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Based on observations the facility failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4. This condition has the potential to affect the entire facility.

Finding include:

While inspecting smoke barrier walls on August 13, 2014 at 1:30 p.m., the maintenance supervisor and the surveyor observed the smoke barrier walls had the following unsealed penetrations in the following areas:

1. Smoke barrier wall near Rooms 2214 and 2213.

This deficient practice has the potential of affecting 2 of 13 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

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.

Findings include:

While inspecting hazardous areas on August 13, 2014, the maintenance person and surveyor found the following areas to be used as storage and the doors of these areas also did not have a self closing device:

1. Rooms 302-304 on 3th Floor East Wing
2. Rooms 307-310 on 3th Floor East Wing
3. Rooms 311-312 on 3th Floor East Wing
4. Rooms 313-314 on 3th Floor East Wing
5. Mechanical Room on 4th Floor Geriatric West Wing
6. Mechanical Room on 3th Floor West Wing
7. Utility Room on 4th Floor East Wing
8. Shower Room on 4th Floor East Wing

These deficient practices have the potential of affecting 4 of 13 smoke compartments. The administrator and maintenance director were notified during the survey and in the exit conference.

Based on observations, the facility failed to provide a complete manual fire alarm system as directed by NFPA 101 Section 9.6, NFPA 72 Section 4-4.4.2.2.

Findings include:

On August 13, 2014 at 11:00 a.m., the maintenance supervisor and surveyor observed the following areas did not have fire alarm signaling device:

1. The corridor area near Eva ' s Closet 1035 on the 1st Floor East Wing.

This deficient practice has the potential of affecting 1 of 13 smoke compartments. The maintenance supervisor and the administrator were notified during an exit conference.

Based on observation and testing, the facility failed to provide supervision on the sprinkler control valve in accordance NFPA 101 section 9.7.2.1, NFPA 72.

Findings include:

While testing the sprinkler system on August 13, 2014 at 1:00 p.m., the maintenance person and surveyor observed that a local alarm did not sound when the post indicator valves was closed on both North and South areas of the facility.

This condition has the potential to affect all residents and staff of the facility. The administrator and maintenance director were notified during the survey and in the exit conference.