aware of the finding.

NFPA Standard: Sprinkler control valves shall be electrically supervised so that at least a local alarm will sound at a constantly attended location when the valve is turned. 2000 NFPA 101, 18/19.3.5.1 and 9.7.2.1 and 1999 NFPA 13, 5-14.1.1.3, and 1999 NFPA 72, 2-9.1

Based on observation and staff interview, the facility failed to assure that hazardous rooms are separated from other spaces This deficient practice does not provide smoke resistant wall and ceilings, affecting 1 of the 4 smoke zones. The facility has a capacity of 25 residents with a census of 4 residents.

Findings Include:

During the survey on 6/7/16 at 1:30 p.m. the following was observed:

Two holes, one approximately 2"x2" in diameter and the other approximately 12"x8" in diameter were identified in phone room 309.

Facilities Management Director was present and aware of the finding.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1. When the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting ceilings, partitions, and doors. The doors shall be self closing or automatic closing. 2000 NFPA 101.

Based on observation and staff interview, the facility failed to ensure that emergency lights operate under test. This deficient practice fails to provide emergency lighting of at least 90 minutes, affecting 1 of 4 smoke zones. The facility has a capacity of 25 patients with a census of 4 patients.

Findings Include:

During the survey on 6/7/16 at 3:00 p.m. the following was observed:

The emegency light in the maintenance garage did not fucntion when tested.

Facilities Management Director was present and aware of the finding.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3

Based on observation and staff interview the facility failed to ensure that all sprinkler system control valves are appropriately supervised and operational. This deficient practice could result in tampering and/or closing of control valves, affecting 4 of 4 smoke zones. The facility has a capacity of 25 and a census of 4 at the time of the survey.

Findings Include:

During the survey on 6/7/16 at 10:30 a.m. the following was observed:

1. 2015-2016 backflow preventer annual test report indicates that the check valve needs to be repaired.

2. 2015-2016 sprinkler system annual test report indicates that the PIV tamper device needs to be repaired.

Facilities Management Director was present and aware of the finding.

NFPA Standard: Sprinkler control valves shall be electrically supervised so that at least a local alarm will sound at a constantly attended location when the valve is turned. 2000 NFPA 101, 18/19.3.5.1 and 9.7.2.1 and 1999 NFPA 13, 5-14.1.1.3, and 1999 NFPA 72, 2-9.1